Benjamin Sahn

Bowel Preparation for Pediatric Colonoscopy: Report of the NASPGHAN Endoscopy and Procedures Committee

ABSTRACT Pediatric bowel preparation protocols used before colonoscopy vary greatly, with no identified standard practice. The present clinical report reviews the evidence for several bowel preparations in children and reports on their use among North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition members. Publications in the pediatric literature for bowel preparation regimens are described, including mechanisms of action, efficacy and ease of use, and pediatric studies. A survey distributed to pediatric gastroenterology programs across the country reviews present national practice, and cleanout recommendations are provided. Finally, further areas for research are identified.

Review of Foreign Body Ingestion and Esophageal Food Impaction Management in Adolescents

Foreign body ingestion is a common clinical scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life threatening. Initial and follow-up management strategies depend on multiple patient and ingested object-related factors. Available literature on this topic tends to focus on the small child or adult, leaving the clinician caring for adolescents to extrapolate this information to guide decision making for individual patients. This article reviews foreign body ingestion literature with important implications to the adolescent patient and raises awareness of some highly dangerous objects such as large button batteries, high-powered magnets, long sharps, narcotic packages, and super absorbent objects. An additional focus includes the management of esophageal food impaction. We highlight the unique aspects to the care of the adolescent with intentional ingestion and co-morbid psychiatric illness. The article concludes by discussing the challenges to prevention of ingestion in the at-risk patient.

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.

Duodenal hematoma following EGD: comparison with blunt abdominal trauma-induced duodenal hematoma.

Background: Duodenal hematoma (DH) is a rare complication of esophagogastroduodenoscopy (EGD) with duodenal biopsy and uncommon, but better described following blunt abdominal trauma (BAT). We aimed to describe DH incidence and investigate risk factors for DH development post-EGD and compare its features to those post-BAT. Methods: Multiple electronic databases were searched for the diagnosis of DH from 2000 to 2012. Inclusion criteria were patients 0 to 21 years of age who developed a DH following EGD with biopsy or BAT. Exclusion criteria were DH secondary to any other mechanism, EGD performed at another medical center, and insufficient information in the electronic medical record to determine treatments or outcomes. Results: A total of 14 post-EGD and 15 post-BAT patients with DH were included in the study. There were 26,905 EGDs with duodenal biopsies performed during the study period, for an incidence of 1:1922 procedures. Thirteen of 14 (93%) post-EGD DH events occurred between 2007 and 2012 (P < 0.001). The proportion of procedures performed under general anesthesia versus moderate sedation, and performed in the supine position versus left lateral decubitus were close to but did not reach statistical significance. DH-related complications and time to hematoma resolution was similar between groups. Conclusions: In a 13-year study period, 14 patients developed DH after EGD, for an incidence of 1:1922. Method of sedation and supine positioning of the patient during endoscopy warrant further investigation as potential risks. The clinical course and time to recovery with conservative management are similar between patients with EGD and BAT-induced DH.

Vascular malformation as a cause of occult gastrointestinal bleeding.

FIGURE 3. A, Jejunal segment with vascular malformation on the serosal surface. Coil placed in angiography seen within blanched arcade at lesion margin (arrows). B, Proliferation of congested, thickand thin-walled, ectatic vascular channels (arrows) extends from the submucosa through the muscularis propria to the serosal surface. The overlying mucosa is largely unremarkable (surgical resection specimen. Hematoxylin and eosin stain, original magnification 50).

Safety of a 1-Day Polyethylene Glycol 3350 Bowel Preparation for Colonoscopy in Children.

Objectives: Electrolyte-free polyethylene glycol powder (PEG-3350) has been widely used for colonoscopy preparation (prep); however, limited safety data on electrolyte changes exists with 1-day prep regimens. The primary aim of this study was to determine the proportion of patients with significant serum chemistry abnormalities before and at the time of colonoscopy. Secondary aims included evaluation of prep tolerance and bowel cleansing efficacy. Methods: We performed a prospective descriptive observational study of pediatric patients scheduled for outpatient colonoscopy who received our standard 1-day, weight-based 4 g/kg PEG-3350 prep with a single stimulant laxative dose and had serum chemistry testing within 60 days before and at the time of colonoscopy. A standardized bowel cleanliness tool (Aronchick scale) was completed by the endoscopist. Results: One hundred fifty-five patients had serum electrolytes data pre- and postprep. Comparison of each patients chemistries demonstrated statistical equivalence with the 1 exception of blood urea nitrogen levels (P = 0.56). Hypokalemia was detected postprep in 37 subjects (24%), but none had a serum level <3.3 mmol/L, which was deemed to be of no clinical significance. Five patients were hypoglycemic post prep; 3 were 7 years or younger (P = 0.02). The colon cleanliness rating was excellent or good in 77% and suboptimal in 23% of patients. Conclusions: A 1-day, weight-based PEG-3350 bowel prep in children appears safe. Changes in electrolyte levels and renal function were not clinically significant. Children of 7 years or younger seem to be at a higher risk of hypoglycemia compared with older children.

Endoscopic ultrasound with or without fine-needle aspiration has a meaningful impact on clinical care in the pediatric population

Background and Objectives: The safety and utility of endoscopic ultrasound (EUS) for the evaluation and management of gastrointestinal (GI) tract disorders among adults has been established. The literature on safety and efficacy in a pediatric referral population (under 21 years of age) is limited. We hypothesized that EUS is safe and useful in the pediatric population. We reviewed the pediatric EUS experience at a single tertiary-care system. We describe the indications, findings, safety, technical success rate, and impact on clinical outcomes. Patients and Methods: All patients 21 years of age or younger referred for EUS between 5, 2007 and 11, 2012 were identified from our electronic medical record databases. Retrospective chart review was then conducted to document demographics, procedure indications, procedure type (diagnostic or therapeutic), type of anesthesia used, EUS findings, and the clinical impact of EUS on the subsequent management of the patients. Results: Seventy EUS procedures were attempted in 58 patients during the study. Of these, two EUS procedures were aborted due to inadequate moderate sedation and 68 were successfully completed. The median age at initial endoscopy was 18 years (range 6–21 years), 50% were male and 65% were Caucasian. Four patients underwent EUS-guided pseudocyst drainage. Among the remaining 54 patients, the indications for EUS were the evaluation of GI mucosal/submucosal lesions (n = 14), acute or recurrent pancreatitis (n = 10), localization of suspected insulinoma (n = 8), evaluation of pancreatic abnormalities seen on prior imaging (n = 6), surveillance of tumors or evaluation of luminal lesions in hereditary syndromes (n = 6), abdominal pain of suspected pancreatobiliary origin (n = 5), and other rare indications (n = 5). Fine-needle aspiration was performed in 13 (9 diagnostic, 4 therapeutic) and trans-gastric fine-needle contrast injection of the pancreatic duct was performed in one patient without any complications. Sedation (data available for 66 procedures) included general endotracheal anesthesia in 38 (57%), monitored anesthesia care (MAC) in 19 (29%), and moderate sedation in 9 (14%). There were 4 minor intra-procedural anesthesia-related complications (laryngospasm in 2 and hypoxemia from airway obstruction and secretions in 2) in MAC and general endotracheal anesthesia (GA) cases, and 1 postprocedural complication (fever after pseudocyst drainage). EUS can achieve the diagnostic or therapeutic goal and ruled out suspected pathology in 88% of cases precluding need for additional testing. Conclusions: (1) EUS in the pediatric population is technically successful and efficacious. (2) Therapeutic and diagnostic EUS impacted clinical care decisions. (3) There is a low risk of immediate significant complications. (4) The overall efficacy and safety support the performance of EUS in a pediatric population by experienced endoscopists.

The Importance of Measuring IL10 Levels in Patients with Suspected IL10/IL10R Defects

To the Editor: Interleukin 10 (IL-10) is an anti-inflammatory cytokine that is critical tomaintain immune homeostasis in the gastrointestinal tract. Its immunosuppressive effects include the restriction of T cell proliferation, limitation of pro-inflammatory cytokine production, and the downregulation of co-stimulatory protein expression on antigen presenting cells [1]. IL-10 signaling occurs through a heterotetrameric IL-10 receptor (IL10R) complex comprised of IL-10R1 and IL-10R2. IL-10 receptor deficiency is a rare primary immunodeficiency that typically presents early in life with inflammatory bowel disease, folliculitis, multiple abscesses, perianal fistulas, arthritis, and recurrent respiratory diseases [1]. This is caused by loss-of-function mutations in the genes encoding for the IL-10 receptor (IL10R) [2]. The histopathology of affected individuals demonstrates intestinal mucosa ulcers with epithelial inflammatory infiltrates and abscesses. Patients with IL10 deficiency often have minor immunologic abnormalities, including normal or slightly decreased serum immunoglobulin levels, decreased CD4+/CD8+ T cell ratios, and variations in T cell, B cell, and NK cell numbers. Individuals with IL-10 or IL-10R deficiency are typically unresponsive to immunosuppressive therapy. The only known treatment that is curative in these patients is hematopoietic stem cell transplantation (HSCT) [3]. To our knowledge, assessing serum IL-10 levels to attribute a potential signaling defect to the IL-10 receptor has not been previously described in children with IL-10R mutations. This paper describes a patient with IL-10R deficiency that was found to have a high serum IL-10 level as part of his initial immunological evaluation, raising suspicion for the eventual diagnosis of IL-10 receptor deficiency. A 4-year-old Turkish male, the product of a first-cousin consanguineous marriage, with a past medical history of partial central diabetes insipidus, cortical blindness, and global developmental delay, was initially seen in our Allergy clinic at the age of 1 year old with a diagnosis of milk protein proctocolitis secondary to the detection of blood in his stool. The patient subsequently failed an oral challenge to milk and was diagnosed with non-IgE-mediated milk allergy with a negative Immunocap at that time. He remained well on a milk-free diet for the next 2 years. At the age of 3 years, he was hospitalized with oral aphthous ulcers, persistent diarrhea with intermittent hematochezia, perirectal fissures and ulcerations. Gastrointestinal evaluation included an upper endoscopy that revealed aphthous ulcers in the esophagus and duodenum, and a colonoscopy revealed deep ulcers and friable mucosa throughout the colon. Mucosal histology demonstrated acute esophagitis, and focal areas of active ileitis and colitis. He was given a diagnosis of inflammatory bowel disease (IBD) and was placed on an elemental formula diet, antimicrobial therapy and topical steroids for the perirectal disease. He was evaluated in our Immunology clinic and a subsequent workup revealed normal quantitative immunoglobulins, T cell numbers and subpopulations and dihydrorhodamine (DHR) assay that ruled out chronic granulomatous disease. He also had a normal level of glucose 6-phosphate dehydrogenase, a positive * Susanne LaBarba svera1@northwell.edu