Endoscopic Experts Needed In Pediatrics

A recent study (A Schmidt et al. Gastroenterol 2018; 155: 674-86) shows how a new endoscopic technique, over-the-scope clips (OTSC), are more effective than standard endoscopic therapy for patients with recurrent bleeding of peptic ulcers.

Key finding: A multicenter prospective randomized unblinded study with 66 patients (33 in each arm) with found that hemostasis with OTSC had a failure rate (further bleeding) of 15.2% compared with 57.6% in those with standard therapy.

The authors note that standard endoscopic techniques are effective in more than 90% with rebleeding rates of 2-10%.  In those with rebleeding, followup endoscopy has a much lower success rate.

My take:

  • This study highlights a problem in pediatric endoscopy –the lack of expertise in these rare cases.  To learn even ‘standard’ endoscopic therapy, most pediatric GI fellows will need to collaborate with adult gastroenterologists in order to have exposure to a sufficient number of cases.
  • The development of alternatives like hemospray (Hemospray for GI Bleeding) which is technically-easy should be helpful for pediatric endoscopists with less endoscopic training.

Related article: 

P Tran et al. JPGN 2018; 67: 458-63.  This retrospective analysis of 11 pediatric cases (median age 14.7 yrs) reported technical success in all cases, though 2 patients with anastomotic ulcers requred additional medical intervention. The article has some pretty cool pictures.

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Transfusion strategy in acute GI bleeding

A recent study shows that holding off on blood transfusions can improve survival with severe acute upper gastrointestingal bleeidng (NEJM 2013; 368: 11-21).  This finding is not unexpected as this has been shown in observational studies.  In addition, in critical care patients without acute GI bleeding, a restrictive approach to transfusions has also been beneficial.

This study which enrolled 921 patients (>18 years) assigned 461 to a restrictive transfusion strategy (transfusion if <7 g/dL or at discretion of physician) and 460 to a “liberal” strategy (transfusion if <9 g/dL).

In additon to fewer transfusions, the restrictive group had improved survival:

  • 225 in the restrictive group did not require a blood transfusion compared with 65 in the liberal group
  • Survival at 6 weeks: 95% in the restrictive group compared with 91% in the liberal group.  Hazard ratio 0.55 (confidence interval 0.33 to 0.92) –a 45% reduction in the relative risk of 45-day mortality.
  • Recurrent bleeding occurred in 10% of the restrictive group compared with 16% of the liberal group.
  • The patients with cirrhosis (and Child-Pugh class A or B) were most likely to benefit from a restrictive approach with hazard ratio of 0.30.  Child-Pugh class C did not have a benefit from a restrictive approach with hazard ratio of 1.04.  With the liberal approach, there was a higher portal-pressure gradient within the first five days.

The reasons for bleeding in this study included peptic ulcers in about 50%, and varices in 24%.  The other causes included Mallory-Weiss tears, erosisve gastritis/esophagitis, and neoplasms.

Why does giving less blood result in better outcomes?

  1. Transfusion may impair hemostasis in several ways.  It may result in abnormalities in coagulation properties.  It may counteract splanchnic vasoconstrictive response.  And, in those with cirrhosis, it can increase portal pressure (even in the presence of somatostatin).  All of these mechanims may increase rebleeding.
  2. In addition, systemic effects from transfusion can include circulatory overload and pulmonary edema.

Also (unrelated to this posting), a thoughtful comment to a recent post on FDA regulations was posted by Ben Gold (Can the FDA prohibit free speech? | gutsandgrowth).

Related blog references: