Egyptian Pediatric Association Gazette 64 (2016) 160–166 Contents lists available at ScienceDirect Egyptian Pediatric Association Gazette journal homepage: www.elsevier.com/locate/epag Gastrointestinal endoscopic practice in infants: Indications and outcome Nagla H Abu Faddan a,⇑, Almoutaz Eltayeb b, Maha Barakat c, Yasser Gamal d a Department of Pediatrics, Faculty of Medicine, Assuit University, Assuit, Egypt Department of Pediatric Surgery, Faculty of Medicine, Assuit University, Assuit, Egypt c Department of Tropical Medicine, Faculty of Medicine, Assuit University, Assuit, Egypt d Department of Pathology, Faculty of Medicine, Assuit University, Assuit, Egypt b a r t i c l e i n f o Article history: Received July 2016 Revised 21 September 2016 Accepted 25 October 2016 Available online 14 November 2016 Keywords: Infants GIT endoscopy a b s t r a c t Background: Gastrointestinal (GIT) endoscopic procedures are now common in most major pediatric centers and they can be safely performed in small infants Aim of the work: The present study aims to evaluate the diagnostic role and outcome of endoscopy in infants (>one month of age and 6one year old) with different GIT disorders attending Assiut University Children’s Hospital, Egypt Patients and methods: This is a retrospective descriptive hospital based study, conducted from January 2004 to December 2013 All infants (>one month of age and 6one year old) who underwent GIT endoscopy during the study period were included in this study The following data were collected from the hospital database: basic demographic data, preliminary diagnosis, indication for endoscopy, sedation or anesthesia, type of endoscopy used, endoscopic finding, complications and final diagnosis Results: The present study included 177 infants (103 male and 74 female), 40.1% of them were within the first months of age Bleeding was the most common indication for endoscopic examination Mucosal inflammations were the most common findings in infants presented with different gastrointestinal symptoms Erythematus patches were the most common endoscopic findings in cases of inflammation Mixed gastrointestinal lesions detected in 22 (12.4%) of infants were included in this study No complications occurred either from the procedure itself or sedation given Conclusions: Pediatric gastrointestinal endoscopy is a valuable and informative diagnostic procedure in infants Negative endoscopic findings have their role in either reassurance, assistance of diagnosing a functional etiology or may point to the need of further other investigations Ó 2016 The Egyptian Pediatric Association Production and hosting by Elsevier B.V This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Introduction Pediatric gastrointestinal (GIT) endoscopy is a field that has been evolving in the last decades and provides a safe and effective diagnostic tool It is now considered as an important tool in evaluation and treatment of paediatric GIT diseases Currently children of all ages can be safely examined with better anesthetic techniques and technological advances in the size and flexibility of specially designed pediatric endoscopes.1–4 These changes, combined with increasing indications, have resulted in an increased number of endoscopic procedures performed in infancy.3 Because children are not simply young adults, optimal performance of endoscopy in Peer review under responsibility of Egyptian Pediatric Association Gazette ⇑ Corresponding author at: Department of Pediatrics, Faculty of Medicine, Assuit University Children Hospital, Assuit, Egypt E-mail address: nhi-af@hotmail.com (N.H.A Faddan) these patients requires an adequate knowledge and a thorough understanding of the child’s medical background, so endoscopy in children should be performed by pediatric- trained gastroenterologists whenever possible.5,6 Although the indications for GIT endoscopy in pediatric age group are similar to those for adult, the endoscopist must be aware of the fact that all infants, many children, and some adolescents cannot verbalize or describe symptoms accurately.6,7 Occult signs and symptoms that may prompt an endoscopy in infants and children include failure to thrive, limitation of usual activities, unexplained irritability, and anorexia.8 Aim of the work The present study aims to evaluate the diagnostic role and outcome of endoscopy in infants (>one month of age and 6one year old) with different gastrointestinal disorders attending Assiut University Children’s Hospital, Egypt http://dx.doi.org/10.1016/j.epag.2016.10.001 1110-6638/Ó 2016 The Egyptian Pediatric Association Production and hosting by Elsevier B.V This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) 161 Nagla H Abu Faddan et al / Egyptian Pediatric Association Gazette 64 (2016) 160–166 used through incremental doses of midazolam (maximum dose: 0.3 mg/kg) Regarding the equipment, a small diameter video oesophago-gastroscope (Pentax EG 1840) shaft diameter mm, with a working length 105 cm and colonoscopy Videoscope (Pentax EC-3440F) shaft diameter 11.7 mm, with a working length 150 cm were used Our results are shown in Tables 1–5 and Figs 1–4 The results of this study showed that GIT bleeding were the most common indication for endoscopy while, mucosal inflammation (esophagitis, gastritis duodenitis, colitis and/or proctosegmoiditis) were the most commonly detected signs Erythematus patches were the most common endoscopic findings in cases of inflammation where, mixed GIT lesions were detected in 22 (12.4%) of infant included in this study There were no complications occurring either from the procedure itself or sedation given The histopathologic findings of endoscopic mucosal biopsies were villous atrophy of the duodenum suggesting malabsorption syndrome in two infants (2/15 = 13.3%) with chronic diarrhea Histological evidence of colonic inflammation was detected in 51 infants [22 infants with bleeding of rectum, 22 infants with bloody diarrhea and infants with chronic diarrhea] and eosinophilic colitis has been diagnosed in 20 (39.2%) of them [10 infants with bleeding per rectum, of infants with bloody diarrhea and infants with chronic diarrhea] The characteristic mushroom-like mass of mucus and neutrophils at the surface epithelium suggesting psuedomembranous colitis was found in patients (5.9%), one of them without endoscopic Patients and methods This is a retrospective descriptive hospital based study, conducted at gastrointestinal endoscopic unit in Assiut University Children Hospital, Egypt, from January 2004 to December 2013 This study was approved by the Ethics Committee of Faculty of Medicine, Assuit University All infants (>one month of age and 6one year old) who underwent GIT endoscopy during the study period were included in this study The following data were collected from the hospital database: basic demographic data, initial diagnosis, indication for endoscopy, sedation or anesthesia used, type of endoscopy used, endoscopic finding, complications encountered during and after the procedure and final diagnosis Statistics All data were collected in a descriptive form and presented in numbers, percentages and tabulations The numerical data were represented as mean ± SD Results The present study included 177 infants [103(58.2%) males and 74(41.8%) females], 71(40.1%) of them were within the first months of age A written consent obtained from parents (or guardian) of all infants included in this study Intravenous sedation was Table The main indications for endoscopy in 177 infants Upper Endoscopy Hematemsis: n (%) Recurrent vomiting: n (%) Melena: n (%) FB ingestion: n (%) Dysphagia: n (%) Colonoscopy Bleeding per rectum: n (%) Bloody diarrhea: n (%) Panedoscopy Chronic diarrhea: n (%) Males N = 103 Females N = 74 Duration (days) Mean (SD) 66 months N = 71 >6 months N = 106 Total N = 177 31(30.1) 19 (18.4) 6(5.8) 2(1.9) – 21(28.4) 18(24.3) 3(4) 2(2.7) 1(1.4) 23.6(19.8) 116 (99) 24.8 (24.1) (4) – 23 (32.4) 14 (19.7) (1.4) – – 29 (27.4) 23 (21.7) (7.5) (3.8) (0.95) 52 (29.4) 37 (20.9) (5) (2.3) (0.6) 20 (19.4) 14(13.6) 12(16.2) 13(17.6) 29.7(20.7) 35(27.5) 13 (18.3) 15 (21.1) 19 (17.9) 12 (11.3) 32 (18) 27 (15.3) 11(10.7) 4(5.4) 147(132.8) 5(7.1) 10(9.4) 15(8.5) Table Upper endoscopic findings in infants presenting with different GIT symptoms Hematemsis (52) Recurrent vomiting (37) Melena (9) Dysphagia (1) Chronic diarrhea (15) Esophagitis N (%) Gastritis N (%) Duodenitis N (%) Gastric Erosions N (%) Peptic Ulcers N (%) Esophageal varices N (%) GAVD N (%) Duonal Stenosis N (%) Ancylostoma N (%) Achalesia N (%) Normal N (%) 11(21.2)A 15 (40.5)C 2(22.2) – – 19(36.5) 6(16.2) (44.4) – – (15.4) (8.1) 1(11.1) – – 5(9.6) 1(2.7) – – – 1(1.9) 1(2.7) – – – 6(11.5)B – 1(11.1)D – – 3(5.8) – – – – – 1(2.7) – – – – – 1(11.1) – – – – – (100) – 6(11.5) 13(35.1) 2(22.2) – 15 (100) GAVD = gastro-antral vascular dysplasia A = cases of esophagitis with incompetent cardia and cases with hiatus hernia B = one patient have both esophageal and fundal varices C = incompetent cardia present in patients D = the patient had both fundal and esophageal varices NB: more than one lesion could be detected in the same infant Table Colonoscopic findings in infants presenting with different GIT symptoms Bleeding per rectum (32) Bloody diarrhea (27) Chronic diarrhea (15) Colitis N (%) Procto- segmoiditis N (%) Pseudo-membrane N (%) Polyp N (%) Oxyuris N (%) Normal N (%) 15 (46.9) 16 (59.3) (33.3) (21.9) (22.2) (13.3) – (3.7) (13.3) (9.4) – – 1(3.1) – – (18.7) (14.8) (40) 162 Nagla H Abu Faddan et al / Egyptian Pediatric Association Gazette 64 (2016) 160–166 Table Distribution of endoscopic findings in infants with different GIT inflammatory lesions Oesophagitis (n = 28) Gastritis (n = 29) Duodenitis (n = 12) Colitis (n = 36) Procto-semoiditis (n = 15) Erythematous patches Erythema + erosions Erosions and/or ulcerations Psuedomembrane 17(60.7) 11 (37.9) (58.3) 14 (38.9) (53.4) 10 (35.7) 15 (51.8) (25) 12 (33.3) (33.3) 1(3.6) (10.3) 2(16.7) (25) – – – – (2.8) (13.3) Table Mixed GIT lesions detected in infants included in this study Mixed GIT lesions n % Esophgitis + gastritis Gastritis + duodenitis Esophgitis + gastritis + duodenitis Esophgitis + hiatus hernia + gastric ulcer Esophgitis + incompetent cardia + gastric ulcer Duodenitis + gastric erosions Esophageal + fundal varices Esophgeal varices + duodenal polyp Rectal polyp + oxyuoris 1 2 1 4.5 2.8 0.6 0.6 1.1 0.6 1.1 0.6 0.6 Total 22 12.4 characteristic psuedomembranous colitis pattern (the presence of psuedomembrane) Features of nonspecific colitis were detected in the specimens of 28 (54.9%) of the infants Discussion This study was designed to present the diagnostic role of GIT endoscopy in infants Through this study, some practical points are to be discussed Regarding patient preparation, doctors should respect the special physiology as well as the psychosocial and emotional needs of pediatric patients and their parents.9 In this study Parents were provided with sufficient information about potential risks and benefits of the procedure, this was found to be very much allaying for the anxiety parents The proper approach to sedation in pediatric endoscopy remains a controversy ranging from moderate sedation (conscious sedation) to general anesthesia.2 The exact delineation between what could or should be done by pediatric anesthesiologists or pediatric specialist is still not agreed.10 In our center conscious sedation was provided by the endoscopist himself and midazolam was the drug of choice because it has been used safely for many years for sedation in infants and children.11,12 However general anesthesia was required in infants during foreign body retrieval without complications occurring in those two cases Previous studies3,13 have reported that recurrent vomiting and chronic diarrhea were the most common clinical indication for infants younger than year to undergo gastrointestinal endoscopic investigation In this study, endoscopy was done for various indications; the most common indication was GIT bleeding in 67.2% of cases (29.4% hematemsis, 4.5% Melena, 18% bleeding per rectum and 15.3% bloody diarrhea) followed by recurrent vomiting in 20.9% of cases The high percentage of GIT bleeding in this study may be related both to the fact that, bleeding was the most fright- Figure Various imaging of FB ingestion in infants included in this study (A) Ingested pin in the stomach seen on a plain x ray film of 10 month old infant (B) Rusted pin after retrieval (C) & (D) Ingested metal foreign body seen in upper endoscopic examination of month old infant Nagla H Abu Faddan et al / Egyptian Pediatric Association Gazette 64 (2016) 160–166 163 Figure Varying colonoscopic lesions in infants included in this study (A) & (B) diffuse erythema and ulcerations (C) Patchy erythema (D) Diffuse pseudomembrane with ulcerations Figure Varying endoscopic findings in infants included in this study demonstrating (A) Ancylostomiasis-induced gastrointestinal bleeding (A bleeding spot at the worm’s attachment site) in a month old infant, (B) Rectal polyp + oxyuoris worm infestation 164 Nagla H Abu Faddan et al / Egyptian Pediatric Association Gazette 64 (2016) 160–166 Figure Gastrointestinal mucosal biopsies from infants demonstrating (A) villous atrophy of the jejunum (H & E Â100) suggesting malabsorption syndrome, (B) numerous eosinophils in the lamina propria of the colon (H & E Â400) suggestive of eosinophilic colitis, (C) the lamina propria of the colon is edematous, congested and infiltrated by large number of neutrophils and encroached on glands with focal rupture of glands (H & E Â100), (D) focal explosive mushroom-like mass of mucus and neutrophils attached to the mucosa (H & E Â40) characteristic of pseudomembranous colitis ening and motivating event for parents to bring their child for consultation and also to the fact that bleeding is a high indication for referral from pediatrician from different areas to endoscopy to identify the source of bleeding Concerning upper gastrointestinal hemorrhage, mucosal inflammation (esophagitis, gastritis and/ or duodenitis) were the most common causes of hematemsis in this study followed by gastric and/or duodenal erosions whereas esophageal varices were much less common Similar to our study, previous studies reported that nonvariceal lesions dominated by oesophagitis and gastritis were the most common cause of hematemsis in children less than one year old.14–16 One of the interesting findings in this study was detection of hookworm infection in 4-month-old infant presented with melena and severe anemia Ancylostomiasis-induced overt gastrointestinal bleeding has been reported only occasionally.17 Worm bloodfeeding occurs after quick mucosal piercing, with blood loss being aggravated by a repeated feeding behavior.18 This can explain the resulting severe anemia and melena encountered in this infant Foreign body (FB) ingestion is reported to be very rare in infants and newborns However children between the age of months and years are at the highest risk and if the incident has not been witnessed, the diagnosis of FB ingestion can be very tricky in such small age group.19,20 Through this study we reported (2.3%) cases of FB ingestions during the first year of life This relatively small number of cases does not represent the real frequency of FB ingestion in this age group, as most objects fortunately pass out spontaneously without any need for endoscopic examination In fact, this small number represents the rather low occurrence of complications FB retrieval under direct vision was reported to be the method of choice but conventional pediatric esophagoscopes of small size are difficult to achieve such goals, because of limited ‘‘straw” vision, which is further diminished by the passage of manipulating instruments through the lumen.20 In this study, FB retrieved safely by the esopfago- gastroscope but under general anesthesia in two infants and surgical removal was required in the other two Previous studies reported that typical finding of some GIT anomalies on abdominal radiography is not uniformly reported in infants while GIT endoscopies allow direct observation, an immediate and precise diagnosis of these anomalies.21–23 One of the important benefits of endoscopic procedures done in this study was the diagnosis of GIT anomalies [e.g duodenal stenosis (1 infant), achalesia (1 infant), hiatus hernia (3 infants)] This may draw attention to the usefulness of GIT endoscopy in diagnosis of gastrointestinal anomalies in this small age group especially when radiographic studies were inconclusive or not performed because of delayed presentation particularly in minor anomalies In this study colitis was the most common colonoscopic findings This is in accordance of previous studies.3,24,25 Colitis in infancy and early childhood comprises heterogeneous group of conditions and can have similar clinical presentations and similar endoscopic features, a definite diagnosis of specific type of colitis cannot be obtained endoscopically and they usually can be differentiated on histology.26–28 Colonoscopic examination of infants in this study showed the characteristic psuedomembranous colitis pattern (the presence of psuedomembrane) in only 3(5.9%) of infants and varying patterns of erythema and ulcers have been demonstrated in the rest (94.1%) and on histopathologic examination of the specimens, eosinophilic colitis was detected in 39.2% of cases This is in agreement with previous studies which reported that the commonest cause of non-infective colitis in infants is eosinophilic colitis.30 In infants, the most common cause of eosinophilic colitis is food allergy especially cow milk29–31, the diagnosis should be based on history and thorough physical examination32,33 and exclusion of other causes that may result in secondary eosinophilic infiltration, such as intestinal parasites and drugs.34,35 Nagla H Abu Faddan et al / Egyptian Pediatric Association Gazette 64 (2016) 160–166 Through this study, only patients (5.9%) had the characteristic mushroom-like mass of mucus and neutrophils at the surface epithelium which is pathognomonic for psuedomembranous colitis,36 while features of nonspecific colitis were detected in the specimens of 54.9% of the infants So, we can suggest that the final interpretation remains to be made by the clinician, who has to include all relevant clinical, endoscopic and histopathologic data before the diagnosis of specific type of colitis in infants Mixed GIT lesions were detected in 22 (12.4%) of infant included in this study This highlights that the endoscopist shouldn’t rule out the occurrence of mixed problems in the same patient in this small age group Chronic diarrhea was the indication for panendoscopy in 8.5% of infants included in this study, in the majority of cases upper and lower endoscopy were performed during the same session The high occurrence of occult mucosal histological findings and the importance of the histological assessment of endoscopic mucosal biopsies in determining diagnosis, management, and prognosis in infants with chronic diarrhea point to the importance of panendoscopy in this age group.3 Normal or negative endoscopic findings represent one of the important issues to be analyzed through the results gathered in this study with incidence of 20.9% Negative endoscopic findings in infants and early childhood were reported in some studies at different rates ranging from 20.35% to 41% with variable possibilities.3,13,15,37–42 So it has become apparent that the diagnostic role of endoscopic examination does not only necessitate demonstration of organic lesions but a negative endoscopy with normal findings has its role in either reassurance, assistance of diagnosing a functional etiology or may point to the need of further other investigations to identify the etiology Safety of GIT endoscopy performed in our center in infants was highlighted by the fact that there no complications occurred either from the procedure itself or from the sedation given in this 10 years period The two cases of FB ingestion which needed surgical intervention, because of difficult extraction, had smooth post operative course without any morbidity or mortality Conclusions: Pediatric GIT endoscopy is a valuable and informative diagnostic and therapeutic procedure in infants Although its primary role is expressed by documenting the presence of various lesions along the gastrointestinal tract, yet having a negative endoscopic study also has its role in either reassurance, assistance of diagnosing a functional etiology or may point to the need for further other investigations to identify the etiology Conflict of interest All authors declare that the submitted version of this paper is original and is not under simultaneous consideration for publication elsewhere and tables and figures in this study did not reproduced from another source All authors have seen and agreed to the submitted version of the paper in this Journal All Authors declare that there are no conflicts of interest and source of funding is the available resources of Assiut University Children Hospital This study was approved by the Ethical Committee of Faculty of Medicine, Assuit University according to the latest revision of Declaration of Helsinki and informed consent was obtained from participant’s parent/legal guardian Acknowledgements The research team would like to acknowledge Prof Maha Barakat for training members of endoscopy team in pediatric gastrointestinal endoscopy unit, Assiut University Children Hospital, DR 165 Nagla Abu Faddan who perform most of the endoscopic procedures and collect the scientific data retrospectively for this study, Dr Almoutaz Eltayeb who 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VL Gastrointestinal bleeding in infancy and childhood Gastroenterol Clin North Am 2000;29:37–66 39 Dehghani SM, Haghighat M, Hadi Imanieh M, Reza M Upper gastrointestinal bleeding in children in