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0016/5107/83/2904-0279$02.00/0GASTROINTESTINAL ENDOSCOPYCopyright 1983 by the American Society for Gastrointestinal Endoscopy

Upper gastrointestinal fiberoptic endoscopyin pediatric patients

Joao c. Prolla, MDA da S. D ie hl , MD

Giovani A. Bemvenuti, MDSabino V. Loguercio, MD

Denise S. Magalhaes, MDThemis R. Silveira, MD

Porto Alegre, Brazil

Upper gastrointestinal f iberendoscopy in pediatric pat ients is done safely andunder local anesthesia in most instances. This study of 47 children confirmed thevalue of fiberendoscopy in establishing the etiology of upper gastrointestinalhemorrhage and the presence of esophageal varices. It also contributedsignificantly to the management of patients with disphagia, pyrosis, epigastricpain, and ingestion of foreign bodies. No significant morbidity was caused.

The clinical usefulness of upper gastrointestinal endoscopy in children has been the subject of somerecent reports. 1- 6 We report our experience and discusssome aspec ts o f t echnique as well as clinical value,especially in pediatric patients with upper gastrointestinal bleeding and abdominal pain.

M AT ER IA LS AN D M ETH OD SForty-seven patients, aged 19 months to 15 years,were seen at the Gastrointestinal Endoscopy Unit at

the Hospital de Clinicas de Porto Alegre, referred bypediatric departments of several hospitals of PortoAlegre area in Brazil, over a 2-year period (July 1979to July 1981). The indications for endoscopy are listedin Table 1.

Preparation consisted of (a) discussion' of the procedure with the patient and parents; (b) fasting for atmost 4 hours in pat ients aged 2 years or less and 8hours for older pat ients; (c) gastr ic lavage with icedsaline solution in bleeding pat ient s; (d) general orpharyngeal anesthesia; (e) in the 40 patients submittedto pharyngeal anesthesia, 4 to 10 mg of diazepam wasadministered intravenously if necessary.

The Olympus GIF-P2 fiberendoscope was used in42 patients, and no difficulty was experienced in passing it. The duodenum was reached in all patients. Theother five patients, aged 12 years or more, were examined with adult-type endoscopes.From the Gastrointestinal Endoscopy Unit at the Hospi ta l deClinicas de Porto Alegre, Porto Alegre, Brazil. Reprint requests:Dr. J. C. Prolia, Caixa Postal 2300, 90000 Porto Alegre, RS, Brazil.VOLUME 29, NO.4, 1983

RESULTSIn 15 pat ients with upper gastrointestinal hemor

rhage the endoscopic examination revealed esophagealvarices in all seven with known portal hypertension;in five, varices were the source of bleeding, and in theother two patients erosive gastritis was the cause ofbleeding (Table 2). Six of the eight patients withoutportal hypertension had the source of bleeding established by endoscopy: erosive gastritis in four, a duodenal bulbar ulcer in one patient, and a gastr ic )J.lcerin one patient. Two patients had a normal endoscopicappearance and the source of bleeding could not beidentified, but both had stopped bleeding for severaldays before endoscopy was done.

In 14 patients (Table 3) endoscopy was done toverify th e presence or absence of esophageal varices.Seven were patients with known portal hypertension;in five patients esophageal var ices were seen. Theother seven patients were bleeding; all seven hadesophageal varices at endoscopy.

In 12 patients with chronic epigastric pain, the endoscopic examination was normal in five with suspected abnormalities seen at the radiologic examination bu t revealed erosive antral gastritis and duodenitis in two of seven pat ients with normal radiologicexaminations.

In six patients with dysphagia, endoscopy revealedesophageal stenosis in four (two had a history ofcaustic ingestion), achalasia in one, and was normal inone patient.In three patients with foreign body ingestion, removal was achieved in two and failed in one.

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Table 1.Indications for upper gastrointestinal endoscopy in 47children.

Table 3.Upper gastrointestinal endoscopy in 14 children withportal hypertension-detection of varices.

Table 2.Upper gastrointestinal endoscopy in 15 children withupper gastrointestinal hemorrhage.

In two patients with frequent vomiting, endoscopywas normal in both.In two patients with pyrosis, endoscopy revealed

moderate and severe esophagitis.

a series of 17 patients, also did no t use general anesthesia. Ament et ai. I needed general anesthesia in 58of 79 patients, bu t they used primari ly adult-typeendoscopes. The availability of pediatric endoscopeshas reduced th e need for general anesthesia to a fewoccasions.In upper gastrointestinal hemorrhage the endoscopic procedure firmly established the cause of bleeding in 13 of 15 instances. I t is noteworthy that two

patients with esophageal varices were bleeding fromerosive gastritis. I t is important to do the examinationvery early in the course of the hemorrhage; endoscopyfailed to reveal the origin of bleeding in two patientswho had stopped bleeding some days prio r to theprocedure.In our series, the patients without portal hypertension were bleeding from erosive gastritis in four (three

with aspirin ingestion and one with leukemic lesions),duodenal ulcer in one, and a gastric ulcer in one patientwith systemic lymphoma. Ament et ai. I establishedth e cause of bleeding in 17 of 21 patients, most ofwhom had peptic ulcers. Later, Cox and Ament3 demonstrated endoscopically the site of upper gastrointestinal hemorrhage in 68 children and adolescents in 28instances, while upper gastrointestinal contrast studieswere positive in 21 instances and angiography in fiveinstances. Even in the f irst 24 hours of life gastrointestinal endoscopy has been used with success in determining the cause of hemorrhage in one patient.5In portal hypertension, endoscopy is very helpful inestablishing the presence of varices in the esophagus.

In our series (Table 3) this was accomplished in 12 of14 patients. In six of these children the radiologicexamination was at best doubtful and was no t done infive of the bleeders.In patients with chronic epigastric pain, endoscopyfrequently complements radiologic findings or revealsunsuspected lesions. In our series, in five patients theradiologic examination ws considered abnormal bu tendoscopy did no t confirm any suspected lesions (four

antral "polyps" and one web). In two patients withoutx-ray abnormality, endoscopy revealed significant mucosal lesions: one case of antral erosive gastritis andone case of severe duodenitis. Tedesco et ai.6reporteda significant number of such patients with peptic ulcers or mucosal lesions missed by radiology. The difficulties of radiologic diagnosis of peptic ulcer in children were well demonstrated by Deckelbaum et ai. 7who, in a retrospective s tudy of 73 patients, found itnecessary to repeat x-ray studies in 25% of the childrento document the ulcers. Obviously, an unknown numbe r of ulcers were missed by radiology and not included in the study.In patients with dysphagia or pyrosis, endoscopy isquite helpful in th e diagnosis of esophagitis and/orstrictures. In our series of six patients with dysphagia,

2o

151276322

47

Varices no tdetected at endoscopy

No. of patients

57

Varices detected at en

doscopy

n Included also in Table 2.

With upper gastrointestinalhemorrhage n

Without upper gastrointestinal hemorrhage

Types of patients

Type of patients Source of bleeding No. ofseen at endoscopy patientsPatients with portal hy- Eosphageal varices 5

pertensionErosive gastritis 2

Patients without portal Erosive gastritis 4hypertension

Gastric ulcer 1Duodenal ulcer 1Cause not established 2

DISCUSSIONWe agree with Tedesco et ai.6 that fiberoptic endoscopy using pediatric instruments is a safe diagnostictool; no significant complications were encountered in

their series of 50 procedures or our 47 procedures. Intheir series, no general anesthesia was used, even inthe eight patients 2 years old or less; they preferedsedation with diazepam. We used general anesthesiain seven patients; in two patients, aged 5, poor cooperation was the basis of this decision but the other fivepatients were less than 2 years old. Cremer et ai.,4 in

Totaln Patients not bleeding.

IndicationUpper gastrointestinal hemorrhageChronic epigastric painPortal hypertension nDysphagiaForeign body ingestionFrequent vomitingPyrosis

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only one had a normal endoscopy. Endoscopy is alsohelpful in the follow-up and monitoring of treatment.REFERENCES

1. Ament ME, Gans SL, Christ ie DL. Experience with esophagogastroduodenoscopy in diagnosis of 79 pediatric patients withhematemesis, melena or chronic abdominal pain (abstract).Gast roen tero logy 1975;68:858.2. Christie DL, Ament ME. Upper gastrointestinal fiberoptic endoscopy in pediatric patients. Gastroenterology 1977;72:1244.3. Cox K, Ament ME. Upper gastrointestinal bleeding in children

and adolescents. Pediatr ics 1979;63:408-13.4. Cremer M, Peeters JP , Emonts P, et al. Fiberendoscopy of thegastrointestinal tract in chi ld ren. Exper ience with newly designed fiberscopes. Endoscopy 1974;6:186-9.5. Liebman WM, Thaler MM, Bujanover Y. Endoscopic evaluation of upper gastrointestinal bleeding in the newborn. Am JGastroenteroI1978;69:607-8.6. Tedesco F, Goldstein PD, Gleason WA, et al. Upper gastrointestinal endoscopy in the pediatric patient. Gastroenterology

1976;70:492-4.7. Deckelbaum RJ, Roy CC, Lussier-Lazaroff J, et al. Peptic ulcerdisease: a clinical study in 73 children. Can Med Assoc J1974;1111:225-8.

Authors and CorrespondentsThe editor's newaddress, asofNovember

1, 1983, is as follows:Bernard M. Schuman, MDDepartment ofMedicineGastroenterologyMedical College of GeorgiaAugusta, Georgia 30912

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