Adverse Events Following Pediatric Endoscopy –Underestimated Previously

A recent study (RE Kramer, MR Narkewicz. JPGN 2016; 62: 828-33) report the frequency of adverse events that occurred within 72 hours in a prospective observational cohort of 9577 patients from a single center.

The authors characterized complications more precisely and identified a much higher rate of complications than what has previously been reported.  Key findings:

  • The overall adverse event rate was 2.6% with 1.7% of all cases requiring unanticipated medical care.
  • Absolute risk of bleeding was 0.11%, infection 0.07%, and perforation 0.1% (n=12).  In total, these standard measures of complications were 0.28%.
  • Advanced and therapeutic cases had much higher rates of adverse events. Perforations occurred after esophageal dilatation (5), esophageal food impaction (1), polypectomy (4), and primary GJ placement (2).
  • Adverse rate with ERCP was 11.54%
  • Adverse rate with PEG was 10.71%
  • Adverse rate with dilatation was 10.94%.  It is noted that a total of 319 dilatations were reviewed.  5 had perforations.
  • Adverse rate with polypectomy was 6.27%.  It is noted that a total of 128 polypectomies were reviewed.  4 had perforations.
  • The authors did not identify a significantly higher complication rate with trainee physicians.

As noted in a previous entry (see below), studies in adults have an estimated a perforation rate of 0.09% and serious complication rates (GI and non-GI complications) of 0.15% for upper endoscopy and of 0.2% for colonoscopy. In addition, a large pediatric study of endoscopies, found a perforation rate of 0.014% for EGDs and 0.028% for colonoscopies. Thus, this report identifies a higher rate (10-fold) of perforation (driven by therapeutic endoscopy) and a much higher rate of adverse events, including 2.08% in diagnostic EGD and 3.9% for diagnostic colonoscopy.  Furthermore, for diagnostic EGD and for diagnostic colonoscopy, grade 2 (needing ER or unanticipated physician evaluation) or higher adverse events occurred in 1.21% and 2.31% respectively.

My take: Using a broader (and more accurate) definition of complications after endoscopy, the authors have demonstrated a much higher rate of adverse events, particularly following dilatation, PEG, polypectomy, and ERCP.  This report indicates that our preop counseling needs to be modified to inform families that complications are not quite so rare.

Related blog post:  High Endoscopy Complication Rate After Intestinal …

Complication -Unrelated to endoscopy:

pontine myelinosis

Lower Endoscopic Thresholds for Thrombocytopenia

According to an advances in endoscopy report (Ross, WA. Gastroenterology Hepatology 2015; 11: 115-17), lower platelet thresholds are indicated for many endoscopic procedures.  The author works at MD Anderson Cancer Center in Houston.

Key points:

  • We feel that the traditional threshold of 50,000 platelets/microliter that many doctors adhere to or aim for should be put aside, and a lower platelet threshold of perhaps 25,000 or 30,000 platelets/microliter should be employed for endoscopic procedures, including biopsies.
  • “We found that therapeutic maneuvers could be performed to control bleeding.”
  • “This change would require fewer platelet transfusions to prepare a patient for endoscopy.”
  • Based on their published experience (Krishna SG, et al. “Saftey of endoscopic interventions in patients with thrombocytopenia.” Gastrointest Endosc 2014; 80: 425-34), the author notes that “polypectomy could probably be performed with a platelet count under 50,000/microliter, likely in the 30,000-40,000/microliter range, particularly if the polyp was small (<10 mm).”  They caution that cold snare technique may be safer in this setting but is not suitable for larger polyps.
  • Other preventative measures include stopping aspirin use, limiting the number and size of biopsies, and using non thermal means to help stop bleeding, such as clips or injections.
  • “Performing an endoscopic procedure in a patient with an extremely low platelet count, such as 5000/microliter, is associated with a high risk of bleeding.”

“If the procedure is just a simple biopsy, a platelet count of 25,000/microliter to 30,000/microliter should suffice.”

Take-home message: While the data that the author references is derived from adults, it is likely that in pediatrics that endoscopy, if needed, can be performed in patients with platelet counts less than 50,000/microliter.

Liver Biopsy -Risks and Benefits

Even in the ‘old USA,’ there is a mortality risk from liver biopsy in the pediatric population.  A recent study from Los Angeles confirms this (JPGN 2013; 57: 644-48).

This retrospective review of all children (n=213 children & 328 biopsies) who underwent a percutaneous liver biopsy between 2008-2011 were examined.  These biopsies were completed by radiology with ultrasound or CT.  Gel foam was injected in cases of multiple biopsies.

Results:

  • 9 (4.2%) dropped hemoglobin > 2 /dL.
  • 7 (3.3%) needed a transfusion.
  • 1 (0.5%) died.  This was a 2.6 kg infant seen for transplant evaluation.
  • 63 (19%) had insufficient samples for definitive histologic evaluation.
  • In 81% of initial biopsies, “a definitive pathologic diagnosis was obtained.”
  • Biopsies for unexplained elevation of liver function tests were nondiagnostic in 34.9%.

The authors take: “our data demonstrate that percutaneous liver biopsy is generally safe; yet, finite risk remains, with bleeding-related complications occurring 5.2% of children.”

Bottomline: make sure you need the information from the liver biopsy enough to justify the risk, particularly in small children and in those at increased risk for bleeding.

Related blog post (with annotated references):

Liver biopsy risk in children | gutsandgrowth