Diagnostic and therapeutic utility of double-balloon enteroscopy in children

Guidelines for endoscopic diagnosis and treatment of inflammatory bowel diseases

In recent years, we have seen a considerable increase in the number of patients with inflammatory bowel diseases of unknown etiology, including both Crohn's disease and ulcerative colitis. Inflammatory bowel diseases can cause intestinal lesions throughout the gastrointestinal tract, necessitating gastrointestinal endoscopy for examining all relevant aspects, especially lesion characteristics, for differential diagnosis and histological diagnosis, to select the appropriate treatment options, determine treatment effectiveness, etc. Specific guidelines are necessary to ensure that endoscopy can be performed in a safe and more tailored and efficient manner, especially since gastrointestinal endoscopy, including enteroscopy, is a common procedure worldwide, including in Japan. Within this context, the Japan Gastroenterological Endoscopy Society has formulated the "Guidelines for the Endoscopic Diagnosis and Treatment of Inflammatory Bowel Diseases" to provide detailed guidelines regarding esophagogastroduodenoscopy, enteroscopy, and colonoscopy procedures for definitive diagnosis, as well as determination of treatment effectiveness in clinical cases of inflammatory bowel diseases.

Deep enteroscopy in children: techniques, applications, and future directions

Deep enteroscopy, encompassing push enteroscopy (PE) and balloon-assisted enteroscopy (BAE), has revolutionized the diagnosis and treatment of pediatric small bowel disorders. This review examines the evolving role of these techniques in managing conditions such as obscure gastrointestinal bleeding, Crohn's disease, polyposis syndromes, strictures, and small bowel tumors. While PE is effective for both diagnostic and therapeutic interventions in the proximal small bowel, its limited insertion depth has driven the adoption of BAE techniques. These include single-balloon enteroscopy (SBE) and double-balloon enteroscopy (DBE), which provide deeper and more comprehensive access. Both BAE modalities offer greater insertion depth and stability, enabling advanced therapeutic interventions such as polypectomy, stricture dilation, and hemostasis. Pediatric-specific data demonstrate high diagnostic yields for BAE, with comparable outcomes between SBE and DBE. These techniques have proven safe across diverse indications, though younger children may experience slightly higher complication rates due to anatomical considerations. Despite these advancements, challenges persist, including a limited evidence base in pediatrics, barriers to training, and the need for standardized protocols. Additionally, emerging innovations such as artificial intelligence offer opportunities to enhance diagnostic accuracy and procedural efficiency. Comparative analyses of PE, BAE, and capsule endoscopy are necessary to refine procedural selection and optimize outcomes in pediatric patients. Furthermore, structured pediatric training programs and simulation-based learning could address competency gaps, ensuring safe and effective application of these techniques. By addressing current research gaps, embracing technological advancements, and tailoring approaches to pediatric populations, deep enteroscopy can continue to transform the management of small bowel disorders in children.

Review on Advances in Pediatric Endoscopy in the Management of Inflammatory Bowel Disease

Over the past decades, an increased importance has been given to gastrointestinal (GI) endoscopy in the management of children with inflammatory bowel diseases (IBD), considering that mucosal healing has been recognized as the optimal endpoint in the treat-to-target paradigm. The recent advances in technology and anesthesia have facilitated the comprehensive evaluation of the GI tract. In this review, we will discuss the role of ileocolonoscopy, upper GI endoscopy, and device-assisted enteroscopy in the work-up and management of pediatric Crohn's disease (CD) and ulcerative colitis, with particular attention on non-invasive endoscopic techniques, such as wireless capsule endoscopy. We will also analyze the most commonly used endoscopic scoring systems, including small bowel scoring systems and endoscopic recurrence grading of neo-terminal ileum CD. Moreover, we will focus on the endoscopic management of complications, such as strictures, that commonly require surgery. Lastly, we will discuss cancer surveillance in children with IBD, with particular consideration of the role of high-definition endoscopic equipment and chromoendoscopy in dysplasia detection rates.

Clinical Guidelines for Diagnosis and Management of Peutz-Jeghers Syndrome in Children and Adults

BACKGROUND

Peutz-Jeghers syndrome (PJS) is a rare disease characterized by the presence of hamartomatous polyposis throughout the gastrointestinal tract, except for the esophagus, along with characteristic mucocutaneous pigmentation. It is caused by germline pathogenic variants of the STK11 gene, which exhibit an autosomal dominant mode of inheritance. Some patients with PJS develop gastrointestinal lesions in childhood and require continuous medical care until adulthood and sometimes have serious complications that significantly reduce their quality of life. Hamartomatous polyps in the small bowel may cause bleeding, intestinal obstruction, and intussusception. Novel diagnostic and therapeutic endoscopic procedures such as small-bowel capsule endoscopy and balloon-assisted enteroscopy have been developed in recent years.

SUMMARY

Under these circumstances, there is growing concern about the management of PJS in Japan, and there are no practice guidelines available. To address this situation, the guideline committee was organized by the Research Group on Rare and Intractable Diseases granted by the Ministry of Health, Labour and Welfare with specialists from multiple academic societies. The present clinical guidelines explain the principles in the diagnosis and management of PJS together with four clinical questions and corresponding recommendations based on a careful review of the evidence and involved incorporating the concept of the Grading of Recommendations Assessment, Development and Evaluation system.

KEY MESSAGES

Herein, we present the English version of the clinical practice guidelines of PJS to promote seamless implementation of accurate diagnosis and appropriate management of pediatric, adolescent, and adult patients with PJS.

Pediatric Magnet Ingestion, Diagnosis, Management, and Prevention: A European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) Position Paper

Magnet ingestion is a special category of foreign body ingestion associated with high levels of morbidity and mortality worldwide, particularly if it is associated with staggered ingestion of multiple magnets or with simultaneous ingestion of other metallic foreign bodies, especially button batteries. A special category of magnet ingestion is the ingestion of earth magnets, which have higher levels of magnetism and therefore, potentially, carries a worse outcome. Legislative bodies, scientific Societies and community-led initiatives have been implemented worldwide with the aim of mitigating the effects of this growing, yet avoidable potential medical emergency. A scoping literature review summarized epidemiology, diagnosis, management, and prevention, including an algorithm for the diagnosis and management of magnet ingestion is presented and compared to previously published reviews and position papers (North American Society of Pediatric Gastroenterology, Hepatology and Nutrition, National Poison Center, Royal College of Emergency Medicine). The main emphasis of the algorithm is on identification of staggered/multiple magnet ingestion, and early joint gastroenterology and surgical consultation and management.

Diagnostic yield and technical performance of the novel motorized spiral enteroscopy compared with single-balloon enteroscopy in suspected Crohn's disease: a prospective study (with video)

BACKGROUND AND AIMS

Both single-balloon enteroscopy (SBE) and the novel motorized spiral enteroscopy (NMSE) are effective techniques for device-assisted enteroscopy (DAE). To date, no study has prospectively compared both modalities in suspected Crohn's disease (CD).

METHODS

Patients with suspected CD undergoing either SBE or NMSE between March 2021 and December 2021 in a high-volume tertiary center were prospectively compared for technical success (ability to reach the lesion), diagnostic yield, depth of maximal insertion (DMI), procedure time, and total enteroscopy rates.

RESULTS

One hundred seventy-seven patients (37.2% female; aged 7-75 years) with suspected CD underwent 201 DAEs. Technical success was 83% (SBE 81.5% vs NMSE 87.3%, P = .61) and impacted subsequent management in 92% (SBE 88.5% vs NMSE 97.8%, P = .2). Technical success with antegrade NMSE was significantly higher (81.4%) than antegrade SBE (33.3%, P = .007) for lesions in the proximal ileum and beyond. There was no significant difference in the diagnostic yield (SBE 80.8% vs NMSE 83.6%, P = .65). Median procedure time was significantly lower in both antegrade (NMSE, 40 minutes [range, 10-75]; SBE, 60 minutes [range, 20-180]; P < .0001) and retrograde (NMSE, 25 minutes [range, 20-60]; SBE, 60 minutes [range, 20-180]; P < .0001) NMSE. Median DMI was higher with antegrade NMSE (NMSE, 400 cm [range, 70-600]; SBE, 180 cm [range, 60-430]; P < .0001). The total enteroscopy rate was higher with NMSE (37% vs .7% with SBE, P < .0001). All adverse events were mild.

CONCLUSIONS

Both NMSE and SBE are safe and effective for small-bowel evaluation in suspected CD. NMSE is superior to SBE with regard to deeper small-bowel evaluation with complete small-bowel coverage and shorter procedure time.

Small bowel endoscopy for children: Collaboration of capsule endoscopy and device-assisted enteroscopy

Capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE) have become indispensable techniques for the diagnosis and management of small bowel disease in both adult and pediatric cases. However, relevant differences exist in the indications between these cohorts, with body weight and age having particular relevance in decisions for the latter. Both CE and BAE are designed for adult physique and they were not widely used among children. In addition, the types of small intestinal diseases differ between adults and children, and consequently, the indications also differ between them. This review focuses on the issues relevant to pediatric cases and describes the practical application of endoscopy in clinical practice. In conclusion, although there are age and weight restrictions, both CE and BAE are safe and useful devices for use in children, and their indications for use in children are likely to expand in the future.

[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.

Protein-losing enteropathy caused by a jejunal ulcer after an internal hernia in Petersen's space: A case report

BACKGROUND

The incidence of internal hernias has recently increased in concordance with the popularization of laparoscopic surgery. Of particular concern are internal hernias occurring in Petersen's space, a space that is surgically created after treatment for gastric cancer and obesity. These hernias cause devastating sequelae, such as massive intestinal necrosis, fatal Roux limb necrosis, and superior mesenteric vein thrombus. In addition, protein-losing enteropathy (PLE) is a rare syndrome involving gastrointestinal protein loss, although its relationship with internal Petersen’s hernias remains unknown.

CASE SUMMARY

A 75-year-old man with a history of laparotomy for early gastric cancer developed Petersen's hernia 1 year and 5 mo after surgery. He was successfully treated by reducing the incarcerated small intestine and closure of Petersen’s defect without resection of the small intestine. Approximately 3 mo after his surgery for Petersen’s hernia, he developed bilateral leg edema and hypoalbuminemia. He was diagnosed with PLE with an alpha-1 antitrypsin clearance of 733 mL/24 h. Double-balloon enteroscopy revealed extensive jejunal ulceration as the etiology, and it facilitated minimum bowel resection. Pathological analysis showed extensive jejunal ulceration and collagen hyperplasia with nonspecific inflammation of all layers without lymphangiectasia, lymphoma, or vascular abnormalities. His postoperative course was unremarkable, and his bilateral leg edema and hypoalbuminemia improved after 1 mo. There was no relapse over the 5-year follow-up period.

CONCLUSION

PLE and extensive jejunal ulceration may occur after Petersen's hernia. Double-balloon enteroscopy helps identify and resect these lesions.

Single balloon enteroscopy in children for evaluation of small bowel diseases in children: A large, tertiary center study

BACKGROUND AND AIM

Device assisted enteroscopy is the cornerstone for small bowel evaluation. However, the data are limited in pediatric patients. In this study, we aim to evaluate the safety and utility of single balloon enteroscopy (SBE) in children.

METHODS

The data of children (≤18-years) who underwent SBE from November 2010 to July 2020 was analyzed, retrospectively. The safety and diagnostic yield of SBE were assessed.

RESULTS

189-SBE procedures (males 117, mean age 15.1 ± 2.76, range 3-18 years) were performed in 174-children. The indications for SBE were chronic abdominal pain in 119 (68.4%), gastrointestinal bleed 17 (9.8%), chronic diarrhea 17 (9.8%) and vomiting 13 (7.5%). Antegrade, retrograde and combined SBE were performed in 98 (51.8%), 77 (40.7%), 7 (3.7%) children, respectively. The mean length of small bowel intubation in antegrade and retrograde SBE groups were 168.9 ± 58.6 cm and 120.7 ± 52.1 cm, respectively. Overall, a positive finding was seen in 117 (67.2%) cases. The most common findings were ileal and jejunal ulcers with or without strictures in 76 (64.9%) children. A total of 18 therapeutic enteroscopic procedures were performed. There were no major adverse events.

CONCLUSION

SBE is a safe and effective procedure for the evaluation and management of small bowel diseases in children.

Endoscopic Evaluation and Therapeutic Considerations of Small Bowel Crohn’s Disease

Small bowel evaluation is warranted in all newly diagnosed cases of Crohn’s disease (CD) as small bowel is involved in two-thirds of CD patients at diagnosis and the involvement can be discontinuous. Endoscopic evaluation of the small bowel in suspected or established CD can be done by video capsule endoscopy (VCE), device assisted enteroscopy (DAE) (which includes single and double balloon enteroscopy, novel motorized spiral enteroscopy (NMSE) and balloon guided endoscopy (BGE)) and intra-operative enteroscopy (IOE). In suspected CD with a negative ileo-colonoscopy, VCE is the preferred initial diagnostic modality in the absence of obstructive symptoms or known stenosis. VCE should be preceded by cross-sectional imaging or patency capsule testing if obstruction is suspected given with high retention risk. In established cases, small bowel cross-sectional imaging (magnetic resonance or computed tomography enterography) is preferred over VCE as it can assess transmural and extra-luminal involvement. VCE is indicated subsequently if necessary to assess disease extent, unexplained symptoms (e.g., anemia, malnutrition) or mucosal healing. Pan-enteric capsule endoscopy (PCE) and the use of artificial intelligence are the recent developments with VCE. DAE with small bowel biopsy can provide definitive evidence of CD including the extent and severity. A final diagnosis of CD is based on the constellation of clinical, radiologic, histologic and endoscopic features. Newer technologies like NMSE and BGE can help with deeper and faster small bowel evaluation. DAE has also allowed endoscopic treatment of small bowel strictures, small bowel bleeding and retrieval of retained capsule or foreign bodies. Endoscopic balloon dilation (EBD), endoscopic electro-incision, strictureplasty and stenting have shown promising results in CD related small bowel strictures. In conclusion, endoscopic evaluation of the small bowel is rapidly evolving field that has a major role in diagnosis and management of small bowel CD and can alter treatment outcomes in properly selected patients.

High-Tech Diagnostic Methods and Enteroscopic Treatment of Children with Peutz-Jeghers Syndrome

INTRODUCTION

 Peutz-Jeghers syndrome (PJS) is an autosomal dominant hereditary hamartomatous polyposis with predominant localization in the jejunum and ileum and high risk of bowel perforation after traditional polypectomy. The modern enteroscopy is the only possible technique for visualizing and performing intraluminal endoscopic microsurgical manipulations in the deep sections of the small intestine. The study aims to develop an optimal method for the diagnosis and treatment of polyps in children with PJS.

MATERIALS AND METHODS

 During 2015 to 2018 we conducted 30 comprehensive examinations of children with PJS in The Department of Endoscopic Research of the National Medical Research Center for Children's Health. We performed esophagogastroduodenoscopy and colonoscopy with removal of polyps more than 7 mm, then video capsule endoscopy and, guided by this, therapeutic single-balloon enteroscopy. Our technique for removal of polyps is general in all parts: (1) creating a "resistant pillow"; (2) electroexcision of polyp; (3) clipping the removal site.

RESULTS

 Successfully performed electroexcision of polyps, which were located in the deep parts of the small intestine at a distance of 30 segments (one segment is 10 cm), reached a diameter of 2.5 cm, had a long pedicle. The postoperative period was uneventful.

CONCLUSION

 We have developed an optimal method of diagnostic and therapeutic measures, the observance of which allows us to avoid delayed perforations of the small intestine in the area of polypectomy in the postoperative period in children with PJS. Thanks to this technique, modern enteroscopy is becoming the only possible alternative to bowel resection in children with PJS.

Enteroscopy in children and adults with inflammatory bowel disease

Inflammatory bowel disease (IBD) includes Crohn's disease (CD), ulcerative colitis and unclassified entities. CD commonly involves the terminal ileum and colon but at the time of diagnosis it can be confined to the small bowel (SB) in about 30% of the patients, especially in the young ones. Management of isolated SB-CD can be challenging and objective evaluation of the SB mucosa is essential in differentiating CD from other enteropathies to achieve therapeutic decisions and to plan the follow-up. The introduction of cross-sectional imaging techniques and capsule endoscopy (CE) have significantly expanded the ability to diagnose SB diseases providing a non-invasive test for the visualization of the entire SB mucosa. The main CE limitations are the low specificity, the lack of therapeutic capabilities and the impossibility to take biopsies. Device assisted enteroscopy (DAE) enables histological confirmation when traditional endoscopy, capsule endoscopy and cross-sectional imaging are inconclusive and also allows therapeutic interventions such as balloon stricture dilation, intralesional steroid injection, capsule retrieval and more recently stent insertion. In the current review we will discuss technical aspect, indications and safety profile of DAE in children and adults with IBD.

The Safety and Feasibility of a New Through-the-scope Balloon-assisted Enteroscopy in Children

OBJECTIVES

Small bowel involvement in Crohn disease (CD) is clinically important for diagnosis and treatment. Single and double-balloon enteroscopy have already become important diagnostic tools in such cases. The on-demand NaviAid AB device enables deep advancement into the small bowel, using an anterograde or retrograde approach. In adults, this procedure is feasible, safe, and rapid. This work aimed to assess the safety and feasibility of NaviAid AB enteroscopy in pediatric patients.

METHODS

Single-center, prospective study using the through-the-scope balloon-assisted-enteroscopy (TTS-BAE) NaviAid AB device for the evaluation of the small bowel in children with suspected or known inflammatory bowel disease (IBD). The system consists of a single-use balloon catheter inserted through the instrument channel of a standard colonoscope. It consists of an inflation/deflation system (NaviAid SPARK), which is inflated to anchoring pressure. The repetitive push-pull technique enables the advancement of the colonoscope along the small intestine.

RESULTS

Fifty analyzed endoscopic procedures (30 retrograde, 20 anterograde) were performed in 34 children (52.9% boys, mean age 13.7 years). Average maximal depth of insertion (MDI), advancement depth using the NaviAid AB and average total procedure time were 138 cm (range 100-190 cm), 81 cm (range 40-120 cm), and 12.8 minutes (range 7.3-19.0 minutes), respectively, for the anterograde approach and 143 cm (range 100-170 cm), 64 cm (range 20-95 cm), and 21.9 minutes (range 13.9-32.0 minutes), respectively, for the retrograde approach. No serious or device-related adverse events were reported.

CONCLUSIONS

NaviAid AB enteroscopy in children is safe, feasible, and enables assessment of the small intestine in a short period of time.

Arteriovenous malformation that caused prolapse of the colon and was treated surgically in an infant: a case report

Background

Various terms have been used to describe vascular lesions in the intestine, including angiodysplasia, arteriovenous malformation, and telangiectasia. Such lesions are common in adults and are typified by angiodysplasia, a type of arteriovenous malformation. In contrast, these lesions are rarely seen in the pediatric population. Angiodysplasia may cause gastrointestinal bleeding, which is sometimes an indication for treatment. Considering the high rate of recurrence after surgical treatment, conservative treatments are mainly chosen. We herein report an extremely rare case of a prolapsed colon due to an arteriovenous malformation successfully treated by resection in a 1-year-old girl. We also highlight the differences between pediatric and adult cases.

Case presentation

A girl developed bloody stools at 7 months of age. She visited another hospital at 1 year of age because of continuing moderate hematochezia and recent onset of rectal prolapse. Colonoscopy showed a protruding lesion located 15 cm from the anal verge, suggesting a submucosal vascular abnormality. Contrast-enhanced computed tomography and magnetic resonance imaging at our hospital revealed the localized lesion with dilated blood vessels in part of the sigmoid colon; no other lesions were present in the gastrointestinal tract. Laparoscopic-assisted sigmoidectomy was performed. A subserosal vascular lesion was visualized and resected using end-to-end anastomosis. Pathologic examination of the 2.2 × 2.7-cm segment revealed several abnormally enlarged and ectatic blood vessels in the submucosa extending into the subserosa. The lesion was diagnosed as an arteriovenous malformation. The patient had a good clinical course without recurrence at the 2-year follow-up.

Conclusions

An arteriovenous malformation in the sigmoid colon may rarely cause intussusception and prolapse of the colon. Complete resection is a radical and potentially effective treatment. Computed tomography and colonoscopy were useful for evaluation of the lesion in the present case.

Clinical Safety and Utility of Pediatric Balloon-assisted Enteroscopy: A Multicenter Prospective Study in Japan

OBJECTIVES

The benefit of balloon-assisted enteroscopy (BAE) had been recently documented in pediatric patients, but previous reports are based on single institution experiences. We evaluated the feasibility of pediatric BAE in 8 tertiary referral hospitals throughout Japan.

METHODS

This was a prospective, multi-institutional study. Patients younger than 18 years were enrolled between April 2014 and March 2017 to undergo double-balloon or single-balloon enteroscopy. Data were collected prospectively using a standardized questionnaire.

RESULTS

We enrolled 79 pediatric patients (96 procedures, 70 boys, 26 girls; median age 12.7 years, range 1-17 years). Antegrade (oral-route) BAE was performed in 20 procedures (lowest body weight 12.9 kg, youngest age 3.7 years), and retrograde (anal-route) BAE in 76 (lowest body weight 10.8 kg, youngest age 1.6 years). Severe adverse events were associated with BAE in 2 patients: 1 with hemorrhage due to polypectomy and 1 with pancreatitis after double-balloon endoscopic retrograde cholangioscopy. No intestinal perforation was reported. Procedure duration of oral-route BAE for diagnosis was significantly longer than anal-route for diagnosis (P < 0.001). The overall diagnostic yield for rectal bleeding/positive fecal occult blood test and abdominal pain was 48%. Among 40 patients referred for diagnosis who did not undergo capsule endoscopy, diagnoses were confirmed in 17 (42.5%) patients after BAE.

CONCLUSIONS

This prospective multicenter observational study documents the efficacy of BAE in pediatric patients.

Clinical utility of double-balloon enteroscopy in children: A single-centre experience in South China

AIM

Double-balloon enteroscopy (DBE) is a useful tool for the evaluation and treatment of small bowel disease. Limited clinical data are available regarding the indications, clinical findings and safety associated with the use of DBE in children. The aim of this study is to investigate the utility and safety of DBE in children.

METHODS

A total of 72 DBE procedures were performed on 61 children at the Sixth Affiliated Hospital, Sun Yat-sen University, between 1 April 2013 and 31 December 2017. The clinical data were analysed retrospectively.

RESULTS

DBE was attempted 72 times in 61 children (45 boys and 16 girls) of an age range between 6 and 14 years (mean age: 11.9 years). The most common indication for DBE was occult gastrointestinal bleeding and abdominal pain. The positive rate of abnormal findings was 77.5% (55/72). Most children showed non-specific enteritis and Crohn's disease. Eight children underwent successful therapeutic enteroscopy. No serious complication was observed in any child in this case series.

CONCLUSION

DBE can be a useful diagnostic and therapeutic tool for small bowel disorders in children.

Double-balloon enteroscopy for pediatric patients: Application and feasibility evaluation in a medical center in northern Taiwan

BACKGROUND/PURPOSE

The diagnostic and therapeutic benefits of double-balloon enteroscopy (DBE) in adults are established, but few data are available on pediatric patients. The aim of this study was to evaluate the clinical efficacy and safety of DBE in pediatric patients in Taiwan.

METHODS

From April 2005 to September 2015, DBE procedures performed for diagnosis or therapy of small-bowel disease in children less than 18 years of age at Linkou Chang Gung Memorial Hospital, Taiwan were evaluated. The clinical decision to perform DBE via the oral or anal approach was based on the patient's primary clinical presentation. Data on indications, endoscopic findings, treatment outcome, and complications associated with the procedure were collected and reviewed retrospectively.

RESULT

In total, 20 pediatric patients underwent a total of 29 DBEs due to suspicion of small-bowel disease. Among them, nine patients were evaluated for suspected small-bowel bleeding, six for Peutz-Jeghers syndrome, two for chronic abdominal pain, two for chronic diarrhea, and one for suspected protein-losing enteropathy. After excluding the six Peutz-Jeghers syndrome patients, 9 of the 14 patients (64%) got a positive endoscopic finding and diagnosis in 8 of the 14 patients (57%). DBE resulted in a further therapeutic intervention (endoscopic or surgical) in 50% of the patients (10/20) without serious complications.

CONCLUSION

DBE has a high diagnostic yield and leads to therapeutic interventions in pediatric patients and shows promise for assessment and treating small-intestinal diseases in children in Taiwan.

Enteroscopy in children

INTRODUCTION

Device-assisted enteroscopy is a new endoscopic technique for the evaluation of small bowel in adults and children. Data in pediatric population are limited. This review aims to identify diagnostic and therapeutic benefits of enteroscopy in children.

METHODS

We have analysed paediatric literature on device-assisted enteroscopy focusing on indications, technical aspects and complications, with attention given to adult publications that may be applicable to the paediatric population.

RESULTS

Obscure gastrointestinal bleeding, Crohn's disease and small bowel polyps are the main indications of enteroscopy in children. Device-assisted enteroscopy has high diagnostic yield for the main paediatric indications, but MR-enterography and capsule endoscopy should be used beforehand in diagnostic work-up to better identify candidates for enteroscopy and to improve its diagnostic and therapeutic yield. Major complications are rare and mostly related to therapeutic procedures.

CONCLUSION

Despite limited data in the paediatric population, device-assisted enteroscopy represents a useful and safe endoscopic technique in children. Its use, combined with MR-enterography and capsule endoscopy, allows identification and treatment of many of the small bowel paediatric diseases with a low risk of complications.

Pediatric-onset Chronic Nonspecific Multiple Ulcers of Small Intestine: A Nationwide Survey and Genetic Study in Japan

We performed a Japanese nationwide survey of pediatric-onset chronic nonspecific multiple ulcers of the small intestine between January 2000 and July 2013 in 176 institutions of pediatric surgery or pediatric gastroenterology and clarified the clinical features associated with genetic abnormalities in the Solute Carrier Organic Anion Transporter Family, Member 2A1 (SLCO2A1) gene. A total of 4 cases (3 girls and 1 boy) were diagnosed in this series, which had to be differentiated from Crohn disease, Behçet disease, tuberculosis, or drug-induced enteropathy. Clinical symptoms appeared in infants and accurate diagnosis required several years. Medical therapies for inflammatory bowel disease were administered in all patients; however, 2 of the 4 patients had mutation in the SLCO2A1 gene which are responsible for primary hypertrophic osteoarthopathy, and underwent strictureplasty or ileal resection after long-term follow-up. Pediatric gastroenterologists should include this new entity in the differential diagnosis of small intestinal ulcers and inflammatory bowel disease.

NASPGHAN Capsule Endoscopy Clinical Report

Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.

Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology

There are many causes of gastrointestinal bleeding (GIB) in children, and this condition is not rare, having a reported incidence of 6.4%. Causes vary with age, but show considerable overlap; moreover, while many of the causes in the pediatric population are similar to those in adults, some lesions are unique to children. The diagnostic approach for pediatric GIB includes definition of the etiology, localization of the bleeding site and determination of the severity of bleeding; timely and accurate diagnosis is necessary to reduce morbidity and mortality. To assist medical care providers in the evaluation and management of children with GIB, the "Gastro-Ped Bleed Team" of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) carried out a systematic search on MEDLINE via PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) to identify all articles published in English from January 1990 to 2016; the following key words were used to conduct the electronic search: "upper GIB" and "pediatric" [all fields]; "lower GIB" and "pediatric" [all fields]; "obscure GIB" and "pediatric" [all fields]; "GIB" and "endoscopy" [all fields]; "GIB" and "therapy" [all fields]. The identified publications included articles describing randomized controlled trials, reviews, case reports, cohort studies, case-control studies and observational studies. References from the pertinent articles were also reviewed. This paper expresses a position statement of SIGENP that can have an immediate impact on clinical practice and for which sufficient evidence is not available in literature. The experts participating in this effort were selected according to their expertise and professional qualifications.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

Indications for gastrointestinal endoscopy in childhood

Endoscopic examination of the gastrointestinal tract (GIT) for diagnostics and therapy in children has evolved markedly over the last 20 or so years and is now usually undertaken by paediatric endoscopists. Updated diagnostic and management guidelines for common disorders including coeliac disease, gastro-oesophageal reflux disease, eosinophilic oesophagitis and inflammatory bowel disease highlight the central role of endoscopy. Therapeutic endoscopic approaches are also now widely available and further broaden the referral spectrum to include treatment of GIT bleeding, gastrostomy insertion, dilation of strictures and polypectomy. Lastly, the advent of newer technologies allows the examination of hitherto inaccessible areas of the GIT such as the mid-small bowel by wireless capsule video-endoscopy and enteroscopy. We summarise recent current practice and clinical guidelines, focussing on the key indications for referrals that are likely to require endoscopic assessment.

Complications in pediatric endoscopy

The experience of the "endoscopic community" in pediatric patients is limited, but during recent years increased skills of the endoscopists and technological improvements lead to a standardization of pediatric endoscopy and the development of specialized pediatric endoscopy unit. Adverse events related to diagnostic and therapeutic endoscopy in children are usually rare. Diagnosis, prevention and treatment of complications in pediatric endoscopy is crucial when dealing with benign diseases in children. The complication rate of diagnostic EGD and colonoscopy in children are extremely low. Therapeutic procedures have obviously an increased rate of adverse events. Esophageal dilations are the most common indication for endoscopic therapy in children and can lead to perforations which requires prompt diagnosis and management. Complications of ERCP in pediatric age are similar to those reported in adults. The experience in pediatric emergency endoscopy (mainly foreign body removal) is consolidated and related adverse events extremely rare. Sedation of children during endoscopy maybe needs further evaluation and standardization, to reduce the rate of specific complications.

Double-balloon Enteroscopy for Pediatric Patients: Evaluation of Safety and Efficacy in 257 Cases

OBJECTIVES

The safety and efficacy of double-balloon enteroscopy (DBE) in pediatric patients has not been well documented. We aimed to evaluate the clinical efficacy and safety of DBE in children, especially those under 10.

METHODS

We retrospectively analyzed our database of DBE procedures performed between September 2000 and September 2013. Procedures performed in pediatric patients (under 18) were selected from a total of 3980, including double-balloon endoscopic retrograde cholangioscopy (DBERC).

RESULTS

Two hundred fifty-seven DBE procedures were performed in 117 pediatric patients (median age 12.5 years). Antegrade (oral-route) DBE was performed in 166 procedures including 104 DBERC procedures (lowest body weight 13.5 kg, youngest age 3 years), and retrograde (anal-route) DBE in 91 (lowest body weight 12.0 kg, youngest age 2 years). The overall diagnostic yield for obscure gastrointestinal bleeding and abdominal pain was 58.8%. The purpose of DBERC was achieved in 76.9% of procedures. The overall complication rate in our series was 5.4% (1.9% with the DBERC cases removed); in patients under 10, it was 10.4% (7/67). No severe complications associated with enteroscope insertion and sedation were observed. Serum amylase levels tended to be elevated in patients who underwent oral-route DBE.

CONCLUSIONS

DBE is safe and feasible for diagnostic evaluation of small bowel disorders in pediatric patients, even those younger than 10 years. Special attention for possible complications must, however, be paid during therapeutic DBE procedures, including DBERC, especially for patients under 10.

Comparison of Diagnostic Accuracy and Concordance of Video Capsule Endoscopy and Double Balloon Enteroscopy in Children

OBJECTIVES

To compare the diagnostic yield, sensitivity, and specificity of video capsule endoscopy (VCE) with double balloon enteroscopy (DBE), including comparison with histological findings as well as degree of concordance of the studies.

METHODS

Retrospective review of pediatric patients who had DBE following VCE at a single center from 2006 to 2013. VCEs were interpreted by 1 of 4 pediatric gastroenterologists and DBEs were performed by a single endoscopist.

RESULTS

Thirty-six patients ranging from 5 to 20 years had DBE following VCE. There were positive findings in 32 (88.8%) of VCE and 21 (58.3%) of DBE. Significant histological findings were identified in 16 patients (44.4%). When comparing VCE with DBE findings, VCE had a sensitivity of 95% and specificity of 20%. Overall concordance between VCE and DBE findings was weak with calculated kappa index of 0.1702; however, this varied widely by indication. VCE had sensitivity 100% and specificity 20% for detecting histologically significant lesions. DBE had sensitivity of 87% and specificity of 65%.

CONCLUSIONS

This is the first pediatric study to evaluate diagnostic accuracy and concordance of VCE and DBE and to compare both to histological findings. Our study supports the high diagnostic utility of both the studies. VCE is highly sensitive with an excellent negative predictive value both for DBE findings and for histological findings; however, the utility of VCE is limited by low specificity. Sensitivity and specificity of DBE for detecting histologically significant findings were good. Overall agreement between VCE and DBE is low but varies by indication for the study. These results support the use of VCE and DBE as complementary studies.

Informed Consent for Pediatric Endoscopy

Informed consent and refusal for pediatric procedures involves a process in which the provider, child, and parents/guardians participate. In pediatric gastroenterology, many procedures are considered elective and the process generally begins with an office visit and ends with the signing of the consent document. If the process is emergent then this occurs more expeditiously and a formal consent may not be required. Information about the procedure should be shared in a way that allows a decision-making process to occur for both the parent/guardian and the child, if of assenting age.

Advances in Pediatric Small Bowel Imaging

Technological advances for visualizing the small bowel have significantly grown over the past few decades. Balloon-assisted enteroscopy has come to the forefront of these innovations, and has been found to be safe and effective in children with small bowel ailments. The expanding body of research into balloon-assisted enteroscopy will continue to refine the current knowledge base of this technique, along with a growing assessment of the long-term benefits of such interventions.

Lower Gastrointestinal Bleeding in Children

This article provides an overview of the evaluation and management of lower gastrointestinal bleeding (LGIB) in children. The common etiologies at different ages are reviewed. Conditions with endoscopic importance for diagnosis or therapy include solitary rectal ulcer syndrome, polyps, vascular lesions, and colonic inflammation and ulceration. Diagnostic modalities for identifying causes of LGIB in children include endoscopy and colonoscopy, cross-sectional and nuclear medicine imaging, video capsule endoscopy, and enteroscopy. Pre-endoscopic preparation and decision-making unique to pediatrics is highlighted. The authors conclude with a summary of current and emerging therapeutic hemostatic techniques that can be used in pediatric patients.

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

Wireless capsule endoscopy of the small intestine in children

Wireless capsule endoscopy (CE) for the diagnosis of small-bowel disease has been in clinical use for more than a decade, and is no longer an emerging technology, but rather one that has reached fruition. This noninvasive technology has been readily embraced by both physicians and patients. Used in the diagnosis of inflammatory bowel disease, for locating sources of obscure gastrointestinal bleeding, and for assessing small-bowel polyp burden in polyposis syndromes as well as for less common indications, CE has transformed the diagnostic algorithms of small-bowel investigations. Although already in widespread use, the technology incorporated into the various CE platforms continues to improve and expand. Here, we briefly review the indications, limitations, and advances in video capsule technology, with an emphasis on its use in pediatrics.