Hemostasis of Acute Small Intestinal Bleeding

Deep enteroscopy has increased our ability to diagnose, treat, and palliate small intestinal causes of gastrointestinal (GI) bleeding. The therapeutic interventions for small bowel bleeding depend on the etiology, size, and location of the lesions and include primarily injection therapies, thermal coagulation, clip placement, or any combination thereof. Important differences in endoscopic approach exist when treating small bowel bleeding relative to other parts of the GI tract. First, the small bowel is long and tortuous, often making it challenging to obtain a satisfactory endoscopic position to target the lesion of interest. Advanced endoscopic skills are mandatory to maneuver the enteroscope through the small bowel. Second, the wall of the small intestine is thin. Therefore, particular attention is required during injection and/or application of noncontact or contact thermal therapies, such as argon plasma or bipolar coagulation. Third, passage and utilization of available hemostatic tools during deep enteroscopy can be difficult. The proceduralist treating small bowel bleeding disorders should be versed in advanced endoscopic techniques, be familiar with devices available for therapeutic enteroscopy, and be able to improvise and troubleshoot during challenging enteroscopic procedures.