Standardized approach to small bowel bleeding in a hierarchical healthcare network with varying levels of complexity

Abordagem sistematizada para sangramento do intestino médio em uma rede hierárquica de saúde com diferentes níveis de complexidade

ABSTRACT

Background:  The systematized approach to patients with small bowel bleeding (SBB) can reduce risks and costs for both patients and the Unified Health System (SUS).

Aim:  Evaluate the evolution of the systematized approach to SBB in a regulated, hierarchically organized healthcare network of varying complexity.

Methods:  Analysis of the medical records of patients with SBB treated at a tertiary, public, and teaching hospital in two distinct periods: before the implementation of a specialized service and algorithm for SBB (2001–2014, group without algorithm—GSA) and after the establishment of a trained, dedicated team, availability of capsule endoscopy and enteroscopy (2015–2023, group with algorithm—GCA). Demographic, clinical, and care-related data from 184 patient records were collected and entered into the REDCap platform. Additionally, a cost analysis was conducted.

Results:  Among the 184 patients, 82 (45%) were in the GSA group and 102 (55%) in the GCA group. The average number of specific exams per patient was 7.19 in GSA and 6.37 in GCA (p=0.02, p<0.05). Blood transfusions were performed in 64 patients (78.05%) in GSA and 68 patients (66.67%) in GCA (p=0.05). The average time to reach diagnosis was 309.9 weeks in GSA and 75.37 weeks in GCA (p<0.01). The average hospital stay was 7.57 weeks in GSA and 2.55 weeks in GCA (p<0.01). In GSA, 19 patients (23.2%) died due to SBB, while in GCA only six did (5.9%) (p=0.001, p<0.05). The average cost was higher compared to GCA (p<0.01).

Conclusions:  The results of organizing a reference service for SBB care support are sufficient to subsidize the planning of services and regional healthcare networks.

Keywords:
Hemorrhage; Intestine, Small; Capsule Endoscopy; Double-Balloon Enteroscopy; Algorithms

ARTICLE HIGHLIGHTS

Obscure gastrointestinal bleeding (OGIB), now referred to as small bowel bleeding (SBB), is characterized by persistent or recurrent blood loss not clarified by conventional upper and lower gastrointestinal endoscopy.

Small bowel bleeding accounts for approximately 5% of gastrointestinal bleeding cases.

High-cost exams, such as capsule endoscopy (CE) and device-assisted enteroscopy, may expedite effective diagnosis, reducing the need for repetitive testing, transfusions, and hospitalizations.

The establishment of a standardized investigation flowchart can improve prognosis and optimize the cost-benefit ratio of diagnostic procedures.

VISUAL ABSTRACT

CENTRAL MESSAGE  Obscure gastrointestinal bleeding (OGIB), now referred to as small bowel bleeding (SBB), is characterized by persistent or recurrent blood loss not clarified by conventional upper and lower gastrointestinal endoscopy. The difficulty in establishing an etiological diagnosis and providing specific treatment results in frequent repetition of endoscopic and imaging exams, increased need for blood transfusions, prolonged hospital stays, and higher healthcare costs. The incorporation of technological resources and the training of specialists enable the adoption of diagnostic and therapeutic algorithms for patients with SBB.

PERSPECTIVES  The organization of a reference care service for SBB improved the probability of achieving a diagnosis in a shorter timeframe, reduced the need for hospitalization and surgical intervention, and lowered morbidity and mortality rates, thereby offering a better cost-effectiveness ratio. These findings are sufficient to support the planning of services and regional healthcare networks.