Current insights into the diagnosis and management of small bowel bleeding

Small bowel bleeding accounts for 5-10% of gastrointestinal (GI) hemorrhage and remains a diagnostic challenge because of its diverse etiologies and subtle clinical presentation. Advances in small bowel imaging have refined the diagnostic approach and have led to the replacement of the term obscure GI bleeding with suspected small bowel bleeding (SSBB) when findings on upper and lower endoscopy are unrevealing. The initial evaluation requires careful assessment of clinical history, comorbidities, medication use, and physical findings, which may help direct suspicion toward specific etiologies such as inflammatory bowel disease, Meckel's diverticulum, angioectasia, or small bowel neoplasms. Small bowel capsule endoscopy (SBCE) is currently recommended as the first-line investigation in stable patients because it offers high diagnostic accuracy, facilitates subsequent deep enteroscopy, and significantly influences clinical management. Device-assisted enteroscopy, including double-balloon, single-balloon, and spiral enteroscopy, provides both diagnostic confirmation and therapeutic intervention, and its diagnostic yield is optimized when performed within 48-72 hours of bleeding. Cross-sectional imaging modalities, such as computed tomography (CT) and CT angiography, serve complementary roles, particularly in hemodynamically unstable patients or when SBCE is negative or contraindicated. Endoscopic therapy, most commonly argon plasma coagulation, remains the primary treatment for small bowel angioectasia; however, rebleeding is common, and long-term outcomes remain suboptimal. Supportive measures, including iron supplementation and blood transfusion, are essential components of care. Pharmacologic therapies, such as thalidomide or octreotide, show potential benefit; however, they are not routinely recommended. A structured, multimodal diagnostic and therapeutic strategy is therefore essential for the optimal management of SSBB.