**6. Management**

A systematic approach is essential to manage mid-GI successfully. Mid-GI bleeding is generally established when no source of potential bleeding is found in the upper or lower gastrointestinal tract after doing bidirectional endoscopy, i.e., upper endoscopy (including examination with a side-viewing duodenoscope) and ileocolonoscopy. Second-look bidirectional endoscopy should be done considering substantial initial endoscopic miss rates [38]. Next step to evaluate is whether the patient is hemodynamically stable or unstable and whether the patient is having occult or overt GI bleeding. The first investigation to evaluate mid-GI bleeding in a hemodynamically stable patient is VCE unless there are contraindications like small bowel obstruction [39]. On the other hand, in a hemodynamically unstable patient, the first investigation will be angiography for both diagnostic and therapeutic purposes [40].

#### *Digestive System - Recent Advances*

Depending on the location of bleeding lesion in VCE, push enteroscopy or DAE should be done, i.e., push enteroscopy for lesion in the proximal part of the small bowel and DAE for lesion in the mid or distal part of the small bowel. If the VCE is negative, the next step will depend on whether the patient has ongoing blood loss, the rate of blood loss, and the presence of comorbidities:


Definitive therapy should be given according to the findings seen in the above investigations. Treatment modalities of some of the common conditions are listed below:


**29**

*Mid-Gastrointestinal Bleeding*

inhibitors.

• Benign tumors:

preferred [47].

surgery [48].

multiple blood transfusions.

interventions should be considered.

**8. Conclusion**

**7. Prognosis**

*DOI: http://dx.doi.org/10.5772/intechopen.89337*

Adenoma: endoscopic resection.

• Meckel's diverticulum: surgery.

• GIST: surgery and tyrosine kinase inhibitors.

• Non-GIST mesenchymal tumors: surgery.

• Adenocarcinoma of small bowel: surgery, chemotherapy, and checkpoint

Peutz-Jeghers syndrome: segmental resection or endoscopic resection. Because some patients are young with widespread polyps, endoscopic treatment should be

• Ulcerative jejunoileitis due to celiac disease: surgical resection of the ulcerated segment, corticosteroid, elimination diet, and total parenteral nutrition.

Prognosis depends on the etiology of the lesion causing mid-GI bleeding. Vascular lesions carry a good prognosis if they can be successfully treated endoscopically, radiologically, or surgically. Most of the time, vascular lesions can be managed endoscopically. Surgical intervention is required if the bleeding cannot be managed endoscopically or by interventional radiology. Surgery is also required for benign and malignant small bowel tumors, ulcerative jejunoileitis due to celiac disease, and refractory bleeding Crohn's ulcers. Sometimes, patients' comorbidities or old age do not allow invasive procedures or surgery. Symptomatic and palliative treatments are offered in those cases. Sometimes, mid-GI bleeding remains obscure. Patients end up getting multiple hospitalizations, multiple diagnostic tests, and

Mid-GI bleeding is common in our day-to-day clinical practice. Capsule endoscopy and imaging studies have made the diagnostic evaluations much easier than before. Balloon-assisted enteroscopy and spiral enteroscopy are generally done for therapeutic interventions. Interventional radiology and surgery are required if there is massive bleeding or endoscopic therapeutic interventions fail. After hemostasis is obtained, treatment of the underlying condition should be done. Patient's age, comorbidities, pros and cons of the procedures, and radiological and surgical

Lipoma, leiomyoma, and hamartomas: segmental resection.

• Metastatic tumor to the small bowel: palliative treatment.

• Crohn's disease: endoscopic treatment, embolization, corticosteroid, 5-aminosalicylic acid, 6-mercaptopurine/azathioprine, infliximab, and

#### *Mid-Gastrointestinal Bleeding DOI: http://dx.doi.org/10.5772/intechopen.89337*


*Digestive System - Recent Advances*

Depending on the location of bleeding lesion in VCE, push enteroscopy or DAE should be done, i.e., push enteroscopy for lesion in the proximal part of the small bowel and DAE for lesion in the mid or distal part of the small bowel. If the VCE is negative, the next step will depend on whether the patient has ongoing blood loss,

a.If the patient has ongoing blood loss without significant comorbidities, DAE, CTE/MRE, or even laparoscopy with intraoperative enteroscopy should be

b.If the patient does not have ongoing blood loss, further evaluation can be

tion and/or blood transfusion should be given as necessary basis.

c.If the patient has significant comorbidities and slow rate of blood loss, further investigation could be reasonably stopped. Patient should be observed with periodic monitoring of complete blood count (CBC), and iron supplementa-

Definitive therapy should be given according to the findings seen in the above investigations. Treatment modalities of some of the common conditions are listed

• Small bowel angioectasia: it is by far the commonest cause of mid-GI bleeding. Endoscopic ablation is the treatment of choice. Sometimes patients may present with recurrent anemia due to bleeding from widespread or inaccessible angioectasia, and endoscopic treatment is risky because of patients' comorbidities or old age. Pharmacologic treatment is generally offered in those cases. Thalidomide prevents angiogenesis by inhibiting vascular endothelial growth factor (VEGF). One study showed that thalidomide was effective in reducing the rate of recurrent small bowel bleeding due to vascular malformations [41]. Octreotide decreases mesenteric blood flow, inhibits angiogenesis, and improves platelet aggregation. One meta-analysis showed that octreotide therapy reduced the transfusion requirement in patients with recurrent bleeding from gastrointestinal vascular malformations [42]. Other treatment

• Isolated jejunal and ileal bleeding ulcers due to NSAIDs: hold NSAIDs, endoscopic treatment, and/or embolization. In rat model, proton pump inhibitors were found

to worsen NSAID-induced small bowel injury by inducing dysbiosis [43].

• Dieulafoy's lesion: endoscopic (argon plasma coagulation, hemoclip, injection therapy) or angiographic intervention (embolization) or surgery if those

• Small bowel varices: endoscopic treatment if within reach of endoscope. Angiography, transjugular intrahepatic portosystemic shunt (TIPS) placement, or surgery if endoscopic hemostasis fails or is beyond the reach of

• SBNET: surgical resection is the treatment of choice for locoregional disease. Long-acting somatostatin analogs are given for functional and nonfunctional metastatic SBNET because of their antiproliferative effects and ability to

the rate of blood loss, and the presence of comorbidities:

modalities for different conditions include:

interventions fail [44].

control carcinoid symptoms [46].

endoscope [45].

considered to stop the bleeding.

stopped.

below:

**28**

Adenoma: endoscopic resection.

Lipoma, leiomyoma, and hamartomas: segmental resection.

Peutz-Jeghers syndrome: segmental resection or endoscopic resection. Because some patients are young with widespread polyps, endoscopic treatment should be preferred [47].

