Hemostasis of Acute Small Intestinal Bleeding

Vascular lesions

Angiodysplasia

Dieulafoy lesion

Ischemic enteritis

Varices

Portal enteropathy

Aortoenteric fistula

Phlebectasia

Telangiectasia (Osler-Rendu-Weber disease, Turner’s syndrome, systemic sclerosis)

Hemangioma (blue rubber bleb nevus syndrome, Klippel-Trenaunay-Weber syndrome)

Inflammatory lesions

Nonsteroidal anti-inflammatory drug (NSAID)-induced enteropathy

Crohn’s disease

Celiac disease (ulcerative jejunitis)

Vasculitis/ Behcet’s disease

Amyloidosis

Radiation enteritis

Eosinophilic enteritis

Anastomotic ulcer

Nonspecific ulcer

Polypoid lesions

Inflammatory polyp

Lipoma

Hamartoma

Adenomyoma

Lymphangioma

Peutz-Jeghers syndrome

Cronkhite-Canada syndrome

Gardner’s syndrome

Neoplastic lesions

Gastrointestinal stromal tumor (GIST)

Adenoma

Adenocarcinoma

Leiomyosarcoma

MALT lymphoma

Follicular lymphoma

T-cell lymphoma

Neuroendocrine tumor (carcinoid)

Metastasis (melanoma, breast, renal cell)

Diverticulosis

Meckel’s diverticulum

Small bowel diverticulosis

Diverticula retracted by tumors

Diverticula retracted by adhesions

Other lesions

Intestinal intussusception

Whipple’s disease

Strongyloidiasis

Cytomegalovirus

Mycobacterium tuberculosis

Mycobacterium avium complex

Blastomycosis

Fig. 14.1

The most common causes of small bowel bleeding are arteriovenous malformations (AVMS). These can be single (a) or multiple (b). Even small AVMs can result in significant bleeding. Water immersion endoscopy is of particular use to visualize active bleeding, as the blood will spurt into the water (c)

Fig. 14.2

Blood clots and fresh blood may obscure the field of view (a). During device-assisted enteroscopy, the lumen can be cleansed using water flushed through the accessory channel of the scope. In this case, argon plasma coagulation is applied to a bleeding AVM (b, c)

Fig. 14.3

Dieulafoy lesions often cause massive overt obscure GI bleeding. Part A shows large amount of fresh blood clots in a patient with Dieulafoy lesion (a). In this case the lesion was treated using combination therapy starting with injection (b, c). The lesion was first injected with saline-epinephrine mixture (1:20,000) and then cauterized with argon plasma coagulation

Fig. 14.4

Ulcers with visible vessels are found occasionally in patients with overt or occult OGIB

Fig. 14.5

Small bowel polyps and tumors are an important cause for both occult and overt OGIB. The tumors include, but are not limited to, carcinoma (a), gastrointestinal stromal tumor (GIST) (b, c), neuroendocrine tumors (NET) (d, e) and lipomas (f). GIST and NET are most commonly submucosal lesions, often missed by capsule endoscopy

Fig. 14.6

An uncommon but important lesion resulting in OGIB found during retrograde deep enteroscopy is Meckel’s diverticulum (a, b). The ulcers on the diverticulum’s edge are often subtle and can be easily missed (arrows)

Enteroscopic Diagnosis and Accessories for Small Bowel Bleeding

The preferred endoscopic methods to investigate small bowel bleeding include capsule endoscopy (CE) and device-assisted enteroscopy (DAE) [1, 2, 8]. CE does not allow for therapeutic interventions, but is a useful test to screen for causes of OGIB [8]. DAE includes overtube-assisted enteroscopy, balloon-assisted enteroscopy (BAE), and spiral enteroscopy [5, 7–9]. Whereas traditional push enteroscopy allows for the investigation of the proximal third of the small bowel, DAE enables deeper assessment of the small bowel (deep enteroscopy), including the potential for total examination of the small intestine (complete enteroscopy) [2–9]. Deep enteroscopy has significantly increased our ability to treat and palliate small intestinal bleeding (Table 14.2) [3, 6, 8, 10–23].

Table 14.2

Long-term outcomes of patients with GI bleeding treated using balloon-assisted enteroscopy

Author (reference number)	Year	Number of patients	Diagnostic yield	Patients with AVM	Endoscopic treatment	Follow-up months (range)	Overall re-bleeding rate
Samaha [10]	2012	261	51 %	129	129	22 (1–52)	46 %
May [11]	2011	63	NR	44	44	55	42 %
Fujita [12]	2010	87	46 %	NR	21	41 (2–66)	44.8 %
Shinozaki [13]	2010	200	77 %	29	25	30 (6–78)	39 %
Gerson [14]	2009	85	NR	43 %		30 (19–51)	40 %
Arakawa [15]	2009	162	64 %	26	19	18.5	31 %
Hindryckx [16]	2008	n/a	n/a	18	10	21	38 %
Albert [17]	2008	n/a	n/a	112	36	20.7	31 %
Madisch [18]	2008	124	49 %	n/a	n/a	2 (1–5)	18 %
Ohmiya [20]	2007	479	58 %	63	63	55	42 %
Hsu [21]	2007	20	75 %	n/a	n/a	12 (3–28)	35 %
Sun [22]	2007	152	75 %	n/a	n/a	16	12 %

AVM arteriovenous malformation, n/a data not available, NR not reported

Important differences in endoscopic approach, however, exist when treating small bowel bleeding relative to other parts of the luminal GI tract:

The small bowel is long and has many loops, often making it more difficult to obtain a good endoscopic position to target the lesion of interest. Thus, advanced endoscopic skills are needed to maneuver the enteroscope within the tortuous and long small bowel.

The small bowel wall is very thin. Therefore, particular attention should be given when applying noncontact or contact thermal therapies, such as argon plasma or bipolar coagulation.

The utilization of available hemostatic devices during deep enteroscopy for small bowel bleeding can be challenging, in part due to difficult instrument passage through the long working channel of the enteroscope. The endoscopist should be familiar with the advantages and limitations of particular hemostatic devices, such as clip placement, contact coagulation, and argon plasma coagulation, in the context of deep enteroscopy (Table 14.3).

Table 14.3

Endoscopic hemostatic techniques for small bowel bleeding

Thermal therapy	Argon plasma coagulation
	Electrocoagulation
	Monopolar
	Bipolar/Multipolar
	Heater probe
Injection therapy	Epinephrine
	Fibrin glue/thrombin
	Cyanoacrylate
Mechanical	Endoscopic clips
Mechanical	Detachable snare (endoloop)

Technical Details of Enteroscopes and Devices Used for Therapeutic Enteroscopy

Knowledge of the technical details of the deep enteroscopes and accessories available are mandatory when planning endoscopic hemostasis (Tables 14.4 and 14.5) [5, 8, 25]. The spiral overtube is no longer available on a commercial basis and will not be detailed any further. A key difference as regards therapeutic enteroscopy is the need for longer and smaller caliber devices, which can be advanced through the working channel of the enteroscope. The enteroscopes are long and the diameters of their working channels are similar or smaller than that of a diagnostic upper endoscope (Table 14.5). Based on the type of deep enteroscope utilized, proper selection and familiarity with particular hemostatic devices become important. The staff should be well trained in maneuvers related to deep enteroscopy, such as handling of the balloon overtube, as well as devices utilized during the procedure. In addition, the endoscopist treating midgut bleeding should be experienced in small bowel therapeutic endoscopy.

Table 14.4

Selected hemostatic tools available for use during deep enteroscopy

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