Updates in Small Bowel Bleeding

Educational Objectives

The goal of this program is to improve the management of small bowel bleeding. After hearing and assimilating this program, the clinician will be better able to:

1. Evaluate patients with suspected small bowel bleeding.
2. Optimize management of small bowel angioectasias.

Summary

Small bowel bleeding (SBB): refers to bleeding that originates distal to the ligament of Treitz and proximal to the ileocecal valve (ie, it cannot be reached by classic endoscopy or colonoscopy); SBB typically accounts for 5% to 10% of all gastrointestinal (GI) bleeding; it can present as overt bleeding (ie, melena, hematochezia) or occult bleeding with iron deficiency anemia (with or without guaiac-positive stool); SBB was previously referred to as obscure GI bleeding (OGIB); however, with advancements in technology, the definition of OGIB is now limited to bleeding without an identified source after conventional endoscopy (upper and lower), small bowel assessment with video capsule endoscopy (VCE), or device-assisted enteroscopy (DAE), and a negative radiologic assessment

Evaluation: a comprehensive history and physical examination are important because there are several uncommon potential sources of anemia in SBB, eg, amyloidosis, hematopoietic issues, and radiation exposure (eg, radiation enteropathy); age — patients <40 yr of age often present with anatomic defects, eg, neoplasia, polyposis syndromes, Meckel diverticulum, or Crohn disease; patients >40 yr of age often present with angioectasias, nonsteroidal anti-inflammatory drug-induced enteropathy; neoplasia is less common; angioectasias and gastric antral vascular ectasia (GAVE) are often missed (eg, misdiagnosed as gastritis); large hiatal hernias with Cameron erosions are another potential source of blood loss; flat colonic neoplasms and right-sided angioectasias are often overlooked or missed as sources of anemia (attributed to SBB)

Algorithm based on the American College of Gastroenterology guidelines (2015) and the American Society for Gastrointestinal Endoscopy guidelines (2017): if a patient has suspected SBB, assess the quality of the initial upper endoscopy and colonoscopy; consider repeating studies if necessary (eg, in cases of poor preparation); if the study was adequate, consider push enteroscopy for its high diagnostic yield (26%-56% for SBB); patients with suspected SBB often undergo deep small bowel enteroscopy, but 26% of lesions could have been detected with push enteroscopy; VCE is not ideal for visualizing lesions in the duodenum (it visualizes the ampulla in only 10.4% of patients)

Stable patients: VCE is the most appropriate initial test; multiphase computed tomography enterography (CTE) or magnetic resonance enterography is recommended for patients with possible obstruction or stricture, or surgically altered anatomy; if the initial VCE is negative and the patient is <40 yr of age, proceed to multiphase CTE to check for anatomic abnormalities; if VCE or multiphase CTE is positive, consider push enteroscopy or DAE (depending on lesion location); if all are negative, reassess the patient; consider observation and iron supplementation if the patient is stable after a bleeding episode, and there are no findings on the workup; if the patient has recurrent bleeding, reassess the initial testing, eg, repeat esophagogastroduodenoscopy, colonoscopy, and VCE; assess for abnormal lesions (eg, Meckel diverticulum) using imaging; consider surgical options if the bleeding is severe

Unstable patients: stabilize the patient first, then perform angiography for embolization; additional imaging (CT angiography or red blood cell nuclear scan) may be required to confirm bleeding or a targeted lesion before angiography; if CT angiography is negative, specific management (eg, VCE, DAE, surgery) is appropriate; if angiography and CT angiography are negative, reassess stability; if the bleeding episode has stopped, consider observation and iron supplementation; for recurrent bleeding, assess for a proximal lesion in the stomach or a distal lesion in the colon and consider additional workup (eg, VCE) and assess for anatomic defects

Angioectasias: are the most common cause of SBB; endoscopic treatment — includes argon plasma coagulation (convenient and lower risk because the depth and duration of coagulation can be controlled); heater and bipolar probes are effective, but they may be impractical, and it is difficult to control the depth of cautery; endoscopic clips are effective but may not be practical for multiple lesions; radiofrequency ablation catheters (eg, Barrx, Cerablate Cool, Navablator) are effective and convenient; nonendoscopic interventions — angiography can identify active bleeding >0.5 mL/min; selective embolization uses microcoils or a biodegradable gelatin stent, with a success rate of 80% to 90%; there is a high rate of adverse events (5%-9%); surgery — intraoperative enteroscopy can be used if DAE is not available; it is effective but is used a last resort because of its safety profile; morbidity is ≤30%, including serosal tears, avulsion of mesenteric vessels, and prolonged ileus

Rebleeding after endoscopic therapy: occurs in 25% to 46% of cases; the RHEMITT score (Magalhaes et al [2019]) can be used to identify patients who present with bleeding or have evidence of bleeding on VCE and require closer monitoring and follow-up, including possible DAE; a retrospective study found that repeat DAE has a ≤55% diagnostic yield and a 42% therapeutic yield after an initial procedure; Raines et al (2016) found that provoked bleeding (with clopidogrel, rivaroxaban, and heparin) had a yield of 71%, with no adverse events; however, the study included only a small subsection of patients; angioectasias have the potential to regrow and rebleed

Pharmacologic therapy: the first-line therapy is supportive care; oral iron — is given once daily (40–80 mg) or every other day; higher doses of iron cause secretion of hepcidin, which decreases small bowel absorption of iron; intravenous (IV) iron — 200 to 1000 mg/day can be considered for chronic blood loss; newer formulations have lower rates of allergic or transfusion reactions; somatostatin analogs (eg, octreotide) — are the first-line therapy; a dose of 50 to 100 μg is given subcutaneously twice or three times daily (not practical for the outpatient setting); long-acting octreotide or lanreotide (10–30 mg intramuscularly once a month) can decrease the need for blood-transfusions and iron supplements for small bowel and colonic angioectasias but not gastric angioectasias; patients at risk for cholelithiasis should be monitored; thalidomide — downregulates vascular endothelial growth factor (VEGF) expression; a dose of 50 to 200 mg/day for 3 to 4 mo can maintain bleeding cessation for ≤1 yr; adverse effects (AEs) include peripheral neuropathy, somnolence, rash, peripheral edema, congestive heart failure (CHF), and constipation; bleeding decreases by ≤68% (100 mg) and ≤51% (50 mg); lenalidomide (5 mg/day) has fewer AEs but has not been studied as extensively; bevacizumab — inhibits VEGF; it can be used as rescue therapy for angioectasias in the stomach (including GAVE) and small bowel; it is given IV or intranasally every 3 wk; AEs include spontaneous bowel perforation, CHF, and delayed wound healing; estrogen and progesterone — are no longer approved for SBB from angioectasias

Tips: improve VCE and DAE yield by considering appropriate indications, the ability to see the entire small bowel and timing; patients with iron deficiency anemia without evidence of GI bleeding are unlikely to have significant VCE findings; the highest yield of VCE is ≤3 days of the bleeding event (≤90% ≤48 hr; yield remains high ≤2 wk); small bowel visualization can affect lesion detection; to help with motility, use endoscopic placement into the duodenum or prokinetic agents, eg, metoclopramide (Reglan); a rapid small bowel VCE transit time of <2 hr has a high risk for missed lesions; DAE yields high results ≤72 hr (still high ≤1 mo); DAE preceded by VCE increases yield; evaluation for small bowel angioectasia requires adequate resuscitation (angioectasias can blanch with hypotension)

Readings

Chen H, Wu S, Tang M, et al. Thalidomide for recurrent bleeding due to small-intestinal angiodysplasia. N Engl J Med. 2023;389:1649-1659; Ge ZZ, Chen HM, Gao YJ, et al. Efficacy of thalidomide for refractory gastrointestinal bleeding from vascular malformation. Gastroenterology. 2011;141(5):1629-37.e1-e4; Gerson LB, Fidler JL, Cave DR, et al. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol. 2015;110:1265–1287; Khedr A, Mahmoud EE, Attallah N, et al. Role of octreotide in small bowel bleeding. World J Clin Cases. 2022;10(26):9192–9206; Magalhaes RDS, Goncalves TC, Rosa B, et al. RHEMITT Score: Predicting the risk of rebleeding for patients with mid-gastrointestinal bleeding submitted to small bowel capsule endoscopy. Digestive Dis. 2019;38(4):1-11; Monsanto P, Almeida N, Lerias C, et al. Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding? Rev Esp Enferm Dig (Madrid). 2012;104(4):190-196; Raines DL, Jex KT, Nicaud MJ, et al. Pharmacologic provocation combined with endoscopy in refractory cases of GI bleeding. Clin Endosc. 2017;85(1):112-120.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Stephen's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Stephen was recorded virtually at the 24th Annual Educational Meeting in Gastroenterology, held March 1-2, 2024, and presented by Cedars-Sinai Medical Center. For information on upcoming programs from this presenter, please visit Cedars.cloud-cme.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

GE381703

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.