Diagnostic role of upper gastrointestinal endoscopy in pediatric inflammatory bowel disease

BACKGROUND: Discrimination between ulcerative colitis (UC) and Crohn disease (CD) may be difficult on ileo-colonoscopy alone because of a lack of definitive lesions. Retrospective studies show upper gastrointestinal endoscopy may be helpful in confirming diagnosis in such cases. AIMS: To prospectively determine importance of upper gastrointestinal endoscopy in diagnosis of inflammatory bowel disease (IBD) and assess factors predictive of upper gastrointestinal involvement in IBD. METHODS: All pediatric patients were enrolled prospectively and consecutively over a 2-year period and investigated with an ileo-colonoscopy and barium meal follow-through. Children with procto-sigmoiditis, later confirmed histologically to be typical of UC, were excluded from the study. The remainder underwent upper gastrointestinal endoscopy. The protocol and methodology were determined a priori. RESULTS: 65 children suspected of IBD underwent colonoscopy. Of the total, 11 had recto-sigmoiditis with typical macroscopic appearances of UC; once this was confirmed on histology these patients were excluded from the study. Of the 54 children (males, 31; median age, 11.1 years) remaining, 23 were initially diagnosed with CD on ileo-colonoscopy and 18 (33%) were diagnosed with UC. The diagnosis remained ambiguous in 13 (six colonic, four ileo-colonic, three normal colon) on clinical, radiologic and histologic grounds. Upper GI endoscopy helped to confirm CD in a further 11 (20.4%). Two patients were diagnosed with indeterminate colitis.Upper gastrointestinal inflammation was seen in 29 of 54 (22 CD; 7 UC ). Epigastric and abdominal pain, nausea and vomiting, weight loss and pan-ileocolitis were predictive of upper gastrointestinal involvement (P < 0.05). However, 9 children with upper gastrointestinal involvement were asymptomatic at presentation (31%). Overall upper gastrointestinal tract inflammation was most common in the stomach (67%), followed by the esophagus (54%) and duodenum (22%). CONCLUSIONS: Upper gastrointestinal tract endoscopy should be part of the first-line investigation in all new cases suspected of IBD. Absence of specific upper gastrointestinal symptoms do not preclude presence of upper gastrointestinal inflammation.     

Nitrous oxide sedation in pediatric patients undergoing gastrointestinal endoscopy

BACKGROUND: The ideal medication to administer to children before gastrointestinal endoscopy procedures has yet to be found. The efficacy of using inhaled nitrous oxide during endoscopy in children was assessed in a pilot study. METHODS: Patients aged 5 to 17 years, referred to our hospital for diagnostic upper gastrointestinal endoscopy or rectosigmoidoscopy procedures, were eligible for enrollment in this study. All received 50% nitrous oxide in oxygen (Entonox; AGA, Rueil-Malmaison, France) before endoscopy and some of them again during endoscopy. The pediatric endoscopist and the nurse performing the procedure were separately asked to rate cooperation, emotional state, drowsiness and overall efficacy of sedation. Oxygen saturation and adverse effects were recorded throughout the procedure. After endoscopy, children scored their degree of pain during the procedures on a visual analog scale (0, no pain; 100, agony) and on a body outline (projective method). Any adverse effects were noted. RESULTS: Thirty-seven patients were enrolled in the study. Thirty patients underwent diagnostic upper gastrointestinal endoscopy and seven diagnostic rectosigmoidoscopy. The median time from administration of nitrous oxide until insertion of the endoscope was 5 minutes (range, 3-8 minutes). Good or excellent efficacy of the sedation was noted in 92% of children by the endoscopist and in 89% by the nurses. Good or excellent cooperation was noted in 92% of the children by the endoscopist and in 78% by the nurses. The children's pain score on the visual analog scale ranged from 5 to 100 (median, 20) for upper gastrointestinal endoscopy and from 0 to 30 (median, 0) for rectosigmoidoscopy. The time of discharge after endoscopy, defined as the time elapsed between the end of the endoscopy and discharge from the endoscopy suite, varied from 1 to 7 minutes (median, 1.5 minutes). CONCLUSION: Entonox provides rapid and effective analgesia without heavy sedation, leads to adequate relaxation and cooperation, and facilitates quick and efficient endoscopy. The effect of Entonox was of short duration, allowing the children to leave the endoscopy unit without need for a long recovery period. The adverse effects of Entonox appeared to be minor, and their duration was always brief. Nitrous oxide-oxygen inhalation may provide a valuable alternative to conventional sedation regimens during gastrointestinal endoscopy in children, but randomized and prospective studies comparing nitrous oxide sedation and conventional sedation regimens are necessary.     

Upper gastrointestinal endoscopy in infants and children

Fibreoptic endoscopy is a highly efficient diagnostic tool which is now being increasingly used in pediatric age group also. However, certain special considerations like the use of special instruments, use of general anesthesia in younger children and various indications of diagnostic and therapeutic endoscopy need to be clearly emphasized. Over a period of 24 months, 132 children underwent upper gastrointestinal endoscopic examination in our section. Diagnostic endoscopy was carried out on 102 occasions and therapeutic on 162 occasions. Most of the children below 3 years of age required general anesthesia for the procedure. Children above 3 years of age could be managed by intravenous diazepam and pentazocine. The commonest cause of upper gastrointestinal bleed in children was variceal (60.6%) followed by erosive gastritis (27.2%). In children with recurrent abdominal pain no underlying cause was detected at endoscopy. Injection sclerotherapy was found to be a safe and effective mean for control of variceal bleed and most of the foreign bodies ingested by children and still lying proximal to 2nd part of duodenum could be successfully retrieved endoscopically.     

Bacteremia in children following upper gastrointestinal endoscopy or colonoscopy

Fifty children undergoing upper gastrointestinal endoscopy and 25 undergoing colonoscopy were studied prospectively with aerobic and anaerobic blood cultures for the development of bacteremia. Twenty-six of the endoscopies and all the colonoscopies were done under general anesthesia. Cultures were obtained before, at 5 min, and at 30 min after the procedure. Only a single positive blood culture was obtained in an upper endoscopy patient. All cultures from the colonoscopy patients were negative. Biopsy or polypectomy were not important variables in the development of bacteremia. It is concluded that the risk of bacteremia in children following upper endoscopy or colonoscopy is minimal and should not be considered a contraindication to their performance.     

Efficiency of upper gastrointestinal endoscopy in pediatric surgical practice

After the introduction of flexible fiber optic endoscopy to pediatric gastroenterology in the 1970 s, upper gastrointestinal(UGI) endoscopy can be performed for the diagnosis and treatment of all age groups of children. We review indications, contraindications, preparation of patients for the procedure, and details of diagnostic and therapeutic UGI endoscopy used in pediatric surgery. We also discuss potential complications of endoscopy.     

A Clinical Study of Upper Gastrointestinal Endoscopy in Japanese Children

A total of 370 children who underwent upper gastrointestinal endoscopy (534 procedures) were retrospectively studied. All procedures were performed successfully. Side effects were demonstrated in only one case (0.2%), which was complicated by perioral cyanosis during the procedure. As to preendoscopic medication, it was thought that topical pharyngeal anesthesia alone may well be used for school-age children over 7 years of age, general anesthesia with endotracheal intubation for neonates, and intravenous sedation for infants and younger children. Of 370 patients studied, 70.8% had endoscopic diagnoses. The most common diagnosis was gastritis (136 cases), followed by peptic ulcer (75), duodenitis (29), and esophagitis (20). Several conclusions for indications were drawn from the present study. Pediatric upper gastrointestinal endoscopy is a safe and useful method for diagnostic and therapeutic approach, if adequate preendoscopic medication is chosen.     

High incidence of upper gastrointestinal tract involvement in children with Crohn disease

This retrospective study of Crohn disease in 230 children and adolescents with a mean age of 12.5 years at the time of diagnosis and an average follow-up of 6.6 years showed that 30% had lesions of the esophagus, stomach, and duodenum. Three patients had Crohn disease isolated to the upper gastrointestinal tract. The 169 patients with both small and large bowel disease were at greater risk (33%, P less than .05) of having upper gastrointestinal lesions than the 37 with isolated small bowel disease and the 21 with disease limited to the colon and/or rectum. An aggregate of symptoms and signs more likely present in those with upper gastrointestinal involvement included: dysphagia, pain when eating, nausea and/or vomiting, and aphthous lesions of the mouth. Furthermore, weight loss was more severe and hypoalbuminemia more frequent. Because upper gastrointestinal series x-ray studies failed to detect upper gastrointestinal lesions in 13 patients of 69 of those with upper gastrointestinal disease, endoscopy should be considered in all children and adolescents in whom a diagnosis of Crohn disease is entertained. Endoscopy and biopsy of the upper gastrointestinal tract should be done in any patient with symptoms suggestive of proximal involvement. Finally, in view of the fact that endoscopy established the diagnosis of Crohn disease in five patients previously thought to have chronic ulcerative colitis, the procedure should routinely be performed in all patients with chronic ulcerative colitis or indeterminate colitis before surgery is performed.     

Value of esogastroduodenal endoscopy with staged biopsies in children with Crohn's disease

An upper gastrointestinal endoscopy with multiple biopsies was performed in 19 children suspected of Crohn disease (CD) who had also undergone X-ray investigations and colonoscopy with multiple biopsies. Biopsies were performed in pathological and/or normal mucous areas. Upper gastrointestinal endoscopy showed macroscopic changes in 7 children (37%). Histologic examinations of the upper gastrointestinal tract were normal or showed only non specific changes in 12 cases (63%). Histopathologic changes specific for CD were found in 7 cases (37%), while specific histologic changes were identified at the rectal or colic level in 3 of these 7 cases only. Thus, upper gastrointestinal endoscopy with multiple biopsies was most useful for the diagnosis of CD, since it was the only diagnostic means in 4 cases. It should be systematically performed when CD is suspected.     

PERORAL ENDOSCOPIC DUODENAL BIOPSY IN INFANTS AND CHILDREN

ABSTRACT. Peroral endoscopic duodenal biopsy was used in the diagnosis and follow-up of forty-nine infants and children with suspected small intestine disease. Their ages ranged between one month and 12 years. Fifty-four upper gastrointestinal endoscopy procedures were performed and 139 biopsies were taken. The mean procedure time was 3.2 min with a range of 1.5–5.5 min. There were no complications. Tissue adequate for histopathologic examination was obtained in all but one of the fifty-four procedures. On the basis of this experience we think that peroral endoscopic duodenal biopsy is faster, safer and as diagnostic as conventional suction biopsy in infants and children. It is also more informative when other diseases of the upper gastrointestinal tract are suspected.     

儿童上消化道异物所致并发症及其危险因素分析

目的 探讨儿童上消化道异物引起的并发症及相关危险因素。方法 收集2014年1月至2018年12月门诊或住院治疗的上消化道异物患儿772例的临床资料进行分析,通过多因素logistic回归分析上消化道异物患儿发生并发症的危险因素。结果 772例患儿异物均由电子胃镜取出,男414例,女358例,中位年龄2.8岁。消化道异物主要发生在年龄 < 3岁婴幼儿组（59.5%）;异物主要分布于食管段（57.5%）和胃内（28.9%）;异物滞留时间≤24 h 465例（60.2%）, > 24 h 307例（39.8%）。异物的类型主要为圆形金属异物（37.2%）、长条形异物（24.7%）、尖锐异物（16.2%）、电池（14.4%）、腐蚀性物质（4.8%）和磁铁（2.7%）。根据并发症发生情况分为轻度并发症（368例,47.7%）、严重并发症（98例,12.7%）及无并发症（306例,39.6%）。经logistic回归分析结果显示,年龄 < 3岁、基础疾病、异物位置、异物类型、异物滞留时间 > 24 h是引起上消化道异物并发症发生的危险因素（分别OR=2.141、7.373、6.658、8.892、6.376,P < 0.05）。结论 通过对上述导致消化道异物并发症的高危因素地了解,在临床上及时准确地选择恰当的干预方式,可降低各类严重并发症的发生。     

Use of wireless capsule endoscopy in the management of severe Henoch-Schonlein purpura

Henoch-Schonlein purpura is a multisystem vasculitis that primarily affects children. Characteristic symptoms include purpura of the lower extremities and buttocks, abdominal pain, arthralgias, and hematuria. Gastrointestinal bleeding occurs in approximately 50% of children and, although often self-limiting, can be significant. Wireless capsule endoscopy has been found to be safe and effective for children over 10 years of age. It is now the preferred imaging modality for evaluating gastrointestinal bleeding from the small intestine. Here we report an unusual case of chronic Henoch-Schonlein purpura vasculitis, primarily affecting the gastrointestinal tract, in which wireless capsule endoscopy was helpful in evaluating and directing treatment options.     

Fiberoptic upper intestinal endoscopy in infants and children

Fiberoptic upper intestinal endoscopy has been shown in the last decade to be the most sensitive technique to diagnose upper gastrointestinal disease. Diagnostic endoscopy has been shown to be safe, with a low complication rate of less than 2 per cent, and most of those reported have been minor. Furthermore, therapeutic endoscopy has been used to treat bleeding varices by sclerotherapy, avoiding the need for shunting procedures, which often fall in young children. Dilation of strictures with wire-guided dilators, endoscopic incision of antral mucosal diaphragms, and percutaneous placement of gastrostomy tubes are other ways endoscopy is being used as a means of treatment. Electrocoagulation and photocoagulation of bleeding upper gastrointestinal lesions have not been used.     

Use of oral midazolam in pediatric upper gastrointestinal endoscopy

Background: The purpose of this prospective, randomized study was to compare the safety and efficacy of oral versus i.v. midazolam in providing sedation for pediatric upper gastrointestinal (GI) endoscopy. Methods: Sixty‐one children (age <16 years) scheduled for upper GI endoscopy were studied. Patients were randomly assigned to receive oral or i.v. midazolam. Measurements were made and compared for vital signs, level of sedation, pre‐ and post‐procedure comfort, anxiety during endoscopy, ease of separation from parents, ease and duration of procedure, and recovery time. Results: Patients were aged 1–16 years (mean 7.5 ± 3.42 years); 30 patients received oral medication, and 31 received i.v. medication. There were no statistically significant differences in age or gender between groups. There were no significant differences in level of sedation, ease of separation from parents, ease of ability to monitor the patient during the procedure, heart rate, systolic arterial pressure, or respiratory rate. Oxygen saturation was significantly lower in the i.v. group than the oral group 10 and 30 min after removal of the endoscope, and recovery time was longer in the oral than the i.v. group. Conclusions: Oral administration of midazolam is a safe and effective method of sedation that significantly reduces anxiety and improves overall tolerance for children undergoing esophagogastroduodenoscopy.     

The bubble sign in the gasless abdomen of the newborn

The bubble sign (BS) in the gasless abdomen of the newborn is a helpful clue in the diagnosis of an upper gastrointestinal obstruction. The already swallowed air serves as the natural contrast agent. The single, double and triple BS are described in view of 23 cases indicating the level of the obstruction, and its differential diagnosis is discussed. The presence of BS in the gasless abdomen of the newborn is an indication for surgery until proved otherwise. With the increasing experience by ultrasonography, this modality should be considered as the first bed-side procedure when suspecting upper gastrointestinal obstruction, and then be confirmed by radiograms.     

Paediatric endoscopy by adult gastroenterologists in Ile-Ife,Nigeria: A viable option to increase the access to paediatric endoscopy in low resource countries

Background:

Paediatric endoscopy performed by adult gastroenterologists is a service delivery model that increases the access of children to endoscopy in countries where paediatric gastroenterologists with endoscopy skills are scarce. However, studies on the usefulness of this model in Nigeria and Sub-Saharan Africa are scarce. We aimed to evaluate the indications, procedures, diagnostic yield and safety of paediatric endoscopy performed by adult gastroenterologists in a Nigerian tertiary health facility.

Materials and Methods:

It was a retrospective study that evaluated the records of paediatric (≤18 years old) endoscopies carried out in the endoscopy suite of Obafemi Awolowo University Teaching Hospital Complex Ile-Ife, Nigeria from January 2007 to December 2014.

Results:

A total of 63 procedures were successfully completed in children of whom 4 were repeat procedures which were excluded. Thus, 59 endoscopies performed on children were analysed. Most (49; 83.1%) of these procedures on the children were diagnostic with oesophagogastroduodenoscopy being the commonest (43; 72.9%). Epigastric pain (22; 37.3%), haematemesis (17; 28.8%) and dysphagia (9; 15.3%) were the predominant indication for upper gastrointestinal (GI) endoscopy while haematochezia (9; 15.3%) and rectal protrusion (2; 3.4%) were the indications for colonoscopy. Injection sclerotherapy (3; 5.1%) and variceal banding (2; 3.4%) were the therapeutic upper GI endoscopic procedures conducted while polypectomies were performed during colonoscopy in 5 children (8.5%). Abnormal endoscopy findings were observed in 53 out of the 59 children making the positive diagnostic yield to be 89.8%. No complication, either from the procedure or anaesthesia was observed.

Conclusion:

Paediatric endoscopy performed by adult gastroenterologists is useful, feasible and safe. It is being encouraged as a viable option to fill the gap created by dearth of skilled paediatric gastroenterologists.Key words: Endoscopy, gastroenterology, gastrointestinal, Ile-Ife, Nigeria, paediatrics     

Bleeding from duodenal lymphangiectasia.

An 8 year old girl with recurrent upper gastrointestinal bleeding was found to have localised duodenal lymphangiectasia by fibreoptic endoscopy. She did not show physical signs or laboratory evidence of significant enteric protein loss. A low fat diet seemed to prevent further bleeding. Duodenal lymphangiectasia may be associated with gastrointestinal bleeding in children.     

Fiberendoscopy of the gastrointestinal tract in children. A series of 100 examinations.

This article reports the results of our first 100 examinations of the upper gastrointestinal tract and the colon in children and infants, using standard fiberscopes and also pediatric models. The procedure could be performed under sedation in 80% of the cases and general anesthesia was required mainly with standard fiberscopes. Compared to roentgenographic findings, fiberendoscopy proved to be more reliable in superficial mucosal lesions and gastrointestinal bleeding. Colonoscopy though difficult, is valuable in diagnosing rectal bleeding lesions and as a follow-up technique in inflammatory bowel diseases.     

Upper and lower gastrointestinal endoscopy in children with Crohn's disease

Twenty-three children and adolescents with Crohn's disease had systematic upper and lower gastrointestinal (GI) endoscopy as part of the initial diagnostic assessment. Twenty (86%) had evidence of some involvement of the upper GI tract (oesophagus-4, stomach-19, duodenum-5). In 13 children, the upper GI findings were instrumental in making the diagnosis of Crohn's disease. The ileum was viewed in 18 and found to be abnormal in 14 (78%). The colon was affected to some extent in 16 (70%); the proximal colon was affected twice as frequently as the distal colon and rectum. Early upper and lower GI endoscopy is recommended as part of the assessment of suspected inflammatory bowel disease in children. Offprint requests to: D. J. S. Cameron     

Wireless capsule endoscopy: indications, limitations, and future challenges

Wireless capsule endoscopy is one of the recent inventions that has made an impact in the diagnostic work-up of gastrointestinal diseases, mainly in small intestinal pathology, the part of the gut that cannot be totally visualized by upper and lower gastrointestinal endoscopy. Since the first report documenting the use of capsule endoscopy, many adult clinical trials have taken place. Although the Food and Drug Administration approved the use of the capsule in children (ages 10-18 years) in October 2003, few small clinical trials exploring the diagnostic yield of capsule endoscopy in pediatric populations have been published.     

Serum immune response to Helicobacter pylori in children: epidemiologic and clinical applications

Antibody responses to Helicobacter pylori were measured by a solid-phase whole-cell enzyme-linked immunosorbent assay in 150 children and adolescents; in 47 consecutive children undergoing upper gastrointestinal endoscopy, including 17 with H. pylori infection before and after antimicrobial treatment; and in 46 family members of the infected children. Abnormal levels of either IgG or IgA were found in 6% of the 150 children. In the latter group the prevalence of H. pylori seropositivity increased with age. Parents and siblings of the infected children had 94% and 71% seropositivity, respectively, suggesting intrafamilial spread. Abnormal levels of IgG or IgA against H. pylori identified infected children with 95% sensitivity and 84% specificity. Eradication of the infection was accompanied by a significant decrease in IgG and IgA titers, with normalization in 10 cured patients in 12 months or less. We conclude that the method described for evaluation of H. pylori-specific IgG and IgA antibodies gives helpful information on the epidemiology of the infection and represents a useful adjunct to diagnosis and management of chronic gastritis in children.