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Fiberoptic Upper Intestinal Endoscopy in Infants and Children
Pediatric Gastroenterology I
0031-3955/88 $0.00
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Fiberoptic Upper Intestinal Endoscopy in Infants and Children
Marvin E. Ament, MD, * William E. Berquist, MD, t Jorge Vargas, MD,:j: and Vojislav Perisic, MD§
Adult gastroenterology had its greatest growth as a subspecialty during the 1970s with a rapid expansion of training programs, number of welltrained clinical gastroenterologists, explosive growth of both basic and clinical knowledge, and development of sophisticated invasive and noninvasive diagnostic tools for probing every aspect of the gastrointestinal and hepatobiliary systems. 1 Until the early 1970s, there was very limited opportunity to train in the subspecialty of pediatric gastroenterology, and consequently very few pediatric gastroenterologists were trained. Most of those practicing the subspecialty were either self-taught or received some training in adult programs. They had only a few diagnostic tools to use: small intestinal biopsy, rectal biopsy, liver biopsy, and nonperfused catheters for measurement of rectal motility and esophageal sphincter pressures. Their major concerns were to characterize and treat abdominal pain, chronic diarrhea, malabsorption syndromes and constipation, and how to differentiate biliary atresia from neonatal hepatitis. Great emphasis was placed on the effects of the psyche on the gastrointestinal (GI) tract. However, as a result of the rapid growth of adult gastroenterology as a subspecialty and the accompanying technology, pediatricians became increasingly interested in training in the subspecialty and adapting and developing the tools used in adults *Professor of Pediatrics, Department of Pediatrics; Chief, Division of Gastroenterology and Nutrition, UCLA Medical Center, Los Angeles, California tAssociate Professor of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, UCLA Medical Center, Los Angeles, California tAssistant Professor of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, UCLA Medical Center, Los Angeles, California §The Institute for Mother and Child, Novi Beograd, Yugoslavia From the Department of Pediatrics, Division of Gastroenterology and Nutrition, UCLA Medical Center, Los Angeles, California, and the Institute for Mother and Child, Novi Beograd, Yugoslavia
Pediatric Clinics of North America-Vol. 35, No.1, February 1988
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Table 1. Indications for Upper Gastrointestinal Tract Endoscopy in Children 1. Bleeding Hematemesis Melena Occult blood loss 2. Recurrent Abdominal Pain Localized to right upper quadrant mid-epigastric area Associated nausea, vomiting, diarrhea Weight loss 3. Indeterminate Radiographic Studies 4. Identification of Mass Lesions Seen on Radiographic Studies 5. Vomiting 6. Caustic Ingestion 7. Foreign Body Ingestion 8. Esophageal Strictures 9. Sclerotherapy 10. Placement of Gastrostomy Tubes 11. Electro or photocoagulation of bleeding gastric or duodenal ulcers 12. Electrocautery of antral webs
for their pediatric patients. Problems and questions, which heretofore had not been satisfactorily resolved and answered by the early workers in the field, had a chance to be resolved as they had in adult gastroenterology. General pediatricians were taught the indications for upper and lower intestinal endoscopy and gradually by experience learned not to fear but to accept the new diagnostic tools.2-4 The practitioner has learned that, in the hands of a skilled pediatric endoscopist, these studies not only enhance diagnostic accuracy, but can be performed safely. 2-17 They have learned the indication for a procedure should be made on the basis of the potential benefits versus risks in relation to other diagnostic tools and therapeutic maneuvers.
INDICATIONS FOR UPPER INTESTINAL ENDOSCOPY There are at least a dozen indications for performing an upper intestinal endoscopic examination (Table 1). Most of these are diagnostic, but the number of therapeutic measures done through an endoscope is increasing. Some, such as photocoagulation, thermocoagulation, and electrocoagulation in adults, have never or only rarely been reported in children. Others, such as sclerotherapy, have begun to be used widely in pediatric patients with varices. 1S-23 Endoscopic retrograde cholangiopancreatography is not commonly used, but recent developments in instruments and technique have established its place in differential diagnosis of obstructive jaundice and recurrent pancreatitis. 25-27
FREQUENCY OF INDICATIONS FOR UPPER GASTROINTESTINAL ENDOSCOPY
Hematemesis and melena are among the most common reasons to perform an endoscopic examination in an infant or child (Table 2). They
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Table 2. Frequency of Indications for Upper Intestinal Fiberoptic Endoscopy in 365 Children INDICATION
NUMBER
Abdominal pain Hematemesis and melena Dysphagia and vomiting, retrosternal pain, pyrosis Abnormal but nondiagnostic x-rays Portal hypertension Foreign body removal Caustic ingestion
136 119
54 31 14 9 2
account for nearly one third of all cases reported. Endoscopy is clearly superior to contrast studies in identifying the etiology of upper GI bleeding, especially when the patient has hematemesis sufficient to cause a decrease in hemoglobin and hematocrit and gastric aspirate is positive for blood 10ss.4, 6, 9 A 52 per cent false-negative response rate can be calculated when comparing pediatric patients with hematemesis and melena who had both upper GI series and endoscopy to identify the source of bleeding (Table 3). Endoscopy will not identify the site of the bleeding in 10 to 20 per cent of the cases. This may occur because the blood loss was from the nasopharynx or was insignificant in amount. Before an endoscopic procedure is done, a careful look at the anterior nares and oropharynx should be done to look for signs of epistaxis. If it is found, measures should be directed at treating the epistaxis. Emergency endoscopy for hematemesis rarely is indicated at any age. Once the history of hematemesis is verified, the most important thing is to stabilize the patient. Establishing adequate venous access should be done first. The line established should allow for rapid replacement of blood volume. Volume replacement should be done rapidly with normal saline or 5 per cent albumin in normal saline until blood is available. If volume depletion is established by blood pressure and pulse, fluids should be infused as rapidly as possible to normalize blood pressure. Once this has been achieved, the nite of infusion may be decreased to maintain fluid rates until blood becomes available for transfusion or until the patient bleeds again. The stomach should then be lavaged until clear or until Table 3. Comparison of Upper GI Series to Endoscopy in Diagnosis of Upper GI Bleeding UCI SERIES
ENDOSCOPY
ENDOSCOPY
No. Studies NL ABN ND
No. Studies NL ABN
NO GI Series NL ABN
10
10
7
12
3 0 0 0 0
45
30
3
Gleason Ament Liebman Graham Akasaur
3 24 1
TOTAL
4 4 0
0 2 0 5 0
10 26 1 15 19
7
71
NL, normal; ABN, abnormal; and ND, nondiagnostic.
4
4
6 10
0 4
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bleeding has slowed to a minimal level. Most bleeding will stop under these conservative measures and allow examination under controlled conditions with adequate support personnel. ADAPTATION OF THE TECHNIQUES FOR ENDOSCOPIC TREATMENT OF BLEEDING LESIONS In instances in which bleeding is uncontrolled, requiring replacement of the patient's blood volume in less than an hour to an entire day and surgery is contemplated, endoscopy is truly emergent. In situations such as this with massive loss, it may not be possible to visualize the specific site of bleeding. If it is visualized, this can help direct the surgeon where to look. Prior to the development of fiberoptic endoscopy, most pediatric cases with upper GI bleeding went undiagnosed because radiographic studies missed most cases of hemorrhagiC esophagitis, gastritis, Mallory-Weiss tears, and superficial ulcers. When hepatomegaly or splenomegaly were present, esophageal varices were often implicated as the site of bleeding because of their presence in upper GI series and not necessarily because they were seen to bleed. In other instances, esophageal varices have been suspected as the site of bleeding because of the presence of hepatomegaly and splenomegaly or splenomegaly alone. Only by looking through the endoscope can the diagnosis be made, however. Nearly 20 per cent of patients with varices who bleed do so from sources other than varices. 6 . 9.10 Gastritis At one time, hemorrhagic gastritis and both gastric and duodenal ulcers secondary to use of acetylsalicylic acid for fever and pain relief was a common diagnosis made endoscopically. Since the recognition of the association between upper GI bleeding and use of salicylates, pediatricians rarely recommend the use of acetylsalicylic acid for fever control, and parents have been educated not to use it. This has significantly reduced the frequency of this diagnosis over the past decade. Because of awareness that pathologic stress can cause gastritis and ulcers, pediatriCians have been more careful in the administration of medications that may contribute to it, or prophylax against this complication by treating with either antacids or H2 blockers. This is still a major cause of upper GI bleeding in tertiary pediatric centers, however. Rarely in immune competent but frequently in immune compromised patients an infectious agent such as a virus may be the underlying cause. Idiopathic Peptic Ulcers Patients with idiopathic peptic ulcers may be present with abdominal pain, vomiting, or bleeding. 24 The last is a serious complication because it often occurs suddenly and without forewarning. It is a complication that occurs in a disproportionately large number of children. Unfortunately, those pediatric patients who present with either hematemesis or melena usually recur in the same fashion.
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Patients who present with melena or occult blood loss should have upper intestinal endoscopy done first if a nasogastric aspiration is positive. Ten to twenty per cent of upper GI bleeds will be hemoccult negative. If the aspirate is negative, then the physician should consider doing radionuclide studies first to exclude Meckel's diverticulum or other bleeding sites in the small bowel distal to the ligament of Treitz or the colon. Polyps, Crohn's disease, and hemangiomas are among the lesions seen in the area between Treitz and the ileocecal valve. Idiopathic gastric ulcers should always be visualized and biopsied in pediatric patients because malignant ulcers have been described in teenagers. Esophagitis and Esophageal Strictures Esophagitis and esophageal strictures secondary to gastroesophageal reflux are frequently recognized endoscopically when esophagrams are nondiagnostic in cases that are either occult blood positive or where melena is present. Dysphagia or odynophagia may be associated symptoms. 4 Recurrent Abdominal Pain Recurrent abdominal pain in a pediatric patient is not necessarily an indication for upper intestinal endoscopy. Ninety per cent or more of school age children who have pain as their only symptom have no organic cause for it. Endoscopy should, however, be considered as a diagnostic test in those children who consistently localize their pain to the epigastric area or right upper quadrant, have associated nausea, vomiting, diarrhea, weight loss, or occult blood in the stool and who have persistence of the same degree of severity or increasing severity of pain. Carefully done air contrast upper GI series should be done first. If the study is nondiagnostic, the physician must determine whether to proceed with an endoscopy to remove any doubt about the normalcy of the esophageal, gastric, or duodenal mucosa. In most instances, it should not be done. However, if the associated symptoms listed above are present, endoscopy is indicated. Parental willingness to accept a functional diagnosis may influence the decision to endoscope a youngster since some parents will have doubts about the diagnosis unless they are given the ultimate proof endoscopy gives. Indeterminate Radiographic Studies Patients with indeterminate diagnosis on upper GI series such as pylorospasm, duodenitis, antral spasm, delayed gastric emptying, and gastritis should be endoscoped to confirm the radiologic findings. 3. 4, 6, 10 Similarly mass lesions on radiographic studies should be defined by endoscopic examination. Patients diagnosed as having ulcers, but in whom the ulcer cannot be seen in three or more views, should be endoscoped to confirm the diagnosis. Vomiting Not all patients with vomiting as their primary symptom of gastroesophageal reflex need upper intestinal endoscopy. It is warranted if there is
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associated dysphagia, odynophagia, occult blood loss, or hematemesis. Some patients with vomiting alone may show mild changes of loss of vascular pattern of spontaneous friability to the naked eye, whereas others may have changes visualized only by esophageal biopsy. 29 Caustic Ingestions Caustic ingestions have declined in frequency since the development of safety caps. Despite this, they still occur. Endoscopy is. useful to determine whether any of the ingested substance actually has been swallowed and to determine if treatment needs to be started. Hospitalization may be avoided by early endoscopy, and likewise treatment initiated rapidly in those established to have caustic burns in the esophagus and stomach. As a rule, patients free of burns on the lips, buccal mucosa, or oropharynx rarely have a significant burn in the esophageal or gastric mucosa. 4 Endoscopic examination in the patient with caustic ingestion should proceed only as far as the instrument passes without resistance to reduce the risk of perforation. Foreign Body Ingestion Foreign body ingestion is common in infants and children, and 9 out of 10 that reach the stomach, pass through it and out the body by allowing intestinal motility to remove them. Endoscopic removal is indicated if the patient experiences abdominal pain or vomiting and if the object fails to progress through the stomach and GI tract. If an object remains in the stomach for 14 to 28 days, it is unlikely to pass. 30 Objects that become embedded in the mucosa usually become bound down by fibrous adhesions. Smooth or round objects are unlikely to erode through the mucosa and perforate the stomach. The risk of perforation increases with sharp pins, broken glass, and bones; however, we have even seen these pass. Sometimes, by the time the child is brought to the hospital the object may have passed. Therefore, we have usually allowed up to 1 day for these objects to pass as long as the patient is asymptomatic. Objects obstructing the esophagus must be removed immediately. They usually impact in the upper one third of the esophagus. Esophageal Strictures Patients with esophageal stricture should be examined endoscopically to determine their origin. In pediatric patients most are peptic in origin with only an occasional one secondary to caustic ingestion or chronic infection with moniliasis. Esophageal strictures are becoming increasingly rare in children because during the past decade our ability to diagnose and treat clinically significant gastroesophageal reflux has dramatically improved. This has resulted in earlier diagnosis and treatment with fewer cases with late sequelae. We have seen only one new case of stricture secondary to undiagnosed reflux in the past 5 years. Rare cases of malignant strictures have been seen in teenagers at the gastroesophageal junction. Biopsy therefore should always be done to establish the diagnosis. Last, endoscopy serves as a guide for initiating the
FIBEROPTIC UPPER INTESTINAL ENDOSCOPY IN INFANTS AND CHILDREN
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dilation of strictures. It allows for direct visualization and passage of filament type dilators in those persons who have tight strictures and in whom blind passage of dilators would risk possible perforation. Sclerotherapy In recent years, injection sclerotherapy has increasingly been used in adult patients with documented bleeding esophageal varices. Its advantage over shunting procedures are the rapidity with which it can be done, decreased morbidity, and lesser incidence of postsclerotherapy hepatic encephalopathy. It is not without its own complications, .however: esophageal ulcers, stricture, perforation, mediastinitis, and recurrent bleeding. In children, several groups have reported on its usefulness. 19-23 Because shunting procedures in children under 10 years old are associated with a large number of postshunt thromboses in most surgeons' experience, sclerotherapy should be considered as a first level of therapy in those with recurrent bleeding from varices. In those with extrahepatic portal vein hypertension, sclerotherapy can function as a holding procedure until potential spontaneous shunt pathways develop or until the child's vessels are of sufficient size that an adequate surgical shunt can be created. The number of sessions it takes to obliterate varices varies from as few as one to as many as eight. Complications can occur if an excessive amount of sclerosing agent is injected. These complications are similar to adults. In one series, complications occurred in 50 per cent and consisted of ulceration in 5 of 18, hemorrhage in 5 of 18, and stricture in 2 of 18. No one died from the therapy. Children with intrahepatic disease whether or not they are candidates for liver transplantation can avoid the risk of recurrent bleeding as well as the morbidity and mortality associated with shunt surgery. Although almost all reports in the pediatric literature on the procedure have been done under general anesthesia with the use of either flexible fiberscope or rigid ones-our experience over the last 4 years has been exclusively with the use of flexible scopes and standard intravenous sedation. We have found the procedure can be done safely in this manner without the need for use of the operating room and an anesthesiologist. Our results indicate that if the volume of sclerosant does not exceed 4 to 5 ml per session, there is a decreased risk of complications. Sclerotherapy does not necessarily stop all upper GI bleeding; gastric and proximal small intestinal varices may develop in response to the sclerotherapy. If these varices bleed, they are not amenable to sclerotherapy. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) The indications for ERCP are: recurrent unexplained attacks of pancreatitis, unexplained obstructive jaundice, and the need to clarify pancreatic ductal anatomy prior to operation. 25, 26, 31, 32
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Table 4. Differential Tests to Separate Biliary Atresia Neonatal Hepatitis: Results of ERCP in 23 Infants TEST
NUMBER
Normal BT and PD Normal BT Normal PD Choledochal Cyst Failure Anatomical Anomaly
12 6 6 1 2 1
Success rate = 90%. BT, biliary tract; PD, pancreatic duct.
Because of the lack of children who meet the indications for the procedure, experience with ERCP is limited. In adults, alcoholic pancreatitis and cholelithiasis are the primary causes of pancreatitis, whereas in children the four leading causes are medications, trauma, infections, and pancreatic duct abnormalities. Recently, one group reported a large experience in 23 infants with the use of ERCP for differentiating biliary atresia from neonatal hepatitis. 26 They were successfully able to complete the procedure in over 85 per cent of the cases and were able to establish the diagnosis accurately in those in whom the procedure was successful. The report did not provide any data to compare the results to that obtained by doing more conventional studies. Morbidity occurred in 10 to 15 per cent secondary to overdosage with sedation or compression of the trachea. The equipment required to do the procedure. A side-viewing pediatric duodenoscope for cannulation is expensive and would not be cost effective if used- for only an occasional patient. Only centers that see large numbers of infants with unexplained cholestatic liver disease should consider this modality of diagnosis because diagnosis may be made as rapidly with use of HIDA scan ultrasonography and liver biopsy. Diagnosis of biliary atresia by ERCP depends on failure to visualize common bile duct, but ability to visualize pancreatic duct. Since biliary atresia is a condition in which 80 per cent of the cases may be diagnosed by history, physical examination, and presence of acholic stools, there are relatively few patients who require ERCP to establish it. Although investigators have reported success in performing the procedure under intravenous sedation, some indicate general anesthesia works more satisfactorily because breathing may be controlled. In one large series of older children, ERCP failed to document in one half an anatomic abnormality in the pancreatic and biliary tract ducts and a variety of defects in the remainder to explain patients' histories of recurrent pancreatitis and obstructive jaundice. Pediatric gastroenterologists and pediatricians need to be more selective in use of this study because a 50 per cent normalcy rate is high for such an invasive diagnostic study. Complications from the procedure are cholangitis and pancreatitis and occur in fewer than 3 per cent of adults. Complication rates in children are based on small numbers of patients, but in the one large series of infants, problems with sedation and tracheal compression were the most common.
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CONTRAINDICATIONS There are few absolute contraindications to upper GI tract endoscopy in infants and children. These include shock, perforated hollow viscus, and cervical spine injury. Coma is not a contraindication unless the patient is combative. Most patients in coma may be endoscoped without use of any sedation and anesthetics. If the patient is on a ventilator and is combative, small amounts of intravenous sedation may be used. Severe coagulopathy is not an absolute contraindication to endoscopy. To reduce the risk of bleeding, the patient must be sedated to the point of not struggling to reduce the risk of traumatic injury by the endoscope and to reduce the risk of intracerebral hemorrhage. Correction of the coagulation defect should be considered prior to endoscopy if indicated. Upper intestinal endoscopy should not be done in an uncooperative patient. The most common reason for inadequate examination is incomplete sedation. Lack of experience in sedating infants and children is the most common reason for incomplete sedation. Sedation, if done carefully, may take 15 to 30 minutes. Patients who are receiving one or more medications that effect hepatic metabolism of drugs often require larger doses of medication. Endoscopy is not contraindicated in infants and children with congenital heart disease or with prosthetic devices, such as central venous catheters, heart valves, and shunts for hydrocephalus. The risk of bacteremia is low. Only one study has been done in children and it showed a 2 per cent incidence of bacteremia. Data are not available on the routine use of prophylactic antibiotics. The most conservative approach would be to use prophylactic antibiotics as recommended by the American Heart Association to prevent infective endocarditis. This regimen could be used for others with prosthetic devices. We have never used prophylactic antibiotics for over one and a half decades in upper intestinal endoscopy and have never recognized a symptomatic case of bacteremia in any patient with a prosthetic device. INSTRUMENTS AND TECHNIQUES Currently available instruments make upper intestinal endoscopy possible in newborn infants. It is quite possible that infants between 1500 and 2500 gm may be endoscoped effectively if instruments such as the Olympus OES GIF-XPlO, or the Fujinon UGI-RU instruments are used. The physical characteristics of the endoscopes available for examination of the upper GI tract are listed in the table. Instruments that have an outer diameter of <9 mm can be passed without difficulty in all infants less than 2 years of age. Adequate examination of the esophagus, stomach, and duodenum can be done with any of these instruments. Obviously, the older the child the larger the diameter of instrument that can be used. It is seldom necessary for us to use instruments with a diameter greater than 9.8 mm. The larger the instrument that is used, the greater the chance of tracheal compression occurring. Above 10 years of age, any instrument 9 mm and above would
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Table 5. Physical Characteristic of Upper Intestinal Endoscopes INSTRUMENT (MANUFACTURER)
UGI-RU (Fujinon) OES, GIF-XPlO (Olympus) UGI-RB (Fujinon) OES, GIF-P10 (Olympus) UGI-FP2 (Fujinon) FG-28B (Pentax) OES, GIF-XQlO (Olympus) AG-RF (ACMI) OES, GIF-QlO (Olympus) UGI-F2 (Fujinon) FG-34JA (Pentax) OES, GIF-ITlO (Olympus)
LENGTH
DIAMETER
FIELD OF VIEW
(ern)
(mm)
(degrees)
BIOPSY CHANNEL DIAMETER (mm)
110.0
6.40
105
2.7
103.0
7.90
100
2.0
110.0
7.90
105
2.7
103.0
9.00
100
2.0
110.0
9.50
105
2.7
110.0
9.50
93
2.5
103.0
9.80
100
2.8
108.0 103.0
9.80 11.00
90 120
2.5 2.8
110.0
11.00
105
2.8
110.0
11.50
105
3.5
103.0
12.60
100
3.7
be satisfactory. It is obvious that the larger the instrument, the better the visualization will be because of the increased number of fiber bundles carrying light. It therefore would be uncommon for us to use anything smaller than 9.8 mm in this age group. Virtually all of the procedures can be done with intravenous sedation. In the neonate, however, endoscopic procedures can often be done without the use of any sedation. This is often the most effective way to do procedures in the neonatal period. If intravenous sedation is used, the dosage must be slowly and carefully titrated to avoid respiratory depression. Tracheal compression should not be a problem in the hands of most experienced endoscopists if the infant is sedated, is restrained properly, and if the endoscopist is careful in the proper choice and manipulation of the instrument. It is always preferable to examine a neonate with an endoscope of <9 mm in diameter. Endoscopy in the neonate and the young infant requires careful nursing assistance to bundle and fix the position of the infant, and to help with monitoring and suctioning. All infants and children should have cardiac monitors attached during and after the procedure. The role and need for pulse oximetry has not been established. In nearly a decade and a half of upper intestinal endoscopy being performed in infants less than 2 years of age, the number of examinations done using general anesthesia has been but a handful. Many endoscopists darken the endoscopy suite to improve visualization. This is a poor practice. Lights in the endoscopy suite should not be darkened to allow careful monitoring of the color of the infant or child.
FIBEROPTIC UPPER INTESTINAL ENDOSCOPY IN INFANTS AND CHILDREN
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Some endoscopists feel more comfortable examining children under 2 years of age using general anesthesia. It then becomes the responsibility of the anesthesiologist to monitor the patient and control the breathing. Obviously, the use of an anesthesiologist and his or her equipment may greatly increase the cost of the procedure and does not necessarily lower the risk of complications. Whether one is examining a preschool- or school-aged child, some explanation about the procedure is in order. We try to explain in terms as simple as possible to the youngsters the type of test they are going to undergo. Whenever the test is done on an elective basis, we try our best beforehand to explain to the child the test that is going to be done. When the school-aged child is brought to the endoscopy suite, we show them the equipment and let them look through the endoscopes before we proceed with their sedation. Infants under 6 months of age should be fasted for 4 hours before the procedure is done. After 6 months of age, we usually allow a minimum of 6 hours of fasting before the endoscopic procedure. If there is a question when the patient last ate or drank, a nasogastric tube can be passed and the stomach aspirated to determine if it is empty. The endoscopist should inquire and examine the oral cavity before beginning the procedure to check for loose teeth. If they are recognized to be present, they may be removed prior to the procedure. However, this is an uncommon occurrence, and in over a decade and a half of endoscopic examinations, we have not found more than a handful of patients whose teeth became dislodged from the procedure. Some pediatric and adult endoscopists routinely anesthetize the throat with a topical agent. We normally do not anesthetize the throat with a topical agent because it has not resulted in improving our ability to endoscope the patients successfully. Most children become rather excited by the fact that they have lost their ability to swallow. An intravenous infusion is started either in the endoscopy suite or on the inpatient units. It consists of 0.2 normal saline in 5 per cent dextrose water. For sedation, we use a combination of meperidine (Demerol), metazolan (Versed), and in a few instances, promethazine (Phenergan). We initiate sedation with the use of metazolan, giving 0.1 mg per kg of body weight. This is infused over a period of 1 minute. The infusion is allowed to run in rapidly to infuse the medication into the circulation. The advantage of using the metazolam over the diazepam is that it is more rapid acting, it is metabolized more quickly, and does not cause burning when administered. It has a far lower incidence of phlebitis. We wait 2 minutes after the first dosage before the patient is reassessed. At that pinpoint we infuse meperidine, 1 mg per kg over the following 2 minutes. We again wait to assess the patient's sensorium and vital signs after a 2-minute interval. The doses of meperidine are given as 1 mg per kg boluses or less, until the patient is fully sedated or until we reach a maximal dosage of 4 mg per kg. If, at this point, the patient is not fully sedated, promethazine is given in a dosage of 1 mg per kg to a maximum of 25 mg. If following the administration of promethazine the patient is not fully sedated, an additional 0.1 mg per kg of metazolam is given. We wait 5 minutes from the administration of the last dose of
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medication before the procedure is started. The patient is then turned on his or her left side in the left lateral decubitus position and a bite block is placed in the mouth, if the patient has teeth. This is to protect the instrument from the patient's teeth. If the patient is agitated with the passage of the instrument, and if airway compression is not present, further sedation may be given by administering another 1 mg per kg of meperidine. Agitation at times may be a sign of hypoxia and at others a sign of gastric distension. Naloxone, with an attached needle and syringe, should always be available in the endoscopy suite within reach of the endoscopist, in case respiratory depression develops. Other forms of sedation have been used, including ketamine hydrochloride 2 to 3 mg per kg intravenously, but this is considered an anesthetic agent, and is administered by the anesthesiologist. The endoscope may be passed down the pharynx in one of two ways: (1) with the mouthpiece in place and using the index finger as a guide, or (2) under direct vision with the instrument being advanced while the endoscopist visualizes for the esophageal lumen through the endoscope. In either method, the endoscope must be kept in the midline and out of the pyriform sinuses. The instrument should never be advanced using force. Resistance of passage of the instrument and presence of light in the lateral neck warrant withdrawal and attempted repassage of the instrument. Once the tip of the endoscope has passed the upper esophageal sphincter, it should be advanced only under direct vision and only with enough air insuffiation to permit visualization. Once the tip is in the stomach, any fluid found should be aspirated using the suction button of the endoscope. The folds should then be flattened and the fundus and antrum carefully inspected by forward viewing. The endoscope should then be advanced through the antrum to the pyloris. The pyloric channel and duodenal bulb should be viewed first from the outside. The instrument should be passed into the bulb and the tip turned down and to the right into the second part of the duodenum. It is best to try to visualize the duodenal bulb when one is going forward as well as withdrawing the instrument to visualize it before trauma may alter its structure. Visualization of the duodenum may be accomplished with slow withdrawal of the scope, rotating its tip and torquing the shaft from side to side. The stomach should be evaluated both on entering and leaving by slow withdrawal and rotating the tip. Careful inspection of the cardia is done by retroflexing the instrument on itself and rotating it. Before the endoscope is removed, excessive air and fluid are suctioned from the stomach. Endoscopic findings should be confirmed histologically. The gross mucosal appearance may be a poor predictor of histologic change in either the esophagus, stomach, or duodenum. Erythema, paleness, or lack of vascular pattern in the mucosa do not necessarily mean that inflammatory changes will be seen when biopsies are taken. Tissue that looks completely normal may have microscopic change; therefore, in patients in whom either esophagitis, gastritis, or duodenitis are suspected, biopsies should be performed. All gastric ulcers should be biopsied if there is no explanation for them because carcinoma can occur in children. Biopsy specimens from these ulcers should be obtained from the four quadrants of the ulcer and
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FIBEROPTIC UPPER INTESTINAL ENDOSCOPY IN INFANTS AND CHILDREN
Table 6. Frequency of and Complications in Upper Intestinal Fiberoptic Endoscopy in Children NO. PATIENTS EXAMINED
NO. PROCEDURES
Gleason Ament Liebman Graham Akasaka Kohli Prolla
25 142 1 52 25 63 47
27 163 1 52 25
TOTAL
355
NO. COMPLICATIONS
PHLEBITIS
STRIDOR
0 0 0
0
0
3
2
0
47
0 0 0
0 0 0 0 0
378
5
2
63
2
2 0 0 0
2
from the mucosa adjacent to the other. Gastric biopsies should be taken if one is going to interpret the findings seen endoscopically. In the duodenum, duodenal ulcers need not be biopsied because they are not malignant. As in the stomach, duodenal erosions and so-called duodenitis should be biopsied to confirm the presence of inflammatory change. In the immunocompromised patient, opportunistic infections can produce ulcerous erosions. In patients with unexplained gastritis, biopsies of the antral mucosa should be sent for culture for Campylobacter pyloridis. Small intestinal biopsies taken under direct vision endoscopically can replace those taken by perioral small intestinal biopsy instruments. Biopsies taken through endoscopes are of sufficient size to be used diagnostically. Their advantage is that they do not require radiation exposure. 3. 4, 6, 9, 10. 13, 33 As a general rule, foreign bodies should be removed under general anesthesia. This reduces the risk of tracheal aspiration with withdrawal of the instrument. Once the foreign body has been secured in the retrieval instrument, it is drawn up tightly to the end of the endoscope. The endoscope and object are then slowly withdrawn. Continued visualization of the object through the endoscope ensures that the object does not come loose. Care must be taken not to tear the esophagus as sharp objects are being removed. Very large objects either should be broken up or removed surgically. No object should be forced up through the esophagus. Complications Upper endoscopy in children is a safe procedure. The complication rate is at most less than 2 per cent. The complication rate is higher than that reported in adults; however, most of the complications reported are minor and are due to phlebitis from local sedation, transient respiratory arrest due to oversedation, or to bronchospasm from general anesthetic. Complications that have occurred secondary to the procedure are extremely rare. Perforation, transient bleeding from aspiration site, aspiration, retropharyngeal hematoma, and loosened or broken teeth have rarely been reported in children but have been in adults. Perforations have been recorded in fewer than 0.1 per cent of adults and in virtually a similar number of children. Bleeding secondary to biopsies or dislodged clot material is also seen in fewer than 1 per cent of patients. Aspiration occurs in fewer than 0.1 per cent of patients. Risk of doing endoscopic procedures
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is low. Complications occur only when patients are inadequately sedated or oversedated and respond poorly to general anesthesia. The potential for information almost always outweighs the risk when doing endoscopic procedures in children.
REFERENCES 1. Training and education in gastroenterology. Gastroenterology 83:506-518, 1982 2. Cremer M, Peeters JP, Emonts P et al: Fiberendoscopy of the gastrointestinal tract in children. Experience with newly designed fiberscopes. Endoscopy 6:186-189, 1974 3. Gleason W A, Tedesco FJ, Keating JP et al: Fiberoptic gastrointestinal endoscopy in infants and children. J Pediatr 85:810-138, 1974 4. Ament ME, Christie DL: Upper gastrointestinal fiberoptic endoscopy in pediatric patients. Gastroenterology 72:1244-1248, 1977 5. Liebman WM, Thaler MM, Bujanover Y: Endoscopic evaluation of upper gastrointestinal bleeding in the newborn. Am J Gastroenterol 69:697-698, 1978 6. Graham DY, Klish WJ, Ferry GD et al: Value of fiberoptic gastrointestinal endoscopy of infants and children. South Med J 71:558-560, 1978 7. Graham DY, Klish WJ, Ferry GD, Holcome BB: Endoscopy under gnotobiotic conditions. Gastrointest Endosc 24:298-299, 1978 8. Essenfeld-Sekler E, Paez CV, Toledano A et al: Bleeding lymphoid hyperplasia of the small bowel in an adolescent diagnosed by intraoperative endoscopy. Gastrointest Endosc 25:21-22, 1979 9. Akasaka Y, Misaka F, Miyaoka T et al: Endoscopy in pediatric patients with upper gastrointestinal bleeding. Gastrointest Endosc 23: 199-200, 1977 10. Kohli Y, Fuse Y, Kodawa T et al: Upper gastrointestinal endoscopy in pediatric patients. Gastroenterol Endosc 23:1294-1301, 1981 11. lida M, Yao T, ltoh H, et al: Endoscopic features of adenoma of the duodenal papilla in familial polyposis of the colon. Gastrointest Endosc 27 :6-8, 1981 12. Graham MF, Wood R, Halpin TC: Endoscopic small bowel biopsy in children with a modified multipurpose biopsy tube. Gastrointest Endosc 26:36-37, 1980 13. Prolla JC, Diehl AS, Benvenuti GA et al: Upper gastrointestinal fiberoptic endoscopy in pediatric patients. Gastrointest Endosc 29:279-281, 1983 14. Schwartz SE, Rowden DR, Dudgeon DL: Antral mucosal diaphragm. Gastrointest Endosc 24:33-34, 1977 15. Williams CV, Goldblatt M, Delaney PV: Top and tail endoscopy and follow-up in PeutzJeghers syndrome. Endoscopy 14:82--84, 1982 16. Granelli P, Aneglini GP, Tambussi AM et al: Tubular duplication of the oesophagus in a child: Clinical, radiologic and endoscopic features. Endoscopy 15:263-265, 1983 17. Tolia V, Fleming S: Spectrum of upper endoscopy findings in pediatric population. Gastrointest Endosc 32:150, 1986 18. DalJ'Oglio L, Bagolan P, Ferro F et al: Endoscopic injection sclerosis of oesophageal varices in children-indications and techniques. Endoscopy 16:98-100, 1984 19. Hassall E, Ament ME, Berquist WE: Endoscopic sclerotherapy of esophageal varices in childhood. Gastrointest Endosc 31(2): 130(21A), 1985 20. Howard ER, Stamatokis JD: Management of oesophageal varices in children by injection. In Westaby D, MacDougall RRD, Williams R (eds): Variceal Bleeding. Great Britain, Pitman Books Ltd, 1982, pp 165-172 21. Paquet KJ: Endoscopic paravasal injection of sclerosing agents in children with bleeding oesophageal varices. In Westaby D, MacDougall BRD, Williams R (eds): Variceal Bleeding. Great Britain, Pitman Books Ltd., 1972 pp 173-175 22. Donovan TJ, Ward M, Shepherd RW: Evaluation of endoscopic sclerotherapy of esophageal varices in children. J Pediatr Gastroentrol Nutr 5:696-700, 1986 23. Stamatakis JD, Howard ER, Psaharopoulos HT: Injection sclerotherapy for esophageal varices in children. Br J Surg 69:74-75, 1982 24. Murphy MS, Eastham EJ: Peptic ulcer disease in childhood. Long-term prognosis. J Pediatr Gastroenterol Nutr 6:721-724, 1987
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25. Allendorph M, Werlin SL, Geenen JE et al: Endoscopic retrograde cholangiopancreatography in children. J Pediatr 110:206-211, 1987 26. Guelrud M, Jaen D, Torres Pet al: Endoscopic cholangiopancreatography in the infant: Evaluation of a new prototype pediatric duodenoscope. Gastrointest Endosc 33:48, 1987 27. Ament ME (editorial): Is endoscopic cholangiopancreatography needed for the jaundiced infant? Gastrointest Endosc 33:49-50, 1987 28. Apley J: The child with abdominal pains. Ed 2. Oxford, Blackwell Scientific Publications, 1986 29. Biller JA, Winter HS, Grand RJ et al: Are endoscopic changes predictive of histologic changes in children? J Pediatr 103:215-218, 1983 30. Christie DL, Ament ME: Removal of foreign bodies from the esophagus and stomach with flexible fiberoptic panendoscopes. Pediatrics 57:931-934, 1976 31. Waye JD: Endoscopic retrograde cholangiopancreatography in the infant. Am J Gastroenterol 65:461-463, 1976 32. Blustein PK, Gaskin K, Filler R et al: Endoscopic retrograde cholangiopancreatography in pancreatitis in children and adolescents. Pediatrics 68:387-393, 1981 33. Ament ME: Prospective study of risks of complication in 6,424 procedures in pediatric gastroenterology. Pediatr Res 15:524, 1981 34. Mago H, Chen Chao-Long, Wesson DE et al: Incisionless gastrostomy for nutritional support. J Pediatr Gastroenterol Nutr 5:66-69, 1986 Department of Pediatrics Division of Gastroenterology and Nutrition UCLA Medical Center Los Angeles, California 90024
0031-3955/88 $0.00
+ .20
Fiberoptic Upper Intestinal Endoscopy in Infants and Children
Marvin E. Ament, MD, * William E. Berquist, MD, t Jorge Vargas, MD,:j: and Vojislav Perisic, MD§
Adult gastroenterology had its greatest growth as a subspecialty during the 1970s with a rapid expansion of training programs, number of welltrained clinical gastroenterologists, explosive growth of both basic and clinical knowledge, and development of sophisticated invasive and noninvasive diagnostic tools for probing every aspect of the gastrointestinal and hepatobiliary systems. 1 Until the early 1970s, there was very limited opportunity to train in the subspecialty of pediatric gastroenterology, and consequently very few pediatric gastroenterologists were trained. Most of those practicing the subspecialty were either self-taught or received some training in adult programs. They had only a few diagnostic tools to use: small intestinal biopsy, rectal biopsy, liver biopsy, and nonperfused catheters for measurement of rectal motility and esophageal sphincter pressures. Their major concerns were to characterize and treat abdominal pain, chronic diarrhea, malabsorption syndromes and constipation, and how to differentiate biliary atresia from neonatal hepatitis. Great emphasis was placed on the effects of the psyche on the gastrointestinal (GI) tract. However, as a result of the rapid growth of adult gastroenterology as a subspecialty and the accompanying technology, pediatricians became increasingly interested in training in the subspecialty and adapting and developing the tools used in adults *Professor of Pediatrics, Department of Pediatrics; Chief, Division of Gastroenterology and Nutrition, UCLA Medical Center, Los Angeles, California tAssociate Professor of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, UCLA Medical Center, Los Angeles, California tAssistant Professor of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, UCLA Medical Center, Los Angeles, California §The Institute for Mother and Child, Novi Beograd, Yugoslavia From the Department of Pediatrics, Division of Gastroenterology and Nutrition, UCLA Medical Center, Los Angeles, California, and the Institute for Mother and Child, Novi Beograd, Yugoslavia
Pediatric Clinics of North America-Vol. 35, No.1, February 1988
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Table 1. Indications for Upper Gastrointestinal Tract Endoscopy in Children 1. Bleeding Hematemesis Melena Occult blood loss 2. Recurrent Abdominal Pain Localized to right upper quadrant mid-epigastric area Associated nausea, vomiting, diarrhea Weight loss 3. Indeterminate Radiographic Studies 4. Identification of Mass Lesions Seen on Radiographic Studies 5. Vomiting 6. Caustic Ingestion 7. Foreign Body Ingestion 8. Esophageal Strictures 9. Sclerotherapy 10. Placement of Gastrostomy Tubes 11. Electro or photocoagulation of bleeding gastric or duodenal ulcers 12. Electrocautery of antral webs
for their pediatric patients. Problems and questions, which heretofore had not been satisfactorily resolved and answered by the early workers in the field, had a chance to be resolved as they had in adult gastroenterology. General pediatricians were taught the indications for upper and lower intestinal endoscopy and gradually by experience learned not to fear but to accept the new diagnostic tools.2-4 The practitioner has learned that, in the hands of a skilled pediatric endoscopist, these studies not only enhance diagnostic accuracy, but can be performed safely. 2-17 They have learned the indication for a procedure should be made on the basis of the potential benefits versus risks in relation to other diagnostic tools and therapeutic maneuvers.
INDICATIONS FOR UPPER INTESTINAL ENDOSCOPY There are at least a dozen indications for performing an upper intestinal endoscopic examination (Table 1). Most of these are diagnostic, but the number of therapeutic measures done through an endoscope is increasing. Some, such as photocoagulation, thermocoagulation, and electrocoagulation in adults, have never or only rarely been reported in children. Others, such as sclerotherapy, have begun to be used widely in pediatric patients with varices. 1S-23 Endoscopic retrograde cholangiopancreatography is not commonly used, but recent developments in instruments and technique have established its place in differential diagnosis of obstructive jaundice and recurrent pancreatitis. 25-27
FREQUENCY OF INDICATIONS FOR UPPER GASTROINTESTINAL ENDOSCOPY
Hematemesis and melena are among the most common reasons to perform an endoscopic examination in an infant or child (Table 2). They
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Table 2. Frequency of Indications for Upper Intestinal Fiberoptic Endoscopy in 365 Children INDICATION
NUMBER
Abdominal pain Hematemesis and melena Dysphagia and vomiting, retrosternal pain, pyrosis Abnormal but nondiagnostic x-rays Portal hypertension Foreign body removal Caustic ingestion
136 119
54 31 14 9 2
account for nearly one third of all cases reported. Endoscopy is clearly superior to contrast studies in identifying the etiology of upper GI bleeding, especially when the patient has hematemesis sufficient to cause a decrease in hemoglobin and hematocrit and gastric aspirate is positive for blood 10ss.4, 6, 9 A 52 per cent false-negative response rate can be calculated when comparing pediatric patients with hematemesis and melena who had both upper GI series and endoscopy to identify the source of bleeding (Table 3). Endoscopy will not identify the site of the bleeding in 10 to 20 per cent of the cases. This may occur because the blood loss was from the nasopharynx or was insignificant in amount. Before an endoscopic procedure is done, a careful look at the anterior nares and oropharynx should be done to look for signs of epistaxis. If it is found, measures should be directed at treating the epistaxis. Emergency endoscopy for hematemesis rarely is indicated at any age. Once the history of hematemesis is verified, the most important thing is to stabilize the patient. Establishing adequate venous access should be done first. The line established should allow for rapid replacement of blood volume. Volume replacement should be done rapidly with normal saline or 5 per cent albumin in normal saline until blood is available. If volume depletion is established by blood pressure and pulse, fluids should be infused as rapidly as possible to normalize blood pressure. Once this has been achieved, the nite of infusion may be decreased to maintain fluid rates until blood becomes available for transfusion or until the patient bleeds again. The stomach should then be lavaged until clear or until Table 3. Comparison of Upper GI Series to Endoscopy in Diagnosis of Upper GI Bleeding UCI SERIES
ENDOSCOPY
ENDOSCOPY
No. Studies NL ABN ND
No. Studies NL ABN
NO GI Series NL ABN
10
10
7
12
3 0 0 0 0
45
30
3
Gleason Ament Liebman Graham Akasaur
3 24 1
TOTAL
4 4 0
0 2 0 5 0
10 26 1 15 19
7
71
NL, normal; ABN, abnormal; and ND, nondiagnostic.
4
4
6 10
0 4
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bleeding has slowed to a minimal level. Most bleeding will stop under these conservative measures and allow examination under controlled conditions with adequate support personnel. ADAPTATION OF THE TECHNIQUES FOR ENDOSCOPIC TREATMENT OF BLEEDING LESIONS In instances in which bleeding is uncontrolled, requiring replacement of the patient's blood volume in less than an hour to an entire day and surgery is contemplated, endoscopy is truly emergent. In situations such as this with massive loss, it may not be possible to visualize the specific site of bleeding. If it is visualized, this can help direct the surgeon where to look. Prior to the development of fiberoptic endoscopy, most pediatric cases with upper GI bleeding went undiagnosed because radiographic studies missed most cases of hemorrhagiC esophagitis, gastritis, Mallory-Weiss tears, and superficial ulcers. When hepatomegaly or splenomegaly were present, esophageal varices were often implicated as the site of bleeding because of their presence in upper GI series and not necessarily because they were seen to bleed. In other instances, esophageal varices have been suspected as the site of bleeding because of the presence of hepatomegaly and splenomegaly or splenomegaly alone. Only by looking through the endoscope can the diagnosis be made, however. Nearly 20 per cent of patients with varices who bleed do so from sources other than varices. 6 . 9.10 Gastritis At one time, hemorrhagic gastritis and both gastric and duodenal ulcers secondary to use of acetylsalicylic acid for fever and pain relief was a common diagnosis made endoscopically. Since the recognition of the association between upper GI bleeding and use of salicylates, pediatricians rarely recommend the use of acetylsalicylic acid for fever control, and parents have been educated not to use it. This has significantly reduced the frequency of this diagnosis over the past decade. Because of awareness that pathologic stress can cause gastritis and ulcers, pediatriCians have been more careful in the administration of medications that may contribute to it, or prophylax against this complication by treating with either antacids or H2 blockers. This is still a major cause of upper GI bleeding in tertiary pediatric centers, however. Rarely in immune competent but frequently in immune compromised patients an infectious agent such as a virus may be the underlying cause. Idiopathic Peptic Ulcers Patients with idiopathic peptic ulcers may be present with abdominal pain, vomiting, or bleeding. 24 The last is a serious complication because it often occurs suddenly and without forewarning. It is a complication that occurs in a disproportionately large number of children. Unfortunately, those pediatric patients who present with either hematemesis or melena usually recur in the same fashion.
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Patients who present with melena or occult blood loss should have upper intestinal endoscopy done first if a nasogastric aspiration is positive. Ten to twenty per cent of upper GI bleeds will be hemoccult negative. If the aspirate is negative, then the physician should consider doing radionuclide studies first to exclude Meckel's diverticulum or other bleeding sites in the small bowel distal to the ligament of Treitz or the colon. Polyps, Crohn's disease, and hemangiomas are among the lesions seen in the area between Treitz and the ileocecal valve. Idiopathic gastric ulcers should always be visualized and biopsied in pediatric patients because malignant ulcers have been described in teenagers. Esophagitis and Esophageal Strictures Esophagitis and esophageal strictures secondary to gastroesophageal reflux are frequently recognized endoscopically when esophagrams are nondiagnostic in cases that are either occult blood positive or where melena is present. Dysphagia or odynophagia may be associated symptoms. 4 Recurrent Abdominal Pain Recurrent abdominal pain in a pediatric patient is not necessarily an indication for upper intestinal endoscopy. Ninety per cent or more of school age children who have pain as their only symptom have no organic cause for it. Endoscopy should, however, be considered as a diagnostic test in those children who consistently localize their pain to the epigastric area or right upper quadrant, have associated nausea, vomiting, diarrhea, weight loss, or occult blood in the stool and who have persistence of the same degree of severity or increasing severity of pain. Carefully done air contrast upper GI series should be done first. If the study is nondiagnostic, the physician must determine whether to proceed with an endoscopy to remove any doubt about the normalcy of the esophageal, gastric, or duodenal mucosa. In most instances, it should not be done. However, if the associated symptoms listed above are present, endoscopy is indicated. Parental willingness to accept a functional diagnosis may influence the decision to endoscope a youngster since some parents will have doubts about the diagnosis unless they are given the ultimate proof endoscopy gives. Indeterminate Radiographic Studies Patients with indeterminate diagnosis on upper GI series such as pylorospasm, duodenitis, antral spasm, delayed gastric emptying, and gastritis should be endoscoped to confirm the radiologic findings. 3. 4, 6, 10 Similarly mass lesions on radiographic studies should be defined by endoscopic examination. Patients diagnosed as having ulcers, but in whom the ulcer cannot be seen in three or more views, should be endoscoped to confirm the diagnosis. Vomiting Not all patients with vomiting as their primary symptom of gastroesophageal reflex need upper intestinal endoscopy. It is warranted if there is
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associated dysphagia, odynophagia, occult blood loss, or hematemesis. Some patients with vomiting alone may show mild changes of loss of vascular pattern of spontaneous friability to the naked eye, whereas others may have changes visualized only by esophageal biopsy. 29 Caustic Ingestions Caustic ingestions have declined in frequency since the development of safety caps. Despite this, they still occur. Endoscopy is. useful to determine whether any of the ingested substance actually has been swallowed and to determine if treatment needs to be started. Hospitalization may be avoided by early endoscopy, and likewise treatment initiated rapidly in those established to have caustic burns in the esophagus and stomach. As a rule, patients free of burns on the lips, buccal mucosa, or oropharynx rarely have a significant burn in the esophageal or gastric mucosa. 4 Endoscopic examination in the patient with caustic ingestion should proceed only as far as the instrument passes without resistance to reduce the risk of perforation. Foreign Body Ingestion Foreign body ingestion is common in infants and children, and 9 out of 10 that reach the stomach, pass through it and out the body by allowing intestinal motility to remove them. Endoscopic removal is indicated if the patient experiences abdominal pain or vomiting and if the object fails to progress through the stomach and GI tract. If an object remains in the stomach for 14 to 28 days, it is unlikely to pass. 30 Objects that become embedded in the mucosa usually become bound down by fibrous adhesions. Smooth or round objects are unlikely to erode through the mucosa and perforate the stomach. The risk of perforation increases with sharp pins, broken glass, and bones; however, we have even seen these pass. Sometimes, by the time the child is brought to the hospital the object may have passed. Therefore, we have usually allowed up to 1 day for these objects to pass as long as the patient is asymptomatic. Objects obstructing the esophagus must be removed immediately. They usually impact in the upper one third of the esophagus. Esophageal Strictures Patients with esophageal stricture should be examined endoscopically to determine their origin. In pediatric patients most are peptic in origin with only an occasional one secondary to caustic ingestion or chronic infection with moniliasis. Esophageal strictures are becoming increasingly rare in children because during the past decade our ability to diagnose and treat clinically significant gastroesophageal reflux has dramatically improved. This has resulted in earlier diagnosis and treatment with fewer cases with late sequelae. We have seen only one new case of stricture secondary to undiagnosed reflux in the past 5 years. Rare cases of malignant strictures have been seen in teenagers at the gastroesophageal junction. Biopsy therefore should always be done to establish the diagnosis. Last, endoscopy serves as a guide for initiating the
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dilation of strictures. It allows for direct visualization and passage of filament type dilators in those persons who have tight strictures and in whom blind passage of dilators would risk possible perforation. Sclerotherapy In recent years, injection sclerotherapy has increasingly been used in adult patients with documented bleeding esophageal varices. Its advantage over shunting procedures are the rapidity with which it can be done, decreased morbidity, and lesser incidence of postsclerotherapy hepatic encephalopathy. It is not without its own complications, .however: esophageal ulcers, stricture, perforation, mediastinitis, and recurrent bleeding. In children, several groups have reported on its usefulness. 19-23 Because shunting procedures in children under 10 years old are associated with a large number of postshunt thromboses in most surgeons' experience, sclerotherapy should be considered as a first level of therapy in those with recurrent bleeding from varices. In those with extrahepatic portal vein hypertension, sclerotherapy can function as a holding procedure until potential spontaneous shunt pathways develop or until the child's vessels are of sufficient size that an adequate surgical shunt can be created. The number of sessions it takes to obliterate varices varies from as few as one to as many as eight. Complications can occur if an excessive amount of sclerosing agent is injected. These complications are similar to adults. In one series, complications occurred in 50 per cent and consisted of ulceration in 5 of 18, hemorrhage in 5 of 18, and stricture in 2 of 18. No one died from the therapy. Children with intrahepatic disease whether or not they are candidates for liver transplantation can avoid the risk of recurrent bleeding as well as the morbidity and mortality associated with shunt surgery. Although almost all reports in the pediatric literature on the procedure have been done under general anesthesia with the use of either flexible fiberscope or rigid ones-our experience over the last 4 years has been exclusively with the use of flexible scopes and standard intravenous sedation. We have found the procedure can be done safely in this manner without the need for use of the operating room and an anesthesiologist. Our results indicate that if the volume of sclerosant does not exceed 4 to 5 ml per session, there is a decreased risk of complications. Sclerotherapy does not necessarily stop all upper GI bleeding; gastric and proximal small intestinal varices may develop in response to the sclerotherapy. If these varices bleed, they are not amenable to sclerotherapy. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) The indications for ERCP are: recurrent unexplained attacks of pancreatitis, unexplained obstructive jaundice, and the need to clarify pancreatic ductal anatomy prior to operation. 25, 26, 31, 32
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Table 4. Differential Tests to Separate Biliary Atresia Neonatal Hepatitis: Results of ERCP in 23 Infants TEST
NUMBER
Normal BT and PD Normal BT Normal PD Choledochal Cyst Failure Anatomical Anomaly
12 6 6 1 2 1
Success rate = 90%. BT, biliary tract; PD, pancreatic duct.
Because of the lack of children who meet the indications for the procedure, experience with ERCP is limited. In adults, alcoholic pancreatitis and cholelithiasis are the primary causes of pancreatitis, whereas in children the four leading causes are medications, trauma, infections, and pancreatic duct abnormalities. Recently, one group reported a large experience in 23 infants with the use of ERCP for differentiating biliary atresia from neonatal hepatitis. 26 They were successfully able to complete the procedure in over 85 per cent of the cases and were able to establish the diagnosis accurately in those in whom the procedure was successful. The report did not provide any data to compare the results to that obtained by doing more conventional studies. Morbidity occurred in 10 to 15 per cent secondary to overdosage with sedation or compression of the trachea. The equipment required to do the procedure. A side-viewing pediatric duodenoscope for cannulation is expensive and would not be cost effective if used- for only an occasional patient. Only centers that see large numbers of infants with unexplained cholestatic liver disease should consider this modality of diagnosis because diagnosis may be made as rapidly with use of HIDA scan ultrasonography and liver biopsy. Diagnosis of biliary atresia by ERCP depends on failure to visualize common bile duct, but ability to visualize pancreatic duct. Since biliary atresia is a condition in which 80 per cent of the cases may be diagnosed by history, physical examination, and presence of acholic stools, there are relatively few patients who require ERCP to establish it. Although investigators have reported success in performing the procedure under intravenous sedation, some indicate general anesthesia works more satisfactorily because breathing may be controlled. In one large series of older children, ERCP failed to document in one half an anatomic abnormality in the pancreatic and biliary tract ducts and a variety of defects in the remainder to explain patients' histories of recurrent pancreatitis and obstructive jaundice. Pediatric gastroenterologists and pediatricians need to be more selective in use of this study because a 50 per cent normalcy rate is high for such an invasive diagnostic study. Complications from the procedure are cholangitis and pancreatitis and occur in fewer than 3 per cent of adults. Complication rates in children are based on small numbers of patients, but in the one large series of infants, problems with sedation and tracheal compression were the most common.
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CONTRAINDICATIONS There are few absolute contraindications to upper GI tract endoscopy in infants and children. These include shock, perforated hollow viscus, and cervical spine injury. Coma is not a contraindication unless the patient is combative. Most patients in coma may be endoscoped without use of any sedation and anesthetics. If the patient is on a ventilator and is combative, small amounts of intravenous sedation may be used. Severe coagulopathy is not an absolute contraindication to endoscopy. To reduce the risk of bleeding, the patient must be sedated to the point of not struggling to reduce the risk of traumatic injury by the endoscope and to reduce the risk of intracerebral hemorrhage. Correction of the coagulation defect should be considered prior to endoscopy if indicated. Upper intestinal endoscopy should not be done in an uncooperative patient. The most common reason for inadequate examination is incomplete sedation. Lack of experience in sedating infants and children is the most common reason for incomplete sedation. Sedation, if done carefully, may take 15 to 30 minutes. Patients who are receiving one or more medications that effect hepatic metabolism of drugs often require larger doses of medication. Endoscopy is not contraindicated in infants and children with congenital heart disease or with prosthetic devices, such as central venous catheters, heart valves, and shunts for hydrocephalus. The risk of bacteremia is low. Only one study has been done in children and it showed a 2 per cent incidence of bacteremia. Data are not available on the routine use of prophylactic antibiotics. The most conservative approach would be to use prophylactic antibiotics as recommended by the American Heart Association to prevent infective endocarditis. This regimen could be used for others with prosthetic devices. We have never used prophylactic antibiotics for over one and a half decades in upper intestinal endoscopy and have never recognized a symptomatic case of bacteremia in any patient with a prosthetic device. INSTRUMENTS AND TECHNIQUES Currently available instruments make upper intestinal endoscopy possible in newborn infants. It is quite possible that infants between 1500 and 2500 gm may be endoscoped effectively if instruments such as the Olympus OES GIF-XPlO, or the Fujinon UGI-RU instruments are used. The physical characteristics of the endoscopes available for examination of the upper GI tract are listed in the table. Instruments that have an outer diameter of <9 mm can be passed without difficulty in all infants less than 2 years of age. Adequate examination of the esophagus, stomach, and duodenum can be done with any of these instruments. Obviously, the older the child the larger the diameter of instrument that can be used. It is seldom necessary for us to use instruments with a diameter greater than 9.8 mm. The larger the instrument that is used, the greater the chance of tracheal compression occurring. Above 10 years of age, any instrument 9 mm and above would
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Table 5. Physical Characteristic of Upper Intestinal Endoscopes INSTRUMENT (MANUFACTURER)
UGI-RU (Fujinon) OES, GIF-XPlO (Olympus) UGI-RB (Fujinon) OES, GIF-P10 (Olympus) UGI-FP2 (Fujinon) FG-28B (Pentax) OES, GIF-XQlO (Olympus) AG-RF (ACMI) OES, GIF-QlO (Olympus) UGI-F2 (Fujinon) FG-34JA (Pentax) OES, GIF-ITlO (Olympus)
LENGTH
DIAMETER
FIELD OF VIEW
(ern)
(mm)
(degrees)
BIOPSY CHANNEL DIAMETER (mm)
110.0
6.40
105
2.7
103.0
7.90
100
2.0
110.0
7.90
105
2.7
103.0
9.00
100
2.0
110.0
9.50
105
2.7
110.0
9.50
93
2.5
103.0
9.80
100
2.8
108.0 103.0
9.80 11.00
90 120
2.5 2.8
110.0
11.00
105
2.8
110.0
11.50
105
3.5
103.0
12.60
100
3.7
be satisfactory. It is obvious that the larger the instrument, the better the visualization will be because of the increased number of fiber bundles carrying light. It therefore would be uncommon for us to use anything smaller than 9.8 mm in this age group. Virtually all of the procedures can be done with intravenous sedation. In the neonate, however, endoscopic procedures can often be done without the use of any sedation. This is often the most effective way to do procedures in the neonatal period. If intravenous sedation is used, the dosage must be slowly and carefully titrated to avoid respiratory depression. Tracheal compression should not be a problem in the hands of most experienced endoscopists if the infant is sedated, is restrained properly, and if the endoscopist is careful in the proper choice and manipulation of the instrument. It is always preferable to examine a neonate with an endoscope of <9 mm in diameter. Endoscopy in the neonate and the young infant requires careful nursing assistance to bundle and fix the position of the infant, and to help with monitoring and suctioning. All infants and children should have cardiac monitors attached during and after the procedure. The role and need for pulse oximetry has not been established. In nearly a decade and a half of upper intestinal endoscopy being performed in infants less than 2 years of age, the number of examinations done using general anesthesia has been but a handful. Many endoscopists darken the endoscopy suite to improve visualization. This is a poor practice. Lights in the endoscopy suite should not be darkened to allow careful monitoring of the color of the infant or child.
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Some endoscopists feel more comfortable examining children under 2 years of age using general anesthesia. It then becomes the responsibility of the anesthesiologist to monitor the patient and control the breathing. Obviously, the use of an anesthesiologist and his or her equipment may greatly increase the cost of the procedure and does not necessarily lower the risk of complications. Whether one is examining a preschool- or school-aged child, some explanation about the procedure is in order. We try to explain in terms as simple as possible to the youngsters the type of test they are going to undergo. Whenever the test is done on an elective basis, we try our best beforehand to explain to the child the test that is going to be done. When the school-aged child is brought to the endoscopy suite, we show them the equipment and let them look through the endoscopes before we proceed with their sedation. Infants under 6 months of age should be fasted for 4 hours before the procedure is done. After 6 months of age, we usually allow a minimum of 6 hours of fasting before the endoscopic procedure. If there is a question when the patient last ate or drank, a nasogastric tube can be passed and the stomach aspirated to determine if it is empty. The endoscopist should inquire and examine the oral cavity before beginning the procedure to check for loose teeth. If they are recognized to be present, they may be removed prior to the procedure. However, this is an uncommon occurrence, and in over a decade and a half of endoscopic examinations, we have not found more than a handful of patients whose teeth became dislodged from the procedure. Some pediatric and adult endoscopists routinely anesthetize the throat with a topical agent. We normally do not anesthetize the throat with a topical agent because it has not resulted in improving our ability to endoscope the patients successfully. Most children become rather excited by the fact that they have lost their ability to swallow. An intravenous infusion is started either in the endoscopy suite or on the inpatient units. It consists of 0.2 normal saline in 5 per cent dextrose water. For sedation, we use a combination of meperidine (Demerol), metazolan (Versed), and in a few instances, promethazine (Phenergan). We initiate sedation with the use of metazolan, giving 0.1 mg per kg of body weight. This is infused over a period of 1 minute. The infusion is allowed to run in rapidly to infuse the medication into the circulation. The advantage of using the metazolam over the diazepam is that it is more rapid acting, it is metabolized more quickly, and does not cause burning when administered. It has a far lower incidence of phlebitis. We wait 2 minutes after the first dosage before the patient is reassessed. At that pinpoint we infuse meperidine, 1 mg per kg over the following 2 minutes. We again wait to assess the patient's sensorium and vital signs after a 2-minute interval. The doses of meperidine are given as 1 mg per kg boluses or less, until the patient is fully sedated or until we reach a maximal dosage of 4 mg per kg. If, at this point, the patient is not fully sedated, promethazine is given in a dosage of 1 mg per kg to a maximum of 25 mg. If following the administration of promethazine the patient is not fully sedated, an additional 0.1 mg per kg of metazolam is given. We wait 5 minutes from the administration of the last dose of
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medication before the procedure is started. The patient is then turned on his or her left side in the left lateral decubitus position and a bite block is placed in the mouth, if the patient has teeth. This is to protect the instrument from the patient's teeth. If the patient is agitated with the passage of the instrument, and if airway compression is not present, further sedation may be given by administering another 1 mg per kg of meperidine. Agitation at times may be a sign of hypoxia and at others a sign of gastric distension. Naloxone, with an attached needle and syringe, should always be available in the endoscopy suite within reach of the endoscopist, in case respiratory depression develops. Other forms of sedation have been used, including ketamine hydrochloride 2 to 3 mg per kg intravenously, but this is considered an anesthetic agent, and is administered by the anesthesiologist. The endoscope may be passed down the pharynx in one of two ways: (1) with the mouthpiece in place and using the index finger as a guide, or (2) under direct vision with the instrument being advanced while the endoscopist visualizes for the esophageal lumen through the endoscope. In either method, the endoscope must be kept in the midline and out of the pyriform sinuses. The instrument should never be advanced using force. Resistance of passage of the instrument and presence of light in the lateral neck warrant withdrawal and attempted repassage of the instrument. Once the tip of the endoscope has passed the upper esophageal sphincter, it should be advanced only under direct vision and only with enough air insuffiation to permit visualization. Once the tip is in the stomach, any fluid found should be aspirated using the suction button of the endoscope. The folds should then be flattened and the fundus and antrum carefully inspected by forward viewing. The endoscope should then be advanced through the antrum to the pyloris. The pyloric channel and duodenal bulb should be viewed first from the outside. The instrument should be passed into the bulb and the tip turned down and to the right into the second part of the duodenum. It is best to try to visualize the duodenal bulb when one is going forward as well as withdrawing the instrument to visualize it before trauma may alter its structure. Visualization of the duodenum may be accomplished with slow withdrawal of the scope, rotating its tip and torquing the shaft from side to side. The stomach should be evaluated both on entering and leaving by slow withdrawal and rotating the tip. Careful inspection of the cardia is done by retroflexing the instrument on itself and rotating it. Before the endoscope is removed, excessive air and fluid are suctioned from the stomach. Endoscopic findings should be confirmed histologically. The gross mucosal appearance may be a poor predictor of histologic change in either the esophagus, stomach, or duodenum. Erythema, paleness, or lack of vascular pattern in the mucosa do not necessarily mean that inflammatory changes will be seen when biopsies are taken. Tissue that looks completely normal may have microscopic change; therefore, in patients in whom either esophagitis, gastritis, or duodenitis are suspected, biopsies should be performed. All gastric ulcers should be biopsied if there is no explanation for them because carcinoma can occur in children. Biopsy specimens from these ulcers should be obtained from the four quadrants of the ulcer and
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FIBEROPTIC UPPER INTESTINAL ENDOSCOPY IN INFANTS AND CHILDREN
Table 6. Frequency of and Complications in Upper Intestinal Fiberoptic Endoscopy in Children NO. PATIENTS EXAMINED
NO. PROCEDURES
Gleason Ament Liebman Graham Akasaka Kohli Prolla
25 142 1 52 25 63 47
27 163 1 52 25
TOTAL
355
NO. COMPLICATIONS
PHLEBITIS
STRIDOR
0 0 0
0
0
3
2
0
47
0 0 0
0 0 0 0 0
378
5
2
63
2
2 0 0 0
2
from the mucosa adjacent to the other. Gastric biopsies should be taken if one is going to interpret the findings seen endoscopically. In the duodenum, duodenal ulcers need not be biopsied because they are not malignant. As in the stomach, duodenal erosions and so-called duodenitis should be biopsied to confirm the presence of inflammatory change. In the immunocompromised patient, opportunistic infections can produce ulcerous erosions. In patients with unexplained gastritis, biopsies of the antral mucosa should be sent for culture for Campylobacter pyloridis. Small intestinal biopsies taken under direct vision endoscopically can replace those taken by perioral small intestinal biopsy instruments. Biopsies taken through endoscopes are of sufficient size to be used diagnostically. Their advantage is that they do not require radiation exposure. 3. 4, 6, 9, 10. 13, 33 As a general rule, foreign bodies should be removed under general anesthesia. This reduces the risk of tracheal aspiration with withdrawal of the instrument. Once the foreign body has been secured in the retrieval instrument, it is drawn up tightly to the end of the endoscope. The endoscope and object are then slowly withdrawn. Continued visualization of the object through the endoscope ensures that the object does not come loose. Care must be taken not to tear the esophagus as sharp objects are being removed. Very large objects either should be broken up or removed surgically. No object should be forced up through the esophagus. Complications Upper endoscopy in children is a safe procedure. The complication rate is at most less than 2 per cent. The complication rate is higher than that reported in adults; however, most of the complications reported are minor and are due to phlebitis from local sedation, transient respiratory arrest due to oversedation, or to bronchospasm from general anesthetic. Complications that have occurred secondary to the procedure are extremely rare. Perforation, transient bleeding from aspiration site, aspiration, retropharyngeal hematoma, and loosened or broken teeth have rarely been reported in children but have been in adults. Perforations have been recorded in fewer than 0.1 per cent of adults and in virtually a similar number of children. Bleeding secondary to biopsies or dislodged clot material is also seen in fewer than 1 per cent of patients. Aspiration occurs in fewer than 0.1 per cent of patients. Risk of doing endoscopic procedures
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is low. Complications occur only when patients are inadequately sedated or oversedated and respond poorly to general anesthesia. The potential for information almost always outweighs the risk when doing endoscopic procedures in children.
REFERENCES 1. Training and education in gastroenterology. Gastroenterology 83:506-518, 1982 2. Cremer M, Peeters JP, Emonts P et al: Fiberendoscopy of the gastrointestinal tract in children. Experience with newly designed fiberscopes. Endoscopy 6:186-189, 1974 3. Gleason W A, Tedesco FJ, Keating JP et al: Fiberoptic gastrointestinal endoscopy in infants and children. J Pediatr 85:810-138, 1974 4. Ament ME, Christie DL: Upper gastrointestinal fiberoptic endoscopy in pediatric patients. Gastroenterology 72:1244-1248, 1977 5. Liebman WM, Thaler MM, Bujanover Y: Endoscopic evaluation of upper gastrointestinal bleeding in the newborn. Am J Gastroenterol 69:697-698, 1978 6. Graham DY, Klish WJ, Ferry GD et al: Value of fiberoptic gastrointestinal endoscopy of infants and children. South Med J 71:558-560, 1978 7. Graham DY, Klish WJ, Ferry GD, Holcome BB: Endoscopy under gnotobiotic conditions. Gastrointest Endosc 24:298-299, 1978 8. Essenfeld-Sekler E, Paez CV, Toledano A et al: Bleeding lymphoid hyperplasia of the small bowel in an adolescent diagnosed by intraoperative endoscopy. Gastrointest Endosc 25:21-22, 1979 9. Akasaka Y, Misaka F, Miyaoka T et al: Endoscopy in pediatric patients with upper gastrointestinal bleeding. Gastrointest Endosc 23: 199-200, 1977 10. Kohli Y, Fuse Y, Kodawa T et al: Upper gastrointestinal endoscopy in pediatric patients. Gastroenterol Endosc 23:1294-1301, 1981 11. lida M, Yao T, ltoh H, et al: Endoscopic features of adenoma of the duodenal papilla in familial polyposis of the colon. Gastrointest Endosc 27 :6-8, 1981 12. Graham MF, Wood R, Halpin TC: Endoscopic small bowel biopsy in children with a modified multipurpose biopsy tube. Gastrointest Endosc 26:36-37, 1980 13. Prolla JC, Diehl AS, Benvenuti GA et al: Upper gastrointestinal fiberoptic endoscopy in pediatric patients. Gastrointest Endosc 29:279-281, 1983 14. Schwartz SE, Rowden DR, Dudgeon DL: Antral mucosal diaphragm. Gastrointest Endosc 24:33-34, 1977 15. Williams CV, Goldblatt M, Delaney PV: Top and tail endoscopy and follow-up in PeutzJeghers syndrome. Endoscopy 14:82--84, 1982 16. Granelli P, Aneglini GP, Tambussi AM et al: Tubular duplication of the oesophagus in a child: Clinical, radiologic and endoscopic features. Endoscopy 15:263-265, 1983 17. Tolia V, Fleming S: Spectrum of upper endoscopy findings in pediatric population. Gastrointest Endosc 32:150, 1986 18. DalJ'Oglio L, Bagolan P, Ferro F et al: Endoscopic injection sclerosis of oesophageal varices in children-indications and techniques. Endoscopy 16:98-100, 1984 19. Hassall E, Ament ME, Berquist WE: Endoscopic sclerotherapy of esophageal varices in childhood. Gastrointest Endosc 31(2): 130(21A), 1985 20. Howard ER, Stamatokis JD: Management of oesophageal varices in children by injection. In Westaby D, MacDougall RRD, Williams R (eds): Variceal Bleeding. Great Britain, Pitman Books Ltd, 1982, pp 165-172 21. Paquet KJ: Endoscopic paravasal injection of sclerosing agents in children with bleeding oesophageal varices. In Westaby D, MacDougall BRD, Williams R (eds): Variceal Bleeding. Great Britain, Pitman Books Ltd., 1972 pp 173-175 22. Donovan TJ, Ward M, Shepherd RW: Evaluation of endoscopic sclerotherapy of esophageal varices in children. J Pediatr Gastroentrol Nutr 5:696-700, 1986 23. Stamatakis JD, Howard ER, Psaharopoulos HT: Injection sclerotherapy for esophageal varices in children. Br J Surg 69:74-75, 1982 24. Murphy MS, Eastham EJ: Peptic ulcer disease in childhood. Long-term prognosis. J Pediatr Gastroenterol Nutr 6:721-724, 1987
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25. Allendorph M, Werlin SL, Geenen JE et al: Endoscopic retrograde cholangiopancreatography in children. J Pediatr 110:206-211, 1987 26. Guelrud M, Jaen D, Torres Pet al: Endoscopic cholangiopancreatography in the infant: Evaluation of a new prototype pediatric duodenoscope. Gastrointest Endosc 33:48, 1987 27. Ament ME (editorial): Is endoscopic cholangiopancreatography needed for the jaundiced infant? Gastrointest Endosc 33:49-50, 1987 28. Apley J: The child with abdominal pains. Ed 2. Oxford, Blackwell Scientific Publications, 1986 29. Biller JA, Winter HS, Grand RJ et al: Are endoscopic changes predictive of histologic changes in children? J Pediatr 103:215-218, 1983 30. Christie DL, Ament ME: Removal of foreign bodies from the esophagus and stomach with flexible fiberoptic panendoscopes. Pediatrics 57:931-934, 1976 31. Waye JD: Endoscopic retrograde cholangiopancreatography in the infant. Am J Gastroenterol 65:461-463, 1976 32. Blustein PK, Gaskin K, Filler R et al: Endoscopic retrograde cholangiopancreatography in pancreatitis in children and adolescents. Pediatrics 68:387-393, 1981 33. Ament ME: Prospective study of risks of complication in 6,424 procedures in pediatric gastroenterology. Pediatr Res 15:524, 1981 34. Mago H, Chen Chao-Long, Wesson DE et al: Incisionless gastrostomy for nutritional support. J Pediatr Gastroenterol Nutr 5:66-69, 1986 Department of Pediatrics Division of Gastroenterology and Nutrition UCLA Medical Center Los Angeles, California 90024