A Single-center Review of Pediatric Colonoscopy Quality Indicators.

OBJECTIVES: Colonoscopy with terminal ileal (TI) intubation is an important diagnostic and therapeutic tool in the care of children with digestive diseases, especially in those with inflammatory bowel disease. Ileal intubation rate is a recognized quality indicator for pediatric colonoscopy. Our primary aim was to identify our single-center ileal intubation rate and to secondarily identify specific factors, including bowel preparation quality, procedure duration, and cecal intubation rates which affect successful ileal intubation and by extension, complete colonoscopy. METHODS: A retrospective chart review of all colonoscopies in 2015 was completed, identifying 458 procedures. Sixty-seven patients were excluded, resulting in 391 colonoscopies reviewed. RESULTS: We analyzed 391 colonoscopy procedures with a mean patient age of 14.4 ±â€Š5.3 years. The most frequent primary indications for colonoscopy included abdominal pain with "red flag" symptoms (35.5%), known inflammatory bowel disease (25.1%), and isolated abdominal pain (11.5%). Ileal intubation was achieved in 91% of all colonoscopies, with a 94.4% cecal intubation rate. Failure of ileal and cecal intubations was classified into 4 categories: disease-related conditions, bowel preparation, technical aspects, and miscellaneous issues. Potentially modifiable factors accounted for the majority of cases of failed TI intubation. The mean colonoscopy time with and without successful TI intubation were 39 and 48.1 minutes, respectively. CONCLUSIONS: Completion of colonoscopy to the TI is an essential part of a complete colonoscopy. TI intubation was possible in 91% of patients. This rate could potentially improve to 95% with optimization of modifiable factors such as improving bowel preparation or further refinement of endoscopic skills.

Anxiety Associated With High-resolution Anorectal Manometry in Pediatric Patients and Parents.

High-resolution anorectal manometry is an increasingly common procedure performed in pediatric patients to rule out Hirschsprung and assess anorectal function and sensation. The purpose of the present study was to evaluate anxiety of patients and their parents associated with high-resolution anorectal manometry. Preprocedural anxiety was assessed by standardized questionnaire in all parents and children older than 8 years and observed behavioral distress was recorded by the attending pediatric gastroenterologist. Thirty-five children (mean age = 7.2 years, ±2.8) and their parents completed the study. Patient anxiety was found to be markedly elevated. Observed behavioral distress was elevated compared to more invasive procedures. Self-reported parental anxiety was comparable to adults undergoing endoscopic procedures themselves. Despite the low risk of this procedure, healthcare providers should be aware of the high levels of anxiety and distress that occur in patients and their parents associated with anorectal manometry.

Fecal microbiota transplantation in the treatment of refractory Clostridium difficile infection in children: an update.

PURPOSE OF REVIEW: The use of transplanted fecal material for the treatment of diarrheal illness dates back to the fourth-century China. While fecal microbiota transplant has gained increasing popularity over the past 50 years for the treatment of refractory Clostridium difficile infections (RCDIs) in adults, it has only been recently utilized in children. The purpose of this article is to review the use of fecal microbiota transplant (FMT) in the treatment of pediatric RCDIs. RECENT FINDINGS: Minimal pediatric data, including few case reports and series, document the successful use of FMT for treatment of RCDI in the past 2 years. Patients in these reports included otherwise healthy children, those with inflammatory bowel disease as well as significantly immunocompromised children. Donor fecal infusion via nasogastric tube, gastroscope or colonoscope in children aged 16 months and older demonstrated a high rate of symptom resolution and organism eradication. No complications to date have been reported in children who have undergone FMT. SUMMARY: FMT is emerging as a well-tolerated and effective treatment for RCDI in not only adults but also children.

Tolerability, safety, and efficacy of PEG 3350 as a 1-day bowel preparation in children.

OBJECTIVE: The aim of the study was to evaluate the tolerability, safety, and efficacy of polyethylene glycol (PEG) 3350 without electrolytes as a 1-day bowel preparation for colonoscopy in children. METHODS: A prospective study of 45 children undergoing colonoscopy prescribed PEG 3350 without electrolytes mixed with a commercial electrolyte beverage was performed. Patients <45 kg received 136 g of PEG 3350 without electrolytes mixed in 32 ounces of Gatorade. Patients ≥ 45 kg were given 255 g of PEG 3350 without electrolytes in 64 ounces of Gatorade A basic metabolic panel was performed at the time of the clinic visit and just before colonoscopy. Patients completed a survey related to bowel preparation. Endoscopists graded bowel preparation and noted the proximal extent of the examination. RESULTS: A total of 44 patients (14 ± 3 years) completed the study. One patient was excluded due to protocol breach. All subjects reported the preparation was easy (61%) or tolerable (39%). Adverse events included nausea (34%), abdominal pain (23%), vomiting (16%), abdominal distension (20%), bloating (23%), and dizziness (7%). Although significant changes in serum glucose and CO2 were noted, no therapeutic interventions were indicated. Significant changes in sodium, potassium chloride, blood urea nitrogen, or creatinine did not occur. Colonic preparation was rated as excellent in 23%, good in 52%, fair in 23%, and poor in 2% of patients. Intubation of the ileum was successful in 100%. CONCLUSIONS: One-day bowel preparation with high dose PEG 3350 mixed with commercial electrolyte solution is tolerable, safe, and effective in children before colonoscopy.

Measurement of Quality-of-Life Outcomes in Pediatric and Young Adult Patients Treated for Eosinophilic Esophagitis.

Eosinophilic esophagitis is a chronic, immune-mediated esophageal condition that may lead to impairment of quality of life in pediatric and young adult patients. We performed a prospective, cross-sectional study on 40 patients between the ages of 2-21 years with an established diagnosis of eosinophilic esophagitis. The study evaluated physical, emotional, social, and school functioning in patients undergoing treatment with proton pump inhibitors, dietary elimination, or swallowed corticosteroids. There were no statistically significant differences in total or domain-specific quality of life scores between proton pump inhibitors, dietary elimination, and swallowed corticosteroid therapy. Overall, total and domain-specific quality of life were well-preserved in patients with eosinophilic esophagitis, with the highest scores reported in social functioning. There were also no statistically significant associations between clinical, endoscopic, and histologic features and quality-of-life measures.

Ileoscopy via stoma after diverting ileostomy: a safe and effective tool to evaluate for Crohn's recurrence of neoterminal ileum.

BACKGROUND: Recurrence of Crohn's disease (CD) most commonly occurs in the neoterminal ileum near the stoma after fecal diverting ileostomy. Methods used to assess CD recurrence include small bowel series, ileostomy injection, computed tomography (CT) enterography, and capsule endoscopy. Retrograde ileoscopy via stoma is also a valuable tool for recognition of CD recurrence; however, this technique has not been formally studied. OBJECTIVE: To evaluate the safety and utility of retrograde ileoscopy via stoma in patients with CD. METHODS: Patients with CD who underwent ileoscopy via stoma between January 1, 2001, through December 31, 2008 were included. This was a retrospective study in a tertiary referral center. The main outcome measures were procedural complications and findings. RESULTS: A total of 243 ileoscopies were performed on 99 patients. The most common indications for ileoscopy were CD activity assessment in 34.5% and abdominal pain in 33.3%. The procedure was outpatient in 75.8%. Meperidine and midazolam were most commonly used. Average depth of intubation was 28.4 cm. CD recurrence was detected in 70% of patients. Biopsies were obtained during ileoscopy in 117 studies, and biopsy and ileoscopy findings correlated in 111 studies (94.8%). One polypectomy, 24 balloon stricture dilations, and 8 intralesional steroid injections were performed. All patients tolerated the procedure well without procedure- or anesthesia-related complications. No hospital admissions or procedure-related deaths occurred. CONCLUSIONS: Retrograde ileoscopy via stoma is a safe and effective procedure for evaluating recurrence of CD of the neoterminal ileum. It also allows for therapeutic interventions such as balloon dilatation of ileal strictures and steroid injections.

Recent advances in chronic constipation.

PURPOSE OF REVIEW: Chronic constipation remains one of the most frequent complaints in primary and subspecialty pediatric clinics. It is associated with significant emotional and economic burden for both the children and the caregivers. Recently, advances have expanded our understanding of the pathophysiology and treatment options for children with chronic constipation. Here, we review current strategies addressing the cause, diagnostic technologies and treatments of chronic constipation. RECENT FINDINGS: There is some new information presented here on techniques for diagnosis and long-term complications associated with chronic childhood constipation. Comparative data on current laxatives and the development of medications with novel mechanisms of action are reviewed for a glimpse into the horizon of possible new treatments for children with chronic constipation. Studies on effects of growth, quality of life, dietary fiber and symptoms, which may coexist with constipation, are discussed. SUMMARY: The recent literature on chronic constipation has provided some new knowledge providing a more evidence-based approach to treating these patients. We review the scope of this problem and the estimated cost of treating constipation. The availability of long-term outcome data enhances our understanding of the natural history of this problem. Newer pharmacological approaches provide optimism for treatment for this common problem.

Risk of capsule endoscope retention in pediatric patients: a large single-center experience and review of the literature.

OBJECTIVES: Capsule retention is a potential complication of capsule endoscopy (CE). The aims of our study were to determine the incidence of capsule retention in pediatric patients undergoing CE and to identify potential risk factors for capsule retention. MATERIALS AND METHODS: We performed an institutional review board-approved retrospective chart review of pediatric patients undergoing CE studies at a single center. Data collected included patient age, sex, prior diagnosis of inflammatory bowel disease (IBD), CE indication, prior small bowel series results, study result, and complications. RESULTS: Two hundred seven CE procedures were performed in pediatric patients during the study period. Capsule retention occurred in 3 (1.4%) of the 207 studies. All 3 patients had known Crohn disease (CD). The risk of capsule retention in pediatric patients with known IBD was 5.2% (3/58). The risk of capsule retention for patients with suspected IBD and all other indications was 0%. If small bowel disease was identified on upper gastrointestinal series in patients with known CD, then the risk of capsule retention was 37.5% (3/8). Only 7 patients with known IBD had a body mass index (BMI) below the 5th percentile. Of these 7 patients, 3 (43%) had capsule retention. CONCLUSIONS: Red flags for potential CE retention identified in our study include known IBD (5.2% retention risk), previous small bowel follow-through demonstrating small bowel CD (37.5% retention risk), and BMI <5th percentile with known IBD (43% retention risk). Caution is advised in these pediatric patients before capsule ingestion.

Effects of a Psychological Preparation Intervention on Anxiety Associated with Pediatric Anorectal Manometry.

BACKGROUND AND AIMS: High-resolution anorectal manometry (HRM) is associated with significant patient and parent anxiety, which can impact the success and efficiency of the procedure. The nature of HRM necessitates cooperation of an alert child. This study examined effects of psychoeducation intervention on decreasing procedural distress in both pediatric patients and their parents. METHODS: A prospective randomized study of children aged 3-12 years, undergoing HRM, was performed utilizing child-centric educational video. Patients received either psychological preparation intervention or treatment-as-usual. Distress was assessed through self-reported and parent-reported anxiety measures (STAIC-S; STAI-S), physiological arousal measurements, and an observational scale of procedural distress (PBCL). RESULTS: A total of 63 children, aged 3-12 yrs (6.7 ± 2.5), completed the study. Measures of observed and reported distress and anxiety (PBCL; STAIC-S) were significantly less in children receiving intervention. Parents of children in the intervention group also reported significantly less preprocedural anxiety (STAI-S). Effects on physiological arousal were mixed, with significant preprocedural decrease in systolic blood pressure but no difference in heart rate from baseline. CONCLUSIONS: Preprocedural psychological preparation was effective in decreasing pediatric patient and parental self-reported anxiety associated with HRM. Intervention decreased physician time necessary to successfully complete the study and significantly decreased the number of times patients had to endure balloon inflation.

The constipated child: is there a correlation between symptoms and manometric findings?

PURPOSE: The aim of our study was to evaluate patients referred for care of chronic constipation. We compared results of the anorectal manometry studies with a patient/guardian questionnaire about the patients' constipation. PATIENTS AND METHODS: From patients seen for constipation in the department of pediatric gastroenterology, 123 were prospectively enrolled and they completed symptom questionnaires. These patients already were treated with stool softeners, either by the referring primary care physician or by the referring gastroenterologist. Anorectal manometry was performed per standard protocol. RESULTS: Of the 123 patients enrolled in the study, 57.7% were male. Patient age ranged from 0.2 to 17.8 years, and the mean age was 7.5 years. The average duration of constipation was 4.84 years. The average number of stools per week was 3.6. Average time spent in the defecation process was 13.3 minutes. The incidence of hematochezia was 30%. Delayed passage of meconium was reported in 45 of 99 patients (45.5%). Significant correlation was found between frequency of soiling and threshold for rectoanal inhibitory reflex (P = 0.029). The volume of first urge also was positively correlated with frequency of soiling (P = 0.034). There was significant correlation of withholding behavior and the maximum volume tolerated (P = 0.020). The presence of blood in stool was inversely correlated with the maximum volume tolerated (P = 0.004). No correlation was found between severity of complaints and the presence of paradoxical puborectalis contraction. Of the patients, 90.5% had paradoxical puborectalis contraction. CONCLUSIONS: Significant correlation was found between frequency of soiling and rectoanal inhibitory reflex, as well as soiling and volume of first urge. There was correlation between withholding behaviors and maximum volume tolerated. The presence of blood inversely correlated with maximum volume tolerated. Anorectal manometry continues to provide additional new information and to assist in managing patients with this common chronic pediatric affliction.

Safety and efficacy of adalimumab in pediatric patients with Crohn disease.

OBJECTIVES: Adalimumab has recently become available for adult patients with Crohn disease (CD) as a viable alternative tumor necrosis factor-alpha inhibitor to infliximab. To our knowledge, there have been no studies reviewing the use of adalimumab in pediatric patients with CD. Our aim was to examine the safety and efficacy of adalimumab therapy in pediatric patients with CD. PATIENTS AND METHODS: We performed a retrospective chart review of 15 pediatric patients with CD who received adalimumab at a single institution between January 2003 and March 2007. All of the patients had a history of an attenuated response or anaphylaxis to infliximab. Each patient's chart was reviewed for age at diagnosis, sex, extent of disease, age at start of adalimumab therapy, course of therapy, side effects noted during therapy, concurrent medications, and response to adalimumab. Clinical response to adalimumab was classified as complete, partial, or no response based on the patients' ability to be weaned from steroids, increased or decreased need for steroids, or need for surgery during the course of treatment. This study was approved by the Cleveland Clinic Institutional Review Board. RESULTS: Fifteen pediatric patients with CD received adalimumab for a 33-month period. Of those, 14 patients had adequate follow-up, and 1 patient was lost to follow-up. The mean age at initiation of therapy was 16.6 years (median 17.9 years, range 10.3-21.8 years, SD 3.1 years). The majority of patients received an 80-mg loading dose administered subcutaneously and 40-mg doses subsequently every 2 weeks. The median duration of therapy was 6.5 months (range 1-31 months). A total of 272 injections were given. Of the 14 patients with sufficient data for follow-up, 7 (50%) had a complete response, 2 (14%) had a partial response, and 5 (36%) had no response to adalimumab. Complete response was achieved after a median of 5 injections (range 3-11). Of the 14 patients with adequate follow-up, 5 had fistulizing disease; 3 of these maintained fistula closure, 1 had temporary closure, and 1 required surgery to assist with closure. Twenty-six adverse events occurred during therapy. Eight (57%) patients had at least 1 adverse effect. The most common events were abdominal pain and nausea. No serious adverse events were reported, no serious infections occurred, and no adverse events required discontinuation of adalimumab. CONCLUSIONS: Adalimumab was well tolerated in pediatric patients with CD. Complete or partial response was observed in 64% of patients. No serious adverse events occurred during therapy. Additional studies are needed to evaluate the efficacy and to determine optimal dosing of adalimumab in the pediatric population with CD.

Low Indeterminate Rates Associated With Use of the QuantiFERON-TB Gold In-Tube Test in Children With Inflammatory Bowel Disease on Long-term Infliximab.

Background: Tumor necrosis factor alpha (TNF-α) inhibitors are linked with increased risk of reactivation of active tuberculosis. The QuantiFERON-TB Gold In-Tube test is approved for screening latent tuberculosis infection in children and adults. There are limited data on the test performance in children on long-term treatment with TNF-α inhibitors. The objective of this study was to assess the proportion of indeterminate results for the QuantiFERON-TB Gold In-Tube in children with inflammatory bowel disease (IBD) on long-term infliximab treatment and to evaluate the range of interferon-γ responses to mitogen. Methods: A single-center prospective study of children 5 to 19 years of age with IBD on long-term infliximab treatment (>3 months). Each child was assessed for tuberculosis exposure risk and had blood drawn for the QuantiFERON-TB Gold In-Tube. Data on the range of interferon-γ responses and final QuantiFERON-TB Gold In-Tube test results were collected. Results: Ninety-three children were included, with a median age of 16 years. The median total duration of infliximab therapy was 34 months (range, 3-119 months). The QuantiFERON-TB Gold In-Tube was indeterminate in 1 patient (1.1%), positive in 2 patients, and negative in 90 patients. The maximum interferon-γ response to mitogen (10 IU/mL) was observed in 82 patients (88%), with only 1 patient having an inadequate response. The proportion of indeterminate results was significantly lower than the prospectively hypothesized rate of 8%, based on prior studies in nonimmunosuppressed patients (P = 0.004). Conclusions: Pediatric patients with IBD on long-term treatment with infliximab had an adequate interferon-γ response to mitogen and a low indeterminate rate when assessed with the QuantiFERON-TB Gold In-Tube test. This study demonstrates a robust interferon gamma response to phytohemagglutinin stimulation in a pediatric population on long-term therapy with infliximab. The QuantiFERON-TB Gold In-Tube test may therefore be useful as a periodic screening tactic for latent TB in children on long-term infliximab therapy.

Long-term follow up of ileal pouch anal anastomosis in a large cohort of pediatric and young adult patients with ulcerative colitis.

AIM: The study's aim is to determine long-term outcomes in a large cohort of pediatric and young adult patients who underwent proctocolectomy with ileal pouch anal anastomsis (IPAA) for ulcerative colitis (UC). METHODS: Patients diagnosed with UC in childhood or adolescence (age≤21years) who underwent IPAA in childhood, adolescence, or young adulthood between 1982 and 1997 were contacted to determine pouch history, complications, and quality of life. RESULTS: Data were obtained from 74 patients out of a previously reported cohort. Median age at diagnosis of UC was 15years and at surgery was 18years. Median follow-up was 20years. Complications during follow-up were pouchitis (45%), strictures (16%), fistulae (30%), obstruction (20%), and change of diagnosis to Crohn's (28%). Twenty-three percent reported no complications. Fourteen percent had pouch failure, with Crohn's and fistulae reported to be the most frequent complications. Seventy-nine percent reported being very satisfied at 20years follow-up. CONCLUSION: To our knowledge, this study represents the largest cohort with the longest follow-up of pediatric and young adult patients undergoing IPAA for UC. Change in diagnosis to Crohn's and development of fistulae are risk factors for pouch failure. Despite reported complications, IPAA remains an excellent option for pediatric patients with UC.

The endoscopic appearance of a gastrointestinal stromal tumor in a pediatric patient.

Gastrointestinal stromal tumor (GIST) is a mesenchymal tumor that is rare in children. We report a case of GIST in a pediatric patient. A 16-year-old adolescent girl presented after an episode of syncope preceded by one episode of melena. Physical examination results were normal except for Hemoccult-positive stool. Laboratory studies included a hemoglobin level of 6.1 g/dL; complete metabolism profile and coagulation studies revealed normal results. She was transfused with 2 units of packed red blood cells, and an urgent esophagogastroduodenoscopy was performed. Esophagogastroduodenoscopy demonstrated 3 submucosal sessile masses in the gastric antrum ranging from 1 to 3 cm with normal overlying mucosa except for one of the lesions, which was ulcerated. Endoscopic biopsies stained positive for CD117 and were consistent with GIST. Radiologic imaging demonstrated the endoscopically visualized masses and also showed a solitary 1-cm lesion within the liver. She underwent partial gastrectomy and open biopsy of the hepatic lesion. Histologic examination confirmed GIST with hepatic metastasis. Typically with GIST, esophagogastroduodenoscopy will demonstrate a normal surface mucosa and a firm, smooth yellowish submucosal mass, which can be ulcerated. In some cases these tumors can be missed because of their frequent submucosal and extraluminal growth. This case, to our knowledge, is one of the first reports of the endoscopic appearance of GIST in a pediatric patient. Although a rare entity in children, GIST should be considered in pediatric patients with endoscopically visualized submucosal gastric masses.