Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis (161 page)

   Surgical evaluation

   Intraoperative enteroscopy is a procedure whereby the bowel is manually advanced over an endoscope. It is the most common way to examine the entire small bowel. It is successful in identifying a bleeding source 83–100% of the time.

   Exploratory surgery is often considered in patients with recurrent GI bleeding of unclear origin. Simple exploration has a low success rate, with a diagnostic yield of only 10% when unaccompanied by other evaluations (i.e., enteroscopy).

   Stepwise approach to evaluation: In a study of 77 patients, the interval from presentation to diagnosis was >20 months, because of the relatively asymptomatic nature of the conditions and the difficulty in evaluating small bowel bleeding sources.

   Determine the source of bleeding

   In those with a nondiagnostic evaluation of lower and upper GI tracts, small bowel evaluation will be necessary.

   Once the small bowel is assumed to be the bleeding source (i.e., standard examinations are nondiagnostic), proceed to small bowel series.

   If the source is not identified

   Proceed to push enteroscopy, before considering repeat EGD or colonoscopy.

   Sonde enteroscopy may be considered.

   Withhold bleeding scans and angiography, unless the patient is actively bleeding.

   Exploratory surgery can be done with intraoperative endoscopy if needed.

   Video capsule endoscopy.