Applicability, efficacy, and safety of over-the-scope clips in children.

BACKGROUND AND AIMS: Over-the-scope clips (OTSCs) are now becoming popular in endoscopy performed in adults for indications such as acute nonvariceal GI bleeding, anastomotic bleeding, and for closure of gastrocutaneous and postgastrostomy fistulae. Varied sizes of clip are available, but even the smallest, 8.5 to 9.8 mm in diameter with its loading device on the tip of the endoscope, increases device and endoscope intubation diameters up to 14.65 mm. This may present challenges in terms of the size of the patient in whom it might be used. OTSCs appear to be effective and safe in the hands of those who are trained appropriately in endoscopy on adult patients; however, the experience of OTSC application in children is not reported. Here we present results of a service evaluation of this technology at 2 regional/national referral pediatric endoscopy units in the United Kingdom and the United States. METHODS: Two tertiary centers' databases were searched to identify cases in which OTSCs were used. Demographics, presentation, anthropometry, comorbidities, efficacy, adverse events, and postprocedure follow-up were recorded, with identification of resolution or recurrence. RESULTS: OTSC procedures were performed on 24 occasions in 20 patients (11 girls) between February 2018 and February 2021. Patients had a mean age of 12 years (range, 5-17) and a mean weight of 44.42 kg (range, 18.2-70.3). Indications were nonhealing PEG site fistulae (n = 7), acute nonvariceal upper GI bleeding (ANUGIB) from gastric ulcers (5), ANUGIB from duodenal ulcers (3), nonhealing bleeding anastomotic ulcer (3), esophageal mucocutaneous fistula (1), and gastric perforation (1). Technical success was achieved in all but 1 case (95%), and clinical success was achieved in 18 cases (90%). CONCLUSIONS: The OTSC device appears to be effective in children (minimum age 5 years and minimum weight 18 kg) in a limited number of situations including anastomotic ulcer, closure of leaking PEG site, gastric perforation, and bleeding peptic ulcers. The operator should be an experienced endotherapeutic endoscopist with specific OTSC training, and the type and size of the OTSC device should be carefully considered, along with any comorbidities of the patient that may preclude success and/or lead to potential adverse events such as esophageal perforation.

Anastomotic Ulcers: A Tertiary Centre Experience of Endoscopic Management Techniques.

ABSTRACT: Improvements in neonatal care and surgical advances, has led to an increased prevalence of children with small and large bowel anastomoses. Ulceration at the site of anastomosis is a rare, but well-recognised phenomenon, with no clearly understood pathogenesis. Paediatric case series have been reported but there remains no clear effective treatment strategy and there is limited experience with endoscopic techniques in their management. We report our tertiary centre experience of managing nine anastomotic ulcer patients, including endoscopic treatment with argon plasma coagulation and clips.Two patients with inflammatory bowel disease (IBD) responded to optimisation of medical therapy. In our non-IBD patients, those requiring a blood transfusion (n = 2) ultimately required surgery and those who did not require a blood transfusion responded to aminosalicylate treatment (n = 1) or endoscopic therapeutic techniques (n = 3).We conclude that endoscopic interventions can be an effective management strategy for anastomotic ulcers when a blood transfusion isn't required.

The Use and Safety of a Novel Haemostatic Spray in the Endoscopic Management of Acute Nonvariceal Upper Gastrointestinal Bleeding in Children.

AIMS AND BACKGROUND: Advanced endohaemostatic technique performance and experience is extremely variable in distribution amongst paediatric endoscopists. Haemostatic spray (Hemospray), a novel endohaemostatic topically applied powder has the advantage of extreme ease of use and; hence may lower the threshold of competency required by the endoscopist thereby potentially reducing mortality. The aim of the study is to prospectively evaluate the efficacy and the safety of haemostatic spray in paediatric patients with acute upper gastrointestinal bleeding (AUGIB). METHODS: Prospective enrolment of children with AUGIB (Group 1) occurred, either as primary therapy or as an adjunct to standard endohaemostatic therapeutic techniques. Patients were assessed for likely need for endohaemostatic intervention of >8 of 24 of the paediatric Sheffield AUGIB score.A follow-up endoscopy occurred in those deemed to have clinical need pre-discharge. For comparison, another group (Group 2) of patients, who received conventional endohaemostatic treatment in the preceding 36 months, were reviewed. RESULTS: A total of 20 applications of Hemospray occurred in 17 patients (8 boys, median (range) age: 6.5 years (2 days to 17.75 years) and a total of 29 patients were enrolled in Group 2 (16 boys, median [range] age: 5.1 [0.25-17.0]). All patients tolerated haemostatic spray applications with no adverse events. The haemostatic spray group achieved 100% initial haemostasis with 18% rebleeding rate, although only a 6% failure rate after re-application. In the conventional group, similar 100% initial haemostasis was achieved with 24% rebleeding rate and 7% failure rate necessitating surgical interventions. CONCLUSIONS: This paediatric series suggests that monotherapy with haemostatic spray is as effective as conventional approaches in the management of AUGIB.

Two years' experience of using the Bravo wireless oesophageal pH monitoring system at a single UK tertiary centre.

AIM: The Bravo wireless pH monitoring system enables oesophageal pH to be monitored in children intolerant to nasal catheters and records measurements over 48 hours. This study aimed to document the minimum child weight that enabled successful capsule placement and any associated complications. We also compared the diagnostic sensitivity of 48 hours versus 24 hours. METHODS: We included 203 consecutive patients (122 male children) with clinically documented or suspected reflux symptoms. The age range was two years to 19 years, and the minimum weight was 9.29 kg. The pH capsule was deployed endoscopically under general anaesthetic. Recordings taken over 24 and 48 hours were compared to determine the frequency of differences and correlations in the reflux index and DeMeester scores. RESULTS: Testing using the detached probe was successful in 190 children (93.6%) with weight as low as 9.29 kg, with no side effects, with failed deployment being the most frequent problem. Clinically different results in the reflux index were found in 16% of the children's day 1 or day 2 readings (p < 0.0001), suggesting the benefit of 48-hour measurements. CONCLUSION: Measuring oesophageal pH with the Bravo wireless pH monitoring system was successful in 93.6% of cases. A 48-hour test improved the detection rate of gastro-oesophageal reflux disease by 16%.

Diagnostic and therapeutic utility of double-balloon enteroscopy in children.

OBJECTIVES: Diagnostic and therapeutic benefits of double-balloon enteroscopy (DBE) have been documented in adults, with few data available on pediatric patients. We evaluated the diagnostic and therapeutic utility of DBE in children. METHODS: A prospective assessment of 113 DBE procedures in 58 consecutive children younger than 18 years (36 boys, 22 girls; median age 12.7 years, range 1-18 years) was performed for a variety of suspected small bowel (SB) disorders from January 2008 to August 2012 in a tertiary referral center for pediatric patients. All of the children had undergone upper gastrointestinal endoscopy and ileocolonoscopy. A total of 19 patients had undergone radiological investigations for SB (n = 11 magnetic resonance imaging; n = 5 barium enterography; n = 3 computed tomography) and 54 patients had undergone wireless capsule endoscopy (WCE). RESULTS: The overall median (range) examination time was 92.5 (45-275) minutes. The median (range) estimated insertion length of SB distal to pylorus was 230 (80-450) cm and proximal to ileocecal valve was 80 (5-275) cm. The common indications for DBE were polyposis syndromes (n = 21) and obscure gastrointestinal bleeding (n = 16). The findings included polyps (n = 19), mucosal ulcers and erosions (n = 8), submucosal elevations with white nodules (n = 4), and angioma/angiodysplasia (n = 2). The overall diagnostic yield for SB lesions using DBE was 70.7% (41/58) and for WCE was 77.7% (42/54). Endotherapeutic intervention was successfully used in 46.5% (n = 27/58). The endoscopic, medical, and surgical contributions to change in management by DBE were 72.4% (n = 42/58). Three complications (5.2%) were noted with uneventful recovery. CONCLUSIONS: The diagnostic yield of DBE was comparable to WCE, but with the addition of therapeutic possibility and histological yield. We believe this technique could be a valuable addition to existing endoscopic techniques, complementary to WCE, and may be considered as an alternative diagnostic and therapeutic option in the SB in children.

Graded compression and power Doppler ultrasonography versus endoscopy to assess paediatric Crohn disease activity pre- and posttreatment.

OBJECTIVE: The aim of this study was to assess whether power Doppler ultrasound (PDU) can serve as a reliable replacement for endoscopy in follow-up assessment of disease activity in children with Crohn disease. METHODS: Nineteen children (13 boys), median age 14.8 (5.4-15.8) years, with macroscopically diagnosed Crohn disease were included in the study. Clinical parameters, histological evaluation, and graded PDU assessments were undertaken in all patients at diagnosis and following their initial treatment. Discriminant analysis was used to build predictive models from the PDU data for the histological evaluation. RESULTS: The median Pediatric Crohn's Disease Activity Index (PCDAI) was 31.5 (15.5-42.0) at diagnosis. All clinical and ultrasonographic parameters and the histological evaluation showed an improvement between pre- versus posttreatment results; 1-way analysis of variance showed a significant difference because of treatment (P < 0.005) for all variables apart from the superior mesenteric artery flow (SMA); paired sample t tests indicated that these differences were statistically significant (P < 0.001), with the exception of SMA (P = 0.178). There was a statistically significant correlation (P < 0.001) between the platelet count and the bowel wall stratification (STRAT). Significant correlation was also observed between the histology findings and the mean mucosal, transmural, and segmental flow (MFL) and STRAT and between platelets and both MFL and small bowel thickening (SBT) (P < 0.01 in all cases). There was a statistically significant correlation (P < 0.05) between C-reactive protein and MFL and between histology and SBT, MFL, and STRAT. Discriminant analysis using discriminating factors SBT, STRAT, and MFL could assign 84.6% of cases to the correct classification of "no/mild inflammation" or "medium/severe inflammation." CONCLUSIONS: Results obtained using power Doppler ultrasonography and endoscopy showed statistically significant correlations. Power Doppler sonography, in the hands of an experienced examiner, can be used for follow-up assessment of disease activity in children with Crohn disease.

Comparison of quick point-of-care test for small-bowel hypolactasia with biochemical lactase assay in children.

AIM: The aim of the present study was to compare the Biohit Lactose Intolerance Quick Test (BLIQT) to the criterion standard biochemical duodenal lactase (DL) activity assay in the paediatric population using standard statistical comparative tests. METHODS: Using standard Olympus endoscopes, 2 postbulbar duodenal biopsies were taken from 38 prospective children (0-16 years) from June 2008-May 2009 at a single tertiary paediatric gastroenterology unit. The biopsies were used for the BLIQT and for biochemical disaccharides assay. RESULTS: Thirty-eight children (19 boys) of median age 5.45 years (0.3-14.8 years) underwent the combined BLIQT and disaccharidase testing. We subdivided the group into those who had biopsies with a larger endoscope (XQ, n = 26) and those who had a smaller endoscope (XP, n = 12) and thus a smaller biopsy forcep. When using a larger endoscope, the BLIQT showed a sensitivity of 100%, specificity of 86%, and positive and negative predictive value of 57.1% and 100%, respectively, on comparing it with DL. With a smaller endoscope, the BLIQT had a sensitivity of 100%, specificity of 80%, positive predictive value of 50%, and a negative predictive value of 100%. CONCLUSIONS: As in adult studies, the sensitivity and negative predictive value of the BLIQT was 100%. The specificity too appears to be high but variable, probably because of smaller biopsies obtained, and may warrant the need for 2 biopsies. The high sensitivity, specificity, and negative predictive value of the BLIQT for indicating hypolactasia make it an effective point-of-care test for paediatric hypolactasia.

Contemporary outcomes for ulcerative colitis inpatients admitted to pediatric hospitals in the United Kingdom.

BACKGROUND: Pediatric ulcerative colitis (UC) care is variable with a lack of appropriate guidelines to guide practice until recently. METHODS: UC inpatients <17 years old admitted to 23 U.K. pediatric hospitals had clinical details collected between September 2010 and 2011. Comparative data for 248 patients were available from a previous audit in 2008. RESULTS: One hundred and seventy-six patients (98 males) of median age 13 years (interquartile range, 10-13) were analyzed; 23 were elective surgical admissions, 47 new diagnoses, and 106 needed acute medical care for established UC. Median length of stay was 6 days (interquartile range, 3-10) with no deaths. Eighty-eight of 126 patients (70%) with active disease had standard stool cultures performed (3 [2%] were positive), and 57 (45%) had Clostridium difficile toxin tested (none positive). Twenty-five of 66 (38%) emergency admissions had an abdominal x-ray on admission, and 13 of 66 patients (20%) had a Pediatric Ulcerative Colitis Activity Index score. There were 3 cases of toxic megacolon and 2 thromboses. Eighty-one of 116 patients (71%) responded to steroids. Nineteen patients who did not respond adequately to steroids received rescue therapy (7 infliximab, 11 ciclosporin, and 1 both) with overall response rate of 90%; 7 patients needed surgery acutely, 5 without previous rescue therapy. Compared with the 2008 data, stool culture rates improved significantly (86 of 121 [71%] versus 76 of 147 [52%], P = 0.001) as did heparinization rates (15 of 150 [10%] versus 5 of 215 [2%], P = 0.002) and rescue therapy usage (17 of 33 [52%] versus 10 of 38 [26%], P = 0.03). CONCLUSIONS: There were signs of improving UC care with significantly increased rates of stool culture and rescue therapy. The majority of sites, however, did not use Pediatric Ulcerative Colitis Activity Index scores.

Eosinophils in the oesophageal mucosa: clinical, pathological and epidemiological relevance in children: a cohort study.

Objectives Eosinophilic oesophagitis (EO) shows eosinophilic infiltration of the mucosa and can present with symptoms indistinguishable from gastrooesophageal reflux disease (GORD). The authors describe the clinical, endoscopic and histopathological features of all cases of histological EO presenting during 2007-2008 with a 2-year follow-up. The incidence of paediatric EO and the features of a subgroup with features of both GORD and EO ('overlap' syndrome (OS)) are described. Design Biopsies with an average of 15 eosinophils/high-power field (HPF) were reviewed in the cohort. OS was suggested when there was coexistence of clinical and histological features of EO and GORD (abnormal pH study), which improved with proton pump inhibitors. Setting Tertiary care. Participants All cases with ≥15 eosinophils/HPF entered the study. Primary outcome measures Patients with EO had an average of 15 eosinophils/HPF. Secondary outcome measures Other histological features of EO included microabscesses, dilated intercellular spaces, basal cell hyperplasia, papillary elongation, etc. Results 24 cases of EO were identified, 13 men and 11 women. The incidence of paediatric oesophageal eosinophilia in the region was 9/100 000 children. 11 of the 24 patients (46%) presented with some form of allergy, six with poor feeding/food aversion, five with dysphagia and four with vomiting. After follow-up, 56.5% were confirmed to have EO, 30.5% responded to treatment for GORD and were categorised as OS, 9% developed eosinophilic gastroenteritis and 4% did not have further upper gastrointestinal symptoms. Conclusions Accurate diagnosis of EO, especially the differentiation from GORD, requires appropriate clinicopathological correlation. A significant proportion of patients with eosinophilia in the mucosa also have GORD (OS). These patients improve after treating the underlying GORD. The study was registered as a Service Evaluation with the Trust (number SE74).

Percutaneous endoscopic gastrostomy and gastro-oesophageal reflux in neurologically impaired children.

AIM: To investigate the effects of percutaneous endoscopic gastrostomy (PEG) feeding on gastro-oesophageal reflux (GOR) in a group of these children using combined intraluminal pH and multiple intraluminal impedance (pH/MII). METHODS: Ten neurologically impaired children underwent 12 h combined pH/MII procedures at least 1 d before and at least 12 d after PEG placement. METHODS: Prior to PEG placement (pre-PEG) a total of 183 GOR episodes were detected, 156 (85.2%) were non-acidic. After PEG placement (post-PEG) a total of 355 episodes were detected, 182 (51.3%) were non-acidic. The total number of distal acid reflux events statistically significantly increased post-PEG placement (pre-PEG total 27, post-PEG total 173, P = 0.028) and the mean distal pH decreased by 1.1 units. The distal reflux index therefore also significantly increased post-PEG [pre-PEG 0.25 (0-2), post-PEG 2.95 (0-40)]. Average proximal pH was lower post-PEG but the within subject difference was not statistically significant (P = 0.058). Median number of non-acid GOR, average reflux height, total acid clearance time and total bolus clearance time were all lower pre-PEG, but not statistically significant. CONCLUSION: PEG placement increases GOR episodes in neurologically impaired children.