#NASPGHAN18 Highlights and Tweets (part 1)

I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.

Here are a couple of highlights for me:

Slides from postgraduate course on CVS from Dr. Katja Kovacic

The slide from Dr. Lightdale (pg 22 in Syllabus) below suggests it is OK for scope if platelets >20K and OK for biopsies if platelets >50K. It is worth noting that some adult data indicate that even lower biospy thresholds are reasonable for biopsies (Post: Lower Endoscopic Thresholds for Thrombocytopenia). As always, one needs to consider carefully the risks compared with the benefits.

From Postgraduate Course



Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Improved Understanding 18 Years Later

A deeply painful experience for me occurred 18 years ago when a child that I cared for had a complication following an endoscopy.  Now, a recent publication (A Sierra et al. JPGN 2016; 63: 627-32) provides relevant information.  To be clear, this article would not have averted the complication but may help explain why it happened.

This retrospective study from 2010-2014 identified 7 cases of biopsy-induced intraduodenal hematoma (IDH) from a total of 2705 nontherapeutic upper endoscopies and 1163 duodenal biopsies.

Key findings:

  • 6 of 7 children had undergone a bone marrow transplantation and were at risk for graft-versus-host disease (GVHD)
  • 1 had Noonan syndrome
  • Thrombocytopenia was NOT correlated with IDH
  • No early perforations were associated with IDH

As part of this study, the authors reviewed the entirety of published IDH in children, 47 cases.  One prior author, Sahn et al (JPGN 2015; 60: 69-74) suggested that any organ transplant could increase the risk of IDH.  In this series, 29% of their patients had undergone transplantation (2 liver, 1 heart, 1 BMT).  Interestingly, among the entire 47 cases, there had been another report of a child with Noonan syndrome, suggesting some underlying susceptibility in the coagulation or platelet function pathways.

Clinical features of IDH:

  • Following endoscopy, particularly the first 3 days, signs/symptoms included epigastric pain, abdominal tenderness, and vomiting
  • Imaging including U/S, CT and MRI can confirm diagnosis
  • Resolution can take 2-3 weeks, during which parenteral nutrition is needed
  • IDH can cause acute pancreatitis or obstructive cholestasis
  • In trauma-induced IDH, surgery is much more likely than with endoscopic/biopsy-induced IDH

My take: BMT (and other types of transplantation) markedly increase the risk of biospy-induced duodenal hematoma. In this series, 7% of BMT patients had IDH compared with 0.1% of all others.

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