Acute Small Bowel Bleeding

A Distinct Entity with Significantly Different Economic Implications Compared with GI Bleeding from Other Locations



      Historically, acute lower intestinal bleeding has incorporated small bowel with colonic sources. This potentially obscures the unique characteristics of small bowel bleeding, which are eclipsed by the attributes of the much more common colonic bleeding. Separating acute lower intestinal bleeding into small bowel and colonic sources may delineate characteristics of each, thereby making it possible to determine whether clinical outcomes vary by anatomic level of bleeding.


      A total of 29 consecutive patients (15 women, 14 men; age 68.6 ±2.4 years) with acute small bowel bleeding were compared with two other groups, each with 29 consecutive patients, with either acute colonic bleeding or acute upper GI bleeding. Clinical presentation, outcomes, and resource utilization for small bowel bleeding were compared with similar parameters for acute colonic bleeding and upper GI bleeding.


      Although the clinical presentation did not always distinguish the 3 groups, resource utilization was significantly higher in the small bowel bleeding group. The latter group required a higher number of diagnostic procedures (p < 0.001) and blood transfusions (p < 0.001), remained in hospital longer (p < 0.05), and had a higher cost of hospitalization (p < 0.001) compared with the colonic bleeding and upper GI bleeding groups. The mortality rate for patients with small bowel bleeding was 10%. Although none of the patients with upper GI bleeding and only 14% of those with colonic bleeding required greater than 3 diagnostic procedures, 79% of patients with small bowel bleeding required 4 procedures for diagnostic localization (p < 0.0001).


      Small bowel bleeding (“mid-intestinal bleeding”) is a distinct clinical entity with significantly worse outcomes compared with colonic bleeding and upper GI bleeding. The focus of the investigation should be directed to the small bowel, with enteroscopy or capsule endoscopy, when 3 investigative procedures fail to localize recurrent overt GI bleeding.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect



        • Elta GH
        Approach to the patient with gross gastrointestinal bleeding.
        in: Yamada T Alpers DH Loren L Owyang C Powell DW Textbook of gastroenterology. 3rd ed. Lippincott Williams and Wilkins, Philiadelphia1999: 714-742
        • Waye JD
        Diagnostic endoscopy in lower intestinal bleeding.
        in: Sugawa C Schuman BM Lucas CE Gastrointestinal bleeding. Igaku Shoin Medical Publishers, New York1992: 230-241
        • Zuckerman GR
        • Prakash C
        Acute lower intestinal bleeding. Part I: clinical presentation and diagnosis.
        Gastrointest Endosc. 1998; 48: 606-616
        • Zuckerman GR
        • Prakash C
        • Askin MP
        • Lewis BS
        Technical review: the evaluation and management of occult and obscure GI bleeding.
        Gastroenterology. 2000; 118: 201-221
        • Zuckerman GR
        • Prakash C
        Acute lower intestinal bleeding. Part II: etiology, therapy and outcomes.
        Gastrointest Endosc. 1999; 49: 228-238
        • Richter JM
        • Christensen MR
        • Kaplan LM
        • Nishioka NS
        Effectiveness of current technology in the diagnosis and management of lower gastrointestinal hemorrhage.
        Gastrointest Endosc. 1995; 41: 93-98
        • Jensen DM
        • Machicado GA
        Diagnosis and treatment of severe hematochezia: the role of urgent colonoscopy after purge.
        Gastroenterology. 1988; 95: 1569-1574
        • Velacott KD
        Early endoscopy for acute lower gastrointestinal hemorrhage.
        Ann R Coll Surg Engl. 1986; 68: 243-244
        • Caos A
        • Benner KG
        • Manier J
        • McCarthy DM
        • Blessing LD
        • Katon RM
        • et al.
        Colonosocpy after Golytely preparation in acute rectal bleeding.
        J Clin Gastroenterol. 1986; 8: 46-49
        • Klinvimol T
        • Ho YH
        • Parry BR
        • Goh HS
        Small bowel causes of per rectum hemorrhage.
        Ann Acad Med Singapore. 1994; 23: 866-868
        • Prakash C
        • Sreenarasimhaiah J
        • Royal HD
        • Picus DD
        • Willis JR
        • Zuckerman GR
        A varied diagnostic approach to acute lower gastrointestinal bleeding [abstract].
        Am J Gastroenterol. 1997; 92: 1685
        • Briley CA
        • Jackson DC
        • Johnsrude IS
        • Mills SR
        Acute gastrointestinal hemorrhage of small bowel origin.
        Radiology. 1980; 136: 317-319
        • Koval G
        • Benner KG
        • Rosch J
        • Kozak BE
        Aggressive angiographic diagnosis in acute lower gastrointestinal hemorrhage.
        Dig Dis Sci. 1987; 32: 248-253
        • Appleyard M
        • Fireman Z
        • Glukhovsky A
        • Jacob H
        • Shreiver R
        • Kadirkamanathan S
        • et al.
        A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small bowel lesions.
        Gastroenterology. 2000; 119: 1431-1438
        • Appleyard M
        • Glukhovsky A
        • Swain P
        Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding.
        N Engl J Med. 2001; 344: 232-233