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Predictors of clinically significant upper gastrointestinal hemorrhage among children with hematemesis
Stephen B Freedman1, Charles Stewart, Maggie Rumantir
1Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON, Canada. stephen.freedman@sickkids.ca
Insights
Clinically significant upper gastrointestinal hemorrhage (UGIH) is uncommon in children with hematemesis, affecting only 4% of cases. Key predictors include melena, hematochezia, or vomiting large amounts of fresh blood.
Area of Science:
- Pediatric Gastroenterology
- Emergency Medicine
Background:
- Hematemesis in children can be alarming, necessitating evaluation for significant upper gastrointestinal hemorrhage (UGIH).
- Understanding the incidence and predictors of UGIH in pediatric patients is crucial for effective management.
Purpose of the Study:
- To determine the proportion of children presenting with hematemesis who experience clinically significant UGIH.
- To identify clinical and demographic variables that predict the occurrence of significant UGIH in pediatric patients.
Main Methods:
- A retrospective cohort study reviewed emergency department visits of children (0-18 years) with hematemesis from 2000-2007.
- Significant UGIH was defined by hemoglobin drop >20 g/L, blood transfusion, or emergent endoscopy/surgery.
- Statistical analysis identified risk factors associated with clinically significant UGIH.
Main Results:
- Only 4% (27/613) of children with hematemesis experienced a clinically significant UGIH.
- Predictors of significant UGIH included older age, vomiting large amounts of fresh blood, melena, significant medical history, unwell appearance, and tachycardia.
- Melena, hematochezia, unwell appearance, or large volume of fresh vomitus accurately identified all cases of significant hemorrhage (100% sensitivity).
Conclusions:
- Clinically significant UGIH is infrequent in pediatric hematemesis cases.
- Certain clinical signs and symptoms, such as melena and large volume of fresh blood in vomitus, are highly predictive of significant UGIH.
- Well-appearing children without these specific indicators are unlikely to have a clinically significant UGIH.
Objectives:
The aim of the study was to determine the proportion of children with hematemesis who experience a clinically significant upper gastrointestinal hemorrhage (UGIH) and to identify variables predicting their occurrence.
Methods:
A retrospective cohort study was conducted. All of the emergency department visits by children ages 0 to 18 years who presented with hematemesis between 2000 and 2007 were reviewed. The primary aim of the study was to determine the proportion of children who developed a clinically significant UGIH; the secondary aim was to identify risk factors predictive of a clinically significant UGIH. A significant UGIH was defined by any of the following: hemoglobin drop >20 g/L, blood transfusion, or emergent endoscopy or surgical procedure.
Results:
Twenty-seven of 613 eligible children (4%; 95% confidence interval 3%-6%) had a clinically significant UGIH. Clinically significant hemorrhages were associated with older age (9.7 vs 2.9 years; P<0.001), vomiting moderate to large amounts of fresh blood (58% vs 20%; P<0.001), melena (37% vs 5%; P<0.001), significant medical history (63% vs 24%; P<0.001), unwell appearance (44% vs 6%; P<0.001), and tachycardia (41% vs 10%; P<0.001). The frequency of laboratory investigations increased with age (P<0.001). The hemoglobin level was the only laboratory investigation whose results differed between those with and without significant bleeds. The presence of any one of the following characteristics identified all of the children with a clinically significant hemorrhage: melena, hematochezia, unwell appearance, or a moderate to large volume of fresh blood in the vomitus, sensitivity 100% (95% confidence interval 85%-100%).
Conclusions:
The occurrence of a clinically significant UGIH was uncommon among children with hematemesis, especially in well-appearing children without melena, hematochezia, or who had not vomited a moderate to large amount of fresh blood.
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