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Mortality Associated with Gastrointestinal Bleeding in Children: a Retrospective Cohort Study

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Mortality Associated with Gastrointestinal Bleeding in Children: a Retrospective Cohort Study Children's Mercy Kansas City SHARE @ Children's Mercy Manuscripts, Articles, Book Chapters and Other Papers 3-7-2017 Mortality associated with gastrointestinal bleeding in children: A retrospective cohort study. Thomas M. Attard Children's Mercy Hospital Mikaela Miller Children's Mercy Hospital Chaitanya Pant Ashwath Kumar Mike Thomson Follow this and additional works at: https://scholarlyexchange.childrensmercy.org/papers Part of the Digestive System Commons, Gastroenterology Commons, and the Pediatrics Commons Recommended Citation Attard, T. M., Miller, M., Pant, C., Kumar, A., Thomson, M. Mortality associated with gastrointestinal bleeding in children: A retrospective cohort study. World journal of gastroenterology : WJG 23, 1608-1617 (2017). This Article is brought to you for free and open access by SHARE @ Children's Mercy. It has been accepted for inclusion in Manuscripts, Articles, Book Chapters and Other Papers by an authorized administrator of SHARE @ Children's Mercy. For more information, please contact [email protected]. Submit a Manuscript: http://www.wjgnet.com/esps/ World J Gastroenterol 2017 March 7; 23(9): 1608-1617 DOI: 10.3748/wjg.v23.i9.1608 ISSN 1007-9327 (print) ISSN 2219-2840 (online) ORIGINAL ARTICLE Retrospective Cohort Study Mortality associated with gastrointestinal bleeding in children: A retrospective cohort study Thomas M Attard, Mikaela Miller, Chaitanya Pant, Ashwath Kumar, Mike Thomson Thomas M Attard, Department of Gastroenterology, Children’s Mercy Hospital, Adele Hall, 1605.00, 2401 Gillham Rd, Kansas, Mercy Hospital, Kansas, MO 64108, United States MO 64108, United States. [email protected] Telephone: +1-816-3028149 Mikaela Miller, Clinical Decision Support, Children’s Mercy Fax: +1-816-2341553 Hospital, Kansas, MO 64108, United States Received: September 7, 2016 Chaitanya Pant, Department of Gastroenterology, The Peer-review started: September 10, 2016 University of Kansas Hospital, Kansas, KS 66160, United States First decision: October 28, 2016 Revised: November 11, 2016 Ashwath Kumar, University of Missouri Medical School, Accepted: January 2, 2017 Kansas, MO 64108, United States Article in press: January 3, 2017 Published online: March 7, 2017 Mike Thomson, Sheffield Children’s Hospital, Western Bank, Sheffield S10 2TH, United Kingdom Author contributions: Attard TM and Pant C designed the research; Miller M performed the research; Miller M and Kumar Abstract A contributed analytic tools; Attard TM, Miller M and Thomson AIM M wrote the paper. To determine the clinical characteristics of children with gastrointestinal bleeding (GIB) who died during the Institutional review board statement: The study was reviewed course of their admission. and approved for publication by our Institutional Reviewer. METHODS Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript. We interrogated the Pediatric Hospital Information System database, including International Classification Data sharing statement: The original anonymous dataset is of Diseases, Current Procedural Terminology and available on request from the corresponding author at tmattard@ Clinical Transaction Classification coding from 47 cmh.edu. pediatric tertiary centers extracting the population of patients (1-21 years of age) admitted (inpatient or Open-Access: This article is an open-access article which was observation) with acute, upper or indeterminate GIB selected by an in-house editor and fully peer-reviewed by external (1/2007-9/2015). Descriptive statistics, unadjusted reviewers. It is distributed in accordance with the Creative univariate and adjusted multivariate analysis of the Commons Attribution Non Commercial (CC BY-NC 4.0) license, associations between patient characteristics and which permits others to distribute, remix, adapt, build upon this treatment course with mortality was performed with work non-commercially, and license their derivative works on mortality as primary and endoscopy a secondary different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons. outcome of interest. All analyses were performed using org/licenses/by-nc/4.0/ the R statistical package, v.3.2.3. Manuscript source: Unsolicited manuscript RESULTS The population with GIB was 19528; 54.6% were Correspondence to: Thomas M Attard, MD, Consultant male, overall mortality was 2.07%; (0.37% in patients Gastroenterologist, Department of Gastroenterology, Children’s with the principal diagnosis of GIB). When considering WJG|www.wjgnet.com 1608 March 7, 2017|Volume 23|Issue 9| Attard TM et al. Mortality associated with pediatric gastrointestinal hemorrhage only the mortalities in which GIB was the principal This deficit hinders the evidence based allocation of diagnosis, 48% (12 of 25 principal diagnosis GIB resources and the implementation of standardized mortalities) died within the first 3 d of admission, protocols, potentially adversely impacting outcomes whereas 19.8% of secondary diagnosis GIB patients in children. died with 3 d of admission. Patients who died were One of the co-authors, has identified the presence more likely to have received octreotide (19.8% c.f. of > 3 comorbid conditions, presentation to a teaching 4.04%) but tended to have not received proton pump hospital, the presence of upper GIB; age under 5 inhibitor therapy in the first 48 h, and far less likely to years and health coverage with private insurance as have undergone endoscopy during their admission (OR independent risk factors associated with an increased = 0.489, P < 0.0001). Chronic liver disease associated rate of hospital admission with GIB[5]. Hemorrhage with a greater likelihood of endoscopy. Mortalities occurred in 0.5% of all discharges from inpatient care, were significantly more likely to have multiple complex was more prevalent in males and older than 11 years. chronic conditions. Esophageal and intestinal perforation were identified as at highest risk of associated mortality, together CONCLUSION accounting for 17% of all patients with GI haemor- GIB associated mortality in children is highest within 7 rhage and who died[6]. d of admission. Multiple comorbidities are a risk factor Disease classification in adult GIB cannot be whereas early endoscopy during the admission is extrapolated to the pediatric population. Risk factors protective. identifiable in adults, foremost amongst which are age, non-steroidal anti-inflammatory drug, selective Key words: Pediatrics; Gastrointestinal hemorrhage; serotonin reuptake inhibitor, aspirin, antiplatelet and Endoscopy; Proton pump inhibitors; Mortality; Liver anticoagulant therapy and chronic renal and cardiovas- disease; Hospital Information Systems; Octreotide cular disease, are clearly not applicable to children[7]. © The Author(s) 2017. Published by Baishideng Publishing Conversely, the impact of predominantly pediatric and Group Inc. All rights reserved. especially neonatal disease processes (e.g., prema- turity) on the risk of GIB remain unknown. This limits Core tip: The management of gastrointestinal haem- the applicability of pre- and postendoscopic predictive orrhage in children is challenging insofar as the timing scoring systems [Rockall, Blatchford (aka Glasgow), and impact of different interventions remains poorly Addenbrooke] to identify patients at high risk (need defined. The authors analysed the characteristics and for blood transfusion, surgical intervention, rebleeding associated interventions associated with mortality as and mortality) and those requiring immediate endo- an outcome with gastrointestinial bleeding in children scopic intervention as opposed to at low risk who can past infancy. Death associated with gastrointestinal be safely discharged[8-10]. The Sheffield Scoring system haemorrhage was reported in 2% overall albeit less is, to date the only successful attempt at predicting (0.4%) in the cohort with haemorrhage as admitting the need for endoscopic hemostatic intervention based diagnosis. Patients who died were far less likely to have on the clinical presentation, hemodynamic parameters undergone endoscopy during the admission and more and need for blood products[11]. An understanding of likely to have received octreotide and less likely to have the epidemiologic context of GIB in children holds the received proton pump inhibitor therapy during the first promise of directing future research toward impro- two days of admission. ving predictive models of disease outcomes including mortality. The Pediatric Health Information System (PHIS) Attard TM, Miller M, Pant C, Kumar A, Thomson M. database is a repository of diagnostic, therapeutic and Mortality associated with gastrointestinal bleeding in children: procedure records from 48 regional pediatric tertiary A retrospective cohort study. World J Gastroenterol 2017; centers in the United States that has been in existence 23(9): 1608-1617 Available from: URL: http://www.wjgnet. since 2004, the data is available in de-identified form com/1007-9327/full/v23/i9/1608.htm DOI: http://dx.doi. to health information management administrators and org/10.3748/wjg.v23.i9.1608 academicians in the respective institutions. Herein we report on the PHIS recorded demo- graphic and clinical profile of children with upper or indeterminate gastrointestinal bleeding at admission INTRODUCTION or during their inpatient course and resulting in death. Gastrointestinal bleeding (GIB) is a foremost indica- tion for emergent diagnostic and therapeutic endos- copy
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