In the United States and Europe, the causes of small bowel bleeding have been well established; vascular abnormalities are the commonest cause with a frequency of 30-40% [16
]. Tumors reportedly account for only about 6.4% of small intestinal bleeding in these regions [16
]. However, in our series of Chinese patients tumors (58.3%) were the most frequent cause of small bowel bleeding, followed by enteritis or subepithelial ulcerated lesions (12.5%), diverticula of the small intestine (9.7%), angiopathy (9.7%), Crohn’s disease (4.2%) and other diseases (5.6%). Thus, there are major differences between western countries and China in the causes of small bowel bleeding. We found that tumors were the leading cause of jejunoileal bleeding both in patients older and younger than 40
years; however, the proportion of jejunoileal hemorrhage caused by tumors did differ significantly between these age groups (P
0.05). The reasons for this difference are unknown and may include inherited factors.
Benign tumors are reportedly more often responsible for small intestinal bleeding than malignant tumors. The most common benign tumor that causes small bowel bleeding is leiomyoma, whereas the commonest malignant tumor is leiomyosarcoma. Benign tumors seem to bleed more often than malignant tumors [18
]. In contrast, malignant tumors (which were most often primary interstitialomas) accounted for 75% of all the tumor-related jejunoileal bleeding in our series. Benign tumors (which were mainly primary angiomas and leiomyomas) accounted for only 25%. In the 33 cases with tumors and identified location of bleeding, 63.6% (21/33) of those tumors were located in the jejunum. However, bleeding caused by enteritis, diverticula and angiopathy of the small intestine most often originated in the ileum. The difference between causes of hemorrhage from the jejunum versus from the ileum was significant (P
In our series, repeated, intermittent hematochezia or hematochezia accompanied by abdominal pain were the commonest initial symptoms of patients with jejunoileal bleeding. This most frequently took the form of melena (58.3%), followed by maroon (25.0%) and red stools (8.3%). There was a statistically significant difference (P
0.05) between male and female patients in the cause of jejunoileal hemorrhage. Tumors, followed by enteritis or subepithelial ulcerated lesions and angiopathy, were the most frequent cause in men. However in the 26 women, although tumors were also the main cause (18/26, 69.2%), no case of angiopathy were identified. We recommend that female patients aged over 40
years with hematochezia accompanied by abdominal pain and a high suspicion of a small bowel bleeding should undergo urgent further examination because of the high probability of jejunoileal tumor. For male patients with copious jejunoileal bleeding that is not accompanied by abdominal pain, we suggest that the diagnosis of angiopathy should be considered after jejunoileal tumor has been excluded.
Current options for the diagnosis and management of small bowel bleeding include selective angiography, radiographic means such as small bowel series and enteroclysis, push enteroscopy, CE, single-balloon enteroscopy, double-balloon enteroscopy, intraoperative enteroscopy (IOE), and exploratory laparotomy [15
]. Because it is a noninvasive procedure, capsule endoscopy is recommended as the first diagnostic test for patients with suspected small bowel bleeding in developed countries [10
]. IOE and exploratory laparotomy are now accepted as the procedure of choice for complete evaluation of the small bowel [24
]. However, in our series only 54.2% of all cases were diagnosed by IOE and laparotomy, followed by 23.6% by capsule endoscopy, 9.7% by selective angiography, 8.3% by small bowel series and enteroclysis and 2.8% by both push enteroscopy and colonoscopy. A diagnosis was made during the first hospital admission in only 51.4% of all cases in our series. Conversely, a diagnosis was not made during the first admission in about half of the patients in our series. This may be because China is still a developing country and CE examination was unavailable in many of the surveyed hospitals in the years we studied, especially before 2005.
All of the 72 patients with jejunoileal hemorrhage had obtained a surgical consultation. And according to the surgeon's advice, 50 patients underwent surgical treatment including 42 of tumors,7 of angiopathy and 1 of enteritis. The remaining 22 were treated by conservative medical means. Surgical treatment was indicated so often in these patients because tumors are the major cause of jejunoileal bleeding in China.
In our series, 41.7% of cases had various complications including anemia, intestinal obstruction, abdominal metastasis, shock, ankylenteron, and intestinal perforation. The commonest causes of complications were tumors; 47.6% of the complications were in tumor patients. Conversely, 66.7% of patients with tumors had complications. Anemia, intestinal obstruction, abdominal metastases, shock, ankylenteron and intestinal perforation were all primarily found in tumor patients. Thus, patients presenting with jejunoileal bleeding and serious complications have a high probability of having small bowel tumors.