This blog entry has abbreviated/summarized the presentations. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.  Link to full syllabus:

PG Course Syllabus 2014

The Dreaded Wake-Up Call (Part A) –Maercedes Martinez (NY Presbyterian Hospital) (pg 55 syllabus)

Variceal Bleeding – “When RED is not attractive”

Discussed presentation of varices (gastric/esophageal), etiologies, association with portal hypertension. Reviewed variceal grading.

Medical management:

• PICU admit
• Avoid over-transfuse (goal ~ 8 g/dL)
• Correct coagulopathy
• Role of platelets is controversial/if trouble with endoscopy, may be helpful
• Suggested dosing for octreotide/somatostatin: 2 mcg/kg bolus then 1-2 mcg/kg/hr (typically max 100 mcg/hr), antibiotics
• Most patients do not require emergency overnight endoscopy.
• Sclerotherapy and banding reviewed -including complications.
• Transjugular intrahepatic portosystemic shunts (TIPS) and Surgical options briefly discussed

The Dreaded Wake-Up Call (Part B) –Lee Bass (Children’s Hospital of Chicago) (pg 67 in syllabus)

Nonvariceal GI Bleeding Management

• Start with ABCs -airway, breathing, cardiovascular –fluid resuscitation/blood products
• Restrictive transfusion strategy (Hgb <7 as threshold) (Villanueva et al NEJM 2013) helpful for survival in adults
• Treatment with PPI improves rates of high risk stigmata on endoscopy
• Prokinetics can improve identication of bleeding lesions
• Preparation for endoscopy is most important (slide on page 70 of syllabus)
• Also on page 70, pictures of typical findings with GI bleeding: nonbleeding vessel, adherent clot, spurting blood, oozing blood, and flat pigmented spot and clean base
• Endoscopic management -combination of two techniques appears to be more effective than single method. injection, thermal probe, hemoclips, hemospray (not available in U.S.

Endoscopic Interventions for Biliary Tract Disease — Victor Fox (pg 75 in Syllabus)

Choledocholithiasis is most common need for interventional biliary endoscopy and increasing related to increase risk with increase in obesity.(Buxbaum J. Gastrointest Clin N Am 2013;23:251‐75)

Requires advanced training to achieve high level of skill and experience

• >200 cases needed to achieve selective cannulation required for interventions
•  Acquisition and maintenance of skills by pediatricians is controversial

Other points:

• No equipment is favorably designed for young or small children
• Success and complication rates are similar as in adults (Varadarajulu S, et al. Gastrointest Endosc 2004;60:367)
• Discussed biliary strictures (etiologies, management/stents), choledochocele, papillotomy, bile leak (Soukup ES et al. J Pediatr Surg 2014;49:345‐8)

• “Most strictures and leaks can be successfully managed endoscopically without need for surgical intervention”

Take-home message: Endoscopic biliary interventions are increasingly employed in children with similar safety and technical success as adult patients

Related blog posts:

• All bleeding stops | gutsandgrowth
• Transfusion strategy in acute GI bleeding | gutsandgrowth
• Is a Continuous IV Proton Pump Inhibitor Really Necessary …
• Why an ERCP Study Matters to Pediatric Care | gutsandgrowth
• What and When for ERCP with Gallstone Pancreatitis …
• Indomethacin to prevent post-ERCP pancreatitis …
• What is the role for preventing variceal bleeding in Biliary …
• Expert advice on portal hypertension | gutsandgrowth

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