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Guidelines

ASGE evidence-based guidelines provide clinicians with recommendations for the evaluation, diagnosis, and management of patients undergoing endoscopic procedures of the digestive tract. Guidelines are not a substitute for physicians’ opinion on individual patients. Final decision on an intervention should always be based on local expertise and patient preferences.

All recommendations follow a rigorous process based on a systematic review of medical literature as outlined by the National Academy of Medicine (formerly Institute of Medicine) standards for guideline development.

Whenever possible, guidelines are based on the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology.

Panels consist of content experts, stakeholders from other specialties, patient representatives, and members of the ASGE Standards of Practice (SOP) Committee.

Each recommendation is based on consideration of the best medical literature, the balance between risks and benefits, cost-effectiveness, patients’ values, and equity. For more information, see the American Society for Gastrointestinal Endoscopy clinical practice guideline development policy and checklist.

Panel members provide ongoing conflict of interest (COI) disclosures, including intellectual conflicts of interest, throughout the development and publication of all guidelines in accordance with the ASGE Policy for Managing Declared Conflicts of Interests.

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Newly Published
GRADE Guidelines
Upper GI
Lower GI

The role of endoscopy in the management of suspected small-bowel bleeding

Nov 14, 2016, 20:27 PM
This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was conducted by using PubMed. Additional references were obtained from a search of Web of Science, SCOPUS, and the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).1 The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.”
Suryakanth R. Gurudu, MD, FASGE , David H. Bruining, MD , Ruben D. Acosta, MD , Mohamad A. Eloubeidi, MD, MHS, FASGE , Ashley L. Faulx, MD, FASGE , Mouen A. Khashab, MD , Shivangi Kothari, MD , Jenifer R. Lightdale, MD, MPH, FASGE (NASPGHAN representative) , V. Raman Muthusamy, MD, FASGE , Julie Yang, MD , John M. DeWitt, MD, FASGE (Chair)
Title : The role of endoscopy in the management of suspected small-bowel bleeding
Doi org link : http://dx.doi.org/10.1016/j.gie.2016.06.013
Volume : Gastrointest Endosc 2017; Volume 85, Issue 1; P22-31
URL :
Select a choice : Keep
Content created : Jun 29, 2016, 09:32 AM
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ExternalPK : 18802

Abbreviations

  1. ASGE (American Society for Gastrointestinal Endoscopy)
  2. BAE (balloon-assisted enteroscopy)
  3. CTA (CT angiogram)
  4. CTE (CT enterography)
  5. DAE (device-assisted enteroscopy)
  6. DBE (double-balloon enteroscopy)
  7. MRE (magnetic resonance enterography)
  8. NSAID (nonsteroidal anti-inflammatory drug)
  9. OGIB (obscure GI bleeding)
  10. RBC (red blood cell)
  11. VCE (video capsule endoscopy)
This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was conducted by using PubMed. Additional references were obtained from a search of Web of Science, SCOPUS, and the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).
1.
Guyatt, G. ∙ Oxman, A. ∙ Vist, G. ...
GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
Br Med J. 2008; 336:924-926
Crossref
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 The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.”
Quality of evidenceDefinitionSymbol
High qualityFurther research is very unlikely to change our confidence in the estimate of effect.⊕⊕⊕⊕
Moderate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.⊕⊕⊕○
Low qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.⊕⊕○○
Very low qualityAny estimate of effect is very uncertain.⊕○○○
Table 1
GRADE system for rating the quality of evidence for guidelines
1.
Guyatt, G. ∙ Oxman, A. ∙ Vist, G. ...
GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
Br Med J. 2008; 336:924-926
Crossref
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GRADE, Grading of Recommendations Assessment, Development and Evaluation.
Adapted from Guyatt et al.
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Br Med J. 2008; 336:924-926
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This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.
Obscure GI bleeding (OGIB) has been defined as overt or occult bleeding of unknown origin that persists or recurs after an initial negative bidirectional endoscopic evaluation including ileocolonoscopy and EGD. Overt OGIB refers to visible bleeding (eg, melena or hematochezia), whereas occult OGIB refers to cases of fecal occult blood positivity and/or unexplained iron deficiency anemia. Recent advances in small-bowel imaging, including video capsule endoscopy (VCE), angiography, and device-assisted enteroscopy (DAE), have made it possible to identify a small-bowel bleeding source and therefore manage the majority of patients who present with OGIB.
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 As a result, a recent clinical guideline recommends a shift from the term obscure GI bleeding to small-bowel bleeding.
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 The term OGIB would be reserved for patients in whom the sources of bleeding cannot be identified anywhere in the GI tract after completion of comprehensive evaluation of the entire GI tract, including the small bowel.
Of all the sources of GI bleeding, only a small percentage (5%) is attributed to small-bowel sources.
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 and are more commonly seen in older patients. Small-bowel tumors (eg, GI stromal tumors, carcinoid tumors, lymphomas, and adenocarcinomas) can present with small-bowel bleeding in both younger and older patients.
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 and Crohn’s disease.
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 Techniques for evaluation of the small bowel include VCE, DAE, multiphase CT enterography (CTE), magnetic resonance enterography (MRE), and, in rare instances, intraoperative enteroscopy. These modalities can recognize small-bowel lesions and may impact therapeutic strategies, often preventing surgical interventions. Despite these advances, the most cost-effective approach to the management of patients with suspected small-bowel bleeding has not been fully determined. This guideline is an update of a prior ASGE document on the management of small-bowel bleeding.
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Evaluation and management of patients with small-bowel bleeding

The evaluation and management of patients with small-bowel bleeding depends on clinical factors, such as the age of the patient, quality of the prior endoscopic evaluation, and the overt or occult status of the bleeding. Clinical signs, such as the nature of the bleeding (eg, melena vs hematochezia), can help direct the choice of endoscopic tests. In addition, local availability of procedures, patient preferences, physician expertise, risks, and costs are also important determinants of management.
Hemodynamic resuscitation is key to the management of all patients with GI bleeding.
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 Moreover, patients on antithrombotic therapy should be managed according to recently published guidelines.
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 A suggested algorithm for the management of suspected overt and occult small-bowel bleeding is shown in Figure 1.
Figure 1 Suggested management approach to overt and occult small-bowel bleeding. Positive test results should direct specific therapy. Because diagnostic tests can be complementary, more than 1 test may be needed, and the first-line test may be based on institutional expertise and availability. PE, push enteroscopy; VCE, video capsule endoscopy; DAE, device-assisted enteroscopy; CTE, CT enterography; MRE, magnetic resonance enterography; RBC, red blood cell.

Overt small-bowel bleeding

In patients with overt bleeding and a clinical presentation compatible with upper GI bleeding (eg, hematemesis), early EGD (within 24 hours) should be performed before small-bowel evaluation.
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 If an upper endoscopy has been performed recently and was of sufficient quality, then a repeat upper examination could be performed with push enteroscopy to examine for proximal small-bowel lesions. If this does not reveal a source of bleeding, consideration should be given to repeat colonoscopy with evaluation of the terminal ileum.
For hemodynamically stable patients with overt bleeding, after upper and lower endoscopic examinations with normal results, VCE is recommended as the next diagnostic test. DAE can be considered in patients with positive bleeding sources identified on VCE. Multiphase CTE or MRE should be performed first if the patient has potential reasons for capsule retention.
For patients who present with hemodynamically significant bleeding, urgent angiography is recommended for embolization. A CT angiogram (CTA)
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 or red blood cell (RBC) scan can be considered for localization of the bleeding source and to guide timing of the angiogram in hemodynamically stable patients. In patients with surgically altered anatomy in whom portions of the GI tract are bypassed (eg, Roux-en-Y gastrojejunostomy), DAE is the preferred endoscopic modality to assess the excluded luminal segment inaccessible to conventional and capsule endoscopic approaches.
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 If these test results are negative, and bleeding recurs, technetium-99m pertechnetate scintigraphy (Meckel scan) can be considered in younger patients. Provocative testing with anticoagulants is rarely considered in patients with recurrent small-bowel bleeding, given safety concerns and limited benefit.
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Occult small-bowel bleeding

In patients with occult bleeding, repeat EGD should be considered when an upper GI lesion is suspected, such as in patients with risk factors for mucosal disease caused by NSAID use or if details of the prior EGD are uncertain. Repeat colonoscopy should be considered when the quality of the bowel preparation on the initial examination was suboptimal or when other questions about the quality of the examination exist. Additionally, when there is clinical suspicion for missed colon lesions, repeat colonoscopy may be performed.
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VCE is considered the first diagnostic step in the evaluation of small-bowel sources of occult bleeding once the upper GI tract and colon have been satisfactorily cleared as potential sources. A follow-up push enteroscopy or DAE is usually recommended for further management of positive results on VCE. Barium radiographic studies, such as small-bowel follow-through and enteroclysis, have low diagnostic yields and no longer have a role in the evaluation of these patients. Multiphase CTE may have a higher sensitivity compared with VCE when patients are being assessed for small-bowel neoplasms and should be performed first if stricture, bowel obstruction, or inflammatory bowel disease is suspected.
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 If the VCE result is negative, the patient’s clinical status should dictate the next step. Stable patients may be observed without further evaluation. For patients who need further work-up or who have recurrent bleeding, additional diagnostic modalities can be used. Patients who did not have a second-look endoscopy may benefit from repeat EGD and/or ileocolonoscopy. A repeat VCE also may be informative, particularly in patients whose presentations change from occult to overt bleeding or those with decreases in hemoglobin levels of ≥4 g/dL.
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Role of second-look endoscopy

Repeat EGD may yield a bleeding source even when the initial EGD is negative. For example, in studies of patients with suspected small-bowel bleeding that used small-bowel imaging technologies, suspected sources of bleeding were found within the reach of a standard EGD in 2.8% (4/140)
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Role of push enteroscopy

The diagnostic yield of push enteroscopy for a bleeding source in the setting of suspected small-bowel bleeding is approximately 24% to 56%.
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Role of VCE

VCE enables visualization of the entire small intestine in the majority of patients undergoing capsule endoscopy but lacks the potential for therapeutic intervention. A detailed description of VCE can be found in a separate ASGE Technology document.
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Specific therapy for small-bowel bleeding sources

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 and they can be considered for patients who are not candidates for endoscopic therapy or who continue to bleed after endoscopic therapy.

Recommendations

1.
For patients with signs or symptoms consistent with recurrent upper or lower GI sources of bleeding, we suggest repeating EGD and colonoscopy, respectively, before small-bowel evaluation. ⊕⊕○○
2.
We suggest VCE as the initial test for patients with overt or occult small-bowel bleeding. Positive VCE results should be followed with push enteroscopy if within reach or DAE. ⊕⊕○○
3.
We suggest DAE or push enteroscopy if VCE is unavailable or nondiagnostic in patients with overt small-bowel bleeding. ⊕⊕○○
4.
We suggest that in select circumstances (eg, high level of suspicion of small-bowel angiectasias or in patients with surgically altered anatomy) DAE may be considered as the initial small-bowel diagnostic procedure in patients with small-bowel bleeding. ⊕⊕○○
5.
We suggest that after an appropriate negative evaluation, clinically stable patients without recurrent bleeding may be treated with iron therapy and clinically followed if iron deficiency is present. ⊕⊕○○
6.
We suggest multiphase CTE or MRE in patients with obscure bleeding and suspected small-bowel neoplasms. ⊕⊕⊕○
7.
Following appropriate hemodynamic resuscitation, we recommend angiography for selective embolization in patients who present with hemodynamically unstable suspected small-bowel bleeding. ⊕⊕⊕○
8.
We suggest a CTA or RBC scan for localization of the bleeding site and to guide timing of angiography in hemodynamically stable patients with suspected active small-bowel bleeding. ⊕⊕○○

Disclosures

R. Muthusamy is a consultant for Boston Scientific and received research support from Covidien GI Solutions. M. Khashab is a consultant for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication.

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Categories :
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  • Small Bowel Endoscopy
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Biliary and Pancreatic Endoscopy
Adverse Events
Privileging and Credentialing
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Quality in Endoscopy

Quality documents define the indicators of high-quality endoscopy and how to measure it. ASGE quality indicators are based on a rigorous review process which results in valid metrics for evaluating GI endoscopic procedures.

Quality in Endoscopy