Persistent Blood in Stool: When to Consider Small Bowel Endoscopy?

Persistent bloody stools with no identifiable bleeding source on examination: Is a small bowel endoscopy necessary?

Symptoms: First episode of bloody stool from January 9 to January 11.
Patient: 68-year-old female with a history of mild gastric ulcer and elevated cholesterol.
Treatment: On January 9, in the afternoon, the patient had bloody stools three times and experienced dizziness.
An ambulance was called for emergency transport to the medical center's emergency department for observation.
Hemostatic agents were administered every 8 hours, and glucose plus normal saline was continuously infused.
On January 11, a sigmoidoscopy was performed, but no bleeding point was found.
The emergency physician prescribed hemostatic medication for three days, and the patient was discharged that afternoon.
Symptoms: Second episode of bloody stool from January 13 to January 19.
Treatment: On January 13, in the morning, the patient had bloody stools three times, felt dizzy, and experienced chills.
An ambulance was called for emergency transport to the medical center's emergency department, where hospitalization for observation was deemed necessary.
Hemostatic agents were administered every 8 hours, and glucose, normal saline, and potassium were continuously infused without interruption, along with ulcer medication every 12 hours.
On January 15, an upper gastrointestinal endoscopy was performed, but no bleeding point was found.
There were signs of gastric ulcer repair with white spots, and gastroesophageal reflux was noted.
On January 16, the patient passed a large amount of bloody stool, appeared pale, and experienced night sweats.
Blood pressure was low at 120/50, and blood glucose was normal at 168.
The attending physician indicated that blood tests showed hemoglobin at 6.62, which is below the standard value, necessitating an emergency transfusion of 500cc.
On January 17, a colonoscopy was performed, but no bleeding point was found, although internal hemorrhoids were noted.
On January 18, the infusion of fluids and hemostatic agents was stopped, and a normal diet was provided while observing the stool color.
The stool color was dark red with white.
The attending physician assessed the internal hemorrhoids and used suppositories, resulting in white stools.
The dark red color was attributed to gas observed during the colonoscopy.
On January 19, blood tests for hemoglobin and platelets returned normal values, and discharge was arranged.
On January 22 at 10:30 AM, the stool was formed and brown, but when flushed, it appeared bloody, raising concerns.
Dr.
Chen, should the patient be referred to the outpatient gastroenterology and hepatology department or the colorectal surgery department? The patient's mother passed away due to liver disease, and the patient herself has fatty liver.
Could this lead to ongoing bloody stools? Is there a need for a small bowel endoscopy? I kindly request your insights on these questions.
Thank you!

pinggu, 60~69 year old female. Ask Date: 2022/01/22

Dr. Chen Shidian reply Gastroenterology and Hepatology

It should not be related to the liver.
It is necessary to work with a gastroenterologist and take some time for a thorough examination.
Small bowel endoscopy and angiography are both considerations.

Reply Date: 2022/01/22

More Info

When dealing with persistent blood in the stool, especially in a 68-year-old female patient with a history of mild gastric ulcers and elevated cholesterol, it is crucial to approach the situation with a comprehensive understanding of potential underlying causes and appropriate diagnostic measures. Given the complexity of gastrointestinal bleeding, the absence of identifiable bleeding sources in previous examinations, including colonoscopy and gastroscopy, raises the question of whether small bowel endoscopy is warranted.

The patient's history indicates multiple episodes of hematochezia (the passage of fresh blood through the anus), accompanied by symptoms such as dizziness and hypotension, which suggest significant blood loss. The initial evaluations, including a sigmoidoscopy and gastroscopy, did not reveal any active bleeding sites, which can be frustrating for both the patient and the healthcare provider. The presence of internal hemorrhoids noted during the colonoscopy may explain some of the bleeding, but given the recurrent nature of the symptoms, further investigation is necessary.

In cases where upper and lower gastrointestinal evaluations fail to identify the source of bleeding, small bowel endoscopy (also known as enteroscopy) becomes a valuable tool. This procedure allows for direct visualization of the small intestine, which is often a challenging area to assess due to its length and location. Conditions such as small bowel tumors, Crohn's disease, or vascular malformations can lead to obscure gastrointestinal bleeding, and these may not be detected through standard colonoscopy or gastroscopy.

Additionally, other non-invasive diagnostic options should be considered before proceeding to small bowel endoscopy. These include imaging studies such as a CT enterography or a capsule endoscopy. Capsule endoscopy involves swallowing a small camera that takes pictures of the small intestine as it passes through, providing a less invasive means of identifying potential sources of bleeding.

Regarding the patient's concerns about her family history of liver disease and her own fatty liver condition, it is essential to clarify that while liver disease can lead to gastrointestinal bleeding, it typically manifests through portal hypertension and variceal bleeding, which would likely have been identified during the previous evaluations. Therefore, it is unlikely that her fatty liver is directly causing the recurrent blood in her stool.

In terms of follow-up care, it would be prudent for the patient to consult with a gastroenterologist who can evaluate her symptoms in the context of her overall health and family history. The gastroenterologist may recommend further imaging studies or consider small bowel endoscopy based on the findings from her previous tests and her current symptoms.

In summary, persistent blood in the stool, especially when previous evaluations have not identified a source, warrants a thorough investigation. Small bowel endoscopy should be considered if other non-invasive tests do not yield results. The patient should be closely monitored, and a multidisciplinary approach involving gastroenterology and possibly colorectal surgery may be beneficial in managing her condition effectively.

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