Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

Gastric heterotopic pancreas in children: A prospective endoscopic study

PURPOSE

To document the prevalence and variable appearance of gastric heterotopic pancreas (HP) in children undergoing upper gastrointestinal (GI) endoscopy.

METHODS

A prospective 4-year study of children undergoing flexible upper GI endoscopy in a single institution.

RESULTS

A total of 607 upper GI endoscopies were performed in 478 pediatric patients during the 4-year period. Eleven children (6 girls, 5 boys) aged 2.9 to 16.9 years had endoscopic features typical of gastric HP. All but one lesion was located in the gastric antrum and most appeared as an umbilicated submucosal nodule measuring 1-2 cm in diameter. Five of 13 children with repaired esophageal atresia (EA) and two of nine children with trisomy 21 had gastric HP. The prevalence of endoscopically visualized gastric HP in children without a history of EA or trisomy 21 was 1.1%.

CONCLUSIONS

Gastric HP is present in about 1% of pediatric upper GI endoscopies. It is significantly more common in patients with EA and may also be associated with trisomy 21. Gastric HP typically appears as a single 1-2 cm antral submucosal nodule, usually with a central pit. Recognition of this lesion is important to avoid misdiagnosis and inappropriate treatment.

LEVEL OF EVIDENCE

Level II (diagnostic).

Caustic ingestion in children: A 6-year retrospective study

Some aspects of the management of caustic ingestion in children are still debated. We aimed to determine the predictive value of epidemiological and clinical features of caustic ingestion, and to define guidelines adherence. This is a retrospective study on children ≤18 years referred to our Emergency Department over 6 years because of caustic ingestion. Statistical significance at p<0.05. Overall, 107 caustic ingestions were identified, mainly accidental <5 years (87.85%). Bleach was the most common caustic (46.73%). Forty-six patients underwent endoscopy; 57.38% children who should have endoscopy on guidelines, actually did not (p<0.0001), but no complications were reported. No or minimal lesions were reported in asymptomatic children; ≥2 symptoms correlated with the severity of lesions (p<0.0002). Therapy of severe cases was correct; overtreatment was observed for minor injuries (p<0.0001). Asymptomatic children after caustic ingestion have a very low-probability of moderate-severe endoscopic lesions, and the risk of severe damage increases proportionally with ≥2 symptoms. Prospective studies are needed to evaluate the efficacy of intensive clinical observation versus EGD on low-risk children to identify those with clinically relevant esophageal lesions.

Biodegradable Stents in the Management of Refractory Esophageal Strictures in Children

Background: Management of refractory esophageal strictures in children is challenging and mostly involves frequent and prolonged dilatations that are associated with significant physical and psychological complications. Biodegradable stents (BDS) have recently been used and it is particularly attractive in children as stent removal is avoided due to their dissolution. Report of Cases: We report our experience with BDS use in 3 children with severe refractory esophageal strictures. Two of the patients had strictures as a result of caustic ingestion and 1 after long-gap esophageal atresia repair. Median number of dilatations prestent is 5 per year. Custom-made uncovered BDS were inserted under general anesthesia. Median follow-up period was 23 months. Results: Minor postprocedure complications occurred in 1 patient. Stent insertion led to temporary improvement in swallowing in all cases. However, all of the patients developed recurrent symptoms as severe as before stenting and need for dilatations remained unchanged. They also experienced mucosal hyperplasia that contributed to their recurrent symptoms. Conclusion: All of the cases in our series did not have a favorable outcome with BDS use. BDS is yet to be proven as an effective management option for refractory esophageal strictures in children from our experience as well as most other published reports.

Urgent endoscopy in children: epidemiology in a large region of France

Background and study aims  The real burden of urgent endoscopy in children has not been studied yet. Our aim was to evaluate the need for urgent endoscopy in children. Patients and methods  Information was collected about all the calls that were received during the 24 hour on-call shift for pediatric endoscopy in the region of Ile-de-France (12.1 million inhabitants) during a 6 months period (February-July 2017). Results  A total of 237 calls (19 calls/y/100,000 children) were collected regarding children of an average age of 3.2 years (range 2 days-18 years). Most of the calls (68 %) were for foreign body ingestions. Gastroscopy was required in 32 % of children: 24 % of those calling for foreign body ingestion, 48 % for gastrointestinal bleeding, 63 % for caustic ingestions ( P  = 0.01). The average time between the call and the urgent endoscopy were below the international recommendations for each situation. Conclusions  Calling the endoscopist seems to have become a recurrent practice, although in most cases, urgent endoscopy did not appear necessary, especially for foreign body ingestion. This organization of pediatric endoscopy on call was able to guarantee the performance of urgent endoscopy in adequate timing for a highly populated region.

Complications of esophageal strictures dilatation in children. A tertiary-center experience

OBJECTIVES

To report the results of endoscopic dilatation of esophageal strictures in children, its complications, and their management. The outcomes of esophageal dilatation differ according to the underlying etiology.

METHODS

The study included 46 patients who underwent esophageal dilatation between 2014-2019. All patients underwent a contrast study of the esophagus before endoscopic dilation to determine the location, number, and length of the narrowing. In addition, the type of dilators (balloon versus semi-rigid dilators), the number of dilatation sessions, the interval between them, and the duration of follow-up were also documented. The median age was 2.47 years, and 26 patients were females. Dysphagia was the main presenting symptom, and the leading cause of stricture was esophageal atresia.

RESULTS

The main treatment modality was endoscopic balloon dilatation (n=29, 63%). The esophageal diameter was significantly increased after dilation (9 [7-11] versus 12 [10-12.8]) mm; p less than 0.001). Topical mitomycin-C was used as adjuvant therapy in 3 patients (6.5%). Esophageal perforation was reported in 2 cases (4.3%). Patients needed a median of 3 dilatation sessions, 25-75th percentiles: 1-5, and the median duration between the first and last dilatation was 2.18 years 25-75th percentiles: 0.5-4.21.

CONCLUSION

Esophageal dilatation is effective for the management of children with esophageal stricture; however, repeated dilatation is frequent, especially in patients with corrosive strictures. Complications are not common, and open surgery is not frequently required.

Diagnostic findings and long-term prognosis in children with anemia undergoing GI endoscopies

BACKGROUND AND AIMS

Intestinal diseases are regarded as a common cause of anemia, but the diagnostic outcomes of children with anemia undergoing endoscopic investigations are unclear. We investigated this issue in a large cohort of children.

METHODS

Indications for and findings of consecutive gastrointestinal (GI) endoscopies were collected. Clinical presentation and diagnostic outcomes were compared between anemic and nonanemic patients and between anemic patients with and without a diagnosis. Diagnoses received during follow-up were collected.

RESULTS

Of 2395 consecutive endoscopies, 251 children with and 613 children without anemia had undergone either diagnostic esophagogastroduodenoscopy (EGD) (51.4% and 51.4%, respectively), colonoscopy (4.0% and 11.4%), or both (45.8% and 37.8%). Children with anemia more often received diagnoses (72.9% vs 39.3%; odds ratio [OR], 4.18; 95% confidence interval [CI], 3.03-5.77), particularly of celiac disease (26.3% vs 15.5%, P < .001) and of inflammatory bowel disease (31.1% vs 9.1%, P < .001), than did nonanemic children. The diagnosis in anemic patients was predicted by age 5 to 12 years (OR, 3.52; 95% CI, 1.27-9.75), presence of diarrhea (OR, 2.04; 95% CI, 1.07-3.90), melena/hematochezia (OR, 2.40; 95% CI, 1.17-4.92), poor growth (OR, 3.94; 95% CI, 1.70-9.15), positive celiac serology (OR, 11.81; 95% CI, 3.47-40.12), high calprotectin (OR, 12.86; 95% CI, 4.00-41.32), hypersedimentation (OR, 2.65; 95% CI, 1.29-5.44), and hypoalbuminemia (OR, 5.05; 95% CI, 1.56-16.34). Thirty children with anemia (12.0%) had no GI symptoms, and 22 of them (73.3%) were given diagnoses at the time of the endoscopies. All 22 had additional laboratory abnormalities, whereas these were present in only 2 of 8 undiagnosed children. None of them was diagnosed later in the follow-up of up to 11 years, in contrast to 4 (6.7%) of all anemic and 33 (8.9%) of all nonanemic patients.

CONCLUSIONS

Anemia increased the probability of being given a diagnosis, emphasizing its importance as an alarm symptom. However, endoscopies in anemic patients without additional symptoms or laboratory abnormalities seldom improved the diagnostic yield.

Gastrointestinal Endoscopy in the Neonate

Gastrointestinal endoscopy permits direct observation of the alimentary tract, acquisition of mucosal tissue for histopathologic examination, and other diagnostic and therapeutic maneuvers. Endoscopes of appropriate size for many neonates and an expanding array of compatible tools and accessories have broadened what is possible, although few neonatal data exist to guide use. Evaluation and treatment of gastrointestinal bleeding, evaluation and dilation of fibromuscular congenital esophageal stenosis, and the bedside placement of gastrostomy tube have been described. Careful consideration of risks, benefits, and discussions between involved specialties permit patient-specific application of these tools and techniques to augment care of this vulnerable population.

Effects of Sedation Performed by an Anesthesiologist on Pediatric Endoscopy: a Single-Center Retrospective Study in Korea

BACKGROUND

Endoscopy is used for diagnosing and treating various digestive diseases in children as well as in adults. However, in pediatric patients, it is recommended that sufficient sedation should be ensured before conducting endoscopy, since insufficient sedation may cause serious complications. However, in Korea, no studies have yet described the types of sedation drugs, effects of sedation, and efficiency of endoscopy with respect to the sedation instructor. Thus, we investigated the effectiveness of sedative procedures performed by anesthesiologists.

METHODS

We retrospectively reviewed the medical records of patients aged < 18 years who underwent endoscopy during March 2014-July 2019. Data of sedation instructors, sedation drugs and their doses, complications, and the recovery after sedation were evaluated.

RESULTS

Of 257 patients, 217 underwent esophagogastroduodenoscopy (EGD) and 40 underwent colonoscopies. Before EGD, 29 patients (13.4%) underwent sedation by the pediatric endoscopist and 188 (86.6%) were sedated by the anesthesiologist. The anesthesiologist performed the sedation for all 40 patients who underwent colonoscopy. Endoscopic examinations performed by the anesthesiologist were relatively more time-consuming (401.0 ± 135.1 seconds vs. 274.9 ± 106.1 seconds, P < 0.001). We observed that in patients who underwent EGD, there was a difference in the dose of midazolam administered (P = 0.000). When comparing EGD and colonoscopy in patients undergoing sedation by the anesthesiologist, there were no significant differences in the doses of midazolam and ketamine, but the dose of propofol increased for colonoscopy (2.50 ± 0.95 mg/kg vs. 4.71 ± 1.66 mg/kg, P = 0.000). The cognitive recovery time according to drug dose was associated with propofol only in EGD with a shorter endoscopy time. The longer cognitive recovery time in colonoscopy and the discharge time of EGD and colonoscopies were not associated with propofol use.

CONCLUSION

When sedation is performed by an anesthesiologist, various drugs are used with sufficient doses and complications are reduced, but the discharge time does not change. For performing pediatric endoscopy in Korea, anesthesiologists should be considered for inducing anesthesia.

Pediatric Endoscopy in the Era of Coronavirus Disease 2019: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper

The delivery of endoscopic care is changing rapidly in the era of Coronavirus Disease 2019 (COVID-19). The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Endoscopy and Procedures Committee has formulated this statement to offer practical guidance to help standardize endoscopy services for pediatric patients with the aim of minimizing COVID-19 transmission to staff, patients, and caregivers and to conserve personal protective equipment (PPE) during this critical time. Appropriate use of PPE is essential to minimize transmission and preserve supply. Pediatric endoscopic procedures are considered at high risk for COVID-19 transmission. We recommend that all pediatric endoscopic procedures are done in a negative pressure room with all staff using proper airborne, contact, and droplet precautions regardless of patient risk stratification. This includes appropriate use of a filtering face-piece respirator (N95, N99, FFP2/3, or PAPR), double gloves, facial protection (full visor and/or face shield), full body water-resistant disposable gown, shoe covers and a hairnet. In deciding which endoscopic procedures should proceed, it is important to weigh the risks and benefits to optimize healthcare delivery and minimize risk. To inform these decisions, we propose a framework for stratifying procedures as emergent (procedures that need to PROCEEED), urgent (PAUSE, weigh the benefits and risks in deciding whether to proceed) and elective (POSTPONE procedures). This statement was based on emerging evidence and is meant as a guide. It is important that all endoscopy facilities where pediatric procedures are performed follow current recommendations from public health agencies within their jurisdiction regarding infection prevention and control of COVID-19.

Clinical relevance of endoscopy with histopathological assessment in children with suspected gastrointestinal graft-versus-host disease

Endoscopy with histopathological assessment is an established practice to confirm gastrointestinal graft-versus-host disease (GI-GVHD). However, the clinical relevance of this approach in children is incompletely evaluated. In a retrospective cohort study, we investigated the frequency of treatment changes in response to histopathological findings in all children (<18 years) in Sweden who underwent endoscopy for suspected GI-GVHD (2000-2013) after receiving hematopoietic stem cell transplantation. Sixty-eight children with ninety-one endoscopic occasions were enrolled. At the time of endoscopy, anti-GI-GVHD treatment was ongoing in 71% (65/91). In 18% (12/65) with ongoing treatment, no histopathological evidence of GI-GVHD or another cause to justify anti-GI-GVHD treatment was found. In 48% (44/91), endoscopy with histopathological assessment led to changes in the treatment regimen. Re-endoscopy was more frequent among those with treatment changes, versus unchanged treatment, 39% (17/44) and 13% (6/47), respectively (P = .007). Histopathological findings generating treatment changes were as follows: GI-GVHD in 68% (30/44), normal histology in 25% (11/44), and an alternative diagnosis in 7% (3/44). In conclusion, this study supports that endoscopy with histopathological assessment should be considered in all children with suspected GI-GVHD.

Eosinophilic esophagitis in esophageal atresia: Tertiary care experience of a "selective" approach for biopsy sampling

BACKGROUND

A high prevalence (9.5-30%) of eosinophilic esophagitis (EoE) in patients with esophageal atresia (EA) has been reported. The application of the EoE criteria to EA patients might be problematic. To date, only studies using a "routine" biopsy approach, even in asymptomatic patients, have been performed. The aim of the study was to establish the prevalence of EoE among symptomatic EA patients (EA/EoE group) without anastomotic stricture (AS) and to compare their characteristics with those of EoE patients from general population (EoE group).

METHODS

From 2005 to 2018, we reviewed charts of children with EA and EoE. "Selective" biopsy approach only in EA children without AS and/or endoscopic feature of EoE was performed. Characteristics of EA/EoE and EoE groups were compared.

RESULTS

Among 370 EA and 118 EoE, 15 EA/EoE patients were detected (4.0% of EA patients). Male predominance and a high prevalence of allergy without differences between EA/EoE and EoE groups was observed. EA/EoE children were significantly younger (p < 0.0001). PPI-responder patients were significantly more prevalent in EA/EoE group (p = 0.045).

CONCLUSION

Our data confirm that EA patients are at high risk for developing EoE. High incidence, early onset, and high prevalence of PPI-responders might suggest that esophageal motility disorders interact to increase propensity to EoE in EA patients. However, our study also suggests that overdiagnosis of EoE may occur in EA and that adapted criteria for EoE diagnosis should be developed for EA patients.

TRIAL REGISTRATION

Not applicable for this retrospective study.

Pediatric Endoscopy, Update 2020

Optimal management of pediatric endoscopy requires a multidisciplinary approach. In most hospitals, endoscopy in pediatric patients is performed by conventional gastroenterologists and only a few centers have specialized pediatric gastroenterologists. This is due to the fact that the number of pediatric gastroenterologists is limited and not all of them are experienced in endoscopic techniques. However, there are also some pediatric centers offering a high-quality and high-volume endoscopy service provided by very experienced pediatric gastroenterologists. Up to now, the literature on pediatric endoscopy is rather sparse. In this article, we describe current knowledge and practice of endoscopic procedures in pediatric patients, which should be relevant for both the adult and pediatric gastroenterologists.

Split dose versus full single-dose regimen of polyethylene glycol for bowel preparation in pediatric colonoscopy: a pilot study of randomized controlled trial

OBJECTIVES

Previous meta-analyses in adults comparing a full single dose vs. split doses of polyethylene glycol with electrolyte solution demonstrated that the split-dose group had a higher rate of successful bowel preparation. To date, no similar study in children has been conducted. Therefore, we compared the efficacy of bowel preparation between the two regimens of polyethylene glycol with electrolyte solution in pediatric colonoscopy. The secondary outcomes were tolerability, acceptability, and compliance.

METHODS

An investigator-blinded randomized controlled trial was conducted to enroll children aged 2-18 years who underwent an elective colonoscopy at a teaching hospital between March 2018 and February 2019. Patients were randomly assigned to receive polyethylene glycol with electrolyte solution as a full single dose or two split doses. The Boston Bowel Preparation Scale was used for the efficacy (i.e. successful bowel preparation if score ≥ 6). Secondary outcomes were evaluated by using a standardized questionnaire.

RESULTS

A total of 45 colonoscopies (22 in the full single-dose and 23 in the split-dose group) were performed. Mean age was 9.2 years old (SD 4.4). We noted a higher rate of successful bowel preparation in the split-dose group (95% vs. 72%, P = 0.047). Significant higher rate of willingness to repeat the same protocol (83% vs. 36%, P = 0.002) and a trend of lower rate of nausea/vomiting (39% vs. 68%, P = 0.051) in the split-dose group were found.

CONCLUSION

The split-dose regimen of polyethylene glycol with electrolyte solution for bowel preparation suggests superior efficacy, potential tolerability, and acceptability as compared to the traditional full single-dose regimen.

Foreign Body Ingestion in Pediatrics: Distribution, Management and Complications

Background and Objectives: Foreign body (FB) ingestion is a common problem in children, causing serious complications. This study aimed to identify the distribution of types and locations of these foreign bodies and create Chiang Mai University (CMU) Guidelines. Materials and Methods: A retrospective descriptive study was conducted. All patients under 15 years old with foreign body ingestion (International Statistical Classification of Diseases and Related Health Problems; ICD-10 codes T18) treated in CMU Hospital from January 2006 to December 2017 were included. The data were analyzed using descriptive statistics. The guidelines were created, which paralleled the standard guidelines. Results: In total, 194 episodes of FB ingestion were recorded. These included 53.6% males and 46.4% females with a median age of 43.5 months. A history of foreign body ingestion complaints occurred in 77.8% of cases. Presentation was divided into asymptomatic (44.3%) and symptomatic (55.7%). The most common symptom was vomiting (23.2%). In the majority of cases, foreign bodies were located in the esophagus (37%). The most common type of foreign body was a coin (41.2%). Management included spontaneous passing (60.3%), endoscopy (35.6%), and others (3.1%). Complications before treatment were recorded in 9.3% of cases and after treatment in 2.1% of cases. Conclusions: Foreign body ingestion is common among children younger than four years old. Coins are the most common foreign body found, and the esophagus is the most common location. We recommend our created CMU Guidelines for management.

A Case Series of Ingested Open Safety Pin Removal Using a Proposed Endoscopic Removal Technique Algorithm

PURPOSE

Safety pin ingestion is common in some regions of the world and may lead to severe morbidity and mortality. The aim of this study was to present some practical suggestions for ingested safety pins using an accompanying algorithm, presented for the first time in the literature to the best of our knowledge.

METHODS

Twenty children with ingested safety pins during a 4-year period were retrospectively included in the study.

RESULTS

Median age of patients was 9.5 months (interquartile range, 6.3-14 months), and 70% were girls. On endoscopic examination, safety pins were observed in the stomach (25%), duodenal bulb (20%), upper esophagus (15%), middle esophagus (10%), and second part of the duodenum (10%) but were not observed in 20% of the cases. Safety pins were removed using endoscopy in 15 cases (75%). In four cases (20%), no safety pin was observed on endoscopic examination. In one case (5%) involving a 6-month-old infant, the safety pin could not be removed although it was observed using endoscopy. No surgical intervention was needed for any patient. No complications such as perforation or deaths developed, except for erosions, due to the foreign body removal procedure.

CONCLUSION

Safety pins are easily removed endoscopically. The best option is to remove the safety pin using endoscopy while it is still in the esophagus and stomach. For this reason, endoscopic procedures should be performed as soon as possible in children who have ingested safety pins.

Sub-10-minute High-quality Diagnostic Colonoscopy With Terminal Ileum Intubation in Children Is Feasible and Safe

OBJECTIVES

To critically appraise ileocolonoscopy (IC) practice in a large tertiary center, where IC is exclusively performed by experienced pediatric colonoscopists, particularly focusing on indications for the procedure; bowel preparation efficacy; IC completion rates and timings; diagnostic yield; and complications.

PATIENTS AND METHODS

We prospectively evaluated all patients referred to our clinic between July 2015 and June 2016. Data on age, height and weight, sex, surgical history, indications for colonoscopy, bowel preparation given, and bowel cleansing efficacy were collected. The following were calculated: percentage of terminal ileal (TI) intubation; time to terminal ileum; total duration of each procedure. In addition, we evaluated the number and the type of complications encountered and the number of patients readmitted within 30 days from the elective procedure. Endoscopic diagnostic yield, stratified for indication, was calculated.

RESULTS

A total of 1392 patients were referred; 181 required an endoscopic evaluation of the lower gastrointestinal (GI) tract (Outpatient Department conversion rate: 13%). Main indications for IC were: recurrent abdominal pain 38.1%; unexplained chronic diarrhea 16%; suspected inflammatory bowel disease (IBD) 24.9%; isolated rectal bleeding 13.2%; occult GI bleeding 1.6%; unexplained faltering growth 1.6%; IBD restaging 2.6%; and miscellaneous 1.6%. Terminal ileum was reached in all the patients (TI intubation rate = 100%). Median time to TI was 9.8 minutes (1-50 minutes). Time to TI was lower in younger patients compared to older ones (P = 0.005). Bowel cleansing was judged as grade 1 in 49.2%; grade 2 in 33.7%; grade 3 in 13.3%; and grade 4 in 3.9%. A significant statistical correlation was recorded between bowel cleansing and time to TI. The positive diagnostic yield was: 11.6% in patients with abdominal pain; 37.9% in patients with chronic diarrhea; 51.1% in patients with suspected IBD; 29.2% in patients with isolated rectal bleeding; 33.3% in patients with occult GI bleeding; 0% in patients with faltering growth; and 33% in the miscellaneous group.

CONCLUSIONS

In conclusion, appropriately targeted IC in the management of children with GI symptoms is a safe, fast, and useful investigation. TI intubation rates of 100% are achievable and desirable and can be conducted quickly. Poor bowel preparation impacts negatively on this and IC duration may be faster in younger children. High diagnostic yields have been recorded in patients with a clinical suspicion of IBD. Diagnostic yield in isolated recurrent abdominal pain is low. Training to excellence in pediatric IC should be a persistent goal.

Management of Peutz-Jeghers Syndrome in Children and Adolescents: A Position Paper From the ESPGHAN Polyposis Working Group

Peutz-Jeghers syndrome (PJS) is a well-described inherited syndrome, characterized by the development of gastrointestinal polyps, and characteristic mucocutaneous freckling. Development of small bowel intestinal polyps may lead to intussusception in children may require emergency laparotomy with potential loss of bowel. Gastrointestinal polyps may lead to bleeding and anemia. This European Society for Paediatric Gastroenterology Hepatology and Nutrition position paper provides a guide for diagnosis, assessment, and management of PJS in children and adolescents and guidance on avoiding complications from PJS or from the endoscopic procedures performed on these patients.This is the first position paper regarding PJS published by European Society for Paediatric Gastroenterology Hepatology and Nutrition. Literature from PubMed, Medline, and Embase was reviewed and in the absence of evidence, recommendations reflect the opinion of pediatric and adult experts involved in the care of polyposis syndromes. Because many of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, some of the recommendations are based on expert opinion. This position paper will be helpful in the appropriate management and timing of procedures in children and adolescents with PJS.

Utility of Esophagogastroduodenoscopy in the Evaluation of Uncomplicated Abdominal Pain in Children

Esophagogastroduodenoscopy (EGD) is commonly performed for abdominal pain in children, and in the presence of alarm symptoms, the diagnostic yield of this procedure is high. The aim of this study was to investigate the utility of EGD when performed for uncomplicated abdominal pain in children in the absence of alarm symptoms. Charts of all children less than 18 years of age who underwent EGD at the University of Florida between January 2016 and October 2018 were reviewed. Of 1478 children who underwent EGD for any indication, 287 patients (male-to-female = 123:164) were discovered to have undergone EGD, in the absence of colonoscopy, for uncomplicated acute or chronic abdominal pain, nausea, vomiting, gastroesophageal reflux, and/or dyspepsia, with no alarm symptoms. A significant change in clinical management was noted in 20 (7.0%) children. The findings of this procedure changed clinical management in a minority of our study participants.

Endoscopic retrograde cholangiopancreatography in children: Retrospective series with a long-term follow-up and literature review

BACKGROUND/AIMS

To investigate the safety and long-term results of endoscopic retrograde cholangiopancreatography (ERCP) in children with a literature review.

MATERIALS AND METHODS

All patients within the age range of 6-17 years who underwent ERCP between 1994 and 2014 at our institution were retrospectively evaluated.

RESULT

Twenty-four patients with a median age of 15 years underwent ERCP. Cannulation of the papilla was achieved in all patients (100%) without the use of needle-knife papillotomy. Before 1999, ERCP was used as a diagnostic method only in 7 patients (29%). In 17 (71%) patients, the procedure was used for therapeutic purposes. The indications were choledocholithiasis (10 cases, 42%), postoperative complications (5 patients, 21%), and recurrent pancreatitis (2 cases, 8%). In 2 patients (8%), the therapeutic effect was not achieved, thus requiring subsequent operations. There were no major complications. Mild pancreatitis occurred in only 1 patient (4%). Long-term follow-up information was obtained in 16 (67%) patients (median, 18 years; range, 3.5-22.5 years), and no long-term complications were detected.

CONCLUSION

Endoscopic retrograde cholangiopancreatography is a valuable tool in the diagnosis and treatment of pancreatobiliary disorders in the pediatric population. Large-scale studies are required to create evidence-based guidelines specific to children.

Foreign body ingestion in pediatric patients

PURPOSE OF REVIEW

The purpose of this article is to review clinical manifestations and management of common pediatric foreign body ingestions, with a particular focus on some of the current trends.

RECENT FINDINGS

Foreign body ingestion (FBI) is a problem that is frequently encountered by pediatric providers. As new toys and products enter the marketplace, there may also be new dangers from those objects not initially recognized. Some of the recent trends and findings in pediatric FBI include an increase in adolescent injury from ingestion of laundry detergent pods because of a popular game where participants are encouraged to bite or swallow the pods, and injuries associated with ingesting parts of a popular toy known as a 'Fidget Spinner'.

SUMMARY

Adverse events resulting from FBI range the entire gamut from nonexistent or minor symptoms to moderate injury and rarely may be fatal. Factors such as age, type of object ingested, anatomic location of the foreign body, and timing from ingestion to receipt of medical attention all determine the risk posed to the child and guide management decisions. Because of the constant development of products, and the potential for the emergence of new and dangerous trends among children, continued surveillance by the medical community is important in monitoring and managing injuries associated with FBI.

Pancreatic disorders in children: New clues on the horizon

Pancreatic disorders in children represent a growing health problem in pediatric patients. In the past two decades, several advances have been made in the knowledge of pediatric pancreatic disorders, with better understanding of different etiologies and clinical manifestations of these disorders. Moreover, many efforts have been made in pancreatology, aiming to define guidelines in the management of pancreatitis in children, initially based on the available information in adults. A multidisciplinary and multicenter approach is necessary to better determine pancreatic disease pathways and treatment options in children.

Endoscopy in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto IBD Group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition

Endoscopy is a central tool for the evaluation and management of inflammatory bowel disease (IBD). In the last few decades, gastrointestinal (GI) endoscopy has undergone significant technological developments including availability of pediatric-size equipment, enabling comprehensive investigation of the GI tract in children. Simultaneously, professional organization of GI experts have developed guidelines and training programs in pediatric GI endoscopy. This prompted the Porto Group on Pediatric IBD of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition to develop updated guidelines on the role of GI endoscopy in pediatric IBD, specifically taking into considerations of recent advances in the diagnosis, disease stratification, and novel therapeutic targets in these patients.

Clinical Presentation and Outcomes of Diagnostic Endoscopy in Newly Presenting Children With Gastrointestinal Symptoms

OBJECTIVES

Paediatric endoscopy is an important diagnostic tool; however, there is little published data to guide clinicians in selecting patients for endoscopy. This study aimed to evaluate a single centre's experience of newly presenting children focusing on presenting symptoms, investigations, and diagnostic yield.

METHODS

Clinical factors and endoscopic plus histological findings over a 6-month period were assessed. Only first diagnostic endoscopies were included. All biopsies were reviewed in a weekly histopathology multidisciplinary team meeting with a final agreed outcome. Abnormal histology was used as the criterion standard for reporting abnormality.

RESULTS

A total of 218 endoscopies were reviewed in 164 children. Approximately 65% were histologically normal (49% of children had macroscopically and histologically normal findings). Macroscopic and histological abnormalities (respectively) were 44% and 28% of oesophagogastroduodenoscopy (OGD) patients, 25% and 25% of colonoscopy alone, and 53% and 53% of those undergoing both OGD and colonoscopy (OGD&Col). For OGD-only patients, excluding those with raised anti-tissue transglutaminase antibodies, vomiting led to the highest rate of abnormal histology (22%). For colonoscopy-only and OGD&Col patients, per rectum bleeding led to the highest rates of abnormal histology (14% and 29%, respectively), after excluding those with laboratory abnormalities (anaemia and raised erythrocyte sedimentation rate) suggestive of inflammatory bowel disease.

CONCLUSIONS

This study showed that half of all first diagnostic endoscopies in our unit had neither macroscopic nor histological abnormalities. There was discrepancy between macroscopic abnormalities and histological findings in OGD. Prospective studies are needed to develop guidelines in appropriately predicting abnormality and selecting patients for endoscopy.

Choice of Endoscopic Procedure in Children With Clinically Suspected Gastrointestinal Graft-versus-host Disease

OBJECTIVES

Gastrointestinal graft-versus-host disease (GI-GVHD) is a potentially life-threatening complication after hematopoietic stem cell transplantation. Symptoms indicating GI-GVHD motivates endoscopy with biopsy sampling and histopathological confirmation. Optimal extent of endoscopy in children is, however, presently unknown. Therefore, we aimed to evaluate whether biopsies from the rectosigmoid area versus the rest of the colon/ileocolon with or without biopsies from simultaneous upper endoscopy, were equally reliable for detection of GI-GVHD and relevant differential diagnoses.

METHODS

Retrospective multicenter study based on histopathological re-evaluation of biopsies and hospital record data, collected from children with suspected GI-GVHD.

RESULTS

Forty-four children with 51 endoscopic occasions (81 procedures) were included. Thirty-nine of 51 (76.5%) were diagnosed as GI-GVHD, 14 (27.4%) received a differential diagnosis and 7 (13.7%) had normal histology findings. Comorbidity, that is, simultaneous detection of a differential diagnosis and GI-GVHD, was observed in 9 (23.1%) cases. Cytomegalovirus infection was the most frequent differential diagnosis, 6 of 7 were detected in biopsies from rectosigmoid and esophagogastroduodenal areas. Sensitivity for detection of GI-GVHD in biopsies collected from rectosigmoid-ileocolonic-, rectosigmoid-, or esophagogastroduodenal areas were 97.4%, 84.6%, 83.3%, respectively, and 97.4% when the latter 2 were merged. The difference, nondetected GI-GVHD in the rectosigmoid area versus detected elsewhere in the GI tract, was statistically significant (P = 0.03).

CONCLUSIONS

Biopsies collected from the rectosigmoid area solely were not optimal for detection of pediatric GI-GVHD. When biopsy sampling from rectosigmoid and upper GI tract areas was combined, the sensitivity for GI-GVHD was, however, equally high as for ileocolonoscopy or full upper and lower endoscopy.

Quality indicators in pediatric colonoscopy in a low-volume center: Implications for training

AIM

To study implications of measuring quality indicators on training and trainees’ performance in pediatric colonoscopy in a low-volume training center.

METHODS

We reviewed retrospectively the performance of pediatric colonoscopies in a training center in Malaysia over 5 years (January 2010-December 2015), benchmarked against five quality indicators: appropriateness of indications, bowel preparations, cecum and ileal examination rates, and complications. The European Society of Gastrointestinal Endoscopy guideline for pediatric endoscopy and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition training guidelines were used as benchmarks.

RESULTS

Median (± SD) age of 121 children [males = 74 (61.2%)] who had 177 colonoscopies was 7.0 (± 4.6) years. On average, 30 colonoscopies were performed each year (range: 19-58). Except for investigations of abdominal pain (21/177, 17%), indications for colonoscopies were appropriate in the remaining 83%. Bowel preparation was good in 87%. One patient (0.6%) with severe Crohn’s disease had bowel perforation. Cecum examination and ileal intubation rate was 95% and 68.1%. Ileal intubation rate was significantly higher in diagnosing or assessing inflammatory bowel disease (IBD) than non-IBD (72.9% vs 50.0% P = 0.016). Performance of four trainees was consistent throughout the study period. Average cecum and ileal examination rate among trainees were 97% and 77%.

CONCLUSION

Benchmarking against established guidelines helps units with a low-volume of colonoscopies to identify area for further improvement.

Advanced Therapeutic Gastrointestinal Endoscopy in Children - Today and Tomorrow

Gastrointestinal (GI) endoscopy plays an indispensable role in the diagnosis and management of various pediatric GI disorders. While the pace of development of pediatric GI endoscopy has increased over the years, it remains sluggish compared to the advancements in GI endoscopic interventions available in adults. The predominant reasons that explain this observation include lack of formal training courses in advanced pediatric GI interventions, economic constraints in establishing a pediatric endoscopy unit, and unavailability of pediatric-specific devices and accessories. However, the situation is changing and more pediatric GI specialists are now performing complex GI procedures such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography for various pancreatico-biliary diseases and more recently, per-oral endoscopic myotomy for achalasia cardia. Endoscopic procedures are associated with reduced morbidity and mortality compared to open surgery for GI disorders. Notable examples include chronic pancreatitis, pancreatic fluid collections, various biliary diseases, and achalasia cardia for which previously open surgery was the treatment modality of choice. A solid body of evidence supports the safety and efficacy of endoscopic management in adults. However, additions continue to be made to literature describing the pediatric population. An important consideration in children includes size of children, which in turn determines the selection of endoscopes and type of sedation that can be used for the procedure.

Sedation in Pediatric Esophagogastroduodenoscopy

Pediatric esophagogastroduodenoscopy (EGD) has become an established diagnostic and therapeutic modality in pediatric gastroenterology. Effective sedation strategies have been adopted to improve patient tolerance during pediatric EGD. For children, safety is a fundamental consideration during this procedure as they are at a higher risk of severe adverse events from procedural sedation compared to adults. Therefore, a detailed risk evaluation is required prior to the procedure, and practitioners should be aware of the benefits and risks associated with sedation regimens during pediatric EGD. In addition, pediatric advanced life support by endoscopists or immediate intervention by anesthesiologists should be available in the event that severe adverse events occur during pediatric EGD.

Diagnostic yield of esophagogastroduodenoscopy in children with chronic abdominal pain

INTRODUCTION

Chronic abdominal pain (CAP) is one of the most common indications of esophagogastroduodenoscopy (EGD) in the pediatric population. However, there is not enough information about the diagnostic yield of EGD in children with CAP. We aimed to evaluate the diagnostic yield of EGD in children with CAP in the Eastern Black Sea region of Turkey.

MATERIAL AND METHODS

The study included children (n = 372) who underwent EGD for the primary indication of chronic abdominal pain during an 18-month period. We collected data on demographic features (age, sex), clinical characteristics (alarm symptoms), and EGD results for each patient.

RESULTS

Patients' mean age was 13 years (range: 4-17 years; mean ± SD: 12.65 ±3.39 years), and the majority were female (n = 234, 62.9%). Endoscopy was diagnostic in 209 patients (56.2%; 95% CI: 30.35-40.05%). The most common diagnosis was Helicobacter pylori gastritis (35.2%) followed by reflux esophagitis. Significantly greater diagnostic yield of EGD was determined in patients with alarm symptoms (65.1%) compared to those without (45.2%) (OR = 2.26, 95% CI: 1.49-3.44, p = 0.001).

CONCLUSIONS

We determined a high diagnostic yield of EGD in children with CAP. Although the diagnostic yield of EGD in the assessment of CAP was found to be higher in the presence of alarm symptoms, a significant number of children without alarm symptoms were also found to have gastrointestinal system pathology diagnosed by EGD.

Management of Benign Esophageal Strictures in Children

Esophageal strictures are seldom in children. In many countries, accidental ingestion of corrosives is a major cause of risk for stricture formation. Therefore, their management is a challenge. Safety and long-term efficacy of esophageal dilation for benign esophageal strictures has been confirmed in children. Because most children with structures are toddlers or younger, balloon dilatation is often preferred over bouginage. There is increasing evidence that short duration administration of high doses steroids may be of benefit in some specific situation (IIb esophagitis according to Zargar classification). Mytomycin-C application needs to be further evaluated. Stenting was reported to be successful in some refractory cases.

Overview of paediatric IBD

Inflammatory bowel disease (IBD) is a chronic complex disease of children and adults requiring a range of medications and surgical techniques to induce and maintain remission. In common with other immune-mediated inflammatory disorders, it has shown an ever-increasing rise in incidence worldwide over the last 50 years. The cause of IBD arises from interactions between the microbiome in the gut and the gastrointestinal and systemic immune system in genetically susceptible persons, and with environmental triggers to both develop IBD and have relapses of IBD. The burden of IBD in children and adolescents can be high, and treatment needs a multi-disciplinary approach aiming to abolish symptoms, promote growth and development, and support a restriction-free life. Achieving healing of the intestinal mucosa promotes long-term remission and helps to avoid disease complications.

Clinical features and standardized diagnosis and treatment of esophageal foreign bodies

AIM

To summarize the clinical characteristics of esophageal foreign bodies and to explore their standardized diagnosis and treatment.

METHODS

This retrospective study was conducted at our hospital from July 2011 to July 2017, and we reviewed the clinical data for 1190 patients with esophageal foreign bodies with regard to their sex, age, department patients first visited, treatment time, type, incarcerated site, treatment plan, and length of hospital stay.

RESULTS

Of 1190 patients included, 568 were male and 622 were female, with a male-to-female ratio of 1.0:1.1. They aged from 2 mo to 99 years (mean, 45 years ± 28.44 years), with a median age of 54 years; 293 (24.6%) patients were under 15 years, 293 (24.6%) were between 15 and 55 years, and 604 (50.8%) over 55 years. Otolaryngology and head surgery department was the most first-visited department (966, 81.2%), followed by gastroenterology department (138, 11.6%), thoracic surgery department (46, 3.4%), and others (40, 3.4%). There were 716 (60.2%) patients who visited hospital within 24 h, 126 (10.6%) in 24 to 72 h, and 348 (29.2%) over 72 h. The foreign bodies were plant-based in 448 (37.6%) patients, animal-based in 403 (33.9%), metallic in 200 (16.8%), and composite material-based in 139 (11.7%), with jujube pits, chicken bones, and coins accounting for 62.9% (750 patients) of all cases. The foreign bodies were most commonly located in the upper orifice of the esophagus (827, 69.5%), followed by the upper part (245, 20.6%), the middle and lower parts (94, 7.8%), and others (25, 2.1%). We treated 1088 (91.4%) patients by endoscopy and 41 (3.4%) by surgery. The duration of hospitalization ranged from 1 to 71 d (median, 5 d; mean, 5.9 d ± 4.9 d).

CONCLUSION

Esophageal foreign bodies most commonly occur in the upper orifice of the esophagus. Standardized diagnosis and treatment are important. Esophageal foreign bodies should be taken out within 24 h. Timely correction of water and electrolyte disturbance, effective antibiotic therapy, high nutrition support, and temporary esophageal, if necessary, are beneficial to the patient's recovery.

Diagnostic Yield of Upper and Lower Gastrointestinal Endoscopies in Children in a Tertiary Centre

INTRODUCTION

Endoscopy is integral to the diagnosis and management of many gastrointestinal problems in children. Recently the number of endoscopic procedures performed has increased considerably worldwide raising questions about their appropriateness and cost-efficacy.

OBJECTIVES

The aim of the study was to determine the diagnostic yield (the likelihood that a procedure or test will provide information required to establish a diagnosis) of endoscopy in a paediatric population in a large tertiary referral centre and to determine the terminal ileum intubation (TII) rate of paediatric ileocolonosocopy (IC) in an active training environment and compare with previously calculated rates.

METHODS

Random selection of cases from a theatre electronic database from a 30-month period covering April 2012 to October 2014. The data were collected for initial presenting symptoms; age at diagnosis; indications for endoscopy; endoscopic findings; histopathological findings; and any change in management postendoscopic procedure. The diagnostic yield of the endoscopies and the TII rate of IC were calculated. Change in and contribution to management was assessed.

RESULTS

Median age 9.58 (0.5-16.5) years and M:F ratio 1:1.42. The positive diagnostic yield was 18.9% for oesophago-gastro-duodenoscopy alone, 32.6% for IC alone, and 39.2% when both occurred. In 45% management was actively changed due to endoscopy/histopathology findings and a significant management contribution occurred in all patients. TII was achieved in 98% of cases, which compares favourably to a TII rate of 89% at the same centre during the period 2009 to 2011.

CONCLUSIONS

Diagnostic yield was 32.6% for IC and 39.2% when oesophago-gastro-duodenoscopy also occurred. A TII rate of 98% should be achievable in children. A change in management occurred in 45% and as a significant negative finding may be as important as a positive diagnosis for exclusion of suspected disorders, with consequent reassurance and change in management. Contribution to management was therefore identified in all cases.

Readmission after Gastrointestinal Bleeding in Children: A Retrospective Cohort Study

INTRODUCTION

To compare the demographic, clinical, and therapeutic characteristics in a cohort of patients discharged following acute gastrointestinal bleeding, representing to the emergency department (ED) and readmitted within 30 days of discharge with the characteristics of non-readmitted patients.

STUDY DESIGN

Hospitalization data was obtained from the Pediatric Hospital Information System including 49 tertiary children's hospitals in the US. Children 1-21 years of age diagnosed with acute gastrointestinal bleeding, admitted between January 2007 and September 2015 were included. The primary outcomes in this study were 30-day inpatient readmission through the ED and 30-day return to the ED only. Unadjusted, univariate followed by multivariable analysis of the associations between patient characteristics and treatment course at the index encounter using the R statistical package, v. 3.2.3.

RESULTS

During the study period, 9902 patients were admitted with acute gastrointestinal bleeding; in the following month, 1460 (16.1%) represented to the ED and 932 (9%) were readmitted; 68.7% within 14 days from discharge. Readmission was most frequently associated with portal hypertension or esophageal variceal hemorrhage. There was a decreased likelihood of readmission with endoscopy (OR 0.77, 95% CI, 0.661, 0.906) and with Meckel scan (OR 0.513, 95% CI 0.362, 0.727) during the initial admission. Multiple comorbidities, longer initial stay and the early proton pump inhibitor therapy were associated with higher likelihood of readmission.

DISCUSSION

Readmission following acute gastrointestinal bleeding is common and is more likely following variceal hemorrhage, long initial admission, and chronic comorbidities.

Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures

Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.