Evaluation of suspected small bowel bleeding in hemodynamically stable patients*

GI: gastrointestinal; VCE: video capsule endoscopy; CTE: computed tomographic enterography; MRE: magnetic resonance enterography; CTA: computed tomographic angiography.
* Small bowel bleeding should be suspected in patients with signs of GI bleeding who have had a negative initial endoscopic evaluation (typically upper endoscopy and colonoscopy). The evaluation of hemodynamically unstable patients is discussed in the context of the specific bleeding manifestations (eg, hematemesis). Refer to UpToDate topic reviews on the evaluation and management of GI bleeding for details.
¶ For patients with risk factors for hemobilia or hemosuccus pancreaticus, the upper endoscopy should have included evaluation with a side-viewing duodenoscope. Patients with risk factors for an aortoenteric fistula should also have undergone CTA. If the initial upper endoscopy and/or colonoscopy was inadequate (eg, fair or poor visualization, failure to reach the cecum), repeat examination should be considered before initiating an evaluation for small bowel bleeding.
Δ VCE should be done as close to the acute bleeding episode as possible to increase diagnostic yield. Patients at risk for capsule retention should undergo small bowel imaging (eg, CTE) or a patency capsule study prior to VCE.
◊ In patients with significant comorbid illnesses with slow rates of blood loss, it may be reasonable to stop the evaluation and treat with iron repletion and/or transfusions as needed.
§ Push enteroscopy is an alternative if not already done and if deep small bowel enteroscopy is not available. Intraoperative enteroscopy is an alternative if there are contraindications to deep small bowel enteroscopy, such as dense intra-abdominal adhesions.
¥ The choice of test will depend on the rate of bleeding, patient characteristics, and the degree of suspicion for a small bowel lesion. A Meckel's scan should be performed in younger patients with overt bleeding. Angiography or CTA can be obtained if there is active bleeding. Surgical exploration is appropriate if no other studies have revealed a source and significant bleeding continues or if there is high suspicion for a small bowel neoplasm. If the evaluation is still negative, non-GI sources of blood loss should be reconsidered.