Suspected Small Bowel Bleeding: A Single-Center Retrospective Study on Long-Term Prognosis and Predictive Factors.

Suspected small-bowel bleeding (SSBB), bleeding between the ampulla of Vater and the ileocecal valve, suspected when GI bleeding persists after negative upper and lower endoscopy. Small-bowel capsule endoscopy (SBCE) is recommended as the FIRST-LINE examination, before other endoscopic and radiological tests (strong, moderate). ESGE does NOT recommend routine second-look endoscopy prior to SBCE in suspected small-bowel bleeding or iron-deficiency anemia (strong, low). In OVERT suspected small-bowel bleeding, perform SBCE as soon as possible after the bleeding episode, ideally within 48 hours, to maximize diagnostic and therapeutic yield (strong, high). Device-assisted enteroscopy (DAE) is recommended to confirm and possibly treat lesions identified by SBCE (strong, high); in overt suspected small-bowel bleeding, DAE should optimally be performed within 48-72 hours of the bleeding episode (strong, high). Where SBCE is unavailable or contraindicated, DAE and/or dedicated small-bowel cross-sectional imaging may be considered first, depending on availability, expertise and clinical suspicion (weak, low). After a HIGH-QUALITY NEGATIVE SBCE, ESGE recommends conservative management (strong, moderate), the 2015 wording qualified this as patients without ongoing bleeding evidenced by overt bleeding or continued transfusion requirement, and the 2022 update carries this qualifier as a separate companion recommendation: for patients with a high-quality negative SBCE who have ONGOING overt bleeding or a continued need for blood transfusions, ESGE recommends further investigation using repeat SBCE, DAE, or dedicated small-bowel cross-sectional imaging (strong, moderate). SBCE is also recommended first-line in iron-deficiency anemia when small-bowel evaluation is indicated (strong, high), and after unremarkable or nondiagnostic dedicated small-bowel cross-sectional imaging if likely to influence management (strong, low). CROHN'S DISEASE: in SUSPECTED Crohn's with negative ileocolonoscopy, SBCE is the initial small-bowel modality ONLY in the absence of obstructive symptoms or known bowel stenosis (strong, high); in that group ESGE explicitly does NOT recommend routine cross-sectional imaging or a patency capsule before SBCE (strong, HIGH quality). With obstructive symptoms or known stenosis, dedicated cross-sectional imaging (MRE/MR-enteroclysis or CTE/CT-enteroclysis) is used FIRST (strong, moderate), and a patency capsule is recommended before SBCE in suspected Crohn's with obstructive symptoms (strong, low), even when cross-sectional imaging is negative. In ESTABLISHED Crohn's, a patency capsule before SBCE is recommended to decrease the retention rate (strong, moderate). SMALL-BOWEL TUMORS: SBCE is recommended where there is increased risk of a small-bowel tumor (strong, moderate); ESGE does NOT recommend specific investigations before SBCE in suspected small-bowel tumor UNLESS the patient is considered at risk of capsule retention (strong, low). If imaging has ALREADY demonstrated a suspected small-bowel tumor, DAE is preferred over SBCE (strong, low). Cross-sectional imaging is recommended for staging and operability when SBCE shows a tumor with high diagnostic certainty (strong, low); where the capsule diagnosis is uncertain, biopsy sampling AND tattooing of the location by DAE is recommended (strong, low); for a subepithelial mass, confirm by DAE and/or cross-sectional imaging per local availability/expertise (strong, low). SBCE is NOT recommended for follow-up of treated small-bowel tumors, for lack of data (strong, low). PATENCY/RETENTION generally: GI obstruction is an absolute contraindication to SBCE. If the patency capsule is egested intact, retention of a real capsule is unlikely; if not egested within 30 hours, cross-sectional imaging (not plain abdominal radiography) is favored to localize it. In Peutz-Jeghers syndrome, routine patency capsule use is NOT recommended and should be considered case-by-case.