Acute upper gastrointestinal bleeding in childhood: development of the Sheffield scoring system to predict need for endoscopic therapy.

BACKGROUND/AIMS: Upper gastrointestinal bleeding (UGIB) is a rare and potentially life-threatening condition in childhood. In adults with UGIB, validated scoring systems exist, but these are not applicable to children. The aim of this study was to construct a clinical scoring system to accurately predict the need for endoscopic haemostatic intervention. METHODS: A retrospective data collection occurred during a 3-year period at a tertiary children's hospital. A total of 69 patients who had had endoscopic assessment were divided into group 1 (no intervention required) and group 2 (intervention required). A wide range of clinical parameters were collated including preexisting conditions, melaena, haematemesis and degree, transfusion requirement, parameters of hypovolaemia, presenting haemoglobin (Hb), Hb drop during 24 hours, platelet count, coagulation indices, liver function tests, and urea/electrolytes. RESULTS: Parameters that reached statistical significance for endoscopic intervention (group 1 vs group 2) were the presence of significant preexisting condition, melaena, large haematemesis, heart rate (HR) >20 mean HR for age, prolonged capillary refill time (CRT), Hb drop of >20 g/L, need for fluid bolus, need for blood transfusion (Hb < 80 g/L), and need for other blood products. Using these parameters, a number of scoring models were tested, and the most predictive resulted in a scoring system constructed with a total of 24 and a cutoff for intervention of 8. According to this design, there were 4 false-negatives in the interventional group with 3 false-positives in the noninterventional group. This resulted in a positive predictive value (PPV) of 91.18% (95% confidence interval [CI] 76.3-98.04), negative predictive value (NPV) of 88.57% (95% CI 73.24-96.73), sensitivity of 88.7% (95% CI 73.24-96.73), and specificity of 91.18% (95% CI 76.3-98.04). CONCLUSIONS: In our study population, we were able to formulate a scoring system with reasonable PPV and NPV to predict the need for endoscopic intervention in acute UGIB in children. Prospective evaluation is now required.

Blood ordering for haematemesis.

The blood ordering practices for acute upper gastrointestinal bleeding were assessed in 162 consecutive patients presenting with haematemesis admitted via the Accident and Emergency Centre. The patients were classified according to their estimated blood loss and haemoglobin level at the time of admission, and the amounts of blood ordered and given in the next 24 h were determined. The crossmatch: transfusion (CT) ratio was very high in one group (14.9), although the overall ratio of 2.4 was acceptable. There were marked variations in the ordering pattern of different medical officers, possibly because of the absence of clear guidelines. From the data obtained, a set of guidelines for ordering blood in this clinical condition was developed. It was estimated that if these guidelines had been used, there would have been a reduction of one-third of all units crossmatched, and that the overall CT ratio would have been reduced to 1.6.