Antithrombotic and management of small bowel bleeding – time to throw caution into the wind?

Purpose of review – Small bowel bleeding (SBB) represents a significant diagnostic and therapeutic challenge. The use of antithrombotic therapy (oral anticoagulants and antiplatelet agents) has led to an increase in gastrointestinal bleeding events, particularly in the small bowel. The endoscopic management of SBB in patients receiving antithrombotic therapy remains a clinical dilemma. This review explores the current perspectives on the endoscopic management of SBB in patients receiving antithrombotic therapy and discusses whether the traditional cautions approach should be reconsidered. Recent findings – Recent studies confirmed a higher diagnostic yield of small bowel capsule endoscopy (SBCE) in patients administered with antithrombotic agents, and an increased prevalence of SBB from vascular lesions. Device-assisted enteroscopy (DAE) is the reference standard for endoscopic therapy; however, rebleeding rate remains high. Summary – Endoscopic management of SBB in patients receiving antithrombotic therapy remains suboptimal. Maintenance of therapy increases the diagnostic yield of SBCE; however, guidelines recommend to discontinue the therapy before DAE. This mismatch highlights a substantial disconnection between evidence and clinical practice. Prospective studies and expert consensus are needed to optimize outcomes in this population.