Potential benefits of a PEG versus NGT
-less tube displacement/reinsertion
-reduced risk of aspiration
better cosmetic appearance
-safer, more reliable enteral access
-optimizes development of oral skills
-larger diameter, shorter length - less blockage
-cost-effective longer-term solution
-less interference in daily activities/better quality of life
-avoids nasal irritation/congestion/septa trauma
-reduces anxiety at mealtimes, shorter feeding times
-reduces ENT complications
Absolute Contraindications to PEG
Absolute Contraindications:
- uncorrectable coagulopathy (INR > 1.5, pTT> 50s, plt count < 50,000/mm3)
- clear interposition of enlarged organs (liver, colon)
- frank peritonitis
Other Considerations
- portal hypertention - severe peristomal varices can develop
- gastric varices
- ascites
- peptic ulcer disease/active gastritis
- severe neuromuscular/neurodevelopmental disorders with mod-to-severe kyphoscolioses
- peritoneal dialysis
- microgastria
- large hiatal hernia
- severe psychosis/anorexia nervosa
- lack of direct indentation on endoscopy views or clear identification by transillumination of the stomach wall during the actual procedure
Indications for PEG
- optimize nutritional status and growth
- preempt undernutrition (e.g. chemotherapy/radiotherapy and transplant)
- maintain hydration
- support unpalatable diet (metabolic disease, exclusive enteral nutrition
- decompress gastric stasis
- improve adherence to medication
- ensure safe feeding access/prevent aspiration
- improve QOL for child and caregiver
Complications of PEG
Major Complications
- Gastric perf - Gastrocolic fistula - Internal leakage - Track dehiscence - Peritonitis - Periprocedural aspiration pneumonia - Subcutaneous abscess - Bleeding - Gastric outlet obstruction - Cellulitis/nec fas - Massive pneumoperitoneium - Buried bumper syndrome
Minor Complications:
- Tube blockage - Tube dislodgement - Tube degradation - External leackage - Unplanned removal - Transient gastroparesis - Gastric wall ulceration - Overgranulation - Site infections
Contraindications and relative contraindications for Video Capusle Endoscopy
- Suspected obstruction
- Bowel stricture
- Bowel fistula
- Known obstructing bowel tumor or lesion
- Smaller sized patient
- Allergy to material
- Presence of pacemaker or other electromagnetic device that interferes with CE electronics
Adequate size of liver bx for BA
- Core specimens for BA are “adequate” if they measure:
○ At least 2.0 cm long and 0.2 mm wide
○ Or contain at least 10 portal tracts
-Wedge specimens are adequate if they contain at least 6 complete portal tracts independent of the liver capsule- A core of 20 mm long and 1.8 m in diameter is require for optimal “routine” histopathological interpretation
- A liver sample should be stored in formalin for histopathological investigation with, if possible, a portion snap frozen and held for additional special studies
Minor complications of Liver Bx
- Minor complications:
○ Pain - transient localized discomfort
○ Bleeding- subcapsular that does not require transfusion or prolong hosp (2.8%)
§ No significant risk found btw spring loaded or aspiration needles
○ Infection
○ Minor bile leak or hemobilia
○ Ateriovenous fistula
Major complications of Liver bx
- Major complications: ○ Perforation § Pneumothroax and hemothorax (0.2%) § Bowel perforation § Biliary perforation (0.6% for biliary leak/hemobilia) ○ Intraperitoneal hemorrhage ○ Bile peritonitis ○ Infection ○ Inadvertent renal puncture/bx ○ Death (0.6%)
Risk factors for Liver Bx Complication
- LMWH use
- Focal lesion
- ALF
- Infants < 3 mon
- Massive ascites
- Thrombocytopenia
- Previous malignancy or BMT
- CRF
- Biliary tract dilatation
What does Masson Trichrome stain
- Type I Collagen
- Good for showing fibrosis
What does Reticulin stain
- Type III collagen
- Necrosis and regeneration
What does PAS with diastase stain
○ Shows complex carbohydrates - nonglycogen
Good for bile duct injury (basement membranes), necrosis (lipofuscin-filled macrophages) and alpha1antitrypsin globules
What does Iron stain
○ Shows hemosiderin
Good for brown pigments (hemosiderin, lipofuscin and bile)
