The diagnostic yield of upper endoscopy procedures in children- is it cost effective?

Esophageal Microbiome in Healthy Children and Esophageal Eosinophilia

OBJECTIVES

There is limited knowledge about the role of esophageal microbiome in pediatric esophageal eosinophilia (EE). We aimed to characterize the esophageal microbiome in pediatric patients with and without EE.

METHODS

In the present prospective study, esophageal mucosal biopsies were obtained from 41 children. Of these, 22 had normal esophageal mucosal biopsies ("healthy"), 6 children had reflux esophagitis (RE), 4 had proton pump inhibitor (PPi)-responsive esophageal eosinophilia (PPi-REE), and 9 had eosinophilic esophagitis (EoE). The microbiome composition was analyzed using 16S rRNA gene sequencing. The age median (range) in years for the healthy, RE, PPi-REE, and EoE group were 10 (1.5-18), 6 (2-15), 6.5 (5-15), and 9 (1.5-17), respectively.

RESULTS

The bacterial phylum Actinobacteria, Bacteroidetes, Firmicutes, Fusobacteria, and Proteobacteria were the most predominant. The Epsilonproteobacteria, Betaproteobacteria, Flavobacteria, Fusobacteria, and Sphingobacteria class were underrepresented across groups. The Vibrionales was predominant in healthy and EoE group but lower in RE and PPi-REE groups. The genus Streptococcus, Rahnella, and Leptotrichia explained 29.65% of the variation in the data with an additional 10.86% variation in the data was explained by Microbacterium, Prevotella, and Vibrio genus. The healthy group had a higher diversity and richness index compared to other groups, but this was not statistically different.

CONCLUSIONS

The pediatric esophagus has an abundant and diverse microbiome, both in the healthy and diseased states. The healthy group had a higher, but not significantly different, diversity and richness index compared to other groups.

Pediatric Endoscopy Quality Improvement Network Pediatric Endoscopy Reporting Elements: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality procedure reports are a cornerstone of high-quality pediatric endoscopy as they ensure the clear communication of procedural events and outcomes, guide patient care and facilitate continuous quality improvement. The aim of this document is to outline standardized reporting elements that achieved international consensus as requirements for high-quality pediatric endoscopy procedure reports.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used Delphi methodology to identify key elements that should be found in all pediatric endoscopy reports. Item reduction was attained through iterative rounds of anonymized online voting using a 6-point scale. Responses were analyzed after each round and items were excluded from subsequent rounds if ≤50% of panelists rated them as 5 ("agree moderately") or 6 ("agree strongly"). Reporting elements that ≥70% of panelists rated as "agree moderately" or "agree strongly" were considered to have achieved consensus.

RESULTS

Twenty-six PEnQuIN group members from 25 centers internationally rated 63 potential reporting elements that were generated from a systematic literature review and the Delphi panelists. The response rates were 100% for all three survey rounds. Thirty reporting elements reached consensus as essential for inclusion within a pediatric endoscopy report.

DISCUSSION

It is recommended that the PEnQuIN Reporting Elements for pediatric endoscopy be universally employed across all endoscopists, procedures and facilities as a foundational means of ensuring high-quality endoscopy services, while facilitating quality improvement activities in pediatric endoscopy.

The utility and safety of paediatric endoscopy in a district general hospital in Southeast England

This study was done to evaluate the appropriateness, diagnostic yield, and quality of paediatric gastrointestinal endoscopy in a large DGH with tertiary paediatric gastroenterology services. It was a retrospective cohort study of children who had at least one gastrointestinal endoscopy during 31 months (May 2018-Dec 2020) in a district general hospital in Southeast England. The participants were children (2-17 years). Two hundred ninety-three procedures were performed in total, 80% were diagnostic and 20% for surveillance. The median age was 12 years and 52.5% were males. Oesophago-gastro-duodenoscopy (OGD) corresponded to 79.5% of procedures, ileo-colonoscopy (IC) to 7.2% and the remaining had both procedures. The main diagnostic indication was persistent abdominal pain in 33.5% of cases, followed by suspected GORD (14.8%), recurrent vomiting (14.3%), dysphagia (9.1%) and blood loss per rectum (8.6%). A total of 64.7% showed abnormal macroscopic findings, and 69.2% showed histopathological signs of disease. The most common histological diagnosis was gastritis in 23% followed by coeliac disease in 13%, reflux oesophagitis in 12.2% and inflammatory bowel disease in 9.6%. Procedures were performed with utmost safety with two reported cases of complications, which were appropriately managed. The completion rate of diagnostic IC was 87%. A waiting time of 6 weeks was achieved in 50.4% of cases.

CONCLUSION

Paediatric endoscopy can be safely performed in a district general hospital with the right setup and can aid in the management of gastrointestinal disease in the paediatric patient. It is important to monitor and regularly audit such practices to improve the quality of specialist services.

WHAT IS KNOWN

• Paediatric endoscopy is predominantly performed in large tertiary centres and included in the diagnostic algorithm for many paediatric gastrointestinal conditions. • There are recommendations on clinical indication endorsed by ESPGHAN and key quality indicators published jointly by JAG and BSPGHAN.

WHAT IS NEW

• Paediatric endoscopy can be appropriately and safely performed in district general hospital by trained professionals, decreasing the workload in larger tertiary paediatric centres. • Adoption of regular audit practices is essential to ensure and improve quality and appropriateness of this specialist service.

Pediatric Gastrointestinal Endoscopy: Diagnostic Yield and Appropriateness of Referral Based on Clinical Presentation: A Pilot Study

Objectives: There is a lack of evidence-based consensus for the utility of gastrointestinal endoscopy (GIE) in an array of frequently occurring symptoms in children. We aimed to assess the diagnostic yield of endoscopy in an effort to aid clinical decision making. Methods: Retrospective analysis included patients ≤18 years who underwent GIE during one calendar year at Shaare Zedek Medical Center. We excluded children referred for predefined obvious indications for GIE, planned follow-up procedures, and therapeutic endoscopy. Clinician-assigned indication for endoscopy as well as endoscopic and histologic findings were recorded. Diagnostic yield of GIE was determined according to referral indication. Results: There were 794 endoscopies performed of which 329 were included in the analysis (mean age 9.3 ± 5.0 years, 51% female). No significant complications of GIE were recorded. Six major referral indications were identified among which abdominal pain was the most frequent 88/329 (26%) of whom 32/88 (36%) had a significant diagnostic finding. Among the other major indications, diagnostic findings were found in 36/85 (43%) children with primary indication of chronic diarrhea, 14/33 (42%) failure to thrive, 15/32 (46%) short stature, 30/56 (54%) iron deficiency, and 20/48 (42%) weight loss. Conclusions: Pediatric GIE is a safe procedure with diverse clinical indications. The diagnostic yield of endoscopy is variable, depending on the referral indication. These data can assist formulating judicious referral practices.

Diagnostic Yield of Endoscopic Procedures in Children: Experience of a Portuguese Center

Background

Over the last decades, the use of gastrointestinal (GI) endoscopic procedures has been increased in children worldwide, allowing the early diagnosis and therapeutic intervention in multiple GI diseases.

Aims and Methods

In order to evaluate the appropriateness and the diagnostic yield of initial GI endoscopic techniques in children in a Portuguese tertiary hospital, we performed a retrospective cohort study during a 12-month period.

Results

A total of 308 procedures were performed in 276 patients; the median age was 11 years and 50.4% were males. Esophago-gastro-duodenoscopy (EGD) corresponded to 81.8% of the procedures and ileo-colonoscopy (IC) to the remaining; 11.6% of the patients underwent both EGD and IC. Overall, 51.3% of the exams showed abnormal macroscopic findings, and 69.6% showed histopathological signs of disease, with IC showing significantly more positive results than EGD (p < 0.05). Considering the different indications independently, abnormal serology for celiac disease, suspected ingestion of foreign bodies, suspected inflammatory bowel disease, and food impaction were frequent in our population; and in the majority of the cases, the suspected diagnosis was confirmed: celiac disease, ingestion of foreign bodies, inflammatory bowel disease, and eosinophilic esophagitis, respectively. On the other hand, despite the high frequency of epigastric pain in this population, only nearly one-third of the patients showed abnormal histological findings. The final diagnosis was established in 63% of the patients, and 39.1% initiated the new treatment.

Discussion

Our results emphasize the importance of endoscopic procedures, especially IC, in the diagnosis of GI diseases in pediatric patients, as well as the careful choice of the endoscopic techniques in those with less specific symptoms, as chronic abdominal pain. In this particular situation, given the proportion of cases that may be due to functional disease, good characterization of the clinical context is needed, and endoscopy should be reserved for a second-line approach.

Conclusion

It is important to monitor and examine the endoscopic techniques as an index of quality criteria for clinical practice.

Gastroscopy in pediatric surgery: indications, complications, outcomes, and ethical aspects

Background. The aim of this study was to map gastroscopies performed at a single tertiary pediatric surgery centre to investigate indications, complications, outcomes, and ethical aspects. Material and Methods. A retrospective study of gastroscopies performed during two time periods (2001-2004 and 2011-2014) was conducted. Data regarding indications, outcomes, and complications of pediatric gastroscopies were analysed from a prospectively collected database. Results. The indications for gastroscopies changed over time. Therefore, 376 gastroscopies performed from 2011 through 2014 were studied separately. The median patient was four years old. The predominant indications were laparoscopic gastrostomy (40%), investigation of gastroenterological conditions (22%), obstruction in the upper gastrointestinal tract (20%), gastroesophageal reflux disease (GERD) (15%), and other indications (3%). Percentages of gastroscopies with no positive findings for each condition were laparoscopic gastrostomy, 100%; gastroenterological conditions, 46%; obstruction in the upper gastrointestinal tract, 36%; GERD, 51%. Furthermore, gastroscopies did not lead to any further action or change in treatment in 45% of gastroenterological conditions and 72% of GERD cases. The overall complication rate was 1%. Conclusion. The results are valuable to educate pediatric surgeons and to inform health care planning when including gastroscopy within clinical practice.