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Nigerian J Paediatrics 2019 vol 46 issue 3

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Advances in gastrointestinal endoscopy Shaping diagnosis and therapy of gastrointestinal disorders in children
Niger J Paediatr 2019; 46 (3):124 – 128
REVIEW
Eke CB
CC – BY Advances in gastrointestinal
endoscopy: Shaping diagnosis and
therapy of gastrointestinal
disorders in children
DOI:http://dx.doi.org/10.4314/njp.v46i3.1
Accepted: 22nd July 2019
Abstract :
In parallel to the
superiority in terms of diagnostic
growth of paediatric gastroen-
yield over earlier methods of diag-
Eke CB
(
)
terology sub-speciality, gastroin-
nosing common as well as rare
Department of Paediatrics
testinal disorders requiring endo-
gastrointestinal disorders.
College of Medicine, University of
scopy for diagnosis or therapy
This review sought to review the
Nigeria, Enugu State
have shown a rising incidence
recent advances in gastrointestinal
Email: christopher.eke@unn.edu.ng
globally. With the development of
endoscopy modalities which have
fibre-optic endoscope, gastroin-
led to the explosion in its use for
testinal endoscopy has become a
diagnosis and therapy of different
revolutionary diagnostic as well
gastrointestinal disorders in chil-
as therapeutic tool.
dren.
Generally, endoscopy has shown
Introduction
tion ranging from neonates to adolescents is usually un-
dertaken in most reference centres by certified paediatric
Gastrointestinal endoscopy in children and adolescent
gastroenterologists who have been trained in accredited
fellowship programmes.
2,9,10
has evolved over the past 40years with increasing diag-
They ensure that standard
nostic as well as therapeutic indications. Technological
1
protocols for effective gastrointestinal endoscopy are
advancements in endoscopy design and its devices have
maintained including pre-procedure preparation of pa-
contributed to the evolution of paediatric gastrointestinal
tients, peri- procedure maintenance as well as continued
endoscopy.
2,3
Improvement in sedation and anaesthe-
post-operative care.
sia, as well as skills in monitoring of vital signs of pa-
4
tients,
5
during endoscopic procedures have equally
Indications and Modalities of Paediatric Gastrointesti-
added to the explosion of the endoscopic modality of
nal Endoscopy
treatment.
In parallel to the growth of paediatric gastroenterology
Currently children of all age groups including neonates
sub-speciality, gastroenterological disorders requiring
can now be examined endoscopically with high safety
6
endoscopy for diagnosis or therapy have shown a rising
records enabling the increase in the diagnosis of com-
incidence globally. With the development of fibre-optic
mon as well as diagnostic dilemmas in paediatric gastro-
endoscope, gastrointestinal endoscopy has become a
intestinal diseases including Coeliac disease of which
revolutionary diagnostic as well as therapeutic tool.
endoscopic biopsy is the gold standard diagnostic tech-
Endoscopy has shown superiority in terms of diagnostic
nique, severe gastro-oesophageal reflux disease, eosi-
7
8
yield over earlier methods of diagnosing common as
nophilic oesophagitis, and the inflammatory bowel dis-
well as rare gastrointestinal disorders. Changing indica-
eases among others.
6
tions for paediatric endoscopy over the past two to three
Diagnostic and therapeutic varieties of gastrointestinal
decades have generally influenced the detection and
endoscopy are diverse and include oesophagogastro-
characterization rate of some gastrointestinal disorders,
11
including Coeliac disease,
12
duodenoscopy, colonoscopy, polypectomy, haemostatic
and inflammatory bowel
disease, among others.
6,13
therapy, balloon dilation, and placement of percutaneous
endoscopic gastrostomy (PEG) tube. These are funda-
mental to the assessment, treatment, and care of infants
Gastrointestinal endoscopy has stood out as an accurate
and children with various gastrointestinal disorders.
9
and informative method of assessing upper and lower
It is essential that safety is maintained through acquisi-
gastrointestinal disorders and the procedures should
tion of adequate medical knowledge and technological
therefore be performed only in clinical conditions in
know-how specific to performing gastrointestinal endo-
which it has shown superiority over other diagnostic
methods.
9
scopic procedures in children, in order to ensure effec-
10
tiveness.
Various expert groups including North American Soci-
ety for Paediatric Gastroenterology Hepatology and Nu-
Medical gastrointestinal endoscopy in paediatric popula-
trition (NASPGHAN) and European Society for Paediat
125
Paediatric gastroenterology Hepatology and Nutrition
Consent issues:
(ESPGHAN) have assessed the different guidelines for
the use of gastrointestinal endoscopy in children.
14
The
Preparation for endoscopy in paediatric patients requires
objective is to have a clear underlying evidence that
the physician paying attention to the child’s physiology
findings from the endoscopic procedure will impact
as well as the emotional and psychosocial wellbeing of
both patient and his or her primary caregivers. Early
9
positively on patient’s diagnosis and/or treatment.
Endoscopy is not usually indicated in older children for
emotional and psychosocial support of the child as well
the evaluation of functional gastrointestinal disorders,
as the patients/caregivers is beneficial for the endoscopic
including self- limited abdominal pain, constipation and
procedures particularly in centres where conscious seda-
tion is used. The parents/legal guardian of the child
20
encopresis. Exceptional indications may include chil-
15
dren with ‘red flag’ symptoms and signs such as ab-
should be adequately counselled about the procedure as
dominal pain waking the child up from sleep, other asso-
well as the child if s/he is old enough otherwise relevant
ciated systemic symptoms like fever, joint pain or un-
role play models could be applied in counselling the
usual rash, significant vomiting especially with bile or
younger child. However, in most tertiary centres with
blood, recurrent mouth ulcers, associated malnutrition or
adequate anaesthetic support, general anaesthesia is pre-
poor growth; dysphagia; and mucous or blood in the
ferred in children as it is associated with improved out-
faeces.
6
comes. Also in children less than three years, the air-
ways have to be protected from the compression exerted
Gastrointestinal symptoms including haematemesis,
by gastroscope as it is being passed.
chronic abdominal pain, persistent vomiting, anaemia,
Informed consent should ideally be obtained from an
dysphagia, and foreign body ingestion are indications
appropriately designated parent or legal guardian as re-
for endoscopy.
quired by the State while assent should be obtained
when appropriate from an older child. At the point of
9
Oesphagogastroduodenoscopy
(upper gastrointestinal
endoscopy) is particularly useful endoscopic modality in
consent, the nature of the procedure including risk of
evaluating common paediatric foregut disorders includ-
anaesthesia and its possible complications should be
ing allergic, infectious, peptic oesophagitis and gastritis,
explained.
coeliac disease,as well as diagnosis and treatment of
strictures and variceal bleeding in children with portal
Pre-procedure assessments
hypertension arising from different aetiologies.
6,16
Colonoscopy (lower gastrointestinal endoscopy) is an-
Here a complete physical examination is ascertained.
other endoscopic modality which may be performed in
Emphasis is also laid on the respiratory and cardiovascu-
infants and children with rectal bleeding. A diagnosis of
lar system. Also it is important to exclude possibilities
inflammatory bowel disease can be established as well
of the child having loose tooth/teeth and enlarged tonsils
as defining the extent and the severity of the disease,
as they could compromise the airway in sedated pa-
which may identify complications and influence initial
tients.
management. It can also be important in follow up as-
Generally all patients to be anaesthesized should have a
sessment of disease progress. Further uses of colono-
thorough pre-procedure anaesthetic review and should
scopy may also include diagnosing cause of allergic
be certified fit prior to the procedure.
colitis, colitis caused by other conditions like granulo-
Basic laboratory tests including a full blood count
matous diseases including mycobacterium organisms as
should be documented. In cases of possible endoscopic
well as lower gastrointestinal haemorrhage, chronic diar-
therapeutic interventions like variceal banding, scre-
rhoea, cancer surveillance particularly in children with
lotherapy it is important that platelet count, coagulation
multiple polyposis syndrome.
profile and liver function tests are determined prior to
Therapeutic colonoscopy is used in the management of
the procedure and adequate interventions put in place
polyps, foreign body removal, stricture dilatation, percu-
including provision of relevant blood product at the
taneous caecostomy as well as reduction of intussuscep-
point of the procedure. Endoscopy should be deferred in
tion.
17,18
patients with severe coagulopathy as it should be cor-
rected accordingly.
6
With further technological advancements newer modali-
ties of endoscopy have been developed including small
Patient Preparations
bowel enteroscopy (double balloon enteroscopy),narrow
band imaging, endoscopic retrograde cholangiopancrea-
General anaesthesia is known to decrease the protective
tography (ERCP),
wireless capsule endoscopy with
laryngeal reflexes and to increase the risk of pulmonary
higher diagnostic and therapeutic potentials
.6
aspiration. The American Society of Anaesthesiologists
Wireless capsules passed via the oral route allow muco-
(1999), Association of Paediatric Anaesthetists of Great
sal visualization of the small bowel (from the duodenum
Britain and Ireland (2003), and European Society of
to the caecum) thus aiding the diagnosis of some gastro-
Anaesthesia (2005), the times needed are 2hours of pre-
intestinal pathologies previously posing with diagnostic
operative fasting for clear fluids, 4hours of fasting for
breast milk, and 6hours of fasting for solids.
21
dilemmas including occult gastrointestinal bleeding,
suspected Crohn’s disease, Coeliac disease, and small
Further as part of the pre- colonoscopy preparations ade-
bowel polyps in individuals with hereditary polyposis
quate bowel cleansing of the patient with standard bowel
syndromes.
3,19
preparation regimens prior to the endoscopic procedure
126
is essential for a clear endoscopic field. Various clean-
22
belled as possible cases of Inflammatory Bowel Disease
sing regimens including polyethylene glycol with elec-
particularly Crohn’s disease and its treatment with vari-
trolytes, polyethylene with normal saline enema, bisaco-
ous immunosuppressive therapy and the attendant side
dyl suppositories are in use either singly or in combina-
effects as well as indirect economic costs to the child
tion.
23
However, no standardized bowel preparation
and affected families.
29
regimen or paediatric colon cleanliness index exists for
During upper gastrointestinal endoscopy biopsies should
children; recommendations have been made concerning
obtained from different sites for histological diagnosis;
pre-procedural preparation complemented by the indi-
as even in the absence of any macroscopic findings on
vidual experience of the specific endoscopic centre. This
3
endoscopy, important diagnosis have been made from
bowel preparation should be emphasized so as to allow
tissue biopsies obtained from normal appearing parts of
for a clear visible gut during the colonoscopies.
the gut, thus enabling either a modification or change of
Some gastrointestinal endoscopic procedures require pre
patient’s management for the better in such circum-
stances. In a study by Thakkar and colleagues
30
-procedural parenteral antibiotic prophylaxis such as
the
during percutaneous endoscopic gastrostomy (PEG)
overall rate of change of management after endoscopic
tube insertion because of its high risk of infection. Anti-
evaluation in children with Inflammatory Bowel Disease
biotic recommendation therefore has to be determined
was 42% necessitating addition of a new medication as
by a combination of procedure-related risk of bacterae-
the most common intervention.
mia and patients’ risk, and as well as local experience.
24
Complications
Intra – Procedure Monitoring
These complications could be related to sedation/
Patient monitoring during endoscopic procedures is cru-
anaesthesia, procedure or patient’s underlying condition
cial for a successful procedural outcome. The American
and include hypoxia, bleeding, respiratory distress, nau-
Academy of Paediatrics has issued recommendations
sea/vomiting,
gut
perforation,
pneumoperitoneum
regarding sedation and monitoring for diagnostic and
among others. However the risks are very rare and by
therapeutic procedures in children.
25
These guidelines
and large the therapeutic and diagnostic benefits of en-
recommend continuous pulse oximetry, and heart rate
doscopy by for outweigh these risks.
20,24,31,,32
In a cross-
monitoring at all levels of sedation by a dedicated
sectional database review of the complications arising
trained attendant who is specifically assigned to monitor
from
oesophagogastroduodenoscopy (EGD) from 13
the child’s vital signs including oxygen saturation, heart
facilities between 1999-2003 that reviewed 10,236 pro-
rate, respiratory rate, blood pressure and in some set-
cedures performed in 9234 paediatric patients, reported
tings electrocardiography. Monitoring of vital signs dur-
an immediate complication rate of 2.3% associated with
ing an endoscopic procedure is important particularly in
EGD. The most common complications noted in that
younger children as they can desaturate often without
study were hypoxia (1.5%) and bleeding (0.3%). Higher
showing obvious signs and symptoms.
3
complication rate was more in the youngest age group
who desaturates easily, those with highest American
Diagnostic yields
Society of Anesthesiologists (ASA) class, and those who
received intravenous sedation rather than general anaes-
The sensitivity of all endoscopic examinations in paedi-
thesia.
24
atric patients varies with the age of the child and indica-
Absolute contraindication for gastrointestinal endoscopy
tion for the procedure. In upper gastrointestinal endo-
should be identified prior to the procedure and include
scopy, Chang and colleague,
26
reported an 85% ability
unstable airway, cardiovascular collapse, intestinal per-
of the oesphagogastroduodendoscopy to pick up source
foration and peritonitis, while relative contra-indication
of upper G1 bleeding in a cohort of 23 patients. In an-
are bowel obstruction, severe thrombocytopaenia, co-
other study of 16 patients undergoing upper gastrointes-
agulopathy, recent gastrointestinal surgery, respiratory
tinal endoscopy in six out of the 16 patients (37.5%),
infection and recent food intake prior to the commence-
had endoscopically detected abnormalities despite nor-
ment of the procedure as patient must be fasted as per
protocol
.3,33,34
mal radiographic reports.
27
The results of biopsy in endoscopic procedures have
markedly improved the diagnosis of some gastrointesti-
Paediatric gastrointestinal endoscopy in sub-Saharan
nal diseases including Helicobacter pylori infection re-
Africa
lated gastric and small intestinal ulcers, Coeliac disease,
inflammatory bowel disease and associated secondary
Huge gap exists on gastrointestinal endoscopy practice
infections during acute flare up of ulcerative colitis
in children in sub-Saharan Africa with limited data re-
including Cytomegalovirus colitis/infection.
28
ported jointly by adult physicians and paediatricians in
37
and Nigeria.
38-41
Sudan, Egypt,
36
Biopsy tissues taken during colonoscopic procedures
Zambia,
35
Currently
from abnormal and even macroscopically normal parts
comprehensive paediatric endoscopy training and ser-
of the gut has helped to diagnose some common differ-
vice in the sub- Sharan African region exists only in the
entials of colitis in children particularly abdominal tu-
Republic of South Africa where certified sub-specialty
berculosis in our setting, enabling treatment with anti-
training in gastroenterology is obtainable.
tuberculous therapy in such cases with often good prog-
Many paediatricians from different sub- Saharan African
nosis thus sparing such children the risks of being la-
countries are now being trained as sub-specialists in
127
gastroenterology from South African institutions
42
and
devices.
will form the critical mass that will drive rapid explo-
These changing indications for paediatric endoscopy
sion in the paediatric gastrointestinal endoscopy services
over the past two to three decades have generally influ-
in the region to meet the increasing need.
enced the detection, characterization rate and therapy of
diverse gastrointestinal disorders with promising results.
Efforts are being made to establish and improve gastro-
intestinal endoscopy services and training to match the
Conclusion
rising demand for paediatric endoscopy in the sub-
Saharan African region.
Gastrointestinal endoscopy in children and adolescent
has evolved over the past few decades with increasing
Conflict of interest: None
diagnostic and therapeutic indications owing to new
Funding: None
technological advancements in endoscopy design and its
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