In some cases, surgical assistance may be needed. Intraoperative enteroscopy is carried out in the operating room under general anesthesia. The surgeon, often working with a gastroenterologist (a doctor who specializes in the GI tract), inserts the endoscope through the patient’s mouth or through a small incision in the small bowel (an enterotomy). The surgeon then advances the endoscope through the intestine, allowing for full examination of the entire small intestine. The advantage of intraoperative enteroscopy is that it allows the doctor to treat the cause of bleeding at the time of discovery (for AVMs), or to remove masses or polyps that are found. Because it is an invasive, surgical procedure, however, intraoperative enteroscopy is usually reserved for cases where other methods have failed to find or treat the source of bleeding. Overall, it is effective in treating the source of bleeding in approximately 70% of the patients who require the procedure.
How is small bowel bleeding treated?
In cases of AVMs (Arteriovenous malformations), a small amount of electric current can be delivered via a special catheter through the endoscope to cauterize the abnormality. If the AVM is discovered during endoscopy, the treatment can be applied immediately without requiring further endoscopy. If the bleeding source is found by capsule endoscopy, treatment options include endoscopy, standard enteroscopy, double-balloon enteroscopy, or intraoperative enteroscopy (depending on the location of the lesion and prior attempts at treating it). In rare cases where numerous AVMs are present within a segment of small bowel, the segment of small bowel may need to be removed surgically. Polyps can be removed with an endoscope or at the time of surgery in cases where the polyp cannot be removed with an endoscope. Tumors, both benign and malignant, typically require surgical removal (while benign tumors do not necessarily need to be removed in all cases, if they are causing significant blood loss removal is usually recommended). Other causes of small intestinal bleeding can be treated medically (e.g., Crohn's disease or medication induced ulcers).
Bleeding from the small intestine is a rare, often difficult to diagnose cause of GI blood loss. AVMs account for many cases, and are the primary source of bleeding in patients over the age of 40. Tumors (benign and malignant), polyps, Crohn’s disease, and ulcers are some of the other sources of bleeding. Multiple techniques are used to diagnose and treat the source of small bowel bleeding, including: endoscopy, push enteroscopy,
x-ray studies, capsule endoscopy, deep small bowel enteroscopy, and intraoperative enteroscopy. AVMs can typically be treated with cautery delivered through an endoscope or enteroscope. Tumors (benign and malignant) can be biopsied and have their location marked using endoscopy, but surgery is typically required for their removal. Other conditions, such as Crohn’s disease, are often treated with medications.
Author(s) and Publication Date(s)
Cave, D. (2020, June 1). Evaluation of Suspected Small Bowel Bleeding (Formerly Obscure Gastrointestinal Bleeding). (J. R. Saltzman & A. C. Travis, Eds.). https://www.uptodate.com. (Citation Inserted by: Allan Barbish, MD, FACP, FACG)
Hoffman, M. (2019, May 18). Picture of the Intestines. Intestines (Anatomy): Picture, Function, Location, Conditions. https://www.webmd.com/digestive-disorders/picture-of-the-intestines. (Citation Inserted by: Allan Barbish, MD, FACP, FACG)
John R. Saltzman, MD, FACG, and Anne C. Travis, MD, MSc, FACG, Brigham and Women's Hospital, Harvard Medical School, Boston, MA – Updated February 2009. Updated December 2012.
John R. Saltzman, MD, FACG, and Richard S. Tilson, MD, Gastroenterology Consultants of Greater Lowell, North Chelmsford, MA – Published June 2004.
Mukherjee, R., & Leffler, D. A. (2019). In DDSEP: Digestive Diseases Self-Education Program: Version 9.0 (pp. 563–602). essay, Medical Trends. (Citation Inserted by: Allan Barbish, MD, FACP, FACG)
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