Quality indicators for pediatric colonoscopy: results from a multicenter consortium.

BACKGROUND AND AIMS: Currently, there are no quality measures specific to children undergoing GI endoscopy. We aimed to determine the baseline quality of pediatric colonoscopy by using the Pediatric Endoscopy Database System-Clinical Outcomes Research Initiative (PEDS-CORI), a central registry. METHODS: We conducted prospective data collection by using a standard computerized report generator and central registry (PEDS-CORI) to examine key quality indicators from 14 pediatric centers between January 2000 and December 2011. Specific quality indicators, including bowel preparation, ileal intubation rate, documentation of American Society of Anesthesiologists Physical Status Classification System (ASA) class, and procedure time, were compared during the study period. RESULTS: We analyzed 21,807 colonoscopy procedures performed in patients with a mean age of 11.5 ± 4.8 years. Of the 21,807 reports received during the study period, 56% did not include bowel preparation quality, and 12.7% did not include ASA classification. When bowel preparation was reported, the quality was described as excellent, good, or fair in 90.3%. The overall ileal intubation rate was 69.4%, and 15.6% reported cecal intubation only, calculated to be 85% cecum or ileum intubation. Thus, 15% of colonoscopy procedures did not report reaching the cecum or ileum. When excluding the proportion of procedures not intended to reach the ileum (31.5%), the overall ileal intubation rate increased to 84.0%. The rate of ileum examination varied from 85% to 95%, depending on procedure indication. CONCLUSIONS: Colonoscopy reports from our central registry revealed significant variations and inconsistent documentation in pediatric colonoscopy. Our study identifies areas for quality improvement and highlights the need for developing accepted quality measures specific to pediatric endoscopy.

Proteomic Analysis in Esophageal Eosinophilia Reveals Differential Galectin-3 Expression and S-Nitrosylation.

BACKGROUND AIMS: Esophageal eosinophilia (EE) can be caused by gastroesophageal reflux disease (GERD), proton-pump inhibitor-responsive EE (PPI-REE) or eosinophilic esophagitis (EoE). This study quantified protein expression and S-nitrosylation (SNO) post-translational modifications in EE to elucidate potential disease biomarkers. METHODS: Proximal and distal esophageal (DE) biopsy proteins in patients with EE and in controls were assayed for protein content and fluorescence-labeled with and without ascorbate treatment. Protein SNO was determined, and selected protein spots were identified by matrix-assisted laser desorption ionization time-of-flight/mass spectrometry. Western blot and ingenuity pathway analysis were performed. RESULTS: Ninety-one of 648 proteins showed differential expression. There were significantly altered levels of abundance for 11 proximal and 14 DE proteins. Hierarchal clustering revealed differential SNO in inflamed tissues, indicating reactive nitrogen/oxygen species involvement. Galectin-3 was upregulated in both proximal (p < 0.04) and distal (p < 0.004) esophageal EE biopsies compared to controls. In distal EE samples, galectin-3 was significantly S-nitrosylated (p < 0.004). Principal component analysis revealed sample group discrimination distally. CONCLUSION: Proteomic analysis in EE esophageal mucosa revealed a distinct abundance and nitrosylation profile, most prominently in distal biopsies. Galectin-3 was upregulated in expression and SNO, which may indicate its potential role in mucosal inflammation. These results call for more studies to be performed to investigate the role of galectin-3 in GERD, PPI-REE and EoE.

Outcomes of children after esophagogastroduodenoscopy for chronic abdominal pain.

BACKGROUND & AIMS: Chronic abdominal pain is the most common indication for esophagogastroduodenoscopy (EGD) in children. However, little is known about the accuracy of EGD-based diagnosis or the outcomes of the patients who undergo this procedure. We examined the diagnostic yield of EGD and short-term outcomes of children who underwent this procedure for chronic abdominal pain. METHODS: We conducted a prospective study of 290 children (4-18 years old; mean age, 11.9 ± 3.5 years; 93 girls) who underwent EGD for the primary indication of chronic abdominal pain (216 with at least 1 alarm feature) at a US pediatric gastroenterology referral center. We collected data on demographic features (age, sex), clinical characteristics (alarm features, Rome III criteria), and EGD results for each patient. All subjects with diagnostic lesions were followed for at least 1 year after EGD to determine short-term outcomes. RESULTS: Overall, EGD provided an accurate diagnosis for 109 children (38%). Diagnoses included esophagitis (21.0%), eosinophilic gastroenteritis (4.1%), eosinophilic esophagitis (3.8%), Helicobacter pylori infection (2.0%), celiac disease (0.6%), and Crohn's disease (0.4%). Short-term outcomes were available for 81% of patients with diagnostic findings, and medical therapy was effective in approximately 67% of these children. CONCLUSIONS: EGD is valuable for the diagnosis of children with abdominal pain, with a 38% diagnostic yield. EGD identified disorders for which medical therapy was effective in 67% of children during the year after diagnosis.

Colorectal polyps in childhood.

PURPOSE OF REVIEW: Colorectal polyps are a common cause of gastrointestinal bleeding in children. This review updates the information on colorectal polyps and summarizes the recent advances in genetics, diagnosis, and treatment of polyps in the large intestine. RECENT FINDINGS: A review of recent literature regarding colorectal polyps demonstrates an estimated detected prevalence of 6.1% overall and 12.0% among those with lower gastrointestinal bleeding during pediatric colonoscopy. Non-Caucasian races (e.g., black and Hispanic) are at higher risk for colorectal polyps in childhood. Recent data show juvenile polyps may recur in approximately 45% of children with multiple polyps and 17% of children with solitary polyps. A clinical trial showed that celecoxib, a cyclooxygenase (COX)-2 inhibitor, significantly reduced the number of colorectal polyps in children with familial adenomatous polyposis (FAP). Ethical challenges related to genetic tests for FAP have been newly examined. The utility of novel endoscopic techniques (e.g., enteroscopy) in Peutz-Jeghers Syndrome to prevent intussusception have been newly described. SUMMARY: Although colorectal polyps in children are generally benign and easily removed, careful clinical evaluation and ongoing research are needed to identify the small proportion of children at risk for cancer. The current paradigm of using the polyp number at presentation as a primary determinant of subsequent surveillance may be inadequate for many patients.

Prevalence of colorectal polyps in pediatric colonoscopy.

BACKGROUND: The available data regarding the prevalence, types, and clinical determinants of colonic polyps in children is limited. AIMS: We aimed to estimate the prevalence of colorectal polyps in a large cohort of children. METHODS: We conducted a cross-sectional study to determine the presence, number, and location of colorectal polyps reported in all children (0-20 years) who underwent colonoscopy at 14 pediatric facilities between January 2000 and December 2007 recorded in Pediatric Endoscopy Database System Clinical Outcomes Research Initiative (PEDS-CORI). We compared procedures with and without polyps with respect to procedure indication, age, sex, and race. We also reviewed a sample of histopathologic reports from one participating center. RESULTS: We analyzed 13,115 colonoscopy procedures performed in 11,637 patients. Colorectal polyps were reported in 810 procedures (6.1%; 95% CI: 5.7-6.5%) performed in 705 patients, and in 12% of patients with lower GI bleeding. Children with colorectal polyps were significantly younger (8.9 years vs. 11.9 years; p < 0.0001), male (58.3% vs. 49.0%; p < 0.001), non-white race (27.5% vs. 21.9%; p < 0.001), and had lower GI bleeding (54.4% vs. 26.6%; p < 0.001) as compared to children without polyps. In a sample of 122 patients with polyps from a single center, the histological types were solitary juvenile in 91 (70.5%), multiple juvenile in 20 (15.5%), adenoma in 14 (10.9%) and hyperplastic polyps in four patients (3.1%). CONCLUSIONS: Colorectal polyps are detected in 6.1% overall and in 12.0% among those with lower gastrointestinal bleeding during pediatric colonoscopy. Approximately 26% are multiple juvenile or adenoma.

Impact of endoscopy on management of chronic abdominal pain in children.

BACKGROUND: Endoscopy is performed frequently in children with chronic abdominal pain (CAP), but its impact on clinical management is unclear. AIMS: We aimed to examine the frequency of changes in immediate medical management resulting from endoscopy with biopsy evaluating CAP in children. METHODS: We conducted a prospective cross-sectional study to assess the frequency and determinants of management change in children who underwent endoscopy for evaluation of chronic abdominal pain. Patients were screened prior to undergoing endoscopy according to inclusion criteria. Each endoscopist was contacted prior to performing endoscopy and recorded a management plan if endoscopy could not be performed. These responses were compared with management recommendations by the same physician after the endoscopy and review of histopathology. RESULTS: We analyzed 92 endoscopic procedures [63 esophagogastroduodenoscopies (EGDs) and 29 EGD/colonoscopy] performed in 92 children (mean age 11.6 years) with CAP. Overall, gastroenterologists changed management plans post endoscopy in 61 (66.3%) patients. In 46 (75%) of these cases, management was changed as a direct result of endoscopic or histologic findings. Overall, management changes included: reassurance in 17 cases, dietary changes in 6 cases, proton pump inhibitor (PPI) trial in 11 cases, antispasmodic/anticholinergic medication trials in 4 cases, and food allergy testing in 4 cases. No significant association was found between management changes and type of histologic findings or presence of alarm symptoms. CONCLUSIONS: The overall rate of management change after endoscopic evaluation in children with CAP was approximately 66% (61/92). Management outcome was not associated with type of histologic findings.

Repeat endoscopy affects patient management in pediatric inflammatory bowel disease.

OBJECTIVES: Endoscopy is commonly performed in the diagnosis of children with inflammatory bowel disease (IBD). The utility of repeat endoscopy for the management of pediatric IBD has not been subject to investigation. The frequency and determinants of changes in medical management resulting from endoscopy are unknown. METHODS: We conducted a cross-sectional cohort study to assess the frequency and determinants of management change in all children (0-21 years) who underwent endoscopy for the surveillance or evaluation of established IBD between July 2002 and July 2006 at 2 referral centers in the United States. Patients were sampled from the Pediatric Endoscopy Database System Clinical Outcomes Research Initiative and a chart review was performed to identify demographic features (age, gender), blood work (hemoglobin, albumin, erythrocyte sedimentation rate, C-reactive protein), and endoscopy results (endoscopic and histologic). An endoscopic score was used to assess mucosal injury. Subjects were divided into two groups for comparative analysis: (i) patients with management changes based on endoscopic or histologic findings, and (ii) patients without changes. RESULTS: We analyzed 285 endoscopic procedures (137 colonoscopies, 109 esophagogastroduodenoscopy (EGD) with colonoscopy, 25 sigmoidoscopies, 8 EGDs, 6 EGDs with sigmoidoscopy) performed in 230 children (mean age 14.5) with established IBD, including 147 with Crohn's disease, 80 with ulcerative colitis, and 3 with indeterminant colitis. Management changes were documented in 119 (42%) procedures, including 58 (20%) immediately after endoscopy, 52 (18%) after histology review, and 9 (3%) after both. Management changes included new medications in 86 cases, discontinuation of a medication in 3 cases, hospital admission in 11, and surgical consult in 14. No significant differences between groups occurred with regard to age, gender, endoscopy type, or infliximab use. The presence of anemia, hypoalbuminemia, or elevated markers of inflammation (ESR, CRP) did not correlate with management outcome. Management changes after endoscopy were more frequent in patients with Crohn's disease as compared to patients with ulcerative colitis. Patients with mucosal injury were more likely to have a management change than those with mucosal healing (80% vs. 20%; P<0.001). CONCLUSIONS: The overall rate of management change after endoscopic evaluation in children with IBD is approximately 42%. Addition of a new medication is the most common intervention. Blood work and patient symptoms before the procedure did not predict management outcome; however, mucosal healing may be an important end point. Our findings suggest that endoscopy is valuable for the evaluation of children with IBD.

Disaccharidase activity in children undergoing esophagogastroduodenoscopy: A systematic review.

AIM: To investigate the utility of intestinal disaccharide analysis during esophagogastroduodenoscopy (EGD) in children, we performed a systematic review of studies examining disaccharide activity. METHODS: All full-length articles published in English during 1966-2014 were included if: (1) participants had small intestinal biopsy evaluation of disaccharide activity; (2) levels of lactase, sucrase, maltase or palatinase were reported; and (3) age of participants was under 18 years. RESULTS: Thirty articles examining 34753 disaccharide assays fulfilled the specific search, inclusion, and exclusion criteria. All of the studies were observational in design and 57% (17) were prospective. Sixteen studies were conducted in the United States and 9 European studies were identified. The biggest study enrolled about 30, 314 procedures and 13 studies investigated fewer than 50 procedures. Eleven studies examined Caucasian subjects, 3 studies examined Asian subjects, and 6 examined African subjects. Only one Hispanic subject was included. In studies reporting disaccharide deficiency, the overall proportion of lactase deficiency was 39.2%, sucrase deficiency was 9.0%, maltase deficiency was 12.6% and palatinase deficiency was 9.1%. The prevalence of duodenal inflammatory changes ranged from 6% to 24% for non-specific histological lesions (e.g., duodenitis). Sixteen studies examined the association of histologic findings with disaccharide activities, and 12 studies reported an inverse association between degree of histologic inflammation and disaccharide levels. CONCLUSION: We reviewed 30 studies including 34753 biopsy specimens with disaccharide analysis from children undergoing EGD. Our findings advocate a large study is to further illuminate the importance of EGD with disaccharide analysis in children.

Diarrhea in severely burned children.

BACKGROUND: Diarrhea is a common problem in critically ill patients. Our patients are fed a high-carbohydrate enteral formula. We hypothesized that diarrhea in our patients may be related to the osmotic effects of unabsorbed carbohydrate in the small intestine and colon. METHODS: We studied 19 patients, 3 months to 17 years, with burns >40% total body surface area. Each subject was studied weekly for up to 4 weeks postburn. Breath H2 concentration was measured. For the 24-hour period before the breath H2 measurement, the enteral carbohydrate intake, stool volume, and total enteral fluid volume were recorded. At each of several weekly intervals for each subject, the times when stool volume and enteral carbohydrate intake were each maximal were noted. RESULTS: Maximal stool volume ranged from 12 to 69 mL/kg/d. At the time point of maximal carbohydrate intake, diarrhea (stool volume >10 mL/kg/d) occurred in 18 of 19 patients, and maximal stool volume occurred in 10 of 19. Breath H2 concentration (ppm/5% CO2; mean +/- SEM) was 5.5 +/- 3.5 at the time of maximal carbohydrate intake, and was 25 +/- 20 at maximal stool volume. There were no correlations among breath H2 concentration, stool volume, enteral fluid intake, and enteral carbohydrate intake. CONCLUSIONS: Almost all the subjects had diarrhea over several weeks postburn. The lack of correlation of either carbohydrate intake or breath H2 with stool volume suggests that diarrhea in these patients may be caused by factors other than carbohydrate malabsorption. These data do not support altering nutrition support because of watery diarrhea.

Gastroesophageal reflux and asthma in children: a systematic review.

CONTEXT: The relationship between gastroesophageal reflux disease (GERD) and asthma in children has been investigated; however, the nature of the association (if any) between these 2 conditions is unclear. OBJECTIVE: We performed a systematic review of the literature to examine the association between GERD and asthma in children. METHODS: A search of the medical literature was conducted by using PubMed and Embase (1966 through December 2008). Full-length articles in English that described at least 20 subjects younger than 18 years were included if they reported the prevalence of GERD (symptoms, pH studies, endoscopy/histology) in individuals with asthma or the prevalence of asthma in individuals with GERD. We calculated pooled odds ratios from studies that examined control groups, and we pooled prevalence estimates from all studies. RESULTS: A total of 20 articles that described 5706 patients fulfilled the inclusion and exclusion criteria. Seventeen studies used objective methods for documenting reflux (eg, pH probe, contrast imaging, impedance, esophagogastroduodenoscopy), 2 studies relied on symptom-based questionnaires, and 1 study used diagnostic codes. Most studies (n = 19) examined the prevalence of GERD in 3726 individuals with asthma and reported highly variable estimates (19.3%-80.0%) and a pooled average of 22.8% with GERD symptoms, 62.9% of 789 patients with abnormal esophageal pH, and 34.8% of 89 patients with esophagitis. Only 5 studies included controls and enrolled 1314 case-patients with asthma and 2434 controls without asthma. The average prevalence of GERD was 22.0% in asthma cases and 4.8% in controls (pooled odds ratio: 5.6 [95% confidence interval: 4.3-6.9]). CONCLUSIONS: There is a possible association between GERD and asthma in pediatric patients seen with asthma in referral settings. However, because of methodologic limitations of existing studies, the paucity of population-based studies, and a lack of longitudinal studies, several aspects of this association are unclear.

EGD in children with abdominal pain: a systematic review.

BACKGROUND: We performed a systematic review to examine the diagnostic yield (endoscopic and histologic) of esophagogastroduodenoscopy (EGD) for the evaluation of abdominal pain of unclear etiology in children. We also examined the effect of EGD on change in treatment, quality of life, change in abdominal pain, and cost-effectiveness. METHODS: All full-length articles published in English during 1966-2005 were included if: (a) participants had abdominal pain without known underlying gastrointestinal disease, (b) participants underwent EGD primarily for the evaluation of abdominal pain, (c) findings of the EGD were reported, (d) participants were under 18 yr, and (e) sample size greater than 50. RESULTS: Eighteen articles examining 1,871 patients fulfilled the inclusion and exclusion criteria. All were observational and most (13) were prospective. Only three studies were performed in the United States and of those two were prospective. The largest study examined about 400 procedures and 13 studies examined less than 100 procedures. One case of inflammatory bowel disease and 67 duodenal or gastric ulcers were reported, thus diagnostic yield was achieved in 3.6% of cases. The prevalence of nonspecific histological gastrointestinal inflammatory lesions varied between 23% and 93%. Six articles attempted to correlate endoscopic or histologic findings with treatment management decisions. No articles attempted to describe quality of life or cost-effectiveness. None of the studies analyzed the association of alarm symptoms or signs to diagnostic yield. CONCLUSIONS: The diagnostic yield of EGD in children with unclear abdominal pain is low; however, existing studies are inadequate. The effect of EGD on change in treatment, quality of life, improvement of abdominal pain, and cost-effectiveness is unknown. The predictors of significant findings are unclear. Our findings suggest that a large multicenter study examining clinical factors, biopsy reports, and addressing patient outcomes is needed to further clarify the value of EGD in children with abdominal pain.

Complications of pediatric EGD: a 4-year experience in PEDS-CORI.

BACKGROUND: Available estimates of the incidence and type of complications during pediatric EGD are inconsistent. OBJECTIVE: To determine the frequency and the determinants of immediate complications during EGD in children. DESIGN: We conducted a cross-sectional database study. SETTING: The study involved 13 pediatric facilities that use the PEDS-CORI (Pediatric Endoscopy Database System Clinical Outcomes Research Initiative). PATIENTS: Children (0-18 years) who underwent EGD at 13 facilities between November 1999 and December 2003. MAIN OUTCOME MEASUREMENTS: We identified complications (recorded shortly after the procedure) and analyzed their occurrence with respect to procedure indication, American Society of Anesthesiologists (ASA) class, sex, age, anesthesia type, and unplanned interventions. RESULTS: We analyzed 10,236 procedures performed in 9234 patients. Immediate complications were reported in 239 procedures (2.3%, 95% confidence interval 2.0%-2.6%). The most common complications were hypoxia (157 [1.5%]) and bleeding (28 [0.3%]). Complication rates were significantly higher in the youngest age group, highest ASA class, female gender, intravenous (IV) sedation group, and in the presence of a fellow. LIMITATIONS: The study is limited by a lack of specific details and explicit criteria for reported complications. CONCLUSIONS: The overall immediate complication rate of pediatric EGD is 2.3%. All complications were nonfatal, and most were hypoxia related (157/239 [66%]) and reversible. Young age, higher ASA class, female sex, and IV sedation are risk factors for developing complications.