Clinical utility of double-balloon enteroscopy in children: A single-centre experience in South China

Paediatric gastrointestinal endoscopy in the Asian-Pacific region: Recent advances in diagnostic and therapeutic techniques

There has been a rapid expansion in the knowledge of paediatric gastroenterology over the recent decade, with a fast-growing repertoire of diagnostic techniques and management strategies for a wide spectrum of childhood gastrointestinal (GI) diseases. Paediatric GI endoscopy is a core competency every paediatric gastroenterologist should possess, and represents one of the most common procedures performed in children for both diagnostic and therapeutic purposes. Yet there remains a dearth of literature on the utility and outcomes of paediatric GI endoscopy in the Asia-Pacific region. Data on the diagnostic value of paediatric GI endoscopy would be an important aspect of discussion, with the emergence of inflammatory bowel disease (IBD) and eosinophilic GI disease as increasingly common endoscopic diagnoses. Time-based trends in paediatric GI endoscopy do point towards more IBD and gastroesophageal reflux disease-related complications being diagnosed, with a declining incidence of GI bleeding. However, the real-world diagnostic value of endoscopy in Asia must be contextualised to the region-specific prevalence of paediatric GI diseases. Helicobacter pylori infection, particularly that of multidrug-resistant strains, remains a highly prevalent problem in specific regions. Paediatric functional GI disorders still account for the majority of childhood GI complaints in most centres, hence the diagnostic yield of endoscopy should be critically evaluated in the absence of alarm symptoms. GI therapeutic endoscopy is also occasionally required for children with ingested foreign bodies, intestinal polyposis or oesophageal strictures requiring dilation. Endoscopic haemostasis is a potentially life-saving skill in cases of massive GI bleeding typically from varices or peptic ulcers. Advanced endoscopic techniques such as capsule endoscopy and balloon-assisted enteroscopy have found traction, particularly in East Asian centres, as invaluable diagnostic and therapeutic tools in the management of IBD, obscure GI bleeding and intestinal polyposis. State of the art endoscopic diagnostics and therapeutics, including the use of artificial intelligence-aided endoscopy algorithms, real-time confocal laser endomicroscopy and peroral endoscopic myotomy, are expected to gain more utility in paediatrics. As paediatric gastroenterology matures as a subspecialty in Asia, it is essential current paediatric endoscopists and future trainees adhere to minimum practice standards, and keep abreast of the evolving trends in the diagnostic and therapeutic value of endoscopy. This review discusses the available published literature on the utility of paediatric GI endoscopy in Asia Pacific, with the relevant clinical outcomes.

Small bowel endoscopy for children: Collaboration of capsule endoscopy and device-assisted enteroscopy

Capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE) have become indispensable techniques for the diagnosis and management of small bowel disease in both adult and pediatric cases. However, relevant differences exist in the indications between these cohorts, with body weight and age having particular relevance in decisions for the latter. Both CE and BAE are designed for adult physique and they were not widely used among children. In addition, the types of small intestinal diseases differ between adults and children, and consequently, the indications also differ between them. This review focuses on the issues relevant to pediatric cases and describes the practical application of endoscopy in clinical practice. In conclusion, although there are age and weight restrictions, both CE and BAE are safe and useful devices for use in children, and their indications for use in children are likely to expand in the future.

Single balloon enteroscopy in children for evaluation of small bowel diseases in children: A large, tertiary center study

BACKGROUND AND AIM

Device assisted enteroscopy is the cornerstone for small bowel evaluation. However, the data are limited in pediatric patients. In this study, we aim to evaluate the safety and utility of single balloon enteroscopy (SBE) in children.

METHODS

The data of children (≤18-years) who underwent SBE from November 2010 to July 2020 was analyzed, retrospectively. The safety and diagnostic yield of SBE were assessed.

RESULTS

189-SBE procedures (males 117, mean age 15.1 ± 2.76, range 3-18 years) were performed in 174-children. The indications for SBE were chronic abdominal pain in 119 (68.4%), gastrointestinal bleed 17 (9.8%), chronic diarrhea 17 (9.8%) and vomiting 13 (7.5%). Antegrade, retrograde and combined SBE were performed in 98 (51.8%), 77 (40.7%), 7 (3.7%) children, respectively. The mean length of small bowel intubation in antegrade and retrograde SBE groups were 168.9 ± 58.6 cm and 120.7 ± 52.1 cm, respectively. Overall, a positive finding was seen in 117 (67.2%) cases. The most common findings were ileal and jejunal ulcers with or without strictures in 76 (64.9%) children. A total of 18 therapeutic enteroscopic procedures were performed. There were no major adverse events.

CONCLUSION

SBE is a safe and effective procedure for the evaluation and management of small bowel diseases in children.

The role of small-bowel endoscopy in inflammatory bowel disease: an updated review on the state-of-the-art in 2021

The impact of small-bowel (SB) capsule endoscopy and device-assisted enteroscopy on clinical practice, since their introduction 2 decades ago, has been remarkable. These disruptive technologies have transformed the investigation and management of SB pathology and now have a firmly established place in guidelines and clinical algorithms. Furthermore, recent years have witnessed innovations, driven by the demand of new goals in the management of inflammatory bowel disease (IBD), such as mucosal healing and evolving strategies based on tight monitoring and accelerated escalation of care. These developments in SB endoscopy have also been paralleled by refinement in dedicated radiological SB imaging technologies. This updated review highlights the current state of the art and more recent innovations with a focus on their role in IBD.

Endoscopic treatment of blue rubber bleb nevus syndrome in a 4-year-old girl with long-term follow-up: A case report

BACKGROUND

Blue rubber bleb nevus syndrome (BRBNS) is a rare vascular disease, difficult to diagnose and choose a treatment method, especially in young children. There are several limiting factors to the use of enteroscopy for diagnostics and treatment in pediatric patients, in general. The literature on BRBNS cases is limited and presents various therapeutic approaches.

CASE SUMMARY

We present here a case of BRBNS involving a 4-year-old female, whose intestinal venous lesions were successfully treated by endoscopic sclerotherapy and aethoxysklerol foam. Skin lesions, typical for BRBNS, appeared on the 8^th d of the child’s life and their number increased over the next several months. The child also experienced episodes of critical decrease in hemoglobin level (by as much as 52 g/L) for several years, requiring iron supplementation and several blood transfusions. Video capsule endoscopy revealed numerous vascular formations in the small bowel. The combined findings of gastrointestinal venous formations and skin lesions prompted BRBNS diagnosis. Single-balloon enteroscopy was used to perform sclerotherapy, with aethoxysklerol foam. A positive effect was observed within 19 mo of follow-up. We continue to monitor the patient’s hemoglobin level, every 2 wk, and it has remained satisfactory (> 120 g/L).

CONCLUSION

Endoscopic sclerotherapy can be effective in the clinical management of gastrointestinal manifestations of BRBNS in young children.

The Safety and Feasibility of a New Through-the-scope Balloon-assisted Enteroscopy in Children

OBJECTIVES

Small bowel involvement in Crohn disease (CD) is clinically important for diagnosis and treatment. Single and double-balloon enteroscopy have already become important diagnostic tools in such cases. The on-demand NaviAid AB device enables deep advancement into the small bowel, using an anterograde or retrograde approach. In adults, this procedure is feasible, safe, and rapid. This work aimed to assess the safety and feasibility of NaviAid AB enteroscopy in pediatric patients.

METHODS

Single-center, prospective study using the through-the-scope balloon-assisted-enteroscopy (TTS-BAE) NaviAid AB device for the evaluation of the small bowel in children with suspected or known inflammatory bowel disease (IBD). The system consists of a single-use balloon catheter inserted through the instrument channel of a standard colonoscope. It consists of an inflation/deflation system (NaviAid SPARK), which is inflated to anchoring pressure. The repetitive push-pull technique enables the advancement of the colonoscope along the small intestine.

RESULTS

Fifty analyzed endoscopic procedures (30 retrograde, 20 anterograde) were performed in 34 children (52.9% boys, mean age 13.7 years). Average maximal depth of insertion (MDI), advancement depth using the NaviAid AB and average total procedure time were 138 cm (range 100-190 cm), 81 cm (range 40-120 cm), and 12.8 minutes (range 7.3-19.0 minutes), respectively, for the anterograde approach and 143 cm (range 100-170 cm), 64 cm (range 20-95 cm), and 21.9 minutes (range 13.9-32.0 minutes), respectively, for the retrograde approach. No serious or device-related adverse events were reported.

CONCLUSIONS

NaviAid AB enteroscopy in children is safe, feasible, and enables assessment of the small intestine in a short period of time.

Microscopic features of small bowel mucosa of patients with Crohn's disease

BACKGROUND

Double-balloon enteroscopy enables performing numerous small bowel biopsies for pathologic analysis. However, most histopathological characteristics of Crohn's disease are non-specific characteristics. We aimed to explore the small bowel mucosal histopathologic characters of Crohn's disease and identify some disease-specific changes.

METHODS

We included 253 patients without tumors and grouped them into Crohn's disease, suspected Crohn's disease, and non-Crohn's disease groups. These patients underwent double-balloon endoscopy examination and small bowel biopsy at Renji Hospital, Shanghai. All histopathological sections were reviewed, and > 20 histopathological parameters were assessed. Immunohistochemistry was conducted when necessary.

RESULTS

There were different forms of granulomatous lymphangitis on the small bowel mucosa in Crohn's disease. They showed as various macrophages or epithelioid cells in the lumina of lymphatics or in the center of the villi with or without evident obstruction. These features were only observed in Crohn's disease patients. Furthermore, they were correlated with granuloma and lymphangiectasia. Additionally, 15 other features showed significant differences among the three groups, and Crohn's disease patients showed an average of almost seven histopathological characteristics.

CONCLUSIONS

We described the detailed morphologies of granulomatous lymphangitis on the small bowel mucosa and recommend it as a useful histopathological feature for the diagnosis of Crohn's disease. In terms of specificity and sensitivity, it was superior to non-caseating epithelioid granuloma.