Pediatric digestive endoscopy

and some related problems

HO THI Nhan.MD

GI ward, Children Hospital No.2

Introduction

• Upper digestive endoscopy

• Lower digestive endoscopy

• Diagnostic endoscopy (routine)

• Therapeutic endoscopy

Personnel

• Physicians: pediatric GI fellowship or experience with pediatric GI diseases + adequate training in pediatric endoscopy. – should be performed by pediatric-trained gastroenterologists. (3)

• assistants specially trained: – 1st : meet, explain to child + hold , reassure child throughout

procedure. – 2nd: obtain, process tissue + assist with other equipment

• Competent physicians in anesthesia and resuscitation.

Facilities and Equipment

• Routine endoscopy: outpatient setting • Hospital bedside or operating room:

occasionally: more invasive or therapeutic procedure.

• Equipment for monitoring: BP, pulse, SpO2+ emergency medications+ resuscitation.

• Good endoscopy system with size and type appropriate for pediatric use (3)

Indications

• Upper endoscopy – Acid peptic diseases – Suspicion of mucosal inflammation (including

infection); Diarrhea/malabsorption (chronic) – Chronic Abdominal pain with significant morbidity or

signs of organic disease (weight loss, anemia, vomiting, fevers)

– Hematemesis or enema , Hematochezia– Dysphagia or odynophagia – Caustic ingestion, foreign body ingestion – Recurrent vomiting – Others: GER, failure to thrive, Anemia (unexplained),

Indications

•    symptomatic pediatric patients with known or suspected ingestion of caustic substances: should be performed.

in absence of symptoms: should be considered. (1C)

• Therapeutic intervention– Foreign-body removal– Dilation of esophageal and upper-GI strictures– Esophageal varices eradication– Upper-GI bleeding control

Indications

• Colonoscopy – Lower gastrointestinal hemorrhage – Chronic diarrhea (clinically significant with weight

loss, fevers, anemia )– Suspected IBD – Cancer surveillance

• IBD• Polyposis syndromes

– Rejection of intestinal transplant – Lower–GI-tract lesions seen on imaging studies?– Others: Anemia (unexplained), Failure to thrive/weight

loss, Abdominal pain (clinically significant)

Indications

Therapeutic intervention – Polypectomy– Foreign-body removal– Dilation of strictures– Lower-GI bleeding control

Contraindications

• Absolute – suspected perforation of the intestine and peritonitis

in a toxic patient.• Relative:

– Severe neutropenia – Bleeding disorders – Recent history of bowel surgery – Patient with connective tissue diseases: Ehlers-

Danlos , Marfan’s sd ( perforation) – Toxic dilation of the bowel – Partial or complete bowel obstruction – Aneurism of the abdominal or ileac aorta

Preparation

• Upper endoscopy: fasting 2-4h (<6ms), 6-8h ( >2ys) • Colonoscopy (GI ward personnel)

– Fasting – Bowel preparation

• Preprocedural preparation should be individualized according to the patient's age, size, clinical state, and planned procedure. (1C)

• Preprocedural fasting from milk and solids vary, a minimum fasting from all oral intake (including clear liquids) of 2 hours is recommended. (3)

Sedation and Monitoring

• Routine: sedation preferred

• Therapeutic procedures: general anesthesia

• General anesthesia is commonly used for pediatric endoscopy. (1C)

Sedation and Monitoringand related problems

• Monitor: – SpO2, ECG tracing: routine

• All sedated pediatric patients should receive routine oxygen administration + monitored with a minimum of pulse oximetry and heart-rate monitoring. (3)

• In deeply sedated patients: 1 individual monitors the patient's cardiac and respiratory status and to record vital signs. (3)

• personnel trained specifically in pediatric life support and airway management strongly recommended during sedated procedures. (3)

Complications

• Upper digestive endoscopy: 4 types – Sedation related – Procedure related – Those associated with therapeutic

intervention– Those associated with patient’s underlying

diseases or reasons for endoscopy – Multifactoral and undetermined

Complications

• Colonoscopy – Similar to those of upper digestive endoscopy.– Correlation between the frequency of

technical complications and experience of the endoscopist.

– Most important: bleeding, perforation.

Conclusion

•    Endoscopic procedures in the pediatric population: safe and effective. (1C+).

• Consideration for appropriate indications. • Be aware of potential risks and complications

References

1. GUIDELINE: Modifications in endoscopic practice for pediatric patients. by the American Society for Gastrointestinal Endoscopy. Volume 67, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY

2. Gastrointestinal endoscopy. Pediatric gastrointestinal and liver diseases.

Complications of pediatric EGD

• US: in 1978 and 1979: 2046 EGD during 18-month at 25 medical centers: complications in 1.7% of all upper-endoscopy procedures.– bronchospasm, transient respiratory arrest,– fever, phlebitis– 1 perforation

• 1653 EGD (1981-1992) in U.S. centers: complication rate of 0.3%– 2 episodes of significant oxygen desaturation – 1 case of gastric perforation.

Complications of pediatric EGD

• 10,236 procedures performed in 9234 patients. Immediate complications in 239 procedures (2.3%).

• most common complications: – hypoxia (157[1.5%]) and bleeding (28 [0.3%]). – Complication rates were significantly higher in

the youngest age group, female gender, intravenous (IV) sedation group.

Complications of pediatric colonoscopy

• Colonoscopy: – Perforation:

• < 0.5% (Simon E J Janes ,Clinical review) • 0.2-0.4% after diagnostic colonoscopy and 0.3-1.0% with

polypectomy (Jennifer Lynn Bonheur , emedicine). – Bleeding: most common: biopsy or remove colonic

lesions. • 1/1000 (emedicine) • 4.8/1000 (David A. Johnson, Medscape Gastroenterology)

– Serious complications: with biopsy 7/1000 colonoscopies vs 0.9/1000 colonoscopies without biopsy.

• more for larger (> 1 cm) polyps (11.4/1000) than for smaller polyps (6.5/1000)

Complications of pediatric colonoscopy

– Infection: Salmonella species, Pseudomonas species, and Escherichia coli

– Abdominal distension – Splenic rupture – Small bowel obstruction (history of abdominal

surgery and postoperative adhesions )

Sedation and Monitoringand related problems

• Transient reactions at the site of medication administration

• Coughing + a characteristic taste with meperidine infusion.

• Desaturation may without apparent signs. • Neurologically impaired patients: unpredictable. • Dosages reduced: recent weight loss ( IBD,

malignancy, anorexia nervosa. • Reported: respiratory depression, pulmonary

edema, allergic reaction, arrhythmias, hypotension, paradoxical reaction, hallucination

• Moderate sedation in children is most commonly performed by using midazolam, with or without fentanyl, or meperidine.

• General anesthesia and propofol are commonly used for pediatric endoscopy, usually based upon age or anticipated patient intolerance for the procedure

Postprocedure monitoring and discharge

• Monitor for adverse effects: vital signs, SpO2, awareness.

• Before discharge: writen/verbal instructions: – Signs/symtoms of potential adverse

outcomes, complications,