Bleeding from the small intestine

The small intestine: What is it? The small intestine is the part of the intestine located between the duodenum and the colon (large intestine). It is responsible for absorbing nutrients and can reach several metres in length. It can be the source of gastrointestinal bleeding, a problem frequently encountered in gastroenterology.

Bleeding from the small intestine can have various causes. The small intestine is the part of the digestive tract located between the stomach and the colon. Some causes are more common in older people, while others occur more frequently in young adults or children.

Abnormalities of the blood vessels

This is the most common cause.

• Angiodysplasias: small malformations of the blood vessels in the intestinal wall. These vessels are more fragile and may bleed spontaneously, particularly in older people.
• Arteriovenous malformations: abnormalities of blood circulation in which arteries and veins are directly connected, which may promote bleeding.

Inflammatory bowel diseases

Inflammation weakens the intestinal wall and may cause bleeding.

• Crohn’s disease: a chronic disease in which the immune system causes inflammation in certain parts of the digestive tract. This inflammation may lead to ulceration and bleeding.
• Enteritis: inflammation of the small intestine caused by an infection, certain medicines or the side effects of radiotherapy.

Ulcers of the small intestine

An ulcer is a sore that forms in the intestinal wall.

These ulcers may be caused by:

• prolonged use of anti-inflammatory medicines (such as ibuprofen or diclofenac);
• a reduction in the blood supply to the intestine (ischaemia);
• certain infections.

Tumours

Bleeding may sometimes be linked to a tumour.

• Benign tumours: growths that are not cancerous, such as certain polyps.
• Malignant tumours (cancers): these may weaken the intestinal wall and cause bleeding.

Meckel’s diverticulum

Meckel’s diverticulum is a small pouch present on the intestine from birth. Most of the time, it causes no symptoms, but it may sometimes lead to bleeding, especially in children and young adults.

Medicines

Some treatments do not directly cause bleeding but increase the risk when a lesion is already present.

This is particularly the case with:

• anticoagulants, which thin the blood to prevent clots;
• antiplatelet medicines, which prevent platelets (cells involved in blood clotting) from clumping together.

Rarer causes

More rarely, bleeding may be linked to:

• trauma to the intestine;
• ingestion of a foreign body;
• a clotting disorder, that is, difficulty forming a blood clot;
• certain rare diseases affecting the blood vessels.

Depending on their origin, gastrointestinal bleeding can manifest in different ways:

• Vomiting fresh blood (haematemesis)
• Black stools (melaena)
• Fresh blood in the stools (haematochezia)
• Sometimes, the bleeding is invisible to the naked eye (occult) and is detected only through anaemia identified in a blood test, related to iron deficiency

In the event of bleeding originating in the small intestine, the most common manifestations are melaena and anaemia. In all cases, you should consult a gastroenterologist for an assessment.

In the event of visible or occult gastrointestinal bleeding and/or iron-deficiency anaemia, your gastroenterologist may prescribe several examinations, carried out progressively and adapted to your situation:

• Gastroscopy : allows the upper digestive tract (oesophagus, stomach and duodenum) to be visualised
• Colonoscopy : allows the lower digestive tract (large intestine) to be visualised
• An abdominal CT scan with contrast injection (CT angiography), allows any sources of bleeding in the abdomen or intestine to be identified medical imaging link)
• Video capsule examination of the small intestine allows the entire small intestine (located between the duodenum and the large intestine) to be visualised by swallowing a capsule the size of a tablet, equipped with cameras that take photographs throughout its passage through your digestive tract. These photographs are transmitted to a device that you wear over your shoulder for an entire day and are subsequently analysed by your gastroenterologist.
• Double-balloon enteroscopy is an endoscopic examination used to investigate or treat gastrointestinal bleeding in the small intestine, visualised, for example, during a small-intestine video capsule examination or an imaging examination such as a CT scan. This examination is performed under general anaesthesia. It can be carried out through the mouth or the anus, depending on the location of the bleeding in the small intestine.

How can you be treated if the bleeding comes from the small intestine?

In the majority of cases, we can treat the source using double-balloon enteroscopy. More rarely, angiography may be required through the interventional radiology department, or digestive surgery. 

Our department is a reference centre for the diagnosis and treatment of gastrointestinal bleeding and anaemia, particularly bleeding from the small intestine (video capsule endoscopy and double-balloon enteroscopy).  Our experience and multidisciplinary approach, which sometimes also combines the expertise of several disciplines such as radiology, endoscopy and surgery, ensure optimal diagnosis and treatment tailored to each patient.

What does follow-up involve?

Regular follow-up is essential for the proper management of your care:

• Blood tests to assess anaemia and iron deficiency
• Sometimes intravenous iron injections or a transfusion are necessary; these can be administered at the Day Hospital without hospitalisation.

If you experience signs of significant gastrointestinal bleeding (haematemesis, melaena, haematochezia), please go to our Emergency Department as soon as possible; they will contact our team.

If the bleeding is a more chronic phenomenon, please do not hesitate to make an appointment for a consultation (by email at ConsGastroMed [dot] erasme [at] hubruxelles [dot] be (ConsGastroMed[dot]erasme[at]hubruxelles[dot]be) or by telephone on +32 (0)2 555.35.04, or contact the H.U.B’s Gastroenterology Department directly at SecMed [dot] GastroMed [dot] erasme [at] hubruxelles [dot] be (SecMed[dot]GastroMed[dot]erasme[at]hubruxelles[dot]be)