SHORT COMMUNICATION

Niger J Paed 2015; 42 (2): 147 –150

Ikobah JM

Ngim OE

Adeniyi F

Ekanem EE

Abiodun P

Paediatric endoscopy in Nigeria

humble beginning

DOI:http://dx.doi.org/10.4314/njp.v42i2.15

Accepted: 6th January 2015

Abstract: Introduction

residents, 12 (30%) consultant

Paediatric gastroenterology has

become an established subspe-

cialty in the last five decades in

developed and some developing

countries. Endoscopy is the cor-

nerstone of this sub-specialty. In

Nigeria, it is still at its infancy

stage, though with increasing lo-

cal interest. This is a report of the

first Paediatric Endoscopy Work-

shop in Nigeria organized as a pre

paediatricians and six (15%)

nurses. Day 2: 22 (52%) paediatric

residents, 12 (29%) consultant

paediatricians and eight (19%)

nurses.

(

)

Ikobah JM

Ekanem EE

Department of Paediatrics,

Ngim OE

Three children (two females and

one male) had upper GI endoscopy

(with biopsy done in two cases)

during the pre-conference work-

shop as live sessions. They were

aged eight, nine and 16 years. Indi-

cations for endoscopy were recur-

rent haematemesis in an eight year

old female patient and recurrent

upper abdominal pain in the other

two patients (a male and a female).

Gastritis was found in the two pa-

tients and this was confirmed his-

tologically in one of the patients.

Conclusion: The training stirred up

participant’s interest in this sub-

specialty of paediatrics. It brought

to fore the need for paediatric

endoscopy to be developed in Ni-

geria. The procedure should be

performed at tertiary centres at this

stage of our development and the

cost of it covered by the National

Health Insurance Scheme. Four

training centres to aid interested

paediatricians and paediatric

trained nurses acquire the needed

skills are recommended.

Department of Surgery,

University of Calabar Teaching

Hospital, Calabar,

Cross River State, Nigeria.

Email: joanikoba@gmail.com

Adeniyi F

-conference by the Paediatric As-

Department of Paediatrics,

Lagos University College Hospital,

Lagos State, Nigeria

sociation of Nigeria (PAN) and

the Nigerian Society of Paediatric

Gastroenterology, Hepatology and

Nutrition (NISPGHAN).

Aim: The aim of the conference

was to promote and create aware-

ness on paediatric gastroenterol-

ogy as a subspecialty and intro-

duce participants to the practice of

paediatric endoscopy.

Method: This was a two day pre-

conference workshop. Paediatri-

cians, paediatric resisdents and

nurses were in attendance. One

International and three National

resource persons were on ground

to impart the needed knowledge

and skills. Training involved di-

dactic lectures, hands-on sessions

using manikins and three live ses-

sions involving the upper gastro-

intestinal tract.

Abiodun P

Department of Paediatrics,

University of Benin teaching Hospital,

Benin City, Edo State, Nigeria.

Results: There were 40 attendees

on day 1: 22 (55%) paediatric

Keywords: Paediatric endoscopy,

Calabar, Nigeria.

Introduction

took many years for the sub-specialty to be recognized

in paediatrics. Fueled by the application of gastrointesti-

nal endoscopy in children, paediatric gastroenterology

The human desire to peer inside the body was the driv-

ing force in the development of endoscopy. The field of

gastroenterology began with the Philip Bozzini’s crude,

2

began in the early 1960s . The sub-specialty of paediat-

ric gastroenterology, hepatology and nutrition was borne

out of a clinical need to provide optimal care to children.

The first society of paediatric gastroenterology was

founde_-₃d in Europe in 1967 and held its first meeting in

1

candle-powered lichtleiter in 1805 and blossomed with

the introduction of flexible gastrointes₁tinal endoscopy

by Basil Hirschowatz in the late 1950s . The first na-

tional gastroenterology society was established in Ger-

many in 1895, shortly after this the American Gastroen-

1

1968 . It has emerged as one of the most diversed

medical – surgical practices in modern medicine with

the subsequent development of smaller instruments for

1

,2

terology Society was established in 1897 . However, it

1

48

gastrointestinal tract (GIT) endoscopy in the 1990s.

Diagnostic and therapeutic paediatric endoscopic proce-

dures are now the standard of care. The most frequently

performed, mainly diagnostic, procedures are

oesophagogastroduodenoscopy and colonoscopy . Wire-

less capsule endoscopy (CE) or double balloon

enteroscopy for investigation of the small intestine can

also be performed. On the other hand, therapeutic pro-

cedures, such as polypectomy, retrieval of foreign bod-

ies, percutaneous endoscopic gastrostomy (PEG) place-

ment, endoscopicretrograde cholangiopancreaticography

The training involved didactic lectures, hands-on train-

ing using manikins and live sessions. The lectures fo-

cused on pertinent topics including: introduction to gas-

trointestinal endoscopy (brief anatomy of the upper GI,

description of instrument, and procedure), indications

for upper and lower GI endoscopy, endoscopy assess-

ment, sedation and monitoring, introduction to diagnos-

tic and therapeutic endoscopy and management of gas-

trointestinal emergencies. The nurses also obtained

training on patient preparation, aftercare and mainte-

nance of equipment in the endoscopy unit. There was

also hands-on training using manikins which afforded

all participants the opportunity to have a feel of the

training process. Three live sessions involving the upper

gastrointestinal system was carried out (two on the first

day and one on the second day).

4

(

ERCP) or ligation of esophageal varices can now be

performed even in the neonatal period. In contrast to

adults, most endoscopic examinations in children are

usually performed under deep sedation or general anes-

thesia to reduce emotional stress caused by separation

from₄parents and the preparation for the procedure it-

self.

Case reports

Paediatric gastroenterology is at its infancy stage in

Three cases involving the upper GI endoscopy were

done on children aged eight, nine and 16 years (two fe-

males and one male respectively). Indications for the

endoscopy were recurrent haematemesis in the eight

year old female patient and recurrent upper abdominal

pain in the other two patients. Informed consent was

obtained from the parents after the procedure was ex-

plained to them and their children. The children had the

procedure performed after an overnight fast. The proce-

dures were performed by trained paediatric and adult GI

endoscopists. An Olympus Optera !70 Video paediatric

gastroscope and a Karl storz video gastroscope were

used to perform the procedures. All procedures were

done on an outpatient basis. Two endoscopy nurses were

present in the endoscopy room to assist with the proce-

dures. This was performed after insertion of a reliable

venous access, with monitoring of vital signs and oxy-

gen saturation. Conscious sedation was administered by

the anaesthetist using intravenous midazolam and propo-

fol at appropriate doses. Xylocaine pharyngeal spray

was also used. Multiple fragmented biopsies were taken

from the antrum, fundus and duodenum in the 16 year

old patient and from the mid and distal oesophagus, an-

trum, fundus and duodenum of the eight year old patient

and sent for histology. No complications were recorded

in the three procedures.

5

,6

many parts of Africa . In South Africa, it has only re-

cently been registered by the Health Professions Council

5

of South Africa (HPCSA) . In Nigeria, paediatric endo-

scopy is an emerging field and data on this subject at

6

present is scanty . Paediatric endoscopy offers both di-

agnostic and therapeutic benefits though in many parts

of Africa, this is largely carried out by the adult gastro-

enterologist and the lower gastrointestinal endoscopy

7

,8

seems to be an exclusive domain of the surgeons . All

these are due to few trained and certified Paediatric gas-

troenterologists. With the formation of the Nigerian

Society of Paediatric Gastroenterology, Hepatology and

Nutrition (NIPSGHAN) in 2012, more paediatricians are

indicating interest in this sub-specialty. This is a report

of what may be considered the beginnings of hands-on

training in paediatric endoscopy in Nigeria.

Report

The Paediatric Endoscopy training held in the city of

th

Calabar_s,_tCross River state, south-south Nigeria on 20

and 21 of January 2014 at the University of Calabar

Teaching Hospital and Asi Ukpo Medical and Diagnos-

tic centre in Calabar. The training held as a pre-

conference workshop of the annual scientific meeting of

the Paediatric Association of Nigeria (PAN) meeting in

conjunction with the Nigerian Society of Paediatric Gas-

troenterology, Hepatology and Nutrition (NISPGHAN).

The training drew participants from all over Nigeria.

The workshop was advertised at least four months be-

fore the date of commencement and interested partici-

pants indicated interest. There were 12 paediatricians, 22

paediatric residents and six nurses in attendance on the

first day and eight nurses on the second day including

the number of paediatricians and paediatric residents

who were present on the first day. Resource persons

included one international resource person from South

Africa and three national resource persons. The aim of

the conference was to promote and create awareness

about paediatric gastroenterology as a subspecialty with

emphasis on the need for paediatric endoscopy in the

care of patients who may require this for optimum care.

Results

Case 1

Gastroscopy on the16 year old male with history of re-

current upper abdominal pain for four months. Gastro-

scopy showed pre-pylori ulcers with extensive oedema

of the surrounding mucosa in the stomach, erosions on

the greater curvature and multiple ulcers in duodenal

bulb with exudates (Fig 1a). Histology showed sections

of pyloric-antral to early duodenal type epithelium, focal

collection of lymphocytes, plasma cells and neutrophils

in the submucosa mainly, with a spill over into the mu-

cous membrane. No atypia was noticed. Findings were

in keeping with chronic gastritis. Fig 1b.

1

49

stools Therapeutic indications for endoscopy include

conditions such as; oesophageal varices eradication,

foreign body removal, dilatation of oesophageal and

upper GI strictures, PEG/feeding tubes, Mallory-Wiess

Fig 1a

1

1,13

.

syndrome and upper GI bleeding control

High sensitivity of endoscopy in the diagnosis of dis-

eases and lack of radiation are important advantages of

1

3

endoscopy in the care of patient . There is an urgent

need to develop this sub-specialty in Nigeria as there are

studies done which have shown the prevalence of

Helicobacter pylori infection ranging from 66.3% to

8,9

9% in the childhood population . Other GIT prob-

6

Fig 1b

lems are rife in this population. It may well be that chil-

dren in Nigeria, like their counterpart elsewhere, have

inflammatory bowel disease, coeliac disease and other

gastrointestinal diseases which require endoscopy but

the diagnosis are missed due to lack of expertise and

appropriate equipment. The cost of gastrointestinal en-

doscopy in Nigeria is high and most patients are unable

to pay for these services which most of the time is of-

fered by the private sector. Cost of anesthesia in the pae-

diatric age group also makes it even more expensive for

the patients. The average cost of paediatric upper GI

endoscopy in Nigeria is in the range of 200 to 250 US

dollars while the lower GI endoscopy is 250 to 300 US

dollars. This is beyond the reach of most parents in a

country where 70% of the population live below the

poverty line. There is therefore need for government

subsidy in this regard.

Case 2

An eight year old female with history of recurrent upper

GI bleeding. She had two previous gastroscopy done on

her which showed multiple haemorrhagic lesions in the

second and third parts of the duodenum and this was the

third following treatment. The gastroscopy was normal.

Case 3

As far as the safety of the procedures is concerned, most

studies have generally foun₁d₆_-₁t₈hat upper GI endoscopies

. There are also sugges-

A nine year old female who presented with history of

epigastric pain for two weeks and was managed for gas-

tritis. Findings at endoscopy showed multiple erythema-

tous spots in the pylori antrum and streaks of erythema

radiating to the pylorus. No ulcers, nor gastric erosions.

are safe regardless of age

tions that simple diagnostic endoscopies can be per-

formed safely in the primary care setting, leaving secon-

dary care units to concentrate on those patients requiring

sedation, who are acutely ill, and who require therapeu-

1

6

tic procedures . Despite these positive findings, endo-

1

8

scopy does carry some risks. In a study by Quine et al

out of 13, 036 patients undergoing endoscopy, there

were seven deaths, and this was suspected to have been

an underestimation owing to the r₇eliance on self report-

Discussion

1

Paediatric endoscopy offers both diagnostic and thera-

peutic _-b₄ enefits though special instrumentation is re-

ing by doctors. Another study reported significant

complications and deaths from diagnostic oesophageal

gastroduodenoscopy in 1 per 1000 and 1 per 10,000 pro-

cedures respectively. Patients’ sex, age, or preference

for sedation or endoscopist did not affect the morbidity

rate. The United Kingdom National Confidential En-

1

quired Gastrointestinal diseases such as chronic ab-

dominal pain, vomiting and diarrhoea are common all

around the world . Finding causes of gastrointestinal-

problems leads to more efficient treatment and conse-

quently decreases morbidity and mortality rates .

9

19

quiry into Patient Outcome and Death report of 2004

identified a low mortality from therapeutic endoscopy,

with the exception of percutaneous endoscopic gastro-

scopy (PEG), which had a mortality of 6%.The report

made many recommendations to improve the structure

and process of therapeutic endoscopy, including the im-

portance of careful selection for PEG insertion and en-

doscopic retrograde cholangiopancreatography (ERCP),

and the imperative of endoscopy for gastrointestinal

haemorrhagebeing undertaken only by experienced en-

doscopists. Currently there is no study in Nigeria on the

safety or risk of gastrointestinal endoscopy. The Federa-

tion of International Societies of Pediatric Gastroenterol-

Endoscopy is the best method for the diagnosis of most

of these₀d_,₁i₁seases and its application in children is in-

1

creasing . The diagnosis of gastritis was confirmed

following histologic findings on the 16 year old patient

who had biopsy specimen sent for histology (Fig 1b)

and for the third patient with recurrent upper GI bleed-

ing the gastroscopy done on her helped to confirm cure

following treatment. Diagnostic indications for endo-

scopy includes recurrent abdominal pain, upper GI

bleeding, chronic diarrhoea, malabsorption, caustic soda

ingestion, unexplained anaemia, hematochasea/melena

1

50

ogy, Hepatology, and Nutrition (FISPGHAN) is analyz-

ing and developing the implementation of Pediatric En-

doscopy worldwide and aims to introduce a standardized

the establishment of centres of excellence in Paediatric

Endoscopy in Nigeria and Sub-Saharan Africa. Mean-

while, paediatric endoscopy should be done only at terti-

ary centres at this stage of its development in Nigeria.

2

0

curriculum for trainees and training the trainers .

2

1

Thomsonet al has shown the advantages of an inten-

sive training by virtual endoscopy training.

Conflict of interest: None

Funding: None

Recommendations

Acknowledgement

There is a need to make Paediatric Gastroenterology a

sub-specialty by the National Postgraduate Medical Col-

lege. Public-Private Partnership is advocated for the

development of this sub-specialty in Nigeria. This will

enhance training of sub-specialists and provision of the

much needed facilities which the Government alone

cannot provide, as in our index cases. Also, we recom-

mend a subsidized cost for endoscopy in children to

improve access to the service. We strongly recommend

The authors will like to acknowledge the management of

University of Calabar Teaching Hospital and Asi Ukpo

Medical and Diagnostic Centre, Calabar for graciously

granting the use of their endoscopic suites for the pre-

conference training. We also acknowledge Karl Storz,

Nigeria and JNCI Limited, Nigeria for the technical sup-

port they provided during this workshop.

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