DR' L' GANAPATHI RAM

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SMALL BOWEL BLEEDING A DIAGNOSTIC
THERAPEUTIC CHALLENGE

• DR. L. GANAPATHI RAM
• DEPT.OF GENERAL SURGERY
• G.K.N.M.HOSPITAL
• COIMBATORE641037, INDIA

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SMALL BOWEL BLEEDING

• UNCOMMON SITE
• 3 - 5 OF ALL GI BLEEDING
• EARLY DIAGNOSIS RARE
• DIFFICULT TO DIAGNOSE - Relative
  Inaccessibility - Anatomy confounds
  diagnostic techniques

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SMALL BOWEL BLEEDING

• MAY PRESENT AS OCCULT CHRONIC BLOOD
  LOSS
• RECURRENT EPISODES OF MELENA
  HEMATOCHEZIA
• WILL REQUIRE MULTIPLE REPEATED
  EXAMINATIONS

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SMALL BOWEL BLEEDING
CAUSES

• VASCULAR LESIONS
• TUMOURS
• ULCERATIONS
• VASCULAR ANOMALIES
• JEJUNAL DIVERTICULA

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SMALL BOWEL BLEEDING
VASCULAR LESIONS COMMON - 70 - 80

• ANGIODYSPLASIAS
• VENOUS ECTASIA
• TELENGIECTASIA
• HAEMANGIOMAS
• AVMs

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SMALL BOWEL BLEEDING
TUMOURS SECOND MOST COMMON - 5 -10 MOST ARE
BENIGN

• LEIOMYOMAS - commonest to bleed
• LEIOMYOSARCOMAS
• LYMPHOMAS
• CARCINOIDS , ADENOCARCINOMAS
• METASTATIC DEPOSITS
• PANCREATIC MALIGNANCY

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SMALL BOWEL BLEEDING
ULCERATIONS

• CROHNS DISEASE - Commonest
• MECKELS DIVERTICULUM
• ZOLLINGER - ELLISON SYNDROME
• SMALL BOWEL INFECTIONS - TB , Syphilis ,
  Typhoid

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SMALL BOWEL BLEEDING
ULCERATIONS - continued

• MEDICATIONS - Potassium , 6-mercaptopurine
  , NSAIDs
• VASCULITIS - Rheumatoid arthritis , SLE ,
  PAN
• RADIATION INJURY - Early / Late . gt
  4000 rads

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SMALL BOWEL BLEEDING
VASCULAR ANOMALIES

• SMALL BOWEL VARICES
• AORTOENTERIC FISTULA - Primary /
  Secondary
• DIEULAFOY LESION - Caliber Persistent
  Arteries

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SMALL BOWEL BLEEDING
EVALUATION

• SMALL BOWEL SERIES
• ENTEROCLYSIS
• ENTEROSCOPY - Push enteroscopy - Sonde
  enteroscopy - Intraoperative

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SMALL BOWEL BLEEDING
EVALUATION - continued

• RADIOISOTOPE SCANING
• ANGIOGRAPHY
• EXPLORATORY SURGERY

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SMALL BOWEL BLEEDING
EVALUATION - RADIOISOTOPE SCANING

• READILY AVAILABLE
• LOW COST
• COMPLICATIONS RARE
• GOOD SENSITIVITY
• POOR SPECIFICITY
• CANNOT DIAGNOSE NONBLEEDING LESIONS

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SMALL BOWEL BLEEDING
EVALUATION - ANGIOGRAPHY

• POOR AVAILABILITY
• E XPENSIVE
• MORE COMPLICATIONS
• POOR SENSITIVITY
• GOOD SPECIFICITY
• CAN DIAGNOSE NON-BLEEDING LESIONS

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SMALL BOWEL BLEEDING
APPROACH TO DIAGNOSIS IN OCCULT BLEEDING

• UPPER LOWER GI SCOPY - Repeated
  examinations needed
• PUSH ENTEROSCOPY - Relatively easy to
  perform - Can be therapeutic

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SMALL BOWEL BLEEDING
APPROACH TO DIAGNOSIS IN MASSIVE BLEEDING

• RADIOISOTOPE SCAN
• ANGIOGRAPHY - Intraoperative
• EXPLORATORY SURGERY

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SMALL BOWEL BLEEDING
APPROACH TO DIAGNOSIS IN SLOW BLEEDING

• EXPLORATORY SURGERY
• INTRAOPERATIVE ENDOSCOPY

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SMALL BOWEL BLEEDING
APPROACH TO MANAGEMENT

• TREAT ONLY BLEEDING VASCULAR LESIONS
  . PROPHYLACTIC THERAPY IS NOT RECOMMENDED.
• ALWAYS EXCLUDE A BLEEDING DYSCRASIA .
• INDIVIDUALISE THERAPY. THERE IS NO
  UNIFORM TREATMENT.

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SMALL BOWEL BLEEDING
APPROACH TO MANAGEMENT

• SET REALISTIC TREATMENT GOALS -
  COMPLETE CURE MAY NOT BE POSSIBLE .
• BEFORE ANY SURGICAL INTERVENTION EVALUATE
  THE ENTIRE BOWEL . CONCOMITANT DISEASE DO
  EXIST .

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SMALL BOWEL BLEEDING
FINALLY . . . .
THE CARE OF THESE PATIENTS
REQUIRES AN EXPERIENCED AND HIGHLY
DEDICATED TEAM OF CARE GIVERS AND
ENDOSCOPIC AND IMAGING EXPERTS .