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• Author response: Relevance of spiders in the web area
  Billy Bourke
  Published on: 9 January 2022
• Relevance of spiders in the web era
  Nedim Hadzic
  Published on: 9 January 2022

• Published on: 9 January 2022

  Author response: Relevance of spiders in the web area

  • Billy Bourke, Consultant Paediatric Gastroenterologist
  • Other Contributors:
    • Marion Rowland

  Dear Editor,

  We thank Dr Hadzic for his comment on our paper(1). However, we disagree with Dr Hadzic’s difficulties with our conclusions for the following reasons:

  1. Our research suggests that over 2.5% of children five years of age and older may have five or more spider naevi. At present, if we were to screen our population of approximately one million children and adolescents in the Republic of Irel...

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  Dear Editor,

  We thank Dr Hadzic for his comment on our paper(1). However, we disagree with Dr Hadzic’s difficulties with our conclusions for the following reasons:

  1. Our research suggests that over 2.5% of children five years of age and older may have five or more spider naevi. At present, if we were to screen our population of approximately one million children and adolescents in the Republic of Ireland and investigate all of those with more than five spider naevi for the presence of liver disease, then we would screen 25,000 children. Clearly, this is not tenable. The only conclusion that can reasonably be drawn from our study is that, as stated, the “presence of multiple spider naevi in an otherwise well child may not warrant further laboratory investigation”. Clearly, the clinical context will be essential in determining whether the child does or does not require further investigation.

  2. At no stage, did we advocate “dismissing” the clinical sign of spider naevi in children. However, our paper clearly points to the fact that the presence of numbers of lesions in children is neither sensitive nor specific for the presence of underlying chronic liver disease and that this should be taken into account when interpreting their presence or absence in an individual child.

  We, like Dr Hadzic and other hepatologists, will continue to examine children for stigmata of chronic liver disease, including spider naevi. The presence or absence of these lesions will be interpreted within the clinical context for an individual child. Professor Alex Mowat suggested that it was difficult to interpret the relevance of anything up to ten spider naevi in children(2). He also stated that the development of many and enlargement of older ones was suggestive of liver disease. Perhaps this latter observation, not specifically studied in our cross sectional cohort, is worthy of validation within a large group of children with evolving chronic liver disease.

  References:

  (1) Finn SM, Rowland M, Lawlor, F et al. The significance of spider naevi in children. Arch Dis Child 2006;91:604-5).

  (2) Mowat AP (ed). Liver disorders in childhood. 2nd Ed Butterworth & Co, London. 1987; 260.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Relevance of spiders in the web era

  • Nedim Hadzic, Consultant Paediatric Hepatologist

  Dear Editor,

  Finn et al have performed a valiant study to compare the incidence of spider naevi in children with and without chronic liver disease (1). They confirm earlier suggestions that multiple spiders could be seen in completely healthy persons (2). However, their interpretation of the fact that some children with chronic liver disease have no spiders is potentially misleading.

  Some clinical signs...

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  Dear Editor,

  Finn et al have performed a valiant study to compare the incidence of spider naevi in children with and without chronic liver disease (1). They confirm earlier suggestions that multiple spiders could be seen in completely healthy persons (2). However, their interpretation of the fact that some children with chronic liver disease have no spiders is potentially misleading.

  Some clinical signs in paediatric hepatology are obvious, such as jaundice, ascites or splenomegaly. Diagnosis of many potentially life- threatening liver conditions such as autoimmune liver disease, Wilson disease or alpha-1-antitrypsin deficiency could be preceded by a long subclinical interval, where the child’s general health or quality of life may be unaffected. Majority of these children, however, will only have very few or sometimes even absent cutaneous signs, including spiders, palmar erythema, or teleangiectasiae. These could be easily overlooked in a busy primary care setting. Therefore, the authors’ suggestion that “presence of multiple spiders in an otherwise well child may not warrant further laboratory investigations” carries a clear risk of delaying the diagnosis of liver disease and possibly their presenting in a more dramatic, acute manner later. In adult cirrhotic patients a correlation between presence of spider naevi and risk of acute gastrointestinal bleeding has been observed (3). To advocate dismissing one of the few and precious clinical signs of chronic liver disease clearly represents something that paediatric hepatologists could not agree with.

  References:

  1. Finn SM, Rowland M, Lawlor F. et al. The significance of cutaneous spider naevi in children. Arch Dis Child 2006;91:604-5.

  2. Reuben A. Along came a spider. Hepatology 2002;35:735-6.

  3. Foutch PG, Sullivan JA, Gaines JA, Sanowski RA. Cutaneous vascular spiders in cirrhotic patients: correlation with hemorrhage from esophageal varices. Am J Gastroenterol 1988;83:723-6.

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  Conflict of Interest:
  None declared.

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