Procedures

Question 1

Potential benefits of a PEG versus NGT

Answer 1

-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

Question 2

Absolute Contraindications to PEG

Answer 2

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

Question 3

Indications for PEG

Answer 3

• 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

Question 4

Complications of PEG

Answer 4

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

Question 5

Contraindications and relative contraindications for Video Capusle Endoscopy

Answer 5

1. Suspected obstruction
2. Bowel stricture
3. Bowel fistula
4. Known obstructing bowel tumor or lesion
5. Smaller sized patient
6. Allergy to material
7. Presence of pacemaker or other electromagnetic device that interferes with CE electronics

Question 6

Adequate size of liver bx for BA

Answer 6

• 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

Question 7

Minor complications of Liver Bx

Answer 7

• 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

Question 8

Major complications of Liver bx

Answer 8

- 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%)

Question 9

Risk factors for Liver Bx Complication

Answer 9

• LMWH use
  
  • Focal lesion
  • ALF
  • Infants < 3 mon
  • Massive ascites
  • Thrombocytopenia
  • Previous malignancy or BMT
  • CRF
    
    • Biliary tract dilatation

Question 10

What does Masson Trichrome stain

Answer 10

• Type I Collagen

- Good for showing fibrosis

Question 11

What does Reticulin stain

Answer 11

• Type III collagen

- Necrosis and regeneration

Question 12

What does PAS with diastase stain

Answer 12

○ Shows complex carbohydrates - nonglycogen

Good for bile duct injury (basement membranes), necrosis (lipofuscin-filled macrophages) and alpha1antitrypsin globules

Question 13

What does Iron stain

Answer 13

○ Shows hemosiderin

Good for brown pigments (hemosiderin, lipofuscin and bile)