Wireless capsule endoscopy in children: a study to assess diagnostic yield in small bowel disease in paediatric patients

General considerations and updates in pediatric gastrointestinal diagnostic endoscopy

Gastrointestinal and colonic endoscopic examinations have been performed in pediatric patients in Korea for 3 decades. Endoscopic procedures are complex and may be unsafe if special concerns are not considered. Many things have to be kept in mind before, during, and after the procedure. Gastrointestinal endoscopy is one of the most frequently performed procedure in children nowadays, Since the dimension size of the endoscopy was modified for pediatric patients 15 years ago, endoscopic procedures are almost performed routinely in pediatric gastrointestinal patients. The smaller size of the scope let the physicians approach the diagnostic and therapeutic endoscopic procedures. But this is an invasive procedure, so the procedure itself may provoke an emergence state. The procedure-related complications can more easily occur in pediatric patients. Sedation-related or procedure-related respiratory, cardiovascular complications are mostly important and critical in the care. The endoscopists are required to consider diverse aspects of the procedure - patient preparation, indications and contraindications, infection controls, sedation methods, sedative medicines and the side effects of each medicine, monitoring during and after the procedure, and complications related with the procedure and medicines - to perform the procedure successfully and safely. This article presents some important guidelines and recommendations for gastrointestinal endoscopy through literature review.

Wireless capsule endoscopy in pediatric patients: the first series from Japan

PURPOSE

The aim of our study was to determine the safety and usefulness of capsule endoscopy (CE) in pediatric patients.

METHODS

We prospectively examined children (aged 10-18 years) with suspected small bowel disease and recorded capsule transit times, findings, and complications.

RESULTS

We performed 19 CE examinations in 12 patients (median age 11.8 years; range 10-18 years). One of the two patients with obscure gastrointestinal bleeding (OGIB), a 14-year-old girl whose OGIB occurred after cord-blood transplantation due to leukemia, was diagnosed with thrombotic microangiopathy. Repeated CE allowed visualization of real-time mucosal changes, such as the improvement of ulcers and bleeding, and newly emerged lymphangiectasia, without causing the patient physical and mental stress. This information facilitated both subsequent evaluation of the clinical course and determination of the appropriate treatment strategy. In the second patient with chronic OGIB, a 10-year-old girl, the detection of severe ileal stenoses by capsule retention led to the diagnosis of non-specific multiple ulcers of the small intestine. After ileal resection, repeated CE detected the recurrence of multiple ulcers and enabled the optimal treatment strategy to be applied. CE confirmed small bowel involvement in a patient with unresponsive Crohn's disease (CD) and excluded CD in all five patients with suspected CD. Similarly, CE confirmed the absence of small bowel involvement in three of the four patients with recurrent abdominal pain, although one patient had nodular lymphoid hyperplasia.

CONCLUSIONS

Based on our results, CE is a valuable tool in the differential diagnoses of small bowel diseases, and repeated examination can provide real-time information that will enable evaluation of the clinical course in pediatric patients.

Capsule endoscopy performed across the pediatric age range: indications, incomplete studies, and utility in management of inflammatory bowel disease

BACKGROUND

Capsule endoscopy (CE) is used increasingly to evaluate the small bowel in children. An upper GI series is recommended before CE to evaluate the risk of obstruction. Despite normal findings on an upper GI series, CE may still be incomplete. Although large adult studies have demonstrated the safety and diagnostic yield of CE, similar pediatric studies have not been available.

OBJECTIVE

To identify factors associated with incomplete studies and the diagnostic yield in pediatric patients.

DESIGN

Retrospective review of consecutive CE studies from February 2005 through June 2008.

SETTING

Large tertiary children's hospital.

PATIENTS

A total of 123 CE studies in 117 patients; median age 12.9 years (range 0.8-22.4 years).

MAIN OUTCOME MEASUREMENTS

Demographic information, indication, placement technique, pre-CE imaging results, and cecal completion status were recorded. Risk factors were analyzed with bivariate and multivariate regression analysis.

RESULTS

There were 27 (22%) incomplete studies; of these, there were normal pre-CE radiologic study findings in 12 (44%), and findings requiring medical, endoscopic, or operative intervention in 6. Of the 117 patients, CE produced a new diagnosis in 21 (18%). Abnormal findings on previous imaging (odds ratio [OR] 3.0; 95% CI, 1.2-8.0), endoscopic placement (OR 3.1; 95% CI, 1.1-8.4), and female sex (OR 3.3; 95% CI, 1.2-9.4) were associated with incomplete studies.

LIMITATIONS

Retrospective, incomplete follow-up.

CONCLUSIONS

CE may be performed in children as small as 11.5 kg, with 18% yield in all studies, and 28% in pediatric known inflammatory bowel disease. Capsule retention requiring retrieval did not pose life-threatening risk in our series, and CE may be used to identify disease-associated small-bowel stenosis.

Double balloon enteroscopy in children: diagnosis, treatment, and safety

AIM

To assess the feasibility and utility of double balloon enteroscopy (DBE) in the management of small bowel diseases in children.

METHODS

Fourteen patients (10 males) with a median age of 12.9 years (range 8.1-16.7) underwent DBE; 5 for Peutz-Jeghers syndrome (PJ syndrome), 2 for chronic abdominal pain, 4 for obscure gastrointestinal (GI) bleeding, 2 with angiomatous malformations (1 blue rubber bleb nevus syndrome) having persistent GI bleeding, and 1 with Cowden's syndrome with multiple polyps and previous intussusception. Eleven procedures were performed under general anesthesia and 3 with deep sedation.

RESULTS

The entire small bowel was examined in 6 patients, and a length between 200 cm and 320 cm distal to pylorus in the remaining 8. Seven patients had both antegrade (trans-oral) and retrograde (trans-anal and via ileostomy) examinations. One patient underwent DBE with planned laparoscopic assistance. The remaining 6 had trans-oral examination only. The median examination time was 118 min (range 95-195). No complications were encountered. Polyps were detected and successfully removed in all 5 patients with PJ syndrome, in a patient with tubulo-villous adenoma of the duodenum, in a patient with significant anemia and occult bleeding, and in a patient with Cowden's syndrome. A diagnosis was made in a patient with multiple angiomata not amenable to endotherapy, and in 1 with a discrete angioma which was treated with argon plasma coagulation. The source of bleeding was identified in a further patient with varices. DBE was normal or revealed minor mucosal friability in the remaining 3 patients. Hence a diagnostic yield of 11/14 with therapeutic success in 9/14 was achieved.

CONCLUSION

Double balloon enteroscopy can be a useful diagnostic and therapeutic tool for small bowel disease in children, allowing endo-therapeutic intervention beyond the reach of the conventional endoscope.

Evaluation of arterial phase MDCT for the characterization of lower gastrointestinal bleeding in infants and children: Preliminary results

OBJECTIVE

The purpose of this study was to prospectively evaluate the accuracy of MDCT for the characterization of occult lower gastrointestinal bleeding in infants and children.

SUBJECTS AND METHODS

MDCT examinations were prospectively performed on 27 patients (2l boys, six girls; age range, 2 months-18 years). Patients with known causes of lower gastrointestinal bleeding were excluded from the study. Nonionic contrast medium was administered in an amount based on body weight. Images were obtained with a 16-MDCT scanner. For the arterial phase the section thickness was 1 mm; beam pitch, 1; and reconstruction interval, 0.7 mm. The scans were examined for abnormal vessels and extravasation of contrast medium. Two radiologists independently reviewed the images. The sensitivity, specificity, and diagnostic accuracy of MDCT were assessed with the pathologic findings or the final diagnosis as the reference standard.

RESULTS

Twenty of 27 patients had abnormal MDCT findings: arteriovenous malformation in 17 patients and Meckel's diverticulum in three patients. Contrast extravasation was identified in four patients. Surgery was performed on 13 of the 27 patients, and the diagnosis was otherwise confirmed in two additional patients. In these 15 cases, the sensitivity, specificity, and diagnostic accuracy of MDCT were 82%, 50%, and 74%. The interobserver difference was not significant (McNemar exact test, p = 0.063).

CONCLUSION

MDCT can be used to identify the location and source of lower gastrointestinal bleeding in infants and children.

Double balloon enteroscopy in children: Diagnosis, treatment, and safety

AIM: To assess the feasibility and utility of double balloon enteroscopy (DBE) in the management of small bowel diseases in children.

METHODS: Fourteen patients (10 males) with a median age of 12.9 years (range 8.1-16.7) underwent DBE; 5 for Peutz-Jeghers syndrome (PJ syndrome), 2 for chronic abdominal pain, 4 for obscure gastrointestinal (GI) bleeding, 2 with angiomatous malformations (1 blue rubber bleb nevus syndrome) having persistent GI bleeding, and 1 with Cowden’s syndrome with multiple polyps and previous intussusception. Eleven procedures were performed under general anesthesia and 3 with deep sedation.

RESULTS: The entire small bowel was examined in 6 patients, and a length between 200 cm and 320 cm distal to pylorus in the remaining 8. Seven patients had both antegrade (trans-oral) and retrograde (trans-anal and via ileostomy) examinations. One patient underwent DBE with planned laparoscopic assistance. The remaining 6 had trans-oral examination only. The median examination time was 118 min (range 95-195). No complications were encountered. Polyps were detected and successfully removed in all 5 patients with PJ syndrome, in a patient with tubulo-villous adenoma of the duodenum, in a patient with significant anemia and occult bleeding, and in a patient with Cowden’s syndrome. A diagnosis was made in a patient with multiple angiomata not amenable to endotherapy, and in 1 with a discrete angioma which was treated with argon plasma coagulation. The source of bleeding was identified in a further patient with varices. DBE was normal or revealed minor mucosal friability in the remaining 3 patients. Hence a diagnostic yield of 11/14 with therapeutic success in 9/14 was achieved.

CONCLUSION: Double balloon enteroscopy can be a useful diagnostic and therapeutic tool for small bowel disease in children, allowing endo-therapeutic intervention beyond the reach of the conventional endoscope.

Feasibility of video capsule endoscopy in the management of children with Peutz-Jeghers syndrome: a blinded comparison with barium enterography for the detection of small bowel polyps

OBJECTIVES

Peutz-Jeghers syndrome (PJS) in children may present with anaemia, intussusception, or obstruction from an early age and surgery is common. Prophylactic polypectomy may reduce subsequent complications. Traditional barium enterography (BE) has poor sensitivity and requires significant radiation. We compared the performance of capsule endoscopy (CE) with BE in children with PJS.

MATERIALS AND METHODS

Children with PJS (ages 6.0-16.5 years) were prospectively recruited and underwent BE followed by CE, each reported by expert reviewers blinded to the alternate modality. Number of "significant" (>10 mm) and total number of polyps were recorded. Child preference was assessed using a visual analogue questionnaire. Definitive findings were assessed at laparotomy or enteroscopy, when performed.

RESULTS

There was no significant difference for >10 mm polyp detection. Six polyps were found in 3 children by both modalities: 3 polyps in 2 children at CE, 3 polyps in 1 child at BE (P=0.50). Re-review of 1 CE identified 3 polyps that were missed in 1 child at initial reading. Significantly more <10 mm polyps were identified by CE than BE: 61 vs 6 (P=0.02). CE was significantly more comfortable than BE (median score CE 76 [interquartile range 69-87] vs BE 37 [interquartile range 31-68], P=0.03) and was the preferred investigation in 90% (P=0.02).

CONCLUSIONS

CE is a feasible, safe, and sensitive test for small bowel polyp surveillance in children with PJS. It is significantly more comfortable than BE and is the preferred test of most children for future surveillance. There is a learning curve for reporting CE studies in PJS and appropriate training is essential.

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.

Follow-up and surgical management of Peutz-Jeghers syndrome in children

BACKGROUND

Peutz-Jeghers syndrome (PJS) is an autosomal dominant syndrome with an increased risk of polyposis complications and intestinal and extraintestinal tumours.

METHODS

During the last 15 years, we reviewed a series of 11 children with PJS, with special attention to evolution and follow-up. Diagnosis was based on at least 1 hamartomatous polyp associated with 2 of the 3 following criteria: family record of PJS, polyposis localised on small bowel, and mucocutaneous pigmentation. Diagnosis of PJS also could be raised by a single genetic analysis of STK11 gene.

RESULTS

Median age at beginning of symptoms was 6 years old. Seven of the 11 children had genetic tests, which were positive for STK11 gene mutation. Among the 10 children presenting with gastrointestinal complications, 8 were operated on, 6 had at least 1 small bowel resection, and 4 had repeat surgery for recurrent intussusceptions. In case of complications leading to a surgical procedure, we performed intraoperative enteroscopy to remove all large polyps. To prevent any polyposis complications, we suggest a complete check-up of polyposis topography with some of the new endoscopic tools, either double-balloon endoscopy or videocapsule endoscopy.

CONCLUSIONS

Children with PJS have a high risk of numerous laparotomies due to polyps' complications. Therefore, a screening of intestinal polyposis by videocapsule endoscopy is recommended, as well as a screening of the most frequent sites of cancers for the patient's whole life. During any abdominal procedure, they should have an intraoperative endoscopy, this management allowing an increased time interval between 2 laparotomies.

Recent progress in clinical applications of capsule endoscopy

Capsule endoscopy has been widely used since it was approved by the Food & Drug Administration in the USA in 2001. It plays an important role in the investigation of obscure gastrointestinal bleeding, Crohn's disease and complications of coeliac disease, and surveillance of polyposis syndromes in adults. Despite a lag in its use in paediatrics, capsule endoscopy offers an accurate and effective means of investigating the small bowel in children. It has opened up new horizons and provided a noninvasive approach to identify occult lesions in the small bowel. This article reviews the recent advance in clinical applications of capsule endoscopy.

Capsule endoscopy in pediatric patients

Wireless capsule endoscope (WCE) for the investigation of the small bowel is an approved technique both in adults and children (more than 10 years old). The present review provides data on the indications, diagnostic yield, adverse events and limitations of the WCE technique in children and tries to predict the future of WCE usage in this population of patients.

Capsule endoscopy may reclassify pediatric inflammatory bowel disease: a historical analysis

BACKGROUND

Data are sparse on the role of capsule endoscopy (CE) in classifying disease type, affecting patient management, and altering health outcomes in pediatric inflammatory bowel disease (IBD). In a retrospective cohort analysis of symptomatic pediatric patients with previously diagnosed IBD, we evaluated whether data from CE would result in the recognition of new disease locations that could alter the current diagnosis and provide information to better manage the underlying disease.

PATIENTS AND METHODS

CE evaluation was performed in 28 patients an average of 4.2 +/- 3 years after original IBD diagnosis, and was prompted by exacerbation of underlying disease, growth failure/weight loss, or presurgical evaluation. Of the patients, 7 of 28 (25%) were originally diagnosed as having ulcerative colitis (UC) (n = 5) or indeterminate colitis (IC) (n = 2), while 21 of 28 (75%) were diagnosed as having Crohn disease (CD).

RESULTS

Following CE examination, 4 of 5 patients with UC and 1 of 2 patients with IC (total 5 of 7, 71% of UC/IC patients) had their disease reclassified to CD based upon newly diagnosed small bowel mucosal lesions. Moreover, 13 of 21 (62%) patients with CD were found at the time of CE examination to have more extensive small bowel disease with newly diagnosed jejunal disease found in 12 of 13 (92%) patients. In the 5 newly diagnosed patients with CD, all of them had therapeutic changes made. One capsule retention occurred.

CONCLUSIONS

Capsule endoscopy may lead to reclassification of IBD from UC/ IC to definitive CD. In addition, previously diagnosed patients with CD may be found to have a more significant burden of small bowel disease. Taken together, this information may facilitate more targeted and effective therapies and potentially lead to better patient outcomes.

Wireless capsule endoscopy: indications, limitations, and future challenges

Wireless capsule endoscopy is one of the recent inventions that has made an impact in the diagnostic work-up of gastrointestinal diseases, mainly in small intestinal pathology, the part of the gut that cannot be totally visualized by upper and lower gastrointestinal endoscopy. Since the first report documenting the use of capsule endoscopy, many adult clinical trials have taken place. Although the Food and Drug Administration approved the use of the capsule in children (ages 10-18 years) in October 2003, few small clinical trials exploring the diagnostic yield of capsule endoscopy in pediatric populations have been published.

Capsule endoscopy in the evaluation of gastrointestinal disease

PURPOSE OF REVIEW

The small bowel has been a technically difficult area to examine. Indirect modalities such as barium follow-through have the disadvantage of attendant radiation exposure. Capsule endoscopy, a novel wireless method of investigation of the small bowel, has acquired an important role in both adult and paediatric medicine.

RECENT FINDINGS

The clinical utility of capsule endoscopy has rapidly expanded since its approval by the Food & Drug Administration in the USA in 2001. It has developed an established role in adults, in the investigation of obscure gastrointestinal bleeding, small bowel Crohn's disease, complications of coeliac disease and surveillance of polyposis syndromes. Despite a lag in its use in paediatrics, capsule endoscopy offers an accurate and effective means of investigating the small bowel in children. It has opened up new horizons and permitted a noninvasive approach to identifying occult lesions in the small bowel of children when conventional imaging has been unhelpful.

SUMMARY

This review appraises the current literature to define the clinical indications and practical aspects of capsule endoscopy that are of interest to the paediatrician.

Clinical application of wireless capsule endoscopy in pediatric patients for suspected small bowel diseases

Capsule endoscopy (CE) has been demonstrated to be safe and well tolerated in adults with suspicion of small intestinal diseases with negative results of gastroscopy and colonoscopy. However, its value in pediatric patients has not yet been well studied. This study aimed to evaluate the results and safety of CE in pediatric patients with suspicion of small bowel disorders. There were 16 consecutive children and adolescents (12 boys, 4 girls) and 15 adults (9 men, 6 women) referred to us for suspected small bowel diseases from August 2002 to September 2005. Among the pediatrics, six patients were less than 10 years old. Technique for capsule placement, gastric transit time, small bowel transit time, excretion time of capsule endoscopy, capsule findings, and complications were recorded. All 16 pediatric patients described that the capsule was easy to swallow except for three children. Finally we delivered the capsule under gastroscopy with overtube for these three children. No capsule retention occurred during our study. Median recording time was 7 h 44 min (range 6 h 51 min-9 h 11 min). Median gastric transit time was 83.5 min (range 4-296 min). Median small bowel transit time was 270 min (range 142-484 min). Median excretion time of capsule was 33.9 h (range 12-96 h). There was no significant difference in excretion time of capsule, gastric transit time and small bowel transit time between pediatric patients and adult patients (P > 0.05). CE was positive in 12 patients, including Crohn's disease (4), hemangioma (2), angiodysplasia (2), Meckel diverticulum (1), polyp (1), aphthous ulcer in ascending colon (1), and cobblestone appearance of ileal mucosa. CE has been performed safely in a small series of pediatric patients after ingestion or endoscopic placement of the capsule. The high yield of abnormal findings was comparable to those of adult patients.

Pediatric gastrointestinal vascular anomalies: imaging and therapeutic issues

Vascular anomalies are an uncommon cause of gastrointestinal bleeding. Imaging plays an important role in the diagnosis and therapy of these anomalies. Accurate diagnosis, classification and awareness of associated syndromes are mandatory for applying the appropriate management. In this pictorial essay we review the classification, imaging characteristics and treatment of gastrointestinal vascular anomalies.