First successful antegrade single-balloon enteroscopy in a 3-year-old with occult GI bleeding

[Expert consensus on clinical application management of enteroscopy in children]

Small bowel disease is one of the difficulties in the diagnosis and treatment of digestive system diseases, and limited examination techniques seriously restrict the diagnosis and treatment level of digestive tract diseases in children. With the wide clinical application of enteroscopy in pediatrics and the optimization of enteroscopy equipment and accessories, enteroscopy technique provides a new method for the diagnosis and treatment of pediatric digestive tract diseases, but there are still many issues and challenges in the standardization of clinical operation and endoscopic treatment. In order to standardize the diagnosis and treatment techniques for enteroscopy in children and improve the diagnosis and treatment level of small bowel disease, the Subspecialty Group of Gastroenterology, the Society of Pediatrics, Chinese Medical Association organized experts to fully discuss and formulate the expert consensus on the clinical application management of enteroscopy in children, with reference to the latest advances in the application of enteroscopy in children.

Capsule endoscopy followed by single balloon enteroscopy in children with obscure gastrointestinal bleeding: a combined approach

BACKGROUND

This prospective single-centre study aims to evaluate a new diagnostic algorithm using capsule endoscopy, colon capsule endoscopy and single-balloon enteroscopy in the work-up of obscure gastrointestinal bleeding in children.

METHODS

The usefulness of a new diagnostic algorithm was assessed comparing the clinically relevant findings revealed by each technique, and evaluating the clinical outcomes during the follow-up.

RESULTS

A total of 22 paediatric patients were evaluated (14 male; mean age 12.5 years ± 3.9). Capsule endoscopies were positive in 14 (63.6%), suspicious in 5 (22.7%) and negative in 3 (13.6%). A second look with colon capsule identified new lesions in 2/3 (67%) of previous negative cases. Enteroscopies were able to reach the positive and suspicious findings in all but 2, in which an intraoperative enteroscopy was needed. This combined approach showed positive findings in 21/22 of cases with a diagnostic yield of 95%. Eighteen patients (82%) had a complete resolution after therapy. One patient resolved his symptoms spontaneously. Despite diagnosis, in three patients (13.6%) the gastrointestinal bleeding was not resolved after therapy.

CONCLUSION

This algorithm achieves optimal levels of diagnostic yield (95%) and therapeutic outcome (82%). This approach deserves to be studied in a larger multicentre cohort of patients and for a longer follow-up period.

Small bowel endoscopy in children

Endoscopic investigation of small bowel pathology in children has historically been difficult due to location, length and tortuosity of the small bowel. Recently, video capsule endoscopy and balloon-assisted enteroscopy techniques have evolved as new diagnostic tools and are increasingly used in the paediatric population. In this review the current literature is appraised to define the clinical indications and practical aspects of capsule endoscopy and balloon-assisted enteroscopy in children.

Out-of-reach obscure bleeding: single-balloon enteroscopy to diagnose and treat varices in hepaticojejunostomy after pediatric liver transplant

Obscure gastrointestinal (GI) bleeding is defined as bleeding from the GI tract that persists or recurs, with no obvious etiology, after esophagogastroduodenoscopy (EGD), colonoscopy, and radiologic evaluation of the small bowel. We present the case of a 17-yr-old girl who for two years had been suffering from recurrent episodes of melena and/or enterorrhagia. Fifteen yr earlier she had undergone a split-liver transplant with Roux-en-Y biliary reconstruction. A series of endoscopic and radiologic investigations had failed to find the source of the bleeding. Suspecting the presence of ectopic varices, we decided to perform single-balloon enteroscopy (SBE). We observed and aspirated a large amount of fresh red blood in the afferent loop until we found the hepaticojejunostomy. On the edge of the biliary-enteric anastomosis we observed a vascular lesion 5 mm in diameter. Judging this ectopic varix to be the source of bleeding, we placed two endoclips. The second clip placement caused varix rupture with a consequent massive hemorrhage, emergently and successfully treated with cyanoacrylate sclerotherapy. No episodes of rebleeding were observed, and no complications occurred during the entire hospital stay, and after six months of follow-up. This report highlights the importance of afferent loop examination in patients with obscure GI bleeding who have undergone liver transplant with Roux-en-Y biliary reconstruction.

Enteroscopy in children

PURPOSE OF REVIEW

Endoscopic investigation of small bowel disorders in children has historically been difficult due to the length and tortuosity of the organ itself. New technology introduced over the past decade allows minimally invasive, detailed endoscopic evaluation of the small bowel mucosa from the duodenum to the cecum. While understudied in the pediatric population, literature is emerging supporting the use of these techniques and devices in children.

RECENT FINDINGS

Well tolerated and clinically useful capsule endoscopy has been reported a number of times in children, and the indications and potential complications of this procedure are discussed. The limitations of capsule endoscopy, namely inability to biopsy and treat small bowel lesions, have been addressed to some extent by the introduction of balloon enteroscopy, which allows deep intubation of the small bowel, and at times viewing of the entire mucosal surface. Balloon enteroscopy has been safely reported in children as small as 13.1  kg, and has been successfully performed in children with Roux-en-Y anastomoses in the evaluation and therapy of biliary strictures.

SUMMARY

New enteroscopic techniques now allow detailed investigation and therapy of small bowel lesions in a minimally invasive fashion in the pediatric population.

Single-balloon enteroscopy in children: initial experience at a pediatric center

Single-balloon enteroscopy (SBE) allows deep endoscopic access to the jejunum and ileum in adults; however, there are no published series describing the safety of, and indications for, SBE in a pediatric population.Seven pediatric patients (5-17 years) underwent SBE in a 9-month period. Five of 7 procedures achieved the goal. There were no serious complications, and SBE positively affected patient management in 5 of 7 cases.We conclude that SBE is feasible in a pediatric population and can positively affect patient care.