Capsule endoscopy and enteroscopy: modern modalities to investigate the small bowel in paediatrics.

Historically the small bowel has been considered a technically difficult area to examine because of its length (3-5 metres), location and tortuosity. Capsule endoscopy and enteroscopy have revolutionised the investigation pathway of the small bowel in adults. They are now developing increasingly important roles as modalities of investigation in paediatrics. This review appraises the current literature to define the clinical indications and practical aspects of capsule endoscopy and enteroscopy that are of interest to the clinician.     

Capsule endoscopy in the evaluation of gastrointestinal disease

PURPOSE OF REVIEW: The small bowel has been a technically difficult area to examine. Indirect modalities such as barium follow-through have the disadvantage of attendant radiation exposure. Capsule endoscopy, a novel wireless method of investigation of the small bowel, has acquired an important role in both adult and paediatric medicine. RECENT FINDINGS: The clinical utility of capsule endoscopy has rapidly expanded since its approval by the Food & Drug Administration in the USA in 2001. It has developed an established role in adults, in the investigation of obscure gastrointestinal bleeding, small bowel Crohn's disease, complications of coeliac disease and surveillance of polyposis syndromes. Despite a lag in its use in paediatrics, capsule endoscopy offers an accurate and effective means of investigating the small bowel in children. It has opened up new horizons and permitted a noninvasive approach to identifying occult lesions in the small bowel of children when conventional imaging has been unhelpful. SUMMARY: This review appraises the current literature to define the clinical indications and practical aspects of capsule endoscopy that are of interest to the paediatrician.     

A new approach to blue rubber bleb nevus syndrome: the role of capsule endoscopy and intra-operative enteroscopy

Blue rubber bleb nevus syndrome (BRBNS) is a rare vascular malformation disorder with cutaneous and visceral lesions frequently associated with serious, even fatal bleeding and anemia. The syndrome is considered to be autosomaly predominantly inherited. Intra-operative enteroscopy (IOE) is the best method of identification of all lesions (particularly the small ones, less than 3 mm) and treatment by endoscopic electro-coagulation or surgical excision. Capsule wireless endoscopy is optimal for screening before the IOE and for monitoring the effect of therapy (in patients with BRBNS). We report two cases of BRBNS. Anemia, gastrointestinal bleeding, gastrointestinal malformations and multifocal venous malformations of the skin were present in both of our cases. Gastrointestinal lesions were identified by gastroscopy, colonoscopy and capsule endoscopy. The multiple venous malformations were treated partly by endoscopic electro-coagulation (lesions up to 4 mm in diameter) and by wedge resection. Both of our patients were 12-year-old girls at the time of operation. In the first patient 31 venous malformations of the small bowel were coagulated, two were resected by the surgeon. In the second patient 20 lesions were coagulated endoscopically and another 31 nevi were resected during an 8 h procedure. The first girl is doing fine 4 years after the procedure, the second was allowed home 2 weeks after the procedure in excellent condition. IOE is a unique method of small bowel investigation and concurrently provides a solution for pathological findings. Capsule endoscopy is a feasible non-invasive screening procedure. We believe that a radical eliminatory approach by means of combined surgery and IOE is indicated for the BRBNS to prevent ongoing gastrointestinal bleeding.     

推进式双气囊电子小肠镜对儿童小肠疾病诊断的研究

目的评价双气囊电子小肠镜在儿童中应用的安全性、检查范围、临床价值。方法2003年6月—2005年5月,对14例年龄在3～14岁,经多项常规检查阴性,怀疑为小肠疾病的患儿行双气囊电子小肠镜检查。其中13例为原因不明的消化道出血、缺铁性贫血,1例为慢性腹泻。结果双气囊电子小肠镜抵达空、回肠交界部2例,回肠中下端10例和末端回肠2例,检查所用时间分别为,空、回肠交界部40～50min,回肠中下端55～70min和末端回肠78～89min。14例受检患儿中,12例发现病灶,阳性检出率为85．7％。未见操作相关的严重不良反应和并发症。结论双气囊电子小肠是诊断小肠疾病较好的检查手段,在儿童中应用是安全、可行的。     

儿童小肠镜临床应用管理专家共识

小肠疾病是消化系统疾病诊治难点之一,检查技术有限,严重制约了儿童消化道疾病的诊疗水平。随着小肠镜在儿科临床应用的推广与小肠镜设备和附件的优化,小肠镜技术为儿科消化道诊疗提供了新的手段,但临床操作规范化和镜下治疗面临诸多问题和挑战。为规范儿童小肠镜诊疗技术及提高小肠疾病的诊疗水平,中华医学会儿科学分会消化学组牵头,组织专家充分讨论,并参考儿童小肠镜临床应用的最新进展,制定了儿童小肠镜临床应用管理专家共识。     

单气囊小肠镜在小肠出血患儿中的临床应用

目的：探讨单气囊电子小肠镜在小肠出血患儿中的诊断价值和安全性。方法：临床怀疑小肠出血患儿共70例,其中男 38 例,女 32 例,年龄 4～13 岁;均在全麻下行单气囊小肠镜检查,其中经口途径检查 26例,经肛门途径检查 32 例,同时经口和肛门检查12例。结果：70例患儿中检查出小肠病变58例,检查阳性率 83％,其中非特异性炎症 24例,过敏性紫癜 12 例,克隆病 8 例,美克尔憩室 8 例,Peutz-Jeghers综合征 6 例。结论：单气囊小肠镜检查是诊断小肠出血患儿一项较为安全、有效的检查手段。     

小肠镜检查技术在儿童小肠病变中的诊断及治疗价值

小肠镜在成人小肠疾病中有很高的诊断和治疗价值,是一种安全有效的检查和治疗手段。但小肠镜在儿童中应用较少,目前小肠镜被用于儿童不明原因消化道出血、小肠息肉、克罗恩病、小肠狭窄、胆道狭窄等的诊断和治疗,该文介绍了小肠镜检查技术在儿童小肠疾病中的临床应用。     

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??Enteroscopy has high diagnostic and therapeutic value in adult intestinal diseases and is a safe and effective method. However??enteroscopy is rarely used in children. Enteroscopy is used for the diagnosis and treatment of obscure gastrointestinal bleeding??intestinal polyps??Crohn’s disease??intestinal stenosis and biliary stricture in children. The paper summarizes the clinical application of enteroscopy in small bowel disorders in pediatric patients.     

胶囊内镜在儿童小肠疾病诊治中的应用价值

目的 对疑有小肠疾病的儿童进行胶囊内镜检查,评估胶囊内镜在儿科的应用价值以及安全性.方法对2004年6月-2008年6月疑有小肠疾病的住院和门诊儿童43例进行胶囊内镜检查,男28例,女15例,年龄6～18岁,体重15～60 kg,身高110～180 cm,观察胶囊内镜检查成功率和失败率、胶囊内镜通过胃、小肠的平均时间,病变检出率和与最终诊断的符合率,操作过程中患者的耐受性和并发症;由胶囊内镜传送图像的质量评价;禁食8 h后检测时小肠的清洁度.结果 所有患儿均顺利吞服胶囊,检查期间耐受性好.共进行胶囊内镜检查46例次,成功43例次,失败3例次(成功率94%);胶囊内镜通过胃的平均时间为73(3～600)min,小肠内平均运行时间为246(73～413)min;检出病变37例(90%),与最终诊断符合的为31例(84%),出现并发症1例(2%);禁食8 h,小肠的清洁度佳,胶囊内镜所获取图像质量良好.结论 对于儿童不明原因的小肠疾病,特别是不明原因的小肠出血和小肠克罗恩病的诊断,胶囊内镜是一种安全和有效的检查方法.     

胶囊内镜对儿童小肠疾病诊断价值研究

摘要：目的　评价胶囊内镜检查在儿科应用的有效性和安全性。方法　对2007年9月至2010年12月福建医科大学附属漳州市医院28例临床疑诊小肠疾病的患儿进行胶囊内镜检查。观察胶囊内镜通过胃的平均时间、通过小肠的平均时间、成功率和失败率、小肠病变检出率及患儿的耐受性和并发症。结果　28例患儿均成功吞服胶囊内镜并完整排出,检查过程患儿耐受良好。胶囊内镜通过胃的时间20～280 min（中位数64 min）,通过小肠的时间93～380 min（中位数255 min）,检出病变20例（20/28,71.43%）。结论　对疑诊小肠疾病,胶囊内镜检查是的一种有效和安全的方法。     

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目的评价胶囊内镜检查在儿科应用的有效性和安全性。方法对2007年9月至2010年12月福建医科大学附属漳州市医院28例临床疑诊小肠疾病的患儿进行胶囊内镜检查。观察胶囊内镜通过胃的平均时间、通过小肠的平均时间、成功率和失败率、小肠病变检出率及患儿的耐受性和并发症。结果 28例患儿均成功吞服胶囊内镜并完整排出,检查过程患儿耐受良好。胶囊内镜通过胃的时间20～280min(中位数64min),通过小肠的时间93～380min(中位数255min),检出病变20例(20/28,71.43%)。结论对疑诊小肠疾病,胶囊内镜检查是的一种有效和安全的方法。     

Role of wireless capsule endoscopy in reclassifying inflammatory bowel disease in children

ObjectiveTo evaluate the role of wireless capsule endoscopy in identifying small bowel lesions in pediatric patients with newly diagnosed colonic inflammatory bowel disease (IBD) type unclassified (IBDU), and to assess whether capsule endoscopy findings result in altered patient management.MethodsTen pediatric patients recently diagnosed with IBDU through standard investigations were recruited from the pediatric gastroenterology clinic at McMaster Children's Hospital to undergo capsule endoscopy using the Pillcam SB^TM (Given Imaging) capsule. Findings consistent with a diagnosis of Crohn's disease required the identification of at least three ulcerations.ResultsThree out of ten patients had newly identified findings on capsule endoscopy that met criteria for Crohn's disease. Three more patients had findings suspicious for Crohn's disease, but failed to meet the diagnostic criteria. Three additional patients had findings most consistent with ulcerative colitis, and one had possible gastritis with a normal intestine. Findings from capsule endoscopy allowed for changes in the medical management of three patients. In all ten cases, capsule endoscopy allowed for a better characterization of the type and extent of disease. No adverse outcomes occurred in the present cohort.ConclusionThis prospective study reveals that wireless capsule endoscopy is feasible, valuable, and non-invasive, offering the ability to potentially better characterize newly diagnosed pediatric IBDU cases by identifying lesions in the small bowel and reclassifying these as Crohn's disease.     

Utility of capsule endoscopy in pediatric gastroenterology

Wireless endoscopy is a new noninvasive diagnostic method that is able to visualize small bowel lesions. The instrument is small and carries a battery and microcamera that takes two photographs per second. It is indicated in cases of bleeding of unknown origin and for the diagnosis of inflammatory bowel disease, among other disorders. To date, it has mainly been used in adults. We believe that this instrument could play an important role in the pediatric age group since it is noninvasive and can be used to diagnose small bowel lesions, thus avoiding unnecessary diagnostic tests. We report the case of a girl with suspicion of Crohn's disease that was unconfirmed by conventional endoscopic techniques. The capsule showed small bowel lesions compatible with Crohn's disease. Corticosteroid treatment was initiated and the patient is now in clinical remission.     

A novel diagnostic and treatment strategy for small intestinal lesions in children: hybrid treatment using transumbilical minimal incision surgery combined with double-balloon enteroscopy

Introduction

Double-balloon enteroscopy (DBE) is a useful and feasible modality for evaluating small intestinal lesions, even in children.

Methods

DBE makes it possible to perform biopsy, diagnosis, polypectomy and endoscopic therapies including hemostasis, tattooing and clipping of the small intestinal lesions. However, endoscopic procedures in the small intestines of children are more difficult than in adults, because the intestinal wall is thin and the lumen is narrow. A novel hybrid treatment was developed using DBE for small bowel lesions combined with transumbilical minimal incision surgery.

Conclusion

This hybrid treatment is safe, effective, provides excellent cosmetic results and can be used as an alternative for traditional open laparotomy or endoscopic surgery.     

胶囊内镜在以便血为主诉的小肠疾病患儿中的应用价值

目的 评估胶囊内镜在以便血为主诉的小肠疾病患儿中的价值。方法 回顾性收集2015年5月至2019年1月复旦大学附属儿科医院收治的以便血为主诉且行胶囊内镜检查的93例患儿的临床资料及胶囊内镜检查结果,根据胶囊内镜检查结果（空肠及回肠段）分为阳性病变组（n=39）及阴性病变组（n=54）,对两组的临床资料及胶囊内镜下的病变特征进行分析。结果 阳性病变组和阴性病变组患儿的年龄、性别、胶囊内镜检查时间、胃通过时间及小肠通过时间比较差异均无统计学意义（P > 0.05）。阳性病变组患儿的血红蛋白水平低于阴性病变组（P < 0.05）。血红蛋白值与胶囊内镜下阳性病变率呈负相关（r=-0.342,P=0.001）。胶囊内镜下发现有阳性病变的病例中,诊断为梅克尔憩室的比例最高（41%,16/39）,其次为炎症性肠病（21%,8/39）。结论 胶囊内镜对下消化道出血患儿小肠疾病,特别是空肠及回肠段疾病的阳性检出具有一定价值。     

Evaluation of 99mTc-HMPAO leukocyte scintigraphy in the investigation of pediatric inflammatory bowel disease

OBJECTIVE: To evaluate (99m)Tc-HMPAO leukocyte scintigraphy as an investigation for inflammatory bowel disease (IBD). STUDY DESIGN: Scintigraphy was performed in 95 children undergoing investigation for IBD in a tertiary Gastroenterology Department. Diagnosis was based on conventional investigations including small bowel barium contrast radiology (BCR), upper gastrointestinal endoscopy (UGIE), colonoscopy, and endoscopic biopsy (the "gold standards"). IBD was confirmed in 73 (57 Crohn's disease; 10 ulcerative colitis; 6 indeterminate colitis) and excluded in 22 (controls). Scintigraphy was (1) evaluated as a screening test, (2) compared with individual conventional tests, (3) assessed for each gut segment. RESULTS: Screening test: sensitivity 0.75 (95% CI, 0.63-0.85), specificity 0.82 (95% CI, 0.59-0.94), PPV 0.93, NPV 0.5. Comparison with BCR: sensitivity 0.87 (95% CI, 0.72-0.96), specificity 0.57 (95% CI, 0.39-0.73), PPV 0.69, NPV 0.2. Comparison with UGIE: specificity 0.9 (95% CI, 0.79-0.96), NPV 0.13 (sensitivity and PPV unavailable). Comparison with colonoscopy: sensitivity 0.57 (95% CI, 0.41-0.73), specificity 0.71 (95% CI, 0.54-0.85), PPV 0.71, NPV 0.42. Comparison with biopsies paralleled that with endoscopy. False negatives were especially common (NPV< or =0.2) in the proximal gut. CONCLUSIONS: (99m)Tc-HMPAO leukocyte scintigraphy should not be relied on as a screening test for IBD because false negative results are common. This method is especially unreliable at detecting disease in the proximal gut.     

Cytomegalovirus-associated manifestations involving the digestive tract in children with human immunodeficiency virus infection

OBJECTIVE: To study the clinical manifestations of gastrointestinal cytomegalovirus disease in children with human immunodeficiency virus infection. METHODS: Review of clinical records of eight human immunodeficiency virus-infected children and histopathologically confirmed gastrointestinal cytomegalovirus disease from 1995 to 2001. RESULTS: Six of the eight children were younger than 1 year. The most common clinical presentations were fever and chronic diarrhea. Lower gastrointestinal hemorrhage and bowel perforation were noted in four and three patients, respectively. The colon was the most commonly affected site, followed by the small bowel and esophagus. The diagnosis was established by histopathology, obtained during endoscopy and surgery. Mucosal edema, erythema, and ulcer comprised the most common endoscopic findings. Two patients with fever, chronic diarrhea, and lower gastrointestinal bleeding developed remission after being treated with a 14-day course of ganciclovir. CONCLUSION: Gastrointestinal cytomegalovirus disease can result in serious life-threatening complications, such as bowel perforation and massive gastrointestinal bleeding. Patients with chronic diarrhea and fever of unidentified cause might benefit from gastrointestinal endoscopy for early diagnosis and treatment. Although ganciclovir does not eradicate the infection and relapses are frequent, this treatment can prevent complications and reduce morbidity.     

Interventional endoscopy for abdominal transplant patients

Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis.The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients.In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).     

Lymphoid hyperplasia of the intestine in children. 15 cases]

Fifteen cases of nodular lymphoid hyperplasia (NLH) of the bowel in patients aged 17 months to 15 years are reported. Fourteen patients had NLH confined to the small bowel and one had involvement of both the small bowel and colon. Mean age at diagnosis was 10 years. The most common presenting symptoms were intestinal manifestations (86%). Diagnosis was suspected upon roentgenographic studies in one case and digestive endoscopy in ten cases. Histologic confirmation was obtained in all fifteen patients. Immunohistochemical studies, done in 8 patients, demonstrated a paucity of IgA plasmocytes in one patient with an immune deficiency and a polyclonal plasmocyte population with mainly IgA plasmocytes in the seven other patients. Five patients had a deficiency in humoral immunity, with variable expression hypogammaglobulinemia in three patients and IgA deficiency in two; intestinal giardiasis was found in eight patients. Histologic outcome was documented in five cases; evidence of NLH disappeared in only one patient. Metronidazole improved clinical symptoms in most instances.     

《中国儿童消化内镜诊疗相关肠道准备快速指南（2020，西安）》解读

2020年由中华医学会消化内镜学分会儿科协作组及中国医师协会内镜医师分会儿科消化内镜专业委员会共同组织专家制订《中国儿童消化内镜诊疗相关肠道准备快速指南（2020,西安）》,该指南是国内第一个基于系统检索证据和应用GRADE分级系统制订的儿童消化内镜检查前肠道准备指南。该文旨在对《中国儿童消化内镜诊疗相关肠道准备快速指南（2020,西安）》的要点,包括儿童肠道准备健康教育、饮食干预、实施方法、质量评估、补救措施及管理等方面进行详细解读,并分析儿童肠道准备目前所存在的问题,为儿科医师进行儿童消化内镜检查前肠道准备提供更多依据。