Outpatient management of obscure gastrointestinal bleeding: A new perspective in high-risk patients

Abstract

Mid-gastrointestinal bleeding accounts for approximately 5%-10% of all gastrointestinal bleeding cases, and vascular lesions represent the most frequent cause. The rebleeding rate for these lesions is quite high (about 42%). We hereby recommend that scheduled outpatient management of these patients could reduce the risk of rebleeding episodes.

Key Words: Gastrointestinal bleeding; Small bowel bleeding; Recurrent bleeding; Re-bleeding risk; Rebleeding; Outpatient management

Core Tip: A scheduled outpatient management of patients who have suffered gastrointestinal bleeding, by a dedicated team of physicians could reduce the risk of rebleeding in patients who have suffered gastrointestinal bleeding. A multidisciplinary approach is recommended in patients with multiple comorbidities.

INTRODUCTION

Gastrointestinal bleeding is a major cause of hospitalization in patients with gastrointestinal diseases. Mid-gastrointestinal bleeding accounts for approximately 5%-10% of all cases with gastrointestinal bleeding[1] in referral center this incidence could increase, and have accounted for almost 20% of the cases at our center. Vascular lesions represent the most frequent cause of small bowel bleeding and the frequency is affected by age, comorbidities, and concomitant medications[2].

Multiple vascular lesions account for about 46% of the positive findings during small bowel capsule endoscopy[3] and the rebleeding rate associated with these lesions is quite high (about 42%). The risk of rebleeding has been associated with overt bleeding presentation and anticoagulant therapy. A lower risk of rebleeding is associated with therapeutic interventions[4]. Rebleeding episodes often require hospitalization, blood transfusions, medications, and multiple treatments, including small bowel capsule endoscopy and device-assisted enteroscopy, with a greater burden on the health system.

An outpatient management of these patients could reduce the risk of rebleeding. During the outpatient management, a dedicated physician could check the patient for anemia and prescribe long-term therapy such as somatostatin analogs[5], thalidomide[6], bevacizumab[7], and iron supplementation and could schedule further endoscopic examinations if needed.

OUTPATIENT MANAGEMENT OF GASTROINTESTINAL BLEEDING

We report our experience of the multidisciplinary management of gastrointestinal bleeding involving the gastroenterologist as the referral physician, and other specialists such as a cardiologist for the management of antithrombotic therapy or for any therapeutic options that might be needed (left atrial appendage closure could be an option in specific situations), a radiologist and a surgeon for other invasive treatments, or a hematologist for the management of platelet and thrombotic disorders.

In our clinical practice, we introduced dedicated outpatient management for patients with gastrointestinal bleeding from a vascular source of bleeding in particular. Since its introduction, in May 2022, the practice has resulted in the reduction of recurrent bleeding episodes from 1.3 to 0.2 (P < 0.001) and in emergency department visits from 0.8 to 0.1 (P < 0.001).

The management provides a scheduled follow-up for patients with blood tests and a clinical evaluation at least every 6 months or earlier if needed. During the visit, the physician assesses the need for iron supplementation, medical therapy as previously reported, or further endoscopic examination to reduce or resolve the anemia and further bleeding.

The oral intake of iron needs to be assessed for patients with a history of previous gastrointestinal bleeding. A previously conducted study had indicated[8] that iron oral supplementation six weeks after the bleeding episode played a positive role in increasing hemoglobin levels (72% in the treatment group vs 46% in the control group). Long-term support strategy following acute gastrointestinal bleeding is still controversial[8,9], and the available literature and current international guidelines do not provide information regarding the optimal strategy for long-term management of these patients.

The need of active surveillance in bleeding patients has not been examined and it is not known whether active surveillance plays a positive role in reducing the recurrence of bleeding[8-11] or iron deficiency anemia. Published studies available have focused on the predictive risk factors for rebleeding[12-14] and found that comorbidities and severity of clinical status impacted the risk of rebleeding[2,15].

CONCLUSION

A multicenter prospective study on the benefits of outpatient management of patients with gastrointestinal bleeding is required, and if the data confirms the result obtained at our center, the management of small bowel gastrointestinal bleeding can be possible in a dedicated practice, thereby improving the patient’s quality of life and will also be cost saving.