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Su1776 A Series of Detergent Pod Ingestions in Toddlers
Abstracts
Su1772 Diagnostic Yield of Colonoscopy in Children With Chronic Abdominal Pain Kalpesh H. Thakkar*1, Emma M. BRAVO2, Seiji Kitagawa1, Douglas S. Fishman1 1 GI, Baylor College of Medicine, Houston, TX; 2Rice University, Houston, TX Background: Colonoscopy is often performed in the evaluation of chronic abdominal pain (CAP) in children. However, the diagnostic yield in this clinical scenario is unknown. Methods: We conducted a prospective cohort study to examine the diagnostic yield in children (4-18 years) who underwent colonoscopy for the primary indication of CAP between Nov 2007 and March 2010 at a pediatric GI referral center in the USA. Patients were screened prior to colonoscopy to meet inclusion criteria: 1. Abdominal pain for at least 2 months without a known organic etiology; 2. No significant co-morbidities, and 3. No previous endoscopy. Demographics and clinical features (e.g. alarm features, Rome criteria) were systematically captured. . Results: We enrolled 52 patients (mean age 11.9; SD 3.5) undergoing colonoscopy including 30 (66%) females and 19 (75%) patients with diarrhea. Findings from biopsy specimens included lymphonodular hyperplasia (21.0%, nZ17), non-specific colitis (4.1%, nZ16), eosinophilic colitis (3.8%, nZ14), and normal histology (0.3%, nZ5). Short term outcomes were available in 43% of the patients enrolled. We found that medical therapy effectively reduced CAP symptoms in approximately 67% (4/6) of patients with non-specific colitis and 43% (3/7) of patients with eosinophilic colitis. Conclusions: Non-specific colitis is the most common diagnosis followed by eosinophilic colitis. Our findings suggest that colonoscopy has a low diagnostic yield in children presenting primarily with chronic abdominal pain.
Su1773 Gastric and Duodenal Biopsies in Pediatric Eosinophilic Esophagitis John M. Rosen*1, Sunpreet Kaur2, Alyssa Kriegermeier2, Katie Amsden2, Amir Kagalwalla2, Jeffrey B. Brown2 1 Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Mercy Kansas City, Kansas City, MO; 2Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children, Chicago, IL Pediatric gastroenterologists typically obtain biopsies of the esophagus, stomach, and duodenum in the setting of diagnostic EGD for upper GI symptoms. Diagnosis of eosinophilic esophagitis (EoE) is defined by histologic abnormalities in conjunction with characteristic clinical/endoscopic features. After initial diagnosis of EoE, repeat endoscopy with esophageal biopsy is frequently warranted to assess therapeutic response. There are no evidence-based guidelines regarding best practice for extraesophageal biopsy after diagnosis of EoE. The aim of this study was to determine frequency of gastric and duodenal biopsies performed after diagnosis of EoE was established, and to determine their diagnostic yield. Methods: An electronic database at our medical center was used to identify patients diagnosed with EoE from 2010-2012. Inclusion criteria were availability of diagnostic and subsequent endoscopy procedure and pathology reports. Gross and histologic findings, as well as general clinical and demographic information, were analyzed. Results: Fifty-four EoE patients were identified. Mean age at diagnosis was 9.2 +/- 5.5 years (range 1.1-20.2) and 33% were female. Most common presenting chief complaints were dysphagia (26%), vomiting (26%), abdominal pain (19%), and dyspepsia (12%). At initial diagnostic endoscopy 96.3% of patients had extraesophageal biopsies with an average 2.1 gastric and 3.0 duodenal biopsies. Abnormal gastric histology (11.5% of all patients) was most frequently characterized as chemical gastritis and correlated with gross abnormalities (13.5%) in only 1 patient. Abnormal duodenal histology (11.5%) correlated with gross abnormalities (5.8%) in only 1 patient. Two patients were diagnosed with celiac disease and EoE as a result of the initial diagnostic endoscopy. Mean time between initial and subsequent endoscopy was 5.4 months. At the subsequent endoscopy 88.9% of patients had extraesophageal biopsies with an average 1.8 gastric and 2.3 duodenal biopsies. Abnormal gastric histology (18.8%) was again most frequently characterized as chemical gastritis. Gross abnormalities (11.8%) correlated with abnormal histology in 4/6 cases. Abnormal duodenal histology (4.2%) was only identified in patients with known celiac disease and did not correlate with gross abnormalities (2.0%) in any patient. Conclusions: Gastric and duodenal biopsies are frequently obtained during endoscopy subsequent to EoE diagnosis. Gross gastric and duodenal endoscopic abnormalities are rare in patients with EoE and infrequently correlate with histology. In the absence of known co-morbid intestinal disease, extraesophageal biopsies do not provide clinical value and potentially introduce unnecessary risk and expense. Prospective, multicenter studies of endoscopy practice and utility in patients with EoE should be conducted to validate our findings.
Su1774 The Role of Duodenal Bulb Biopsies in the Diagnosis of Celiac Disease Jonathan MOSES*1, Thomas Plesec2, Barbara Kaplan1 1 Pediatric Gastroenterology, Cleveland Clinic Children’s, Cleveland, OH; 2 Department of Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, OH Background: Celiac disease is an autoimmune disorder in which ingestion of gluten causes intestinal inflammation and a variety of gastrointestinal symptoms. Gold standard for diagnosis of celiac disease is upper endoscopy with biopsies. Recent
AB292 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
guidelines have recommended routine biopsies should include samples from the duodenal bulb. Our aim was to evaluate the diagnostic utility of duodenal bulb biopsies in the diagnosis of celiac disease. Methods: This was a retrospective chart review of celiac disease patients 5-21 years of age who had separate duodenal bulb and distal duodenal biopsies at time of diagnosis. Exclusion criteria were patients who had only one set of biopsy specimens from the duodenum. Demographic, laboratory [complete blood count (CBC), complete metabolic panel (CMP), and celiac antibodies] and endoscopic data was collected. Patients with abnormal duodenal bulb biopsies (Marsh 3 grading on histology) were divided into two groups: 1) normal distal duodenal biopsies and 2) Marsh 1 findings in the distal duodenal biopsies. Results: Data were collected on 27 patients. 67% of the patients were female, 100% were Caucasian and mean age was 9.6 years (5.1). 6 of 27 patients (22%) had abnormal visual endoscopic findings in the duodenal bulb and normal endoscopic findings in the distal duodenum. CBC and CMP were normal in 82% of the patients. 2/27 patients (7%) were in group 1 and 5/27 patients (19%) were in group 2. Overall, bulb biopsies contributed to the diagnosis of celiac disease in 7/ 27 patients (26%). Conclusion: Duodenal bulb biopsies contributed to the initial diagnosis of celiac disease in 26% of patients, with 7% of patients having diagnostic findings only in the duodenal bulb. These findings are in line with recent guidelines and obtaining duodenal bulb biopsies should be part of routine practice for establishing the diagnosis of celiac disease.
Su1775 Duodenitis in Children Undergoing Upper Endoscopy Arik Alper*1, Danilo Rojas-Velasquez1, Raffaella Morotti2, Sandra Escalera1, Dinesh Pashankar1, Steven Hardee2 1 Pediatrics, Yale University, New Haven, CT; 2Pathology, Yale University, New Haven, CT Background: Common histopathological findings in children undergoing an upper endoscopy includes gastritis, esophagitis, and duodenitis. Gastritis and esophagitis have been well studied in children, but there is very limited data about duodenitis. Aim: To assess the prevalence, etiology, and clinical features of duodenitis in a large cohort of children undergoing an upper endoscopy. We also assessed gastric and esophageal pathology associated with duodenitis in children. Methods: We studied all children who had upper endoscopy and biopsies in our institute from 2008 to 2012. We reviewed all histopathology reports for duodenitis, gastritis and esophagitis, defined by presence of inflammatory infiltrate and read by pathologists. Clinical charts were reviewed for demographic details, etiology, and clinical features. Presence of gastritis and esophagitis were assessed in children with and without duodenitis. Results: The study included 3064 endoscopies that were performed over a 5year period. Out of 3064 pathology reports, 362 (12 %) had duodenitis. Gastritis and esophagitis were seen in 48% and 20% of cases respectively. The number of children having duodenitis was 352 as few patients had more than one endoscopies. The mean age of patients with duodenitis was 10.5 years (range 0.5 to 18.8) and 49 % were boys. Most common indications for endoscopy included abdominal pain, vomiting, diarrhea, and failure to thrive. In 63 % of cases , no obvious etiology could be associated with duodenitis. When a single underlying pathology could be identified, the most common was celiac disease (20%), followed by Crohn’s disease (9%), Helicobacter infection (5%), and ulcerative colitis (3%) . The table shows presence of gastritis and esophagitis in children with and without duodenitis. While there was no difference in the prevalence of esophagitis, the prevalence of gastritis was significantly higher in children with duodenitis compared to children without duodenitis. Conclusions: Although less frequent than esophagitis and gastritis, duodenitis is not uncommon and has a prevalence of 12 % in children undergoing upper endoscopy. The common etiology of duodenitis includes celiac disease, Crohn’s diseases, Helicobacter infection, and ulcerative colitis. Children with duodenitis are more likely to have associated gastritis compared to children without duodenitis, probably because of an underlying etiology.
Associated gastritis and esophagitis with duodenitis in children Gastritis Esophagitis
Duodenitis
Without duodenitis
P value
62% 21%
45% 20%
! 0.001 0.79
Su1776 A Series of Detergent Pod Ingestions in Toddlers Teena Sebastian*, Kelley C. Shirron, Laurie Conklin Childrens National Medical Center, Washington, DC Laundry detergent pods are brightly colored capsules comprised of a liquid detergent within a water-soluble membrane. The detergent is composed of sulfated and ethoxylated alcohols, with a pH of 6.8-7.4. Most of the reported cases involving laundry detergent pod exposure have been among children less than 5 years of age. A significant number of cases have been associated with vomiting and respiratory side effects, as well as mental status changes. In this case series, we describe six single-center cases of detergent pod ingestion in children under 4 years of age, who presented and were admitted to our institution over a 12 month period. Vomiting occurred in each of the 6 cases and 4 also presented with respiratory symptoms. Two required mechanical ventilation. 2 of the 6 cases underwent upper endoscopy
www.giejournal.org
Abstracts
of which 1 showed grade 1 esophageal injury. Case Descriptions: 1: A 3 year- old who presented with emesis after ingestion. She had normal exam findings her diet was advanced and an EGD was not done. 2: A 21-month old who presented with stridor and drooling. EGD was normal. 3. A 14 month-old who presented with lethargy and respiratory distress requiring mechanical ventilation. Chest radiograph was concerning for aspiration pneumonia. Upper endoscopy revealed grade 1 esophageal injury. 4. An 11 month-old boy who presented with moderate respiratory distress, requiring oxygen via nasal cannula. Chest radiograph was normal. The patient improved within 24 hours and EGD was not done. 5. A 13 month-old who presented with emesis after ingestion. Had a normal physical exam and chest radiograph, hence was discharged within 24 hours without endoscopic evaluation.6. A 3-year-old girl presented with emesis, coughing and respiratory distress following ingestion. She was intubated for airway protection for 24 hours. Serial X-rays were normal. Endoscopy was not performed. Laundry detergent pods have been a commercial success since their introduction in the US in 2010. Our case series highlights potentially serious respiratory sequelae, though esophageal and gastric mucosal injuries were not significant. Complications associated with detergent pod exposure reported in literature are eye injuries, respiratory failure, vomiting, and mental status changes. Vomiting is common and dysphagia has been reported following ingestion. Associated mental status changes may lead to a higher risk aspiration. Injury to the gastrointestinal tract has not been highlighted as a complication in reported cases. Since pH is neutral, endoscopy may not be necessary in all children with detergent pod ingestion, particularly in those with no dysphagia or respiratory symptoms. Physicians and parents should be aware of the potential multisystem effects of detergent pod ingestion in young children.
Su1777 Emergency Endoscopy in the Management of Ingested Foreign Bodies and Food Impaction in Children: a Ten Years Experience Stefano Rodino’*1, Teresa D’Amico1, Ladislava Sebkova1, Domenico Salerno2, Natale Saccà1 1 Gastroenterology Unit, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy; 2Pediatric Surgery, Azienda Ospedaliera PuglieseCiaccio, Catanzaro, Italy Ingestion of foreign bodies of all imaginable types is common in children. The majority of ingested foreign bodies will pass spontaneously. Aim of this study is to retrospectively analyze the incidence of emergency endoscopies performed for accidental ingestion of foreign bodies in children in the last 10 years in our Endoscopy Unit. On a total of 615 endoscopies performed in children less than 14 years old during may 2003 to may 2013, 260 emergent/urgent were retrospectively analyzed. 120 patients (58 M and 62 F, mean ageSD 65 yr, median 2 yr) underwent an emergent/urgent endoscopy for a foreign body ingestion suspicion/diagnosis. 105 foreign bodies were removed while 15 (12,5%) were not found. All children received general anaesthesia with routinely intubation. 75 were extracted from the esophagus, 25 from the stomach while only 5 from the duodenum. Emergent/urgent endoscopy was performed on 30% of observed children with suspected/ proven foreign body ingestion only. 36 coins, 2 toothpiks, 2 holy medals, 10 rings, 4 hair clips, 4 springs, 1 sharpener, 8 food impaction were impacted in the esophagus while 16 coins, 8 disk batteries, 2 screws and 4 keys were extracted from the stomach/duodenum. Chronobiology events analysis showed a peak of extraction incidence at 8 p.m. No complications were recorded during and after the procedure. In conclusion it seems that the ingestion of foreign bodies is most commonly a problem in young children aged 6 month to 5 years. Emergent/urgent endoscopy is a safe procedure to avoid complications of corrosive or sharp-pointed objects impacted in esophagus.
Su1778 Retrospective Analysis Ofaccidental Ingestion of Button Cells in Pediatric Population and Endoscopic Management Maria MUñOz-Tornero*1, Fernando Alberca1, María NavalóN-Rubio2, Javier Alvarez-Higueras1, Juan Egea-Valenzuela1, Fernando Carballo-Alvarez1 1 Gastroenterology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain; 2Pediatric Department, Hospital Clinico Universitario Virgen de la Arrixaca, El palmar-Murcia, Spain Background: The batteries type "button cells " are an emergent element in the daily environment of the child. Because of the low cost of the lithium of these batteries, you can find it in children`s toys. The accidental ingestion of these batteries can have lethal consequences, especially if they remain located in the esophagus, where the hurt can spread to trachea or to aorta artery. Objective: To communicate the cases happened of ingestion of these batteries in the pediatric patients of our region in last 5 years. Methods: Retrospective analysis of ingestion of these batteries in pediatric population in the last 5 years. They were evaluated by: sex, age, socioeconomic level, time from the ingestion of the battery to the consultation, symptomatology of the patients, location of the battery at his arrival, time from the hospital consultation to the endoscopic extraction. Results: There were gathered information of 30 patients (19 males and 11 women). The average age: 3,3 years (110 years). The socioeconomic level of the patients was low in 70 % of the cases. The average time from the ingestion up to the consultation was of 18 h (range: 1 h - 14 days). In the moment of the consultation 11 patients were presenting clinic and 19 were asymptomatic. The location of the battery in the radiological test was: 17 pa-
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tients had the battery lodged at stomach, 10 in esophagus and 3 in intestine. The average time from the consultation up to the endoscopic extraction was 5,8 hours (0,5-72 h). Endoscopy was done in all the cases except in the 3 by location in intestine and in 4 by location in stomach (before spontaneous progression to intestine). Of the 27 endoscopies realized, it showed injuries in 13 cases, 7 of which were consisting of deep sores and / or zones of necrosis. The evolution was satisfactory in the majority of the cases. Two patients had serious complications, one of them, developed mediastinitis and another patient presented a water-pipe aorto-esophagus and he expired for hemorrhagic shock after indented sentry. Conclusions: Our information is alert of an increase of the cases of ingestion of "button cells" in children and great part of they has not been attended, a high index of suspicion needs for it. It is necessary to design a strategy of children’s monitoring with esophagus injuries with the aim to detect prematurely the vascular complications.
Su1779 Updates in the Epidemiology of Foreign Body Ingestions in Children Thomas M. Diehl*, Cade M. Nylund Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD Background: Foreign body ingestion is a primary indication for urgent endoscopy in children. An increasing trend in the ingestion of more dangerous foreign bodies, such as batteries and magnets, has occurred over the last decade. The relative proportions of these more dangerous objects remain unknown, as well as the ages at highest risk. We sought to update foreign body ingestion epidemiology in the context of these emerging trends and identify age groups at risk. Methods: Using data collected from the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS) database, a nationally representative probability sample of US emergency departments, we evaluated emergency visits involving foreign body ingestions in children from 2002 to 2012. Individual objects were identified utilizing NEISS product codes and case narratives. National emergency department visit rates were estimated based on NEISS sampling methods. Results: An estimated 763,830 (95% CI 63,3236-89,4424) foreign body ingestions were reported to US emergency departments from 2002 to 2012. Of those 37.4% (286,302, 95% CI 229,111 - 343,493) occurred in children 0-3yrs, and 88.2% (673,938, 95% CI 552,533 - 795,342) occurred in the pediatric population (!18yrs). Among children, the majority of patients were male (54.6 %). The rate of emergency department visits for foreign body ingestions peaks in children 6 months to 4 years old, with a rapid rise starting at 6 months (Figure 1). In the 0-6 month age group, the three most frequently ingested foreign bodies include coins, toys, and jewelry, respectively. In 7-12 month old children, coins, jewelry, and other metal objects (nails, screws and tacks) were ingested most frequently. The most frequently ingested foreign bodies for 1- to 4-year-old children are coins, followed by batteries, other metal objects, and toys. Magnet ingestions are most prevalent in children 4 years and older, ranking as the sixth most common ingested foreign body for that age group. During the period of study, the incidence of foreign body-related emergency room visits increased an average of 5.1% annually. Conclusions: Although coins remain the most common ingested foreign body, there is a shift in pediatric foreign body ingestions towards objects with a high risk of complications, such as batteries and magnets. In young children, battery ingestions are now the second most common ingested foreign body. In older children (O4yrs), magnets are the sixth most common ingested object. The rapid rise in foreign body ingestions at 6 months of age identifies a target for preventive anticipatory guidance during the 4- and 6-month well child visits. Public and parental preventive education on foreign body ingestions should emphasize the emerging risk of more dangerous objects, such as batteries and magnets.
Figure 1
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB293
Su1772 Diagnostic Yield of Colonoscopy in Children With Chronic Abdominal Pain Kalpesh H. Thakkar*1, Emma M. BRAVO2, Seiji Kitagawa1, Douglas S. Fishman1 1 GI, Baylor College of Medicine, Houston, TX; 2Rice University, Houston, TX Background: Colonoscopy is often performed in the evaluation of chronic abdominal pain (CAP) in children. However, the diagnostic yield in this clinical scenario is unknown. Methods: We conducted a prospective cohort study to examine the diagnostic yield in children (4-18 years) who underwent colonoscopy for the primary indication of CAP between Nov 2007 and March 2010 at a pediatric GI referral center in the USA. Patients were screened prior to colonoscopy to meet inclusion criteria: 1. Abdominal pain for at least 2 months without a known organic etiology; 2. No significant co-morbidities, and 3. No previous endoscopy. Demographics and clinical features (e.g. alarm features, Rome criteria) were systematically captured. . Results: We enrolled 52 patients (mean age 11.9; SD 3.5) undergoing colonoscopy including 30 (66%) females and 19 (75%) patients with diarrhea. Findings from biopsy specimens included lymphonodular hyperplasia (21.0%, nZ17), non-specific colitis (4.1%, nZ16), eosinophilic colitis (3.8%, nZ14), and normal histology (0.3%, nZ5). Short term outcomes were available in 43% of the patients enrolled. We found that medical therapy effectively reduced CAP symptoms in approximately 67% (4/6) of patients with non-specific colitis and 43% (3/7) of patients with eosinophilic colitis. Conclusions: Non-specific colitis is the most common diagnosis followed by eosinophilic colitis. Our findings suggest that colonoscopy has a low diagnostic yield in children presenting primarily with chronic abdominal pain.
Su1773 Gastric and Duodenal Biopsies in Pediatric Eosinophilic Esophagitis John M. Rosen*1, Sunpreet Kaur2, Alyssa Kriegermeier2, Katie Amsden2, Amir Kagalwalla2, Jeffrey B. Brown2 1 Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Mercy Kansas City, Kansas City, MO; 2Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children, Chicago, IL Pediatric gastroenterologists typically obtain biopsies of the esophagus, stomach, and duodenum in the setting of diagnostic EGD for upper GI symptoms. Diagnosis of eosinophilic esophagitis (EoE) is defined by histologic abnormalities in conjunction with characteristic clinical/endoscopic features. After initial diagnosis of EoE, repeat endoscopy with esophageal biopsy is frequently warranted to assess therapeutic response. There are no evidence-based guidelines regarding best practice for extraesophageal biopsy after diagnosis of EoE. The aim of this study was to determine frequency of gastric and duodenal biopsies performed after diagnosis of EoE was established, and to determine their diagnostic yield. Methods: An electronic database at our medical center was used to identify patients diagnosed with EoE from 2010-2012. Inclusion criteria were availability of diagnostic and subsequent endoscopy procedure and pathology reports. Gross and histologic findings, as well as general clinical and demographic information, were analyzed. Results: Fifty-four EoE patients were identified. Mean age at diagnosis was 9.2 +/- 5.5 years (range 1.1-20.2) and 33% were female. Most common presenting chief complaints were dysphagia (26%), vomiting (26%), abdominal pain (19%), and dyspepsia (12%). At initial diagnostic endoscopy 96.3% of patients had extraesophageal biopsies with an average 2.1 gastric and 3.0 duodenal biopsies. Abnormal gastric histology (11.5% of all patients) was most frequently characterized as chemical gastritis and correlated with gross abnormalities (13.5%) in only 1 patient. Abnormal duodenal histology (11.5%) correlated with gross abnormalities (5.8%) in only 1 patient. Two patients were diagnosed with celiac disease and EoE as a result of the initial diagnostic endoscopy. Mean time between initial and subsequent endoscopy was 5.4 months. At the subsequent endoscopy 88.9% of patients had extraesophageal biopsies with an average 1.8 gastric and 2.3 duodenal biopsies. Abnormal gastric histology (18.8%) was again most frequently characterized as chemical gastritis. Gross abnormalities (11.8%) correlated with abnormal histology in 4/6 cases. Abnormal duodenal histology (4.2%) was only identified in patients with known celiac disease and did not correlate with gross abnormalities (2.0%) in any patient. Conclusions: Gastric and duodenal biopsies are frequently obtained during endoscopy subsequent to EoE diagnosis. Gross gastric and duodenal endoscopic abnormalities are rare in patients with EoE and infrequently correlate with histology. In the absence of known co-morbid intestinal disease, extraesophageal biopsies do not provide clinical value and potentially introduce unnecessary risk and expense. Prospective, multicenter studies of endoscopy practice and utility in patients with EoE should be conducted to validate our findings.
Su1774 The Role of Duodenal Bulb Biopsies in the Diagnosis of Celiac Disease Jonathan MOSES*1, Thomas Plesec2, Barbara Kaplan1 1 Pediatric Gastroenterology, Cleveland Clinic Children’s, Cleveland, OH; 2 Department of Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, OH Background: Celiac disease is an autoimmune disorder in which ingestion of gluten causes intestinal inflammation and a variety of gastrointestinal symptoms. Gold standard for diagnosis of celiac disease is upper endoscopy with biopsies. Recent
AB292 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
guidelines have recommended routine biopsies should include samples from the duodenal bulb. Our aim was to evaluate the diagnostic utility of duodenal bulb biopsies in the diagnosis of celiac disease. Methods: This was a retrospective chart review of celiac disease patients 5-21 years of age who had separate duodenal bulb and distal duodenal biopsies at time of diagnosis. Exclusion criteria were patients who had only one set of biopsy specimens from the duodenum. Demographic, laboratory [complete blood count (CBC), complete metabolic panel (CMP), and celiac antibodies] and endoscopic data was collected. Patients with abnormal duodenal bulb biopsies (Marsh 3 grading on histology) were divided into two groups: 1) normal distal duodenal biopsies and 2) Marsh 1 findings in the distal duodenal biopsies. Results: Data were collected on 27 patients. 67% of the patients were female, 100% were Caucasian and mean age was 9.6 years (5.1). 6 of 27 patients (22%) had abnormal visual endoscopic findings in the duodenal bulb and normal endoscopic findings in the distal duodenum. CBC and CMP were normal in 82% of the patients. 2/27 patients (7%) were in group 1 and 5/27 patients (19%) were in group 2. Overall, bulb biopsies contributed to the diagnosis of celiac disease in 7/ 27 patients (26%). Conclusion: Duodenal bulb biopsies contributed to the initial diagnosis of celiac disease in 26% of patients, with 7% of patients having diagnostic findings only in the duodenal bulb. These findings are in line with recent guidelines and obtaining duodenal bulb biopsies should be part of routine practice for establishing the diagnosis of celiac disease.
Su1775 Duodenitis in Children Undergoing Upper Endoscopy Arik Alper*1, Danilo Rojas-Velasquez1, Raffaella Morotti2, Sandra Escalera1, Dinesh Pashankar1, Steven Hardee2 1 Pediatrics, Yale University, New Haven, CT; 2Pathology, Yale University, New Haven, CT Background: Common histopathological findings in children undergoing an upper endoscopy includes gastritis, esophagitis, and duodenitis. Gastritis and esophagitis have been well studied in children, but there is very limited data about duodenitis. Aim: To assess the prevalence, etiology, and clinical features of duodenitis in a large cohort of children undergoing an upper endoscopy. We also assessed gastric and esophageal pathology associated with duodenitis in children. Methods: We studied all children who had upper endoscopy and biopsies in our institute from 2008 to 2012. We reviewed all histopathology reports for duodenitis, gastritis and esophagitis, defined by presence of inflammatory infiltrate and read by pathologists. Clinical charts were reviewed for demographic details, etiology, and clinical features. Presence of gastritis and esophagitis were assessed in children with and without duodenitis. Results: The study included 3064 endoscopies that were performed over a 5year period. Out of 3064 pathology reports, 362 (12 %) had duodenitis. Gastritis and esophagitis were seen in 48% and 20% of cases respectively. The number of children having duodenitis was 352 as few patients had more than one endoscopies. The mean age of patients with duodenitis was 10.5 years (range 0.5 to 18.8) and 49 % were boys. Most common indications for endoscopy included abdominal pain, vomiting, diarrhea, and failure to thrive. In 63 % of cases , no obvious etiology could be associated with duodenitis. When a single underlying pathology could be identified, the most common was celiac disease (20%), followed by Crohn’s disease (9%), Helicobacter infection (5%), and ulcerative colitis (3%) . The table shows presence of gastritis and esophagitis in children with and without duodenitis. While there was no difference in the prevalence of esophagitis, the prevalence of gastritis was significantly higher in children with duodenitis compared to children without duodenitis. Conclusions: Although less frequent than esophagitis and gastritis, duodenitis is not uncommon and has a prevalence of 12 % in children undergoing upper endoscopy. The common etiology of duodenitis includes celiac disease, Crohn’s diseases, Helicobacter infection, and ulcerative colitis. Children with duodenitis are more likely to have associated gastritis compared to children without duodenitis, probably because of an underlying etiology.
Associated gastritis and esophagitis with duodenitis in children Gastritis Esophagitis
Duodenitis
Without duodenitis
P value
62% 21%
45% 20%
! 0.001 0.79
Su1776 A Series of Detergent Pod Ingestions in Toddlers Teena Sebastian*, Kelley C. Shirron, Laurie Conklin Childrens National Medical Center, Washington, DC Laundry detergent pods are brightly colored capsules comprised of a liquid detergent within a water-soluble membrane. The detergent is composed of sulfated and ethoxylated alcohols, with a pH of 6.8-7.4. Most of the reported cases involving laundry detergent pod exposure have been among children less than 5 years of age. A significant number of cases have been associated with vomiting and respiratory side effects, as well as mental status changes. In this case series, we describe six single-center cases of detergent pod ingestion in children under 4 years of age, who presented and were admitted to our institution over a 12 month period. Vomiting occurred in each of the 6 cases and 4 also presented with respiratory symptoms. Two required mechanical ventilation. 2 of the 6 cases underwent upper endoscopy
www.giejournal.org
Abstracts
of which 1 showed grade 1 esophageal injury. Case Descriptions: 1: A 3 year- old who presented with emesis after ingestion. She had normal exam findings her diet was advanced and an EGD was not done. 2: A 21-month old who presented with stridor and drooling. EGD was normal. 3. A 14 month-old who presented with lethargy and respiratory distress requiring mechanical ventilation. Chest radiograph was concerning for aspiration pneumonia. Upper endoscopy revealed grade 1 esophageal injury. 4. An 11 month-old boy who presented with moderate respiratory distress, requiring oxygen via nasal cannula. Chest radiograph was normal. The patient improved within 24 hours and EGD was not done. 5. A 13 month-old who presented with emesis after ingestion. Had a normal physical exam and chest radiograph, hence was discharged within 24 hours without endoscopic evaluation.6. A 3-year-old girl presented with emesis, coughing and respiratory distress following ingestion. She was intubated for airway protection for 24 hours. Serial X-rays were normal. Endoscopy was not performed. Laundry detergent pods have been a commercial success since their introduction in the US in 2010. Our case series highlights potentially serious respiratory sequelae, though esophageal and gastric mucosal injuries were not significant. Complications associated with detergent pod exposure reported in literature are eye injuries, respiratory failure, vomiting, and mental status changes. Vomiting is common and dysphagia has been reported following ingestion. Associated mental status changes may lead to a higher risk aspiration. Injury to the gastrointestinal tract has not been highlighted as a complication in reported cases. Since pH is neutral, endoscopy may not be necessary in all children with detergent pod ingestion, particularly in those with no dysphagia or respiratory symptoms. Physicians and parents should be aware of the potential multisystem effects of detergent pod ingestion in young children.
Su1777 Emergency Endoscopy in the Management of Ingested Foreign Bodies and Food Impaction in Children: a Ten Years Experience Stefano Rodino’*1, Teresa D’Amico1, Ladislava Sebkova1, Domenico Salerno2, Natale Saccà1 1 Gastroenterology Unit, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy; 2Pediatric Surgery, Azienda Ospedaliera PuglieseCiaccio, Catanzaro, Italy Ingestion of foreign bodies of all imaginable types is common in children. The majority of ingested foreign bodies will pass spontaneously. Aim of this study is to retrospectively analyze the incidence of emergency endoscopies performed for accidental ingestion of foreign bodies in children in the last 10 years in our Endoscopy Unit. On a total of 615 endoscopies performed in children less than 14 years old during may 2003 to may 2013, 260 emergent/urgent were retrospectively analyzed. 120 patients (58 M and 62 F, mean ageSD 65 yr, median 2 yr) underwent an emergent/urgent endoscopy for a foreign body ingestion suspicion/diagnosis. 105 foreign bodies were removed while 15 (12,5%) were not found. All children received general anaesthesia with routinely intubation. 75 were extracted from the esophagus, 25 from the stomach while only 5 from the duodenum. Emergent/urgent endoscopy was performed on 30% of observed children with suspected/ proven foreign body ingestion only. 36 coins, 2 toothpiks, 2 holy medals, 10 rings, 4 hair clips, 4 springs, 1 sharpener, 8 food impaction were impacted in the esophagus while 16 coins, 8 disk batteries, 2 screws and 4 keys were extracted from the stomach/duodenum. Chronobiology events analysis showed a peak of extraction incidence at 8 p.m. No complications were recorded during and after the procedure. In conclusion it seems that the ingestion of foreign bodies is most commonly a problem in young children aged 6 month to 5 years. Emergent/urgent endoscopy is a safe procedure to avoid complications of corrosive or sharp-pointed objects impacted in esophagus.
Su1778 Retrospective Analysis Ofaccidental Ingestion of Button Cells in Pediatric Population and Endoscopic Management Maria MUñOz-Tornero*1, Fernando Alberca1, María NavalóN-Rubio2, Javier Alvarez-Higueras1, Juan Egea-Valenzuela1, Fernando Carballo-Alvarez1 1 Gastroenterology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain; 2Pediatric Department, Hospital Clinico Universitario Virgen de la Arrixaca, El palmar-Murcia, Spain Background: The batteries type "button cells " are an emergent element in the daily environment of the child. Because of the low cost of the lithium of these batteries, you can find it in children`s toys. The accidental ingestion of these batteries can have lethal consequences, especially if they remain located in the esophagus, where the hurt can spread to trachea or to aorta artery. Objective: To communicate the cases happened of ingestion of these batteries in the pediatric patients of our region in last 5 years. Methods: Retrospective analysis of ingestion of these batteries in pediatric population in the last 5 years. They were evaluated by: sex, age, socioeconomic level, time from the ingestion of the battery to the consultation, symptomatology of the patients, location of the battery at his arrival, time from the hospital consultation to the endoscopic extraction. Results: There were gathered information of 30 patients (19 males and 11 women). The average age: 3,3 years (110 years). The socioeconomic level of the patients was low in 70 % of the cases. The average time from the ingestion up to the consultation was of 18 h (range: 1 h - 14 days). In the moment of the consultation 11 patients were presenting clinic and 19 were asymptomatic. The location of the battery in the radiological test was: 17 pa-
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tients had the battery lodged at stomach, 10 in esophagus and 3 in intestine. The average time from the consultation up to the endoscopic extraction was 5,8 hours (0,5-72 h). Endoscopy was done in all the cases except in the 3 by location in intestine and in 4 by location in stomach (before spontaneous progression to intestine). Of the 27 endoscopies realized, it showed injuries in 13 cases, 7 of which were consisting of deep sores and / or zones of necrosis. The evolution was satisfactory in the majority of the cases. Two patients had serious complications, one of them, developed mediastinitis and another patient presented a water-pipe aorto-esophagus and he expired for hemorrhagic shock after indented sentry. Conclusions: Our information is alert of an increase of the cases of ingestion of "button cells" in children and great part of they has not been attended, a high index of suspicion needs for it. It is necessary to design a strategy of children’s monitoring with esophagus injuries with the aim to detect prematurely the vascular complications.
Su1779 Updates in the Epidemiology of Foreign Body Ingestions in Children Thomas M. Diehl*, Cade M. Nylund Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD Background: Foreign body ingestion is a primary indication for urgent endoscopy in children. An increasing trend in the ingestion of more dangerous foreign bodies, such as batteries and magnets, has occurred over the last decade. The relative proportions of these more dangerous objects remain unknown, as well as the ages at highest risk. We sought to update foreign body ingestion epidemiology in the context of these emerging trends and identify age groups at risk. Methods: Using data collected from the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS) database, a nationally representative probability sample of US emergency departments, we evaluated emergency visits involving foreign body ingestions in children from 2002 to 2012. Individual objects were identified utilizing NEISS product codes and case narratives. National emergency department visit rates were estimated based on NEISS sampling methods. Results: An estimated 763,830 (95% CI 63,3236-89,4424) foreign body ingestions were reported to US emergency departments from 2002 to 2012. Of those 37.4% (286,302, 95% CI 229,111 - 343,493) occurred in children 0-3yrs, and 88.2% (673,938, 95% CI 552,533 - 795,342) occurred in the pediatric population (!18yrs). Among children, the majority of patients were male (54.6 %). The rate of emergency department visits for foreign body ingestions peaks in children 6 months to 4 years old, with a rapid rise starting at 6 months (Figure 1). In the 0-6 month age group, the three most frequently ingested foreign bodies include coins, toys, and jewelry, respectively. In 7-12 month old children, coins, jewelry, and other metal objects (nails, screws and tacks) were ingested most frequently. The most frequently ingested foreign bodies for 1- to 4-year-old children are coins, followed by batteries, other metal objects, and toys. Magnet ingestions are most prevalent in children 4 years and older, ranking as the sixth most common ingested foreign body for that age group. During the period of study, the incidence of foreign body-related emergency room visits increased an average of 5.1% annually. Conclusions: Although coins remain the most common ingested foreign body, there is a shift in pediatric foreign body ingestions towards objects with a high risk of complications, such as batteries and magnets. In young children, battery ingestions are now the second most common ingested foreign body. In older children (O4yrs), magnets are the sixth most common ingested object. The rapid rise in foreign body ingestions at 6 months of age identifies a target for preventive anticipatory guidance during the 4- and 6-month well child visits. Public and parental preventive education on foreign body ingestions should emphasize the emerging risk of more dangerous objects, such as batteries and magnets.
Figure 1
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