Obscure gastrointestinal bleeding

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.