3373 Acute middle gastrointestinal bleeding: diagnostic implications and cost analysis.

Abstract

Separating traditional acute lower gastrointestinal bleeding into small bowel bleeding (middle gastrointestinal bleeding, MGIB) and colonic bleeding (CB) has helped delineate unique characteristics of bleeding from the two locations. In order to further characterize acute MGIB, clinical characteristics, in-patient work-up and hospital costs incurred were compared between consecutive patients diagnosed with upper gastrointestinal bleeding (UGIB), MGIB and CB. Patients with MGIB were identified by nuclear medicine scans and angiography records, and corroborated with endoscopy and inpatient records over a 4-year period. Matching numbers of consecutive patients with UGIB and LGIB formed the comparison groups, identified from interrogation of the endoscopy database. RESULTS: Twenty-nine patients with MGIB (15F/14M, mean age 68.6 ± 2.4 yr) were identified between 1995 and 1998. The comparison groups consisted of 29 patients with UGIB (13F/16M, mean age 58.3 ± 4.0 yr), and 29 patients with CB (13F/16M, mean age 70.3 ± 2.3 yr). Presentation of MGIB was indistinguishable from other bleeding sites, with stool color resembling bright- or dark-red blood in 41%, melena in 18%, and maroon stool in 41%. Patients with MGIB had a significantly higher in-hospital morbidity requiring longer hospital stays, and incurring significantly higher costs while in hospital, compared to CB or UGIB (p<0.001); there were no significant differences in these parameters between CB and UGIB. Patients with MGIB required 5.3 ± 0.5 investigative procedures (endoscopy, nuclear medicine scans, angiography, or combinations thereof) for localization of the bleeding source, as compared to 1.5 ± 0.1 procedures for UGIB and 2.1 ± 0.2 procedures for CB (p ≤ 0.02 across groups). Seventy-nine percent of patients with MGIB required >3 diagnostic procedures, compared to 0% of patients with UGIB and 14% of CB (p<0.0001). There was 10% mortality among patients with MGIB; there were no deaths among patients with CB or UGIB. CONCLUSIONS: These results suggest that: 1) MGIB has significantly higher morbidity and differing outcomes (longer hospital stay, higher hospital costs) compared to UGIB and CB, 2) Utilization of >3 diagnostic procedures in the localization of an acute bleeding source should increase the index of suspicion for a small bowel bleeding source, 3) Since presentation can be identical to CB or UGIB, early identification of a potential small bowel bleeding source may help improve the diagnostic outcome while decreasing the cost of hospitalization.