Читать книгу Practical Pediatric Gastrointestinal Endoscopy - Группа авторов - Страница 64
Оглавление10 Indications for gastrointestinal endoscopy in childhood
Dalia Belsha, Jerome Viala, George Gershman, and Mike Thomson
KEY POINTS
Diagnostic and therapeutic endoscopy are as available now for children as they were in previous years for adults.
Ideally, a pediatric practitioner would perform these although in adolescents, adult GI practititoners are sometimes involved.
Updated diagnostic and management guidelines for common disorders including celiac disease (CD), gastroesophageal reflux (GER), eosinophilic esophagitis (EE), and inflammatory bowel disease (IBD) illustrate the central role for endoscopy in pediatric practice.
It is also recognized that therapeutic endoscopic approaches are widely available now and further broaden the referral spectrum – these include treatment of GI bleeding, gastrostomy insertion, dilation of strictures, polypectomy, and many others.
The advent of newer technologies allows the examination of hitherto inaccessible areas of the GI tract such as the mid‐small bowel by wireless capsule videoendoscopy and enteroscopy.
Introduction
Endoscopic examination of the gastrointestinal tract (GIT) for diagnostics and therapy has evolved markedly over the last 20 or so years and is now usually undertaken by pediatric endoscopists. Updated diagnostic and management guidelines for common disorders including celiac disease (CD), gastroesophageal reflux (GER), eosinophilic esophagitis (EE) and inflammatory bowel disease (IBD) illustrate the central role for endoscopy. It is also recognized that therapeutic endoscopic approaches are widely available now and further broaden the referral spectrum – these include treatment of GIT bleeding, gastrostomy insertion, dilation of strictures, polypectomy, and many others. Lastly, the advent of newer technologies allows the examination of hitherto inaccessible areas of the GIT such as the mid‐small bowel by wireless capsule videoendoscopy and enteroscopy. This chapter is more symptom focused as the place of endoscopy in various pathologies is covered in the relevant chapters later on.
Changing indications for pediatric endoscopy over the last 25 years may have also influenced other disease detection rates such as that of IBD. In prospective studies, pediatric IBD incidence rates are higher than had been reported previously, which might reflect a real increase but also may have been affected by acquisition bias secondary to wider availability of, and improvement in the quality of, endoscopic assessment
Figure 10.1 Suggested diagnostic algorithm of chronic vomiting. PPI, proton pump inhibitor.
Source: BMJ Publishing Group Ltd and the Royal College of Paediatrics and Child Health.
Figure 10.2 Suggested diagnostic algorithm of lower gastrointestinal bleeding.
Source: BMJ Publishing Group Ltd and the Royal College of Paediatrics and Child Health.
Figure 10.3 Suggested diagnostic algorithm for chronic abdominal pain.
Source: BMJ Publishing Group Ltd and the Royal College of Paediatrics and Child Health.
Figure 10.4 Suggested diagnostic algorithm of chronic diarrhea.
Source: BMJ Publishing Group Ltd and the Royal College of Paediatrics and Child Health.
Figure 10.5 Suggested initial management of upper gastrointestinal bleeding.
Source: BMJ Publishing Group Ltd and the Royal College of Paediatrics and Child Health.
Table 10.1 Therapeutic indications for EGD
| Percutaneous endoscopic gastrostomy (PEG) insertion |
| Changing PEG tube to button/balloon gastrostomy |
| Naso‐jejunal (NJ) or gastro‐jejunal (GJ) tube placement |
| Foreign body removal |
| Food bolus impaction removal |
| Dilation of esophageal strictures ± topical application of antifibrotic mitomycin C |
| Esophageal stent placement – usually reserved for the palliative situation |
| Dilation of achalasia |
| Closure of esophageal fistulae with tissue glue and endo‐clips |
| Upper GI polypectomy |
| Upper GI nonvariceal bleeding therapy |
| Esophageal varices banding (emergency or as prophylactic) |
| Injection of gastric fundal varices with histoacryl glue |
| Division of duodenal web/diaphragm/stenosis |
| Delivery of wireless video capsule |
| Laparoscopy‐assisted percutaneous endoscopic jejunostomy (LAPEJ) |
| Endoscopic fundoplication |
| Endomucosal resection of sessile lesion (EMR) |
| Transgastric drainage of pancreatic pseudocyst |
| Endoultrasound‐guided celiac plexus neurolysis |
| Endoscopic retrograde cholangiopancreatography (ERCP) – stent placement both biliary and pancreatic |
| ERCP – sphincterotomy and removal of biliary stones |
Table 10.2 Indications for therapeutic colonoscopy in children
| Polypectomy |
| Dilation of ileocolonic stenosis |
| Treatment of hemorrhagic lesions |
| Foreign body removal |
| Reduction of sigmoid volvulus (rare and usually not successful) |
| Stenting of strictures |
| Sigmoidostomy |
| Cecostomy |
On the other hand and despite an increase in the number of GI endoscopies over recent years, diagnostic yield with abnormal histology results in overall endoscopic procedures remains constant at 62–76%. This suggests that the increase in number of pediatric endoscopies performed is due to increased demand rather than a lower threshold for the procedures.
In addition to IBD and EE, diagnosis of CD is increasing with increased awareness of the disease.
It is important to bear in mind that, in appropriately trained and experienced hands, endoscopy is very safe, it can be associated rarely with morbidity and it is not cheap compared to other less invasive diagnostic routes and hence a pragmatic approach is required in children.
Diagnostic endoscopy
Indications for diagnostic esophagogastroduodenoscopy (EGD) and/or ileocolonoscopy are provided in algorithms (Figures ). The aim of these algorithms is to provide a guide to when the endoscopy might be necessary based on symptoms (chronic vomiting, dysphagia, chronic iron deficiency anemia, chronic abdominal pain, chronic diarrhea and lower GI bleeding).
Endoscopy is not usually indicated in older children in evaluation of functional GI disorders, including self‐limited abdominal pain, constipation, and encopresis.
Esophagogastroduodenoscopy is not indicated in uncomplicated GER. In addition, it is not indicated for infants or children without overt regurgitation presenting with only one of the following: unexplained feeding difficulties (for example, refusing to feed, gagging or choking), distressed behavior, faltering growth, chronic cough or hoarseness. It is, however, to be considered for those in whom reflux‐type symptoms persist after 1 year of age and in those presenting with dysphagia (a classic presentation of EE). Other considerations include patients with reflux‐type symptoms and refractory iron deficiency anemia and those presenting with other complication factors such as faltering growth.
The reader is referred to the relevant chapters for the following diagnostic indications: eosinophilic esophagitis, Helicobacter pylori, CD, IBD, and less common pathologies (Chapters 20–24, 32, and 42).
Therapeutic indications for endoscopy
The reader is referred to the appropriate chapters dealing with the following: upper gastrointestinal bleeding; foreign body removal; stricture management; polypectomy; PEG placement, and less common interventions.
Indications for therapeutic applications of EGD are listed in Table 10.1 and for therapeutic ileocolonoscopy in Table 10.2.
See companion website for videos relating to this chapter topic: www.wiley.com/go/gershman3e
