Variations in clinical parameters suggest patients with suspected small bowel bleeding deteriorate quickly over time and that close and regular monitoring and the early introduction of small bowel investigations is warranted

Aims Around 10% of subjects presenting with overt GI bleeding will have a small bowel source. While there are established algorithms for assessment and management of upper GI bleeding, including the use of validated clinical scores to triage and risk assess patients, the clinical assessment of those with suspected small bowel bleeding is less clear. As there is no means to identify small bowel bleeding as the source at presentation, most subjects will initially have a normal gastroscopy and possibly a colonoscopy prior to specific small bowel investigation and intervention. The impact on patients with small bowel bleeding of the current approach to overt bleeding assessment is unknown. We aimed to assess the clinical status of patients admitted with overt suspected small bowel bleeding over time.

Methods A retrospective analysis of all patients admitted to our institution from January 2019 to June 2022 with overt suspected small bowel bleeding, with an inital negative gastroscopy and colonoscopy / sigmoidoscopy was performed. Data collected from the electronic patient record included demographics, clinical parameters and laboratory results at presentation and 24 hours after admission. Patients with incomplete records were excluded. Variation in clinical parameters were compared over time. A p value of<0.05 was considered significant.

Results In all 79 patients were identified, mean age 71 years (64-78), 28% (n=22) were female, 20%(n=16) were current smokers and 28% (n=22) were habitual drinkers, while 47% (n=37) and 42% (n=33) were either on antiplatelets and/or anticoagulants respectively. Mean (+/- SD) baseline parameters were as follows Systolic BP mmHg=124.3 [21.8], Heart Rate=80 [72.0;93.0], Haemoglobin g/dL=8.0 [6.60;9.85], Urea mmol/L=8.5 [5.80;14.2]. While results at 24 hours were Systolic BP mmHg=106 [96.5;118], Heart Rate=88 [80.0;101], Haemoglobin g/dL=7.8 [6.50;8.60], Urea mmol/L=8.9 [6.10;14.4]. The changes in all clinical parameters at 24 hours were statistically significant, p<0.0001. Median (95% CI) changes were BP -20.5 [-24, -17.5], Heart rate+9 [6.5, 12.5], Urea+1.4 [0.9, 1.8] and Haemoglobin -1.3 [-1.7, -1]. Gender, age or anticoagulation use did not affect the differences in clinical status over time.

Conclusions In our cohort of patients with overt suspected small bowel bleeding, all clinical parameters regularly employed to assess and triage patients with GI bleeding were significantly worse 24 hours after admission. This could simply reflect a delay to diagnosis based on current management algorithms where suspected small bowel bleeding is defined by negative initial upper and lower GI investigations. As clinical deterioration occurs over time, these patients require close monitoring. Early introduction of small bowel capsule should be considered after a negative upper GI endoscopy.

 

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Conflicts of interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
15 April 2024