Pediatric digestive endoscopy and some related problems

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Pediatric digestive endoscopy and some related
problems

• HO THI Nhan.MD
• GI ward, Children Hospital No.2

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Introduction

• Upper digestive endoscopy
• Lower digestive endoscopy
• Diagnostic endoscopy (routine)
• Therapeutic endoscopy

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Personnel

• Physicians pediatric GI fellowship or experience
  with pediatric GI diseases adequate training in
  pediatric endoscopy.
• should be performed by pediatric-trained
  gastroenterologists. (3)
• assistants specially trained
• 1st meet, explain to child hold , reassure
  child throughout procedure.
• 2nd obtain, process tissue assist with other
  equipment
• Competent physicians in anesthesia and
  resuscitation.

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Facilities and Equipment

• Routine endoscopy outpatient setting
• Hospital bedside or operating room occasionally
  more invasive or therapeutic procedure.
• Equipment for monitoring BP, pulse, SpO2
  emergency medications resuscitation.
• Good endoscopy system with size and type
  appropriate for pediatric use (3)

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Indications

• Upper endoscopy
• Acid peptic diseases
• Suspicion of mucosal inflammation (including
  infection) Diarrhea/malabsorption (chronic)
• Chronic Abdominal pain with significant morbidity
  or signs of organic disease (weight loss, anemia,
  vomiting, fevers)
• Hematemesis or enema , Hematochezia
• Dysphagia or odynophagia
• Caustic ingestion, foreign body ingestion
• Recurrent vomiting
• Others GER, failure to thrive, Anemia
  (unexplained),

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Indications

•     symptomatic pediatric patients with known or
  suspected ingestion of caustic substances should
  be performed.
• in absence of symptoms should be considered.
  (1C)
• Therapeutic intervention
• Foreign-body removal
• Dilation of esophageal and upper-GI strictures
• Esophageal varices eradication
• Upper-GI bleeding control

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Indications

• Colonoscopy
• Lower gastrointestinal hemorrhage
• Chronic diarrhea (clinically significant with
  weight loss, fevers, anemia )
• Suspected IBD
• Cancer surveillance
• IBD
• Polyposis syndromes
• Rejection of intestinal transplant
• LowerGI-tract lesions seen on imaging studies?
• Others Anemia (unexplained), Failure to
  thrive/weight loss, Abdominal pain (clinically
  significant)

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Indications

• Therapeutic intervention
• Polypectomy
• Foreign-body removal
• Dilation of strictures
• Lower-GI bleeding control

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Contraindications

• Absolute
• suspected perforation of the intestine and
  peritonitis in a toxic patient.
• Relative
• Severe neutropenia
• Bleeding disorders
• Recent history of bowel surgery
• Patient with connective tissue diseases
  Ehlers-Danlos , Marfans sd ( perforation)
• Toxic dilation of the bowel
• Partial or complete bowel obstruction
• Aneurism of the abdominal or ileac aorta

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Preparation

• Upper endoscopy fasting 2-4h (lt6ms), 6-8h (
  gt2ys)
• Colonoscopy (GI ward personnel)
• Fasting
• Bowel preparation
• Preprocedural preparation should be
  individualized according to the patient's age,
  size, clinical state, and planned procedure. (1C)
• Preprocedural fasting from milk and solids vary,
  a minimum fasting from all oral intake (including
  clear liquids) of 2 hours is recommended. (3)

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Sedation and Monitoring

• Routine sedation preferred
• Therapeutic procedures general anesthesia
• General anesthesia is commonly used for
  pediatric endoscopy. (1C)

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Sedation and Monitoringand related problems

• Monitor
• SpO2, ECG tracing routine
• All sedated pediatric patients should receive
  routine oxygen administration monitored with a
  minimum of pulse oximetry and heart-rate
  monitoring. (3)
• In deeply sedated patients 1 individual monitors
  the patient's cardiac and respiratory status and
  to record vital signs. (3)
• personnel trained specifically in pediatric life
  support and airway management strongly
  recommended during sedated procedures. (3)

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Complications

• Upper digestive endoscopy 4 types
• Sedation related
• Procedure related
• Those associated with therapeutic intervention
• Those associated with patients underlying
  diseases or reasons for endoscopy
• Multifactoral and undetermined

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Complications

• Colonoscopy
• Similar to those of upper digestive endoscopy.
• Correlation between the frequency of technical
  complications and experience of the endoscopist.
• Most important bleeding, perforation.

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Conclusion

•     Endoscopic procedures in the pediatric
  population safe and effective. (1C).
• Consideration for appropriate indications.
• Be aware of potential risks and complications

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References

• GUIDELINE Modifications in endoscopic practice
  for pediatric patients. by the American Society
  for Gastrointestinal Endoscopy. Volume 67, No. 1
  2008 GASTROINTESTINAL ENDOSCOPY
• Gastrointestinal endoscopy. Pediatric
  gastrointestinal and liver diseases.

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Thank you for your attention!
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Complications of pediatric EGD

• US in 1978 and 1979 2046 EGD during 18-month at
  25 medical centers complications in 1.7 of all
  upper-endoscopy procedures.
• bronchospasm, transient respiratory arrest,
• fever, phlebitis
• 1 perforation
• 1653 EGD (1981-1992) in U.S. centers
  complication rate of 0.3
• 2 episodes of significant oxygen desaturation
• 1 case of gastric perforation.

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Complications of pediatric EGD

• 10,236 procedures performed in 9234 patients.
  Immediate complications in 239 procedures (2.3).
  
• most common complications
• hypoxia (1571.5) and bleeding (28 0.3).
• Complication rates were significantly higher in
  the youngest age group, female gender,
  intravenous (IV) sedation group.

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Complications of pediatric colonoscopy

• Colonoscopy
• Perforation
• lt 0.5 (Simon E J Janes ,Clinical review)
• 0.2-0.4 after diagnostic colonoscopy and
  0.3-1.0 with polypectomy (Jennifer Lynn Bonheur
  , emedicine).
• Bleeding most common biopsy or remove colonic
  lesions.
• 1/1000 (emedicine)
• 4.8/1000 (David A. Johnson, Medscape
  Gastroenterology)
• Serious complications with biopsy 7/1000
  colonoscopies vs 0.9/1000 colonoscopies without
  biopsy.
• more for larger (gt 1 cm) polyps (11.4/1000) than
  for smaller polyps (6.5/1000)

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Complications of pediatric colonoscopy

• Infection Salmonella species, Pseudomonas
  species, and Escherichia coli
• Abdominal distension
• Splenic rupture
• Small bowel obstruction (history of abdominal
  surgery and postoperative adhesions )

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Sedation and Monitoringand related problems

• Transient reactions at the site of medication
  administration
• Coughing a characteristic taste with meperidine
  infusion.
• Desaturation may without apparent signs.
• Neurologically impaired patients unpredictable.
  
• Dosages reduced recent weight loss ( IBD,
  malignancy, anorexia nervosa.
• Reported respiratory depression, pulmonary
  edema, allergic reaction, arrhythmias,
  hypotension, paradoxical reaction, hallucination

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• Moderate sedation in children is most commonly
  performed by using midazolam, with or without
  fentanyl, or meperidine.
• General anesthesia and propofol are commonly used
  for pediatric endoscopy, usually based upon age
  or anticipated patient intolerance for the
  procedure

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Postprocedure monitoring and discharge

• Monitor for adverse effects vital signs, SpO2,
  awareness.
• Before discharge writen/verbal instructions
• Signs/symtoms of potential adverse outcomes,
  complications,