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Abstract Objectives The purpose of this study is to assess the diagnostic efficacy of contrast-enhanced CT scans for small bowel bleeding. Methods This retrospective study evaluated patients diagnosed with non-neoplastic small intestinal bleeding (including duodenum) who underwent abdominal CT at our institution from December 2013 to March 2023. Patients were categorized into diverticulum and non-diverticulum groups based on the cause of bleeding. Active bleeding was defined on the CT images as extravasation of contrast material in the intestinal lumen during the arterial phase and/or progressive accumulation of contrast material during the venous phase. We have documented the original report (extracted from the medical record system and additional consultation opinions from senior radiologists), including the presence of active bleeding and its potential bleeding location. Furthermore, two radiologists reassessed the CT images, seeking consensus on the diagnosis between them. Results The study included 165 patients, predominantly male, with a median age of 30 years. Active bleeding was identified in 48.3% of patients. Notably, all identified bleeding diverticula in the diverticulum group exhibited cul-de-sac termination. Among the identified causes of bleeding, Crohn’s disease was most prevalent (46.7%, N of causes = 64). Significant differences were observed in the diagnostic methods between the diverticulum and non-diverticulum groups, with surgery predominantly applied in the diverticulum group, and endoscopy in the non-diverticulum group (n = 49 vs n = 15, p = 0.001). Contrast agent extravasation was significantly higher in the diverticulum group (n = 54 vs n = 16, p = 0.001), and Meckel’s diverticulum cases appearing tubular were significantly higher than in other diverticulum cases (n = 25 vs n = 3, p

Small bowel bleeding (SBB) accounts for 5%-10% of all gastrointestinal bleeding (GIB) cases. Several diagnostic modalities in SBB are performed. However, the small bowel is beyond the reach of these diagnostic modalities. A large amount of bleeding in GIB is a key factor leading to a poor prognosis. Appropriate and prompt diagnostic and treatment strategies are needed. Several diagnostic and management algorithms have been proposed. However, the processing of algorithm is complex and frequent mistakes are happened. Because of surgical aspects and sudden or gradual development of hemodynamic instability in SBB, algorithms considering surgical role and treatment have been published. The intra-operative enteroscopy (IOE) is a gold-standard method for detecting lesions in SBB. The primary goal of IOE is to detect specific bleeding focus in SBB. The determining the resection range is the secondary goal. In most cases in SBB, segmental resection is treatment of choice. However, in bleeding distal duodenum from distal to the ampulla of Vater to Treitz ligament, pancreas preserving distal duodenectomy could be performed. In terminal ileum bleeding, after resection of pathologic bowel, the reconstruction option is ileo-colic anastomosis or end enterostomy. Because of frequently developed postoperative morbidity and mortality, post-operative critical care is perfectly fit for an acute care surgeon’s role. Therefore, in the entire management process, an interprofessional team or multidisciplinary approach is critical for improving the quality of care of SBB and decreasing mistakes.

Introduction: Small bowel bleeding is being diagnosed with increasing frequency with the development of capsule endoscopy. Case Presentation: We report a case of lipoma that caused hematochezia in an 80-year-old woman with ischemic heart disease receiving antiplatelet therapy and on hemodialysis for renal failure. Contrast-enhanced computed tomography scans, esophagogastroduodenoscopy, and colonoscopy failed to identify the source of hematochezia. Capsule endoscopy revealed a small bowel tumor, which was removed through laparoscopic surgery without interruption of antiplatelet agents. The small bowel tumor was pathologically diagnosed as a lipoma. There was no recurrence of the hematochezia after surgery. Conclusion: Lipomas could cause hematochezia. With appropriate preoperative testing, comorbidity assessment, and surgical planning, we believe that surgical resection is a safe treatment option for the removal of small bowel lipomas even in patients who are on hemodialysis or are taking antiplatelet agents.

The term “obscure gastrointestinal (GI) bleeding” is often replaced by “small bowel bleeding” by some authors. It accounts to 5%–10% of overall GI bleeding. We need to suspect obscure or small bowel bleeding when no source of bleeding is identified during routine standard endoscopy and colonoscopy. Video capsule endoscopy (VCE), balloon enteroscopy, spiral enteroscopy, etc., are some of the advances in small bowel evaluation that have improved the ability to detect the source of bleeding. The common causes in patients with 40 or more years of age are Angioectasia, Dieulafoy's lesions, Nonsteroidal anti-inflammatory drug-induced ulcers, and neoplasm. Black tarry stools with characteristic smell (melena) and/or passing of red blood from rectum (hematochezia) is the most common presentation. Routine performance of second look endoscopy is not always a cost-effective approach. The current available evidence is sufficient to suggest VCE as the first endoscopic investigation in diagnosis of obscure GI bleeding. In routine clinical practice the double balloon enteroscopy, single balloon enteroscopy, and spiral enteroscopy are the three different armamentariums available for evaluating small bowel. Motorized spiral enteroscopy (power spiral) is the new addition to it. Patients in whom the source of bleeding is not identified after appropriate small bowel evaluation should be initially managed conservatively with oral or intravenous iron therapy (strong recommendation). Medical management with iron supplements, somatostatin analogs, or antiangiogenic treatment should be administered to the patients with persistent and recurrent bleeding. The evaluation of small bowel in patients with obscure GI bleeding is a challenging task. There is a huge data on each of the modality involved in investigating small bowel. Systematic review of the topic is need of the hour to help understand the concept of diagnosis and management of obscure GI bleeding.

Abstract Background Angiodysplasia of the gastrointestinal tract is a rare vascular pathology that sometimes causes massive hemorrhage. Angiodysplasias are particularly difficult to find in the small intestine for anatomical reasons, often impeding their diagnosis and treatment. Lesion localization is a major challenge in cases of small bowel bleeding requiring surgical intervention. Case presentation The present case was a 52-year-old woman who was urgently hospitalized with repeated tarry stools. Surgical intervention was chosen after conservative treatment failed to improve her condition. The source of bleeding was suspected to be a vascular lesion discovered in the small intestine during a past double-balloon endoscopy. Abdominal contrast computed tomography revealed a jejunal hemorrhage. We chose selective arterial embolization to stabilize her hemodynamics followed by surgical intervention as her treatment plan. Several embolic and contrast agents (cyanoacrylate, indigo carmine, and Lipiodol) were combined to help identify the location of the lesion during surgery. This multi-pronged approach allowed us to localize the lesion under laparoscopic guidance with high confidence and accuracy, and to excise a 6-cm segment of the small intestine. The lesion was histologically diagnosed as angiodysplasia. No re-bleeding has been observed since the operation. Conclusion We report our experience with a case of jejunal angiodysplasia, which was localized with selective arterial embolization using an array of embolic and contrast agents, and then excised laparoscopically. Selective arterial embolization with indigo carmine dye to treat small bowel bleeding preoperatively not only makes the surgery safer by stabilizing the patient’s hemodynamics, but is also very useful for localizing the lesion intraoperatively.

The small bowel had long been considered a dark unapproachable tunnel until the invention of capsule endoscopy and doubleballoon enteroscopy in the 21st century, which revolutionized the diagnosis and management of small bowel diseases, including bleeding. Various imaging modalities such as computed tomographic enterography, angiography, capsule endoscopy, and balloonassisted enteroscopy play vital roles in the diagnosis and management of small bowel bleeding. The choice of modality to use and timing of application differ according to the availability of the modalities, patient’s history, and physician’s experience. Small bowel bleeding is managed using different strategies as exemplified by medical treatment, interventional radiology, endoscopic therapy, or surgical intervention. Balloon-assisted enteroscopy enables endoscopic interventions to control small bowel bleeding, including electrocautery, argon plasma coagulation, clip application, and tattooing as a prelude to surgery. In this article, we clarify the recent approaches to the optimal diagnosis and management of patients with small bowel bleeding.

Background Small bowel bleeding is an uncommon cause of lower gastrointestinal bleeding, which may require different management. Case Presentation A 37‐year‐old man presenting with hematochezia was promptly diagnosed with small bowel bleeding by computed tomography angiography. Transcatheter arterial embolization was carried out because the patient's hemodynamic status deteriorated. Hemostasis was achieved by embolization with imipenem/cilastatin, although superselective embolization failed. Capsule endoscopy revealed multiple ulcers and erosions. Drug‐induced small bowel injury was suspected to be the cause of small bowel bleeding. Conclusion Computed tomography angiography can facilitate the management of lower gastrointestinal bleeding. Considering transcatheter arterial embolization and choosing an optimal embolic agent depending on the situation are important in the management of hemodynamically unstable patients.

Aim. To consider the possibility of the diagnosis of a rare small bowel tumour complicated by small bowel obstruction and small bowel bleeding, as well as the surgical treatment of this pathology using a minimally invasive surgical approach.Results and discussion. The authors present a clinical case of associated complication of a gastrointestinal stromal tumour (GIST) of the small intestine in a 48-year-old patient. The patient was admitted to a surgical clinic with small bowel obstruction, episodes of intestinal bleeding and anaemia. The diagnosis was determined using CT enterography. In line with the current trends for minimally invasive surgery, minimally invasive laparotomy was performed drawing on the CT mapping of the anterior abdominal wall. The last stage involved in the morphological verification of GIST, which employs a standard procedure of IHC testing, revealed a malignant GIST, spindle cell variant. The verified histotype of a small intestinal tumour provides the opportunity to choose the necessary variant of adjuvant chemotherapy, as well as to improve general and relapse-free survival.Conclusion. Minimally invasive operations can be performed in the complicated course of GIST due to the biological properties of this pathology (absence of lymphogenic metastasis and infiltrative growth) without decreasing five-year survival rate. The use of CT helps make a topical diagnosis and plan minimally invasive surgical treatment.

Evidence for an urgent approach to ongoing overt suspected small-bowel bleeding (SSBB) is scarce. We aimed to analyze our series of urgent small-bowel capsule endoscopies (SBCEs) for ongoing overt SSBB and to identify factors associated with positive findings and outcomes. A retrospective study of all SBCEs performed in the first 48 h after admission for overt SSBB between January 2006 and February 2022 was performed. Descriptive and inferential analyses (univariate and multivariable) were performed. Eighty-three urgent SBCEs were performed for overt SSBB. Patients were mostly men (69.2%, median age 68) and were followed for a median of 58.2 months (range 5–176). The diagnostic yield was 80.7%; in 60.2%, blood was detected in the small bowel (SB), while in 50.6%, a bleeding lesion was identified, mostly angioectasia. Patients with diabetes mellitus or taking NSAIDs were more prone to present SB findings, yet the explanatory power was low. Endoscopic or surgical treatments were performed in 28.9% and 19.3%, respectively, with the “non-conservative” therapeutic yield being 56.6%. Rebleeding occurred in 20.5% and was associated in the multivariable analysis with the female gender and anticoagulants use. This cohort of urgent SBCE, the largest from a European center, reinforces the usefulness of SBCE for ongoing overt SSBB management. This prompt performance of this procedure is highly effective, regardless of patients’ features.

Small bowel bleeding (SBB) accounts for 5-10% of patients with gastrointestinal bleeding and its association is unusual in patients with histoplasmosis. The incidence of gastrointestinal histoplasmosis is unknown since only 3-12% present symptoms, predominantly in immunocompromised patients. However, in immunocompetent hosts, it is reported only in 0.05% of cases. A clinical case of an immunocompetent patient with massive SBB, Grade IV hypovolemic shock associated with systemic histoplasmosis and treated with intestinal resection and amphotericin B is hereby discussed.

Gastrointestinal (GI) angiodysplasia is a rare cause of lower GI bleeding in the paediatric population. This disease caused intermittent per-rectal bleeding and severe anemia in 2-year-old girl with Turner's syndrome. She was initially suspected to have Meckel's diverticulum and taken to the operation room for laparoscopy. A Meckel's diverticula was not found but an extensive distribution of abnormal vessels on the surface of the small bowel was noted from close to the duodeno-jejunal junction to the terminal ileum. GI angiodysplasia was suspected but the lesion was too extensive to be resected. It was also not clear if any specific area was the source of the current bleeding. After conversion to open surgery, an enterotomy was done in the mid portion of the affected bowel and an on table enteroscopy was done. This revealed a normal mucosal lining in the visualized areas and so was not contributory. Prior to closure of the enterotomy a doughnut of bowel was taken for histopathology. This confirmed small bowel angiodysplasia. She had one minor recurrence of lower GI bleeding 4 months later but has been well since then. This case sheds light on angiodysplasia as a cause of lower GI bleeding and we discuss its diagnostic and management options.

The article is dedicated to the results of complex diagnostics and treatment (including the new methods of enteroscopy) of gastrointestinal bleeding with unknown source. From 14.02.2007 to 19.04.2017 the source of bleeding was revealed in 173 (82,7%) of 209 patients, including small bowel bleeding in 154 (89,0%) patients. The most frequent sources of bleeding were vessel malformations in 39,6% of patients and small bowel tumors in 30,5% of patients. Endoscopic treatment was performed in 32 (21,7%) cases, surgical treatment - in 41 (27,9%) cases, conservative treatment - in 74 (50,4%) cases.

Balloon-assisted enteroscopy (BAE) is an important diagnostic modality for ongoing obscure gastrointestinal bleeding (OGIB). However, it is difficult to determine the optimal insertion route. We retrospectively analyzed the records of patients with OGIB contained in a multicenter enteroscopy database of 1108 balloon-assisted enteroscopy (BAE) procedures (875 patients) to find out factors affecting BAE route selection in patients with OGIB. A total of 603 BAE procedures in 512 patients were investigated: there were 392 (65.0%) bidirectional and 211 (35.0%) unidirectional procedures. Overt OGIB was more frequent in the latter group (p = 0.024). Computed tomography (CT) was more frequently performed in the unidirectional group (p < 0.001). Capsule endoscopy and a small bowel barium study were performed more frequently in the bidirectional group (p < 0.001 and p = 0.039, respectively). Multivariate analysis showed that occult OGIB, capsule endoscopy and a small bowel barium study were independently associated with use of the bidirectional approach (p = 0.011, p = 0.013 and p = 0.046, respectively). Conversely, CT was associated with use of the unidirectional approach (p < 0.001). Conclusion: CT can aid the selection of an optimal insertion route in OGIB patients. However, capsule endoscopy and small bowel barium study are unhelpful.

Massive hematochezia caused by a small bowel lesion is a rare entity. Currently, video capsule endoscopy and balloon-assisted enteroscopy are effective in identifying the source of small intestine bleeding. Herein, we report a case of small bowel bleeding caused by a nonmucinous appendiceal adenocarcinoma with ileal invasion which was detected by video capsule endoscopy and single-balloon endoscopy. Despite the advanced disease stage with hepatic and peritoneal metastases, as of September 2016 the patient has had 8 years’ disease-free survival after surgical resection and chemotherapy.

Background: Small bowel bleeding accounts for 5–10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding.Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance.Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy.Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.

The source of most cases of gastrointestinal bleeding is the upper gastrointestinal tract. Since bleeding from the small intestine is very rare and difficult to diagnose, time is required to identify the source. Among small intestine bleeds, vascular abnormalities account for 70–80%, followed by small intestine tumors that account for 5–10%. The reported peak age of the onset of small intestinal tumors is about 50 years. Furthermore, rare small bowel tumors account for only 1–2% of all gastrointestinal tumors. We describe a 29-year-old man who presented with obscure anemia due to gastrointestinal bleeding and underwent laparotomy. Surgical findings revealed a well-circumscribed lesion measuring 45 × 40 mm in the jejunum that initially appeared similar to diverticulosis with an abscess. However, the postoperative pathological diagnosis was a gastrointestinal stromal tumor with extramural growth.

Background: Recent advances in endoscopic devices such as small bowel capsule endoscopy and balloon-assisted endoscopy have improved the level of medical care for small bowel bleeding. However, treating small bowel angioectasia remains challenging because repeated intermittent bleeding can occur from the multiple minute lesions (about 1 mm in size) that develop in a synchronous and metachronous manner. Here, we report a case of small bowel angioectasia in which capsule endoscopy performed early in a bleeding episode contributed to treatment. Case Summary: A 66-year-old man with suspected small bowel bleeding underwent small bowel capsule endoscopy and balloon-assisted endoscopy with argon plasma coagulation hemostasis for a small intestinal angioectasia. Because small bowel bleeding recurred intermittently after the treatment, small bowel capsule endoscopy and balloon-assisted endoscopy were repeated when there was no bleeding, but no abnormalities were found. Subsequent small bowel capsule endoscopy during a bleeding episode revealed bloody intestinal fluid in the proximal small intestine. Peroral balloon-assisted endoscopy was performed 2 days after SBCE for detailed observation of the small intestinal mucosa at the suspected bleeding site, and there a 1-mm Dieulafoy’s lesion with no active bleeding was identified. We performed argon plasma coagulation, and no bleeding was observed thereafter. Conclusions: Small bowel capsule endoscopy immediately after bleeding onset can identify the bleeding source of multiple minute lesions in small bowel angioectasia.

We report an unusual case of ileal intussusception in a 7-year-old girl affected by Peutz Jeghers syndrome, characterized by a very misleading clinical presentation, resembling chronic constipation. Correct diagnosis was guided through appropriate knowledge of inherited condition and cautious ultrasound monitoring. Confirmation was achieved by a timely surgical intervention and subsequent pathologic examination.