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Upper gastrointestinal endoscopy in children - an experience at a paediatric

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Article  in  Mymensingh Medical Journal · August 2003

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Upper Gastrointestinal Endoscopy in Children- An Experience at a
Paediatric Gastroenterology Unit.

Dr.A S M Bazlul Karim, MBBS, FCPS- Associate Professor,

Paediatric Gastroenterology and Nutrition.
Bangabandhu Sheikh Mujib Medical University
(BSMMU) Dhaka, Bangladesh.

Name of the department & institute in which the work was done:

Department of Pediatric Gastroenterology & Nutrition,

Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh.

Corresponding author:
Dr. A.S.M Bazlul Karim
Associate Professor,
Pediatric Gastroenterology & Nutrition
Bangabandhu Sheikh Mujib Medical University (BSMMU)), Shabagh,
Dhaka, Bangladesh.
Telephone No: 880 2 8612241
Fax: 880-2-8613794, 9336363
e-mail:karimb@bangla.net

1
Upper gastrointestinal endoscopy has become a routine procedure and changed the management

of upper gastrointestinal problems in children. The aim of this communication is to share our

experience with 153 cases of upper gastrointestinal endoscopy in children done over a period of

24 months at a paediatric gastroenterology unit of a tertiary care hospital of Dhaka, Bangladesh.

Children who attended the department with various gastrointestinal problems are the subjects of

this paper. Intravenous midazolam and 10% pharyngeal xylocain were used in majority of cases

for sedating the children. The ages of the children were between 15 months to 15 years

(9.41±3.22 years). The positive diagnostic yield was 92 out of 153 cases (60.1%). The major

indication for doing endoscopy in the present series was recurrent abdominal pain (51.6%)

followed by upper gastrointestinal bleeding (28.8%). Combining histopathological findings and

CLO/rapid urease tests the overall positive yield of recurrent abdominal pain was 45 out of 79

(57%). The sources of upper gastrointestinal bleeding could be identified in 79.5% cases.

Esophageal varices indicating portal hypertension were found in 62.5% children who were

endoscoped for un-explained splenomegaly with or without ascites. Endoscopy has become a

safe and valuable procedure in the management of upper gastrointestinal problems in children

and gastric antral biopsy has increased the positive diagnostic yield of recurrent abdominal pain

in the studied children.

Indexing Words : Fiberoptic endoscopy, Upper gastrointestinal tract, Children.

2
INTRODUCTION:

Esophagogastroduodenoscopy (EGD) by flexible fiberoptic/video endoscope has changed the

diagnosis and management of upper gastrointestinal diseases in children. It allows not only direct

visualization of the lesions but also helps in the management of various gastrointestinal (GI)

problems. The application of flexible endoscopy in children was first reported in the 1970s 1,2.

Initially it was limited for basic diagnostic purposes. But over the last few years both diagnostic

and therapeutic endoscopic procedures have become the basic elements of paediatric

gastroenterologic practices.

In Bangladesh endoscopic facilities for adults have been available for a long time and adult

gastroenterologists have been solely doing endoscopy in children. Recently trained paediatric

gastroenterologists have started doing endoscopy in children and at present this facility is

available in three centers of the country. Therefore there is paucity of large series of data

regarding various aspects of endoscopy in children3. The purpose of this communication is to

share our experience with 153 cases of EGD done in children over a period of 24 months at a

paediatric gastroenterology unit of a tertiary care hospital of the country.

MATERIALS AND METHODS:

The paediatric gastroenterology unit of Bangabandhu Sheikh Mujib Medical University

(BSMMU), Dhaka has started doing upper GI endoscopy since February 2001. A total number of

153 upper GI endoscopic procedures had been done till the end of February 2003. These children

attended the department with various GI problems and their findings constitute the subject matter

of this communication. All endoscopic procedures were carried out with the Pentax model FG-

3
24V fiberoptic endoscope (Asahi Optical Co. Ltd, Japan) that has an insertion tube outer

diameter of 7.9 mm and an instrument channel diameter of 2 mm. All the procedures were

carried out following a through clinical and investigative work up as appropriate for each case.

Written consent was obtained from the guardian before endoscopy after explaining the purpose

and potential hazards of the procedure. Intranasal midazolam (0.2 mg/kg undiluted parenteral

preparation, Roche) along with 10% pharyngeal xylocain spray, intravenous midazolam (0.2-0.3

mg/kg) with 10% pharyngeal xylocain spray or 10% pharyngeal xylocain spray alone were used

for sedating the children before the procedure.

RESULTS:

Of the 153 children endoscoped 87 were male and 66 female. The ages of the children varied

between 15 months to 15 years (9.41±3.22 years) and majority (54.4%) were in the age group of

10-15 years. Intranasal midazolam along with 10% pharyngeal xylocain spray were used in the

first 5 cases. Subsequently in 66 children IV midazolam along with 10% pharyngeal xylocaine

spray and in 73 children only 10% pharyngeal xylocaine spray were used before the procedure

for sedating the children. In 9 cases no sedation was used. Recurrent abdominal pain (RAP), GI

bleeding (haematemesis &/or melaena) and splenomegaly with or without ascites were the major

indications for doing endoscopy in the present series (Table-1). Forty one cases of different

grades of esophageal varices followed by 24 cases of gastric antral erythema were the two major

endoscopic findings of the present report and these and other endoscopic findings are shown in

table II. Histopathological examinations with endoscopic biopsy specimens from different sites

were done in 40 children and their results are shown in table-III. Rapid urease tests (CLO test),

to see the presence of H pylori were done with 56 (41 with RAP and 15 without RAP) specimens

4
obtained from gastric antrum and it was found positive in 18 cases. Forty one of these 56

children had RAP and CLO test were positive in 15 cases. CLO tests were also done with the rest

15 children without RAP (children with portal hypertension) and were found positive in 3 cases

(Table-IV) only.

DISCUSSION:

Upper GI endoscopy, fiberoptic/video has replaced the rigid endoscopy and proved it to be

extremely useful in a wide variety of circumstances. Not only for the diagnosis and follow up of

upper GI problems, therapeutically also this procedure has great potential in children4-6. In the

present series the positive diagnostic yield was 92 out of 153 cases (60.1%). Mishra et al7

demonstrated the usefulness of the procedure with a yield of positive findings in as many as

41.8% cases and Mittal8 29.3% cases. Intravenous midazolam along with parenteral opoids are

commonly used to produce a state of conscious sedation in paediatric patients undergoing EGD.

But this technique requires the presence of skill anesthetics with full resuscitation facilities. But

in a developing country this is not always technically possible. Therefore in the first 5 cases

intranasal midazolam along with 10% xylocain pharyngeal anesthetic agent were tried to sedate

children but the results were not satisfactory. Fishbein M et al9 successfully applied intranasal

midazolam during EGD and their success was probably due to simultaneous use of intravenous

meparidine. Thereafter in the present series intravenous midazolam along with 10% pharyngeal

xylocain spray were used in 66 children, only xylocain spray in 73 children and no sedation in 9

children with satisfactory results. Apart from the bitter taste of pharyngeal xylocain spray these

techniques were well tolerated by the children. Intravenous midazolam did not create any

problem except in 2 cases with delayed recovery from sedation.

5
Recurrent abdominal pain (RAP) is a common problem in children and value of upper GI

endoscopy for the proper diagnosis has not yet been well defined. Seventy-nine children with

RAP were endoscoped in the present series. Endoscopically gastric antrum and esophagus were

found erythematous in 24 and 11 cases respectively and duodenal ulcer was found in 2 cases

only. Rest 42 children with RAP were found endoscopically normal. Therefore endoscopically

the positive yield was 37 out of 79 cases (46.8%). Out of these 79 children with RAP biopsy

specimens were obtained from 76 children for either histopathology or for rapid urease test/CLO

test. Infiltration of mononuclear cells in lamina propria indicating gastritis were found in 23 and

CLO test were found positive in 15 cases. Esophageal biopsy was done in 10 cases and

histological evidence of esophagitis were found in 7 cases. Combining these, the overall positive

yield (combination of CLO, 15 cases and histopathology, 30 cases) of RAP were 45 out of 79

(57%) in the present series. Mishra et al7 reported only one case of peptic ulcer in their series of

134 cases. The positive findings in other series were 5 out of 1210 and 21 out of 661 respectively.

Mittal reported only one each case of esophagitis and gastric ulcer in his series of 150 children8.

The high yield of positive findings in the present series could be due to several factors. Besides

different socio-cultural factors and good selection of cases, more biopsy specimens were

obtained in the present series compared to the above studies for histopathological examination.

Biopsy specimens were taken more in the present series because in children it has been reported

recently that there is poor co-relation between endoscopic appearance and histopathologic

findings11-15.

Before the availability of paediatric endoscope, nasogastric lavage was used to see whether a GI

bleeding was from the upper GI tract and also to measure the severity of bleeding. Upper GI

endoscopy now plays a role in the evaluation of most cases of GI bleeding and the bleeding sites

6
from the esophagus to the distal duodenum can be easily identified endoscopically. Mittal in has

series identified the source of bleeding in 19 out of 34 cases8. A total of 7 out of 13 cases of

upper GI bleeding in a series reported by Cadranelo et al10 had positive findings. Similarly, 26

out of 34 cases of haematemesis reported by Ament et al1 had a source identified by endoscopy

while Telesco et al16 could detect the cause in 20 out of 24 cases. In the present series, sources of

GI bleeding could be identified in 35 (26 from esophageal varices, 5 from gastric erosions, 2

each from prolapse gastropathy and duodenal ulcer) out of 44 (79.5%) cases indicating good

selection of cases for endoscopy.

Upper GI endoscopy proved itself to be an essential tool in the diagnosis of esophageal varices

resulting from portal hypertension. Therefore upper GI endoscopy is indicated in suspected cases

of portal hypertension presented with un-explained splenomegaly with or without ascites. Mishra

et al7 in their series identified varices in 24 (17.9%) cases of upper GI endoscopy. In the present

series endoscopy were done in 24 children who presented with un-explained splenomegaly (15

cases) and splenomegaly with ascites (9 cases) but without any history of haematemesis and/or

melaena. Esophageal varices were found in 15 (62.5%) out of these 24 children.

Fiberoptic endoscopy is very useful in obtaining biopsy from distal duodenum in children

suffering from persistent/chronic diarrhoea. It is a much quicker method compared to the

conventional biopsy through the jejunal biopsy capsule. Duodenal biopsy specimens were taken

from 4 children suffering from chronic diarrhoea and villous atrophy were found in 3 and normal

histology in 1 child. Two of these 3 children with villous atrophy were subsequently diagnosed

to be cases of abdominal tuberculosis and were successfully treated with anti-tuberculosis drugs.

The cause of villous atrophy in the 3rd case was not clear and his symptoms did not improve after

introduction of gluten free diet and after anti-giardia treatment. Mishra OP et al17 reported

7
abnormal histopathology in duodenal biopsy specimen in 73.3% of 57 chronic diarrhoea cases

and of these villous atrophy with mononuclear cells infiltration were found in 56.7% cases. They

also reported chronic duodenitis in 16.7% of their cases.

With the introduction of smaller and smaller instrument with video monitor, endoscopy has

become a valuable procedure in the diagnosis and therapy of upper GI problems in infants and

children. The risk of the procedure is low in the appropriate settings with careful monitoring of

vital signs and adequate sedation. There is poor co-relation between endoscopic appearance and

histology and antral biopsy has increased the positive diagnostic yield of recurrent abdominal

pain in children studied in the present series.

8
REFERENCES:

1. Ament ME, Christie DL. Upper gastrointestinal fiberoptic endoscopy in pediatric

patients. Gastroenterology 1977;72:1244-48.

2. Liebman WM, Thaler MM, Bujanover Y. Endoscopic evaluation of gastrointestinal

bleeding in the newborn. Am J Gastroenterol 1978;69:697-98.

3. Hassan T, Nahar N, Mollah AH, Begum HA, Islam AKMN. Endoscopic Evaluation of

Upper Gastrointestinal Tract Disorders in Children. In: Rafiqueuddin AKM, Ahmed S,

editors. Proceedings of the 13th Annual Convention and Scientific Session of the

Association of Physicians of Bangladesh; 2002 April10-11; Dhaka, Bangladesh. Dhaka:

APB;2002. p 20..

4. Yachha SK, Srivastava BC, Sharma BC, Khanduri A, Baijal SS. Therapeutic

Gastrointestinal Endoscopy. Indian J Pediatr 1996;63:633-9.

5. Venkateswara K, Nanda V, Mehta S. Endoscopic removal of foreign bodies. Indian

Pediatr 1988;25:443-46.

6. Yachha SK, Kochhar R, Mehta S. Endoscopic dilatation of esophageal strictures. Indian

Pediatr 1988;25:472-73.

7. Misra YK, Yachha SK, Kochhar R, Thapa BR, Mehta S. Upper GI endoscopy in

children-An experience at pediatric gastroenterology unit. Indian Pediatr 1987;24:820.

8. Mittal SK. Upper Gastrointestinal Endoscopy in Children. Indian Pediatr 1989;26:134-8.

9. Fishbein M, Lugo RA, Woodland J, Lininger B, Linscheid T. Evaluation of Intranasal

Midazolam in Children Undergoing Esophagogastroduodenoscopy. J Pediatr

Gastroenterol Nutri 1997;25:261-6.

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10. Cadranel S, Rodesch P, Peetr SP, Gremer M. Fiberendoscopy of the gastrointestinal tract

in children: A series of 100 examinations. Am J Dis Child 1977;131:41-5.

11. Dohil R, Hassaall E, Jevon G, et al. Gastritis and gastropathy of childhood. J Pediatr

Gastroenterol Nutri 1999;29:378-94.

12. Carpenter HA, Talley NJ. Gastroscopy is incomplete without biopsy: clonical relevance

of distinguishing gastropathy from gastritis. Gastroenterology 1995;108:917-24.

13. Liquornik KN, Liacouras CA, Ruchelli ED, et al. Gastritis in pediatric patients:

correlation of gross endoscopic findings with histologic results. Gastroenterology

1998;114:A205.

14. Black DD, Haggitt RC, Whitington PF. Gastroduodenal endoscopic-histologic correlation

in pediatric patients. J Pediatr Gastroenterol Nutr 1988;7:353-8.

15. Elta GH, Appelman HD, Behler EM, et al. A study of the correlation between endoscopic

and histologic diagnoses in gastroduodenitis. Am J Gastroenterol 1987;82:749-53.

16. Tedesco FJ, Goidstein PD, Gleason WA, Keating JP. Upper gastrointestinal endoscopy in

the pediatric patient. Gastroenterology 1976;70:492-4.

17. Mishra OP, Dhawan T, Singla PN, Dixit VK, Arya NC, Nath G. Endoscopic and

histopathological evaluation of preschool children with chronic diarrhoea. J Trop Pediatr

2001;47:77-80.

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 Table 1. Indications for Endoscopy (n-153).

______________________________________________________________________

Indications No. (%)

______________________________________________________________________

Recurrent abdominal pain 79 (51.6)

Gastrointestinal bleeding 44 (28.8)

a) Haematemesis 11

b) Melaena 08

c) Hematemesis and Melaena 25

Un-explained splenomegaly 15 (9.8)

Splenomegaly with ascites 09 (5.9)

Chronic diarrhoea 06 (3.9)

______________________________________________________________________

11
 Table II. Endoscopic findings (n-92)

______________________________________________________________________

Endoscopic findings No (%)

______________________________________________________________________

Esophageal varices 41 (44.6)

a) Grade- I 08

b) Grade- II 12

c) Grade- III 21 (associated fundic varices-07)

Gastric antral erythema 24 (26.1)

Esophageal erythema at its lower end 11 (12)

Monilial esophagitis 05 (5.4)

Gastric erosion 05 (5.4)

Duodenal ulcer at its 1st part 02 (2.2)

Prolapse gastropathy 02 (02.2)

Multiple nodular swelling (Lymphoma) 01 (01.9)

Gastric stricture following surgery 01 (01.9)

______________________________________________________________________________

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 Table III. Histopathological findings (n-40)

______________________________________________________________________

Histopathological findings No (%)

______________________________________________________________________

Stomach:

Chronic gastritis 23 (57.5)

Normal gastric antrum 02 (05.0)

MALT 01 (02.5)

Esophagus:

Reflux esophagitis 07 (17.5)

Normal lower end of esophagus 03 (07.5)

Duodenum:

Duodenal villous atrophy 03 (07.5)

Normal duodenum 01 (02.5)

______________________________________________________________________

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 Table IV. Findings of Rapid Urease (CLO) Test (n-56)

______________________________________________________________________

CLO test result No. of children No.of children Total

with *RAP without RAP

______________________________________________________________________

CLO test positive 15 03 18

CLO test negative 26 12 38

______________________________________________________________________

Total 41 15 56

* Recurrent abdominal pain

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