Rita Steffen

Use of conscious sedation for lower and upper gastrointestinal endoscopic examinations in children, adolescents, and young adults: a twelve-year review

BACKGROUND Over the past decade, many pediatric endoscopists have replaced general anesthesia with conscious sedation. Sedation is commonly used to minimize discomfort. METHODS To evaluate the safety and efficacy of conscious sedation we reviewed 2711 reports of lower and upper gastrointestinal endoscopic examinations performed in 2026 patients between July 1981 and December 1992. RESULTS Intravenous sedation was accomplished using meperidine and diazepam (914 examinations, 35%) or meperidine and midazolam (1427 examinations, 55%). Single agents were used for 83 examinations (3%), and 96 examinations (3.5%) were performed with the patient under general anesthesia. In the lower endoscopy group sedated intravenously (n = 713), the cecum was reached in 82% of examinations. The procedure could not be completed in 17 cases in which patients were uncooperative despite sedation. In the upper endoscopy group sedated intravenously (N = 1653), all but 91 endoscopies were completed to the descending duodenum. Esophagoscopy had been planned in 76% of these procedures. Minor complications occurred in 7 patients (0.3%). This included two episodes of significant oxygen desaturation that responded to oxygen administration and narcotic reversal. A major complication occurred in 1 patient (0.04%) who had a gastric perforation during esophageal dilation over a defective guide wire. There were no deaths, episodes of cardiorespiratory arrest, or pulmonary aspirations in our series. The combined major and minor complication rate was 0.3%. CONCLUSIONS Intravenous conscious sedation is safe and effective in children undergoing endoscopic examination of the gastrointestinal tract. Selected patients will require general anesthesia.

Recent advances in chronic constipation.

Purpose of review Chronic constipation remains one of the most frequent complaints in primary and subspecialty pediatric clinics. It is associated with significant emotional and economic burden for both the children and the caregivers. Recently, advances have expanded our understanding of the pathophysiology and treatment options for children with chronic constipation. Here, we review current strategies addressing the cause, diagnostic technologies and treatments of chronic constipation. Recent findings There is some new information presented here on techniques for diagnosis and long-term complications associated with chronic childhood constipation. Comparative data on current laxatives and the development of medications with novel mechanisms of action are reviewed for a glimpse into the horizon of possible new treatments for children with chronic constipation. Studies on effects of growth, quality of life, dietary fiber and symptoms, which may coexist with constipation, are discussed. Summary The recent literature on chronic constipation has provided some new knowledge providing a more evidence-based approach to treating these patients. We review the scope of this problem and the estimated cost of treating constipation. The availability of long-term outcome data enhances our understanding of the natural history of this problem. Newer pharmacological approaches provide optimism for treatment for this common problem.

The Spectrum of Eosinophilic Gastroenteritis Report of Six Pediatric Cases and Review of the Literature

Eosinophilic gastroenteritis is an inflammatory disease of unknown etiology characterized by infiltration of the gastrointestinal tract with eosinophilic leukocytes, accompanied by varying abdominal symptoms and usually by peripheral blood eosinophilia. We report our experience with six pediatric cases presenting to the Cleveland Clinic Foundation over the past eight years. Unusual findings in our patients included ascitic fluid without eosinophilia and eosinophilic pericarditis (one patient), and eosinophilic cholecystitis (one patient). Endoscopic examination and biopsy helped to establish the diagnosis in all patients. Bone marrow aspiration supported the diagnosis by demonstrating eosinophilia and identifying reactivation of the disease, even in cases without peripheral eosinophilia. All six patients responded promptly to prednisone. Diagnosis is challenging and eosinophilic gastroenteritis may be more common than is recognized. This series of cases significantly expands the spectrum of the disease in children, and documents the usefulness of diagnostic endoscopy in this condition.

Electrogastrography versus gastric emptying scintigraphy in children with symptoms suggestive of gastric motility disorders.

BACKGROUND Cutaneous electrogastrography is a method of recording gastric electrical activity. Abnormalities of the electrogastrogram have been described in a variety of disorders. The purpose of the study was to correlate the electrogastrograms of children with vomiting and dyspepsia with the results of radionucleotide gastric emptying studies. METHODS Nine patients (5-16 years old) with gastrointestinal symptoms of vomiting and/or abdominal pain were studied. The electrogastrogram was recorded using surface electrodes for 30 minutes in the fasting state and for 120 minutes after a radioisotope-labeled solid meal. Gastric emptying was simultaneously monitored for 120 minutes. The postprandial change in dominant power (power ratio: postprandial/fasting dominant power), percentages of normal slow wave, bradygastria, and tachygastria were recorded and analyzed. RESULTS The patients were divided into two groups. The first group (four patients; five studies) had normal gastric emptying, whereas the second group (five patients) had delayed emptying (half-life, >90 minutes). The median power ratio in the first group was 1.69 and in the second group was 2.78; the difference was not statistically significant (P = 0.90). The median difference in slow wave percentages in the fasting and postprandial periods was 0.99 in the first group and 0.73 in the second group; again, the difference was not statistically significant (P = 0.27). CONCLUSIONS Although it is a method of assessing gastric myoelectrical activity and gastric motility disorders, electrogastrogram does not correlate with nuclear scintigraphic gastric emptying studies in children.

Benign Recurrent Intrahepatic Cholestasis: Improvement of Pruritus and Shortening of the Symptomatic Phase with Rifampin Therapy: A Case Report

Beenign recurrent intrahepatic cholestasis (BRIC) is a rare familial syndrome characterized by recurrent episodes of pruritus andjaundice without evidence of duct obstruction.1-3 Episodes typically last weeks to several months. Very little is known about the etiology and the mechanisms that trigger and maintain the episodes of cholestasis. Alteration in bile acid metabolism has been implicated in the pathophysiology of BRIC. The proposed mechanism involves increased influx of sulfated lithocholic acid conjugates, a strong cholestasis-inducing bile acid, from the intestine in BRIC patients with subsequent development of cholestasis. This is especially likely during a state of reduced bile acid pool size.4,5 Bijleveld et al demonstrated that patients with BRIC have a reduced bile acid pool size due to increased loss of bile acids as a result of intestinal malabsorption.6 BRIC is considered to be a benign condition. Despite numerous episodes of symptomatic cholesta-

Colonoscopy in the pediatric patient

In 1963 the description 1 of the first workable fiberoptic panendoscope heralded a new era of accurate gastrointes- tinal tract diagnosis and therapeutic procedures. Since the introduction of the flexible fiberoptic colonoscope in the early 1970s. colonoscopy has become an established proce- dure for the diagnosis, evaluation, and treatment of large bowel disease in pediatric patients. The number of proce- dures has increased dramatically during the past 10 years. The use and importance of colonoscopy have continued to increase as instruments specifically designed for children come into routine use. Differences between pediatric and adult patients not only influence the approach to the patient but also modify therapeutic decisions when abnormalities are suspected or identified. We review here the value of the procedure, patient selection, instrumentation, and compli- cations. Advances in technique, premedication, and appli-

Chronic Pancreatitis in Late Childhood and Adolescence

Acute pancreatitis is unusual in pediatric patients, and chronic pancreatitis is even less common. Between 1983 and 1988, we diagnosed 24 patients in late childhood and adolescence with chronic pancreatitis. Our review revealed that chronic pancreatitis presents as recurrent abdominal pain in late childhood and adolescence. Individual laboratory and radiological investigations may be normal during acute exacerbations of pain, but the determination of serum amylase and lipase concentrations — combined with ultrasonography — will accurately identify most patients. We found that endoscopic retrograde cholangiopancreatography is a valuable tool in the diagnosis of structural abnormalities. Surgical intervention may reduce symptoms in patients with structural abnormalities. There is a tendency toward decreased frequency and severity of pain as the patients increase in age.

Tolerability, Safety, and Efficacy of Peg 3350 as a 1-day Bowel Preparation in Children

Objective: The aim of the study was to evaluate the tolerability, safety, and efficacy of polyethylene glycol (PEG) 3350 without electrolytes as a 1-day bowel preparation for colonoscopy in children. Methods: A prospective study of 45 children undergoing colonoscopy prescribed PEG 3350 without electrolytes mixed with a commercial electrolyte beverage was performed. Patients <45 kg received 136 g of PEG 3350 without electrolytes mixed in 32 ounces of Gatorade. Patients ≥45 kg were given 255 g of PEG 3350 without electrolytes in 64 ounces of Gatorade. A basic metabolic panel was performed at the time of the clinic visit and just before colonoscopy. Patients completed a survey related to bowel preparation. Endoscopists graded bowel preparation and noted the proximal extent of the examination. Results: A total of 44 patients (14 ± 3 years) completed the study. One patient was excluded due to protocol breach. All subjects reported the preparation was easy (61%) or tolerable (39%). Adverse events included nausea (34%), abdominal pain (23%), vomiting (16%), abdominal distension (20%), bloating (23%), and dizziness (7%). Although significant changes in serum glucose and CO2 were noted, no therapeutic interventions were indicated. Significant changes in sodium, potassium chloride, blood urea nitrogen, or creatinine did not occur. Colonic preparation was rated as excellent in 23%, good in 52%, fair in 23%, and poor in 2% of patients. Intubation of the ileum was successful in 100%. Conclusions: One-day bowel preparation with high dose PEG 3350 mixed with commercial electrolyte solution is tolerable, safe, and effective in children before colonoscopy.

The results of strictureplasty in pediatric patients with multifocal Crohn's disease.

This study is a retrospective review of eight pediatric patients with multifocal intestinal Crohns disease who underwent strictureplasty with or without concomitant bowel resection between January 1978 and April 1992. The patients ranged in age from 9.9 years to 18.5 years. Indications for surgery were partial intestinal obstruction (n = 6), failure of medial therapy or steroid dependence (n = 4), growth failure (n = 2), and entero-cutaneous fistula (n = 2). Thirty-six strictureplasties were performed in the eight patients (median, 4.5 strictureplasties per patient; range, 1–12). Bowel resection was performed in six of the eight patients in areas where strictureplasty was not feasible. The mean length of resection was 40 cm (range, 15–82 cm). The only complication was intestinal hemorrhage, which was conservatively managed in two patients. The patients were followed for a mean of 19 months (range, 3–55 months). Five patients had a weight below the fifth percentile prior to surgery. Postoperatively, there was a weight gain in seven patients, including all five patients who were originally below the fifth percentile. A statistically significant weight gain was found when a paired t test analysis was applied to the entire group (p = 0.04). Five of six patients who were on steroid medication at the time of surgery were successfully weaned within 1.5–3 months (mean, 2.3 months) from the time of surgery. Seven of eight patients had relief of their intestinal symptoms. Strictureplasty with small-bowel resection, or perhaps strictureplasty alone, in pediatric patients with multifocal intestinal Crohns disease can improve gastrointestinal symptoms, promote weight gain, and allow discontinuation of steroid medications. Strictureplasty should be considered for patients who are refractory to medical therapy or dependent on chronic steroid medication for control of their symptoms.

Autoimmune Enteropathy in a Pediatric Patient: Partial Response to Tacrolimus Therapy

A 14-year-old male with severe diarrhea secondary to autoimmune enteropathy was treated with tacrolimus and demonstrated a partial response. The product of an uncomplicated fullterm pregnancy, labor, and delivery, the patient developed protracted diarrhea at 3 months of age. Extensive evaluation excluded other etiologies of malabsorption and failure to thrive including cystic fibrosis, renal tubular acidosis, and immune deficiency. At an outside institution, he was diagnosed with eosinophilic gastroenteritis and multiple food allergies at 1 year of age. After transfer to our institution he underwent endoscopic evaluation; small bowel biopsies demonstrated severe villous atrophy and