Editorial Open Access
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 21, 2024; 30(19): 2502-2504
Published online May 21, 2024. doi: 10.3748/wjg.v30.i19.2502
Outpatient management of obscure gastrointestinal bleeding: A new perspective in high-risk patients
Maria Elena Riccioni, Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, Rome 00168, Italy
Clelia Marmo, CEMAD Centro Malattie Dell’Apparato Digerente, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, Rome 00168, Italy
ORCID number: Maria Elena Riccioni (0000-0002-9239-4312).
Author contributions: Riccioni ME wrote this manuscript; Marmo C consulted and analyzed the literature.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Maria Elena Riccioni, MD, PhD, Academic Research, Adjunct Professor, Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, Largo Gemelli 8, Rome 00168, Italy. mariaelena.riccioni@unicatt.it
Received: January 17, 2024
Revised: April 8, 2024
Accepted: April 25, 2024
Published online: May 21, 2024

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.

Footnotes

Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Corresponding Author's Membership in Professional Societies: SIED Società Italiana di Endoscopia Digestiva; ESGE European Society of Gastrointestinal Endoscopy.

Specialty type: Gastroenterology and hepatology

Country of origin: Italy

Peer-review report’s classification

Scientific Quality: Grade B

Novelty: Grade C

Creativity or Innovation: Grade C

Scientific Significance: Grade C

P-Reviewer: Kono Y, Japan S-Editor: Li L L-Editor: A P-Editor: Zheng XM

References
1.  Gerson LB, Fidler JL, Cave DR, Leighton JA. ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol. 2015;110:1265-87; quiz 1288.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 368]  [Cited by in F6Publishing: 381]  [Article Influence: 42.3]  [Reference Citation Analysis (1)]
2.  Ohmiya N, Nakamura M, Osaki H, Yamada H, Tahara T, Nagasaka M, Nakagawa Y, Shibata T, Tsukamoto T, Kuroda M. Development of a Comorbidity Index to Identify Patients With Small Bowel Bleeding at Risk for Rebleeding and Small Bowel Vascular Diseases. Clin Gastroenterol Hepatol. 2019;17:896-904.e4.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 9]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
3.  Romeo S, Neri B, Mossa M, Riccioni ME, Scucchi L, Sena G, Potenza S, Petruzziello C, Biancone L. Diagnostic yield of small bowel capsule endoscopy in obscure gastrointestinal bleeding: a real-world prospective study. Intern Emerg Med. 2022;17:349-358.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 5]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
4.  Otani K, Shimada S, Watanabe T, Nadatani Y, Higashimori A, Ominami M, Fukunaga S, Hosomi S, Kamata N, Tanaka F, Nagami Y, Taira K, Fujiwara Y. Long-term rebleeding rate and predictive factors of rebleeding after capsule endoscopy in patients with obscure GI bleeding. Gastrointest Endosc. 2022;96:956-969.e3.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 7]  [Reference Citation Analysis (0)]
5.  Goltstein LCMJ, Grooteman KV, Rocco A, Holleran G, Frago S, Salgueiro PS, Aparicio T, Scaglione G, Chetcuti Zammit S, Prados-Manzano R, Benamouzig R, Nardone G, McNamara D, Benallaoua M, Michopoulos S, Sidhu R, Kievit W, Drenth JPH, van Geenen EJM. Effectiveness and predictors of response to somatostatin analogues in patients with gastrointestinal angiodysplasias: a systematic review and individual patient data meta-analysis. Lancet Gastroenterol Hepatol. 2021;6:922-932.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 15]  [Article Influence: 5.0]  [Reference Citation Analysis (0)]
6.  Chen H, Wu S, Tang M, Zhao R, Zhang Q, Dai Z, Gao Y, Yang S, Li Z, Du Y, Yang A, Zhong L, Lu L, Xu L, Shen X, Liu S, Zhong J, Li X, Lu H, Xiong H, Shen Y, Chen H, Gong S, Xue H, Ge Z. Thalidomide for Recurrent Bleeding Due to Small-Intestinal Angiodysplasia. N Engl J Med. 2023;389:1649-1659.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 7]  [Article Influence: 7.0]  [Reference Citation Analysis (0)]
7.  Al-Samkari H, Kasthuri RS, Parambil JG, Albitar HA, Almodallal YA, Vázquez C, Serra MM, Dupuis-Girod S, Wilsen CB, McWilliams JP, Fountain EH, Gossage JR, Weiss CR, Latif MA, Issachar A, Mei-Zahav M, Meek ME, Conrad M, Rodriguez-Lopez J, Kuter DJ, Iyer VN. An international, multicenter study of intravenous bevacizumab for bleeding in hereditary hemorrhagic telangiectasia: the InHIBIT-Bleed study. Haematologica. 2021;106:2161-2169.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 21]  [Cited by in F6Publishing: 23]  [Article Influence: 7.7]  [Reference Citation Analysis (0)]
8.  Chang A, Rugivarodom M, Pungpipattrakul N, Akarapatima K, Suwanno K, Rattanasupar A, Ovartlarnporn B, Prachayakul V. Role of oral iron supplementation for anemia secondary to acute nonvariceal upper gastrointestinal bleeding: a randomized controlled trial. J Gastroenterol Hepatol. 2023;38:1283-1291.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
9.  El-Halabi MM, Green MS, Jones C, Salyers WJ Jr. Under-diagnosing and under-treating iron deficiency in hospitalized patients with gastrointestinal bleeding. World J Gastrointest Pharmacol Ther. 2016;7:139-144.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 7]  [Cited by in F6Publishing: 8]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
10.  Bager P, Dahlerup JF. Randomised clinical trial: oral vs. intravenous iron after upper gastrointestinal haemorrhage--a placebo-controlled study. Aliment Pharmacol Ther. 2014;39:176-187.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 35]  [Cited by in F6Publishing: 28]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
11.  Ferrer-Barceló L, Sanchis Artero L, Sempere García-Argüelles J, Canelles Gamir P, P Gisbert J, Ferrer-Arranz LM, Monzó Gallego A, Plana Campos L, Huguet Malavés JM, Luján Sanchis M, Ruiz Sánchez L, Barceló Cerdá S, Medina Chuliá E. Randomised clinical trial: intravenous vs oral iron for the treatment of anaemia after acute gastrointestinal bleeding. Aliment Pharmacol Ther. 2019;50:258-268.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 12]  [Article Influence: 2.4]  [Reference Citation Analysis (0)]
12.  Kim Y, Kim JH, Kang EA, Park SJ, Park JJ, Cheon JH, Kim TI, Park J, Jeon SR. Rebleeding Rate and Risk Factors for Rebleeding after Device-Assisted Enteroscopy in Patients with Obscure Gastrointestinal Bleeding: A KASID Multicenter Study. Diagnostics (Basel). 2022;12.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
13.  Baba Y, Kawano S, Kono Y, Inokuchi T, Kanzaki H, Iwamuro M, Harada K, Hiraoka S, Kawahara Y, Okada H. Clinical Characteristics and Risk Factors for Rebleeding in Patients with Obscure Gastrointestinal Bleeding. Intern Med. 2020;59:1345-1350.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 5]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
14.  Khan A, Gupta K, Chowdry M, Sharma S, Maheshwari S, Patel C, Naseem K, Pervez H, Bilal M, Ali Khan M, Singh S. Thirty-day readmission rates, reasons, and costs for gastrointestinal angiodysplasia-related bleeding in the USA. Eur J Gastroenterol Hepatol. 2022;34:11-17.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 5]  [Reference Citation Analysis (0)]
15.  Bucci C, Marmo C, Soncini M, Riccioni ME, Laursen SB, Gralnek IM, Marmo R; GISED study group. The interaction of patients' physical status and time to endoscopy on mortality risk in patients with upper gastrointestinal bleeding: A national prospective cohort study. Dig Liver Dis. 2023;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Reference Citation Analysis (0)]