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research letter

Indian Pediatr 2017;54: 507-508

Novel Automated Hematology Parameters in Clinical Pediatric Practice

 

Shyam Sundar Sharma, *Lalit Bharadia and Deepak Shivpuri

Department of Pediatrics, Fortis Escorts Hospital and *Santokba Durlabhji Memorial Hospital; Jaipur, Rajasthan, India.
Email: [email protected]

  

 

We prospectively analyzed the coagulation abnormalities in 111 children with Celiac disease at diagnosis and its association with histology grade on duodenal biopsy; 27% had deranged prothrombin time. There was an increasing proportion of coagulopathy with progression of Marsh Grade on duodenal histology.

Keywords: Coagulation profile, Malabsorption, Prothrombin time.



C
eliac disease is characterized by small bowel villous atrophy and malabsorption. Associated vitamin K deficiency leads to prolonged prothrombin time [1]. We conducted this study to analyze the coagulation profile of children with celiac disease and assess its association with Marsh grading on histology.

Children aged 6 month to 18 years with suspected celiac disease were included based on symptoms and serology. Children with prior administration of vitamin K or those already on gluten free diet (GFD) were excluded. Complete blood count, prothrombin time and activated partial thromboplastin time (aPTT) were tested prior to endoscopy. International normalized ratio (INR) <1.4 was considered as normal [1]. We categorized deranged INR as mild (1.40-2.50), moderate (2.51-5.0) and severe (>5.0) [2]. Abnormal aPTT was defined as the difference between test and control of more than 8 seconds. Normal platelet counts were 1.50-4.50 lakhs/cu.mm. Children with Marsh histology grade II/ III were started on GFD and favorable responses confirmed on follow-up to establish definitive diagnosis of Celiac disease. Children with moderate and severely deranged prothrombin time were given one dose of parenteral Vitamin K before procedure.

Out of 152 children, 111 (65 boys, 46 girls) were confirmed to have celiac disease. The mean age at presentation was 5.5 years, the youngest being 7 months and oldest 15 years. Thirty (27%) children had deranged INR; none had any significant bleeding. The proportion of deranged INR was found to be increasing with the severity of histological abnormalities (Table I). Eighty-two (73.9%) children had normal platelet counts while thrombocytosis was seen in 26.1% children; 19% children had prolonged aPTT.

TABLE I INR in Different Marsh Grades of Celiac Disease
INR Marsh Marsh Marsh Marsh Total
grade 2 grade 3a grade 3b grade 3c (n=11)
(n=9) (n=16) (n=29) (n=57)
<1.40 8 (88.9) 13 (81.3) 23 (79.3) 37 (64.9) 81 (73.0)
³1.40 1 (11.1) 3 (18.8) 6 (20.7) 20 (35.1) 30 (27.0)
INR: International normalized ratio; Values in No.(%).

Mitterstieler, et al. [3] reported four children with celiac disease who had hemorrhagic diathesis due to a low "prothrombin complex". After the administration of vitamin K1, there was an immediate rise in the prothrombin complex and bleeding was quickly stopped.

Most published guidelines on celiac disease recommend confirmation of the diagnosis of celiac disease by documenting villous atrophy on small intestinal biopsy and response to gluten-free diet [5]. In the presence of coagulopathy, thrombocytopenia or portal hypertension, diagnostic endoscopy and mucosal biopsy can cause significant bleeding [6]. Our study has a limitation that we could not demonstrate clinical significance of coagulopathy as none of our patient developed overt bleeding. This may be due to small sample size, and the vitamin K received before procedure may have partly corrected the prothrombin time.

We conclude that almost one-fourth of children with celiac disease have deranged INR before starting treatment, but they do not seem to develop bleeding following upper GI endoscopy.

Contributors: SSS: involved in data collection, manuscript writing, LB: involved in data analysis and manuscript writing. DS: conceptualized and designed the study, supervised data collection, and critically reviewed and revised the manuscript. All authors approved the final manuscript.

Funding: None; Competing interest: None stated.

References

1. Cavallaro R, Iovino P, Castiglione F, Palumbo A, Marino M, Di Bella S, et al. Prevalence and clinical associations of prolonged prothrombin time in adult untreated coeliac disease. Eur J Gastroenterol Hepatol. 2004;16:219-23.

2. Ertekin V, Selimoglu MA. Prevalence of prolonged prothrombin time in children with coeliac disease. Eur J Gastroenterol Hepatol. 2006;18:579-80; (author reply 580).

3. Mitterstieler G, Zieglauer H. Vitamin K deficiency bleeding as a leading symptom in celiac disease (author’s transl). Padiatr Padol. 1978;13:175-82.

4. Francavilla R, Cristofori F, Stella M, Borrelli G, Naspi G, Castellaneta S. Treatment of celiac disease: from gluten-free diet to novel therapies. Minerva Pediatr. 2014;66:501-16.6.

5. Complications of upper Gastrointestinal Endoscopy. Available from: http://www.bsg.org.uk/pdf_word_docs/complications.pdf. Accessed December 10, 2016.

 

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