The most appropriate procedure is push enteroscopy, which will allow for therapeutic intervention. Angiodysplasias are the most common cause of obscure gastrointestinal bleeding. Push enteroscopy will be able to reach the lesion and allow for treatment with electrocautery, argon plasma coagulation, injection therapy, mechanical hemostasis (hemoclips or banding), or a combination of these techniques. This patient had a negative upper endoscopy. Capsule endoscopy was helpful in this patient because it identified active bleeding as well as several angiodysplasias, which are causing the bleeding. Enteroscopy should be performed after a negative upper endoscopy and colonoscopy or after a positive capsule endoscopy. Complications of push enteroscopy are rare but include perforation, mucosal avulsion, and bleeding.

Intraoperative endoscopy is reserved for patients with active bleeding from the small bowel in whom both endoscopy and angiography have failed to identify the small-bowel bleeding source.

A repeat upper endoscopy would not be helpful in this situation because it will be unable to reach the lesion in the small bowel.

Technetium-labeled nuclear scans are used in patients with active bleeding (melena or hematochezia) who are transfusion dependent and hospitalized. This is a diagnostic test that will supply no additional information to what has already been provided by the results of the capsule endoscopy, and it does not allow for therapeutic intervention.