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Endoscopic follow-up of colonic interposition in pediatric patients
PEDIATRIC
ENDOSCOPY
$[:169
171
ENDOSCOPIC FOLLOW-UP OF COLONIC INTERPOSITION 1N PEDIATRIC PATIENTS DM Gold, J Becker, MJ Pettei, TA Weinstein, BH Kessler, JJ Levine. Departments of Pediatric GI and Surgery, Schneider Children's Hospital, New Hyde Park, NY Endoscopic follow-up of pediatric colonic interposition is not well described. Over the period from 1958 to 1994, 59 children underwent colonic interposition (20 esophageal atresia, 22 TE fistula, 8 caustic ingestion, 6 strictures, 1 Barrett's, 2 variees). Surgical technique involved anastomosis of a right (n=57) or left (n=2) colon Segment in an isoperistaltic direction. All patients had a simultaneous pyloroplasty. 53/59 patients have remained clinically well. Six patients were evaluated endoscopically due to GI complaints including melena (n=2), recurrent abdominal pain (n=2), odynophagia (n= 1), and failure to thrive with poor oral intake (n = 1). Mean age at endoscopy was 15.7 years (range 4.25 to 38 years) with the interposition having been in place for a mean of 12.2 years (range 5 months to 33 years). At endoscopy, all six patients had abnormal findings in the interposed colon. Gross erosions and ulceration were noted in 3 patients. One additional patient demonstrated severe mucosal inflammation and edema. The remaining two patients had macroscopically normal colonic mucosa with significant bile reflux. Bile reflux was noted in 1 additional patient. Histopathology of the colon revealed abnormalities in all 6 patients including moderate chronic inflammation with increased eosinophils in three patients, mild to moderate inflammation in the distal interposed colon in two, and acute inflammation and ulceration at the gastro-colic junction in the final patient. Barium swallow in these patients (n =6) demonstrated redundant colon in two but were otherwise normal. 5/6 patients were initially treated with carafate and 1/6 with H-2 antagonists. Clinical symptoms on therapy improved in all six patients. 3/6 underwent follow-up endoscopy for persistent symptoms. Findings included improved macroscopic appearance but persistent colitis in all three patients. Conclusions: Histologic colitis was present in 6/6 symptomatic patients status post colonic interposition with erosions and ulceration noted in 3/6. Bile reflux was commonly identified and may be a contributing factor. Barium swallow was not helpful in demonstrating the inflammatory lesions.
FOREIGN BODY RETENTION IN A CHILD DUE TO DIVERTICULUM OF DUODENAL BULB. P.R. Harris J.A. Wright. Dept. Of Pediatrics. Univ. of Alabama at Birmingham and Children's Hospital of Alabama. Birmingham, AL. Ingested Foreign Bodies (FB) of the upper gastrointestinal tract are common in children. They may accidentally swallow small objects as soon they learn to grasp. Coins and other small round foreign objects generally pass through the gastrointestinal tract once they enter the stomach, and a conservative approach is recommended in that situation. We report a 31-month-old male with a history of swallowing coins at 24 months of age. At that time, the child was asymptomatic and a chest radiograph showed a round metallic object in the stomach. During the next 7 months, he had a good appetite and grew well. There was no history of abdominal pain, vomiting, nausea, gastrointestinal bleeding, abdominal distention or abnormalities in bowel movements. Two different radiographic studies of the abdomen, 4 and 6 months after the ingestion, showed two coins in the medial right upper abdomen. With a barium study, the coins were visualized in the duodenal sweep. During endoscopy for removal of the coins, a large diverticulum of the first portion of the duodenum was found. Two pennies were mobile within the diverticulum and were removed. Duodenal Diverticula (DD) are incidental findings during radiographic studies, endoscopies and operations, and the majority of them are asymptomatic. Failure of the normal development in the duodenum can result in various congenital anomalies including atresias, stenosis, duplications, mucosal diaphragms and DD. This case represents an extraluminal DD, since the diverticulum protrudes outside the intestinal lumen, and this has not been described in the first portion of the duodenum. We conclude that when small round FB fail to pass the stomach or duodenum, congenital foregut anomalies should be considered.
$170
172
ARE VERTICAL LINES IN (DISTAL) E S O P H A G E A L M U C O S A (VLEM) A" TRUE ENDOSCOPIC M~-NIFESTATION OF P E P T I C E S O P H A G I T I S IN CHILDREN? SK Gupta, JF Fitzgerald, JM Croffie, SKF Chong and M Collins. Divisions of G a s t r o e n t e r o l o g y and Surgical Pathology, James Whitcomb Riley H o s p i t a l for Children, Indiana University Medical Center, Indianapolis, IN. Introduction: While d e f i n i t i v e d i a g n o s i s of esophagitis is established by histologic e x a m i n a t i o n of esophageal m u c o s a (EM) biopsies, certain EM changes o n e s o p h a g o g a s t r o duodenoscopy (EGD) suggest esophagitis. We have observed V L E M during EGD to be a sign of esophagitis. These lines are linear indentations of EM that r a d i a t e p r o x i m a l l y from the esophagogastric junction. Aims To e x a m i n e the above observation retrospectively. Methods: A total of 435 EM biopsies were examined at our hospital b e t w e e n 1-1-92 and 8-31-94. Of these, 258 were o b t a i n e d d u r i n g EGD under supervision of the senior author (JFF) and w e r e used for further analysis (remaining 177 were e x c l u d e d to avoid observer differences). The d i c t a t e d EGD and histology reports were reviewed; certain e n d o s c o p y p h o t o g r a p h s were examined in a blinded manner. EGD findings w e r e divided based on appearance of EM: normal (n160); V L E M without other EM changes (n43; 2 patients had esophageal strictures) and other EM a b n o r m a l i t i e s w i t h / w i t h o u t VLEM (n55; these were excluded from further analysis). Histologic reports were classified as I) normal or II) abnormal; - further s u b c l a s s i f i e d b a s e d on the intraepithelial cellular infiltrate [i.e., A) - eosinophils and E) lymphocytes/neutrophils/squiggle cells]. The severity of histologic changes was e s t a b l i s h e d u s i n g standard criteria (i.e., degree of basal zone hyperplasia, papillary lengthening and intra-epithelial cell infiltrate). Data was analyzed using Chi-square. Results: I II A IIB Normal EM (n=160) 92 34 34 VLEM (n= 43) 2 35 6 Of patients with normal EM on EGD, 42.5% (66/160) had esophagitis, in keeping with other reports. In those with VLEM, 95.3% (41/43) had histologic e s o p h a g i t i s [specificity (sp) 97.8%, sensitivity (sn) 37.6% p<0.0001], most (85.3%, 35/41) b e i n g eosinophilic/peptlc (sp 85%, sn 50.7%, p<0.0001). Of the patients w i t h V L E M and eosinophilic esophagitis, 85.7% (30/35) had moderate to severe histologic changes (sp 84.6%, sn 72%, p<0.0001). Conclusions: The presence of V L E M is a h i g h l y specific endoscopic feature of esophagitis; their p r e s e n c e more often indicates peptic esophagitis, u s u a l l y of m o d e r a t e to severe intensity.
338
GASTROINTESTINAL
ENDOSCOPY
DOES ENDOSCOPY AFFECT TREATMENT OUTCOME IN RECURRENT ABDOMINAL PAIN (RAP) OF CHILDHOOD? DM Jones BUK Li, LA Heitlinger, R D Murray & HJ McClung Pediatrics, Ohio State U & Children's Hospital Columbus, O H RAP, defined as three occurrences over a three month period, affects 10-15% of school aged children. We previously reported a high rate (50%) of pathologic findings in 117 children undergoing endoscopic biopsy to evaluate RAP (Gastroint Endo 40:55,1994). Since the impact of these histologic findings on outcome is unknown, we examined their response to treatment. Methods: 92/117 children with RAP ages 4-18 years who underwent endoscopy of the upper GI tract were studied retrospectively. Their response at one month to the initial treatment (Esophagiti.~/Peptic-Hz antagonists, 14. pylori-amoxacillin/bismuth/metronidazole, Giardia-metronidazole, Irritable bowel-antispasmodics, Other-polytherapy/no therapy) was assessed by phone contact and chart review. Both frequency of pain and level of intensity were assessed by analog scale and a pain score (frequency X intensity) was calculated. A therapeutic response was defined as a 50% reduction in pain score. Results: The mean age was 11 -+ 4 (SD) years, the 9:d' ratio was 1.9:1, and the median duration of symptoms was 6 months. The fraction of treated children (~ who responded to therapy (*) is shown below. 67% of all patients received additional therapeutic interventions. At 15 _+ 5 (SD) month follow-up, 89% returned to full activity. Bioosv negative Bionsv nositive - All children (92) 30*/46 ~ 26/46 - Esophagiti~/Peptic (46) 21/22 16/24 - H pylori/Giardia (8) 3/8 - Irritable bowel (IO) 4/10 - Other (28) 5/14 7/14 Conclusions: The high prevalence of patholngic findings in children with RAP guides the initial therapy. In those with suspected peptic disease who are biopsy negative, the high rate of response warrants a trial of H2 antagonists. The treatment outcome in RAP suggests a high incidence of peptic disorders.
VOLUME
41, N O . 4, 1995
ENDOSCOPY
$[:169
171
ENDOSCOPIC FOLLOW-UP OF COLONIC INTERPOSITION 1N PEDIATRIC PATIENTS DM Gold, J Becker, MJ Pettei, TA Weinstein, BH Kessler, JJ Levine. Departments of Pediatric GI and Surgery, Schneider Children's Hospital, New Hyde Park, NY Endoscopic follow-up of pediatric colonic interposition is not well described. Over the period from 1958 to 1994, 59 children underwent colonic interposition (20 esophageal atresia, 22 TE fistula, 8 caustic ingestion, 6 strictures, 1 Barrett's, 2 variees). Surgical technique involved anastomosis of a right (n=57) or left (n=2) colon Segment in an isoperistaltic direction. All patients had a simultaneous pyloroplasty. 53/59 patients have remained clinically well. Six patients were evaluated endoscopically due to GI complaints including melena (n=2), recurrent abdominal pain (n=2), odynophagia (n= 1), and failure to thrive with poor oral intake (n = 1). Mean age at endoscopy was 15.7 years (range 4.25 to 38 years) with the interposition having been in place for a mean of 12.2 years (range 5 months to 33 years). At endoscopy, all six patients had abnormal findings in the interposed colon. Gross erosions and ulceration were noted in 3 patients. One additional patient demonstrated severe mucosal inflammation and edema. The remaining two patients had macroscopically normal colonic mucosa with significant bile reflux. Bile reflux was noted in 1 additional patient. Histopathology of the colon revealed abnormalities in all 6 patients including moderate chronic inflammation with increased eosinophils in three patients, mild to moderate inflammation in the distal interposed colon in two, and acute inflammation and ulceration at the gastro-colic junction in the final patient. Barium swallow in these patients (n =6) demonstrated redundant colon in two but were otherwise normal. 5/6 patients were initially treated with carafate and 1/6 with H-2 antagonists. Clinical symptoms on therapy improved in all six patients. 3/6 underwent follow-up endoscopy for persistent symptoms. Findings included improved macroscopic appearance but persistent colitis in all three patients. Conclusions: Histologic colitis was present in 6/6 symptomatic patients status post colonic interposition with erosions and ulceration noted in 3/6. Bile reflux was commonly identified and may be a contributing factor. Barium swallow was not helpful in demonstrating the inflammatory lesions.
FOREIGN BODY RETENTION IN A CHILD DUE TO DIVERTICULUM OF DUODENAL BULB. P.R. Harris J.A. Wright. Dept. Of Pediatrics. Univ. of Alabama at Birmingham and Children's Hospital of Alabama. Birmingham, AL. Ingested Foreign Bodies (FB) of the upper gastrointestinal tract are common in children. They may accidentally swallow small objects as soon they learn to grasp. Coins and other small round foreign objects generally pass through the gastrointestinal tract once they enter the stomach, and a conservative approach is recommended in that situation. We report a 31-month-old male with a history of swallowing coins at 24 months of age. At that time, the child was asymptomatic and a chest radiograph showed a round metallic object in the stomach. During the next 7 months, he had a good appetite and grew well. There was no history of abdominal pain, vomiting, nausea, gastrointestinal bleeding, abdominal distention or abnormalities in bowel movements. Two different radiographic studies of the abdomen, 4 and 6 months after the ingestion, showed two coins in the medial right upper abdomen. With a barium study, the coins were visualized in the duodenal sweep. During endoscopy for removal of the coins, a large diverticulum of the first portion of the duodenum was found. Two pennies were mobile within the diverticulum and were removed. Duodenal Diverticula (DD) are incidental findings during radiographic studies, endoscopies and operations, and the majority of them are asymptomatic. Failure of the normal development in the duodenum can result in various congenital anomalies including atresias, stenosis, duplications, mucosal diaphragms and DD. This case represents an extraluminal DD, since the diverticulum protrudes outside the intestinal lumen, and this has not been described in the first portion of the duodenum. We conclude that when small round FB fail to pass the stomach or duodenum, congenital foregut anomalies should be considered.
$170
172
ARE VERTICAL LINES IN (DISTAL) E S O P H A G E A L M U C O S A (VLEM) A" TRUE ENDOSCOPIC M~-NIFESTATION OF P E P T I C E S O P H A G I T I S IN CHILDREN? SK Gupta, JF Fitzgerald, JM Croffie, SKF Chong and M Collins. Divisions of G a s t r o e n t e r o l o g y and Surgical Pathology, James Whitcomb Riley H o s p i t a l for Children, Indiana University Medical Center, Indianapolis, IN. Introduction: While d e f i n i t i v e d i a g n o s i s of esophagitis is established by histologic e x a m i n a t i o n of esophageal m u c o s a (EM) biopsies, certain EM changes o n e s o p h a g o g a s t r o duodenoscopy (EGD) suggest esophagitis. We have observed V L E M during EGD to be a sign of esophagitis. These lines are linear indentations of EM that r a d i a t e p r o x i m a l l y from the esophagogastric junction. Aims To e x a m i n e the above observation retrospectively. Methods: A total of 435 EM biopsies were examined at our hospital b e t w e e n 1-1-92 and 8-31-94. Of these, 258 were o b t a i n e d d u r i n g EGD under supervision of the senior author (JFF) and w e r e used for further analysis (remaining 177 were e x c l u d e d to avoid observer differences). The d i c t a t e d EGD and histology reports were reviewed; certain e n d o s c o p y p h o t o g r a p h s were examined in a blinded manner. EGD findings w e r e divided based on appearance of EM: normal (n160); V L E M without other EM changes (n43; 2 patients had esophageal strictures) and other EM a b n o r m a l i t i e s w i t h / w i t h o u t VLEM (n55; these were excluded from further analysis). Histologic reports were classified as I) normal or II) abnormal; - further s u b c l a s s i f i e d b a s e d on the intraepithelial cellular infiltrate [i.e., A) - eosinophils and E) lymphocytes/neutrophils/squiggle cells]. The severity of histologic changes was e s t a b l i s h e d u s i n g standard criteria (i.e., degree of basal zone hyperplasia, papillary lengthening and intra-epithelial cell infiltrate). Data was analyzed using Chi-square. Results: I II A IIB Normal EM (n=160) 92 34 34 VLEM (n= 43) 2 35 6 Of patients with normal EM on EGD, 42.5% (66/160) had esophagitis, in keeping with other reports. In those with VLEM, 95.3% (41/43) had histologic e s o p h a g i t i s [specificity (sp) 97.8%, sensitivity (sn) 37.6% p<0.0001], most (85.3%, 35/41) b e i n g eosinophilic/peptlc (sp 85%, sn 50.7%, p<0.0001). Of the patients w i t h V L E M and eosinophilic esophagitis, 85.7% (30/35) had moderate to severe histologic changes (sp 84.6%, sn 72%, p<0.0001). Conclusions: The presence of V L E M is a h i g h l y specific endoscopic feature of esophagitis; their p r e s e n c e more often indicates peptic esophagitis, u s u a l l y of m o d e r a t e to severe intensity.
338
GASTROINTESTINAL
ENDOSCOPY
DOES ENDOSCOPY AFFECT TREATMENT OUTCOME IN RECURRENT ABDOMINAL PAIN (RAP) OF CHILDHOOD? DM Jones BUK Li, LA Heitlinger, R D Murray & HJ McClung Pediatrics, Ohio State U & Children's Hospital Columbus, O H RAP, defined as three occurrences over a three month period, affects 10-15% of school aged children. We previously reported a high rate (50%) of pathologic findings in 117 children undergoing endoscopic biopsy to evaluate RAP (Gastroint Endo 40:55,1994). Since the impact of these histologic findings on outcome is unknown, we examined their response to treatment. Methods: 92/117 children with RAP ages 4-18 years who underwent endoscopy of the upper GI tract were studied retrospectively. Their response at one month to the initial treatment (Esophagiti.~/Peptic-Hz antagonists, 14. pylori-amoxacillin/bismuth/metronidazole, Giardia-metronidazole, Irritable bowel-antispasmodics, Other-polytherapy/no therapy) was assessed by phone contact and chart review. Both frequency of pain and level of intensity were assessed by analog scale and a pain score (frequency X intensity) was calculated. A therapeutic response was defined as a 50% reduction in pain score. Results: The mean age was 11 -+ 4 (SD) years, the 9:d' ratio was 1.9:1, and the median duration of symptoms was 6 months. The fraction of treated children (~ who responded to therapy (*) is shown below. 67% of all patients received additional therapeutic interventions. At 15 _+ 5 (SD) month follow-up, 89% returned to full activity. Bioosv negative Bionsv nositive - All children (92) 30*/46 ~ 26/46 - Esophagiti~/Peptic (46) 21/22 16/24 - H pylori/Giardia (8) 3/8 - Irritable bowel (IO) 4/10 - Other (28) 5/14 7/14 Conclusions: The high prevalence of patholngic findings in children with RAP guides the initial therapy. In those with suspected peptic disease who are biopsy negative, the high rate of response warrants a trial of H2 antagonists. The treatment outcome in RAP suggests a high incidence of peptic disorders.
VOLUME
41, N O . 4, 1995