0016/5107/83/2904-0279$02.

00/0 GASTROINTESTINAL ENDOSCOPY Copyright 1983 by the American Society for Gastrointestinal Endoscopy

Upper gastrointestinal fiberoptic endoscopy in pediatric patients

Joao c. Prolla, Ada S. Diehl, Giovani A. Bemvenuti, Sabino V. Loguercio, Denise S. Magalhaes, Themis R. Silveira, MD MD MD MD MD MD

Porto Alegre, Brazil

Upper gastrointestinal fiberendoscopy in pediatric patients is done safely and under local anesthesia in most instances. This study of 47 children confirmed the value of fiberendoscopy in establishing the etiology of upper gastrointestinal hemorrhage and the presence of esophageal varices. It also contributed significantly to the management of patients with disphagia, pyrosis, epigastric pain, and ingestion of foreign bodies. No significant morbidity was caused.

The clinical usefulness of upper gastrointestinal endoscopy in children has been the subject of some recent reports. 1-6 We report our experience and discuss some aspects of technique as well as clinical value, especially in pediatric patients with upper gastrointestinal bleeding and abdominal pain.
MATERIALS AND METHODS

RESULTS

Forty-seven patients, aged 19 months to 15 years, were seen at the Gastrointestinal Endoscopy Unit at the Hospital de Clinicas de Porto Alegre, referred by pediatric departments of several hospitals of Porto Alegre area in Brazil, over a 2-year period (July 1979 to July 1981). The indications for endoscopy are listed in Table 1. Preparation consisted of (a) discussion' of the procedure with the patient and parents; (b) fasting for at most 4 hours in patients aged 2 years or less and 8 hours for older patients; (c) gastric lavage with iced saline solution in bleeding patients; (d) general or pharyngeal anesthesia; (e) in the 40 patients submitted to pharyngeal anesthesia, 4 to 10 mg of diazepam was administered intravenously if necessary. The Olympus GIF-P2 fiberendoscope was used in 42 patients, and no difficulty was experienced in passing it. The duodenum was reached in all patients. The other five patients, aged 12 years or more, were examined with adult-type endoscopes.
From the Gastrointestinal Endoscopy Unit at the Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil. Reprint requests: Dr. J. C. Prolia, Caixa Postal 2300, 90000 Porto Alegre, RS, Brazil.
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In 15 patients with upper gastrointestinal hemorrhage the endoscopic examination revealed esophageal varices in all seven with known portal hypertension; in five, varices were the source of bleeding, and in the other two patients erosive gastritis was the cause of bleeding (Table 2). Six of the eight patients without portal hypertension had the source of bleeding established by endoscopy: erosive gastritis in four, a duodenal bulbar ulcer in one patient, and a gastric )J.lcer in one patient. Two patients had a normal endoscopic appearance and the source of bleeding could not be identified, but both had stopped bleeding for several days before endoscopy was done. In 14 patients (Table 3) endoscopy was done to verify the presence or absence of esophageal varices. Seven were patients with known portal hypertension; in five patients esophageal varices were seen. The other seven patients were bleeding; all seven had esophageal 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 but revealed erosive antral gastritis and duodenitis in two of seven patients with normal radiologic examinations. In six patients with dysphagia, endoscopy revealed esophageal stenosis in four (two had a history of caustic ingestion), achalasia in one, and was normal in one 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 47 children.

Indication Upper gastrointestinal hemorrhage Chronic epigastric pain Portal hypertension n Dysphagia Foreign body ingestion Frequent vomiting Pyrosis Total
n

No. of patients

15
12 7 6

3 2 2

47

Patients not bleeding.

Table 2. Upper gastrointestinal endoscopy in 15 children with upper gastrointestinal hemorrhage.

Type of patients Patients with portal hypertension Source of bleeding seen at endoscopy Eosphageal varices Erosive gastritis Patients without portal hypertension Erosive gastritis Gastric ulcer Duodenal ulcer Cause not established No. of patients 5
2
4

1 1 2

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

Types of patients With upper gastrointestinal hemorrhage n Without upper gastrointestinal hemorrhage
n

Varices detected at endoscopy

7

Varices not detected at endoscopy

o
2

Included also in Table 2.

In two patients with frequent vomiting, endoscopy was normal in both. In two patients with pyrosis, endoscopy revealed moderate and severe esophagitis.
DISCUSSION

We agree with Tedesco et ai. 6 that fiberoptic endoscopy using pediatric instruments is a safe diagnostic tool; no significant complications were encountered in their series of 50 procedures or our 47 procedures. In their series, no general anesthesia was used, even in the eight patients 2 years old or less; they prefered sedation with diazepam. We used general anesthesia in seven patients; in two patients, aged 5, poor cooperation was the basis of this decision but the other five patients were less than 2 years old. Cremer et ai.,4 in
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a series of 17 patients, also did not use general anesthesia. Ament et ai. I needed general anesthesia in 58 of 79 patients, but they used primarily adult-type endoscopes. The availability of pediatric endoscopes has reduced the need for general anesthesia to a few occasions. In upper gastrointestinal hemorrhage the endoscopic procedure firmly established the cause of bleeding in 13 of 15 instances. It is noteworthy that two patients with esophageal varices were bleeding from erosive gastritis. It is important to do the examination very early in the course of the hemorrhage; endoscopy failed to reveal the origin of bleeding in two patients who had stopped bleeding some days prior to the procedure. 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 patient with systemic lymphoma. Ament et ai. I established the cause of bleeding in 17 of 21 patients, most of whom had peptic ulcers. Later, Cox and Ament3 demonstrated endoscopically the site of upper gastrointestinal hemorrhage in 68 children and adolescents in 28 instances, while upper gastrointestinal contrast studies were positive in 21 instances and angiography in five instances. Even in the first 24 hours of life gastrointestinal endoscopy has been used with success in determining the cause of hemorrhage in one patient. 5 In portal hypertension, endoscopy is very helpful in establishing the presence of varices in the esophagus. In our series (Table 3) this was accomplished in 12 of 14 patients. In six of these children the radiologic examination was at best doubtful and was not done in five of the bleeders. In patients with chronic epigastric pain, endoscopy frequently complements radiologic findings or reveals unsuspected lesions. In our series, in five patients the radiologic examination ws considered abnormal but endoscopy did not confirm any suspected lesions (four antral "polyps" and one web). In two patients without x-ray abnormality, endoscopy revealed significant mucosal lesions: one case of antral erosive gastritis and one case of severe duodenitis. Tedesco et ai. 6 reported a 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. 7 who, in a retrospective study of 73 patients, found it necessary to repeat x-ray studies in 25% of the children to document the ulcers. Obviously, an unknown number of ulcers were missed by radiology and not included in the study. In patients with dysphagia or pyrosis, endoscopy is quite helpful in the diagnosis of esophagitis and/or strictures. In our series of six patients with dysphagia,
GASTROINTESTINAL ENDOSCOPY

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

REFERENCES
1. Ament ME, Gans SL, Christie DL. Experience with esophago-

gastroduodenoscopy in diagnosis of 79 pediatric patients with hematemesis, melena or chronic abdominal pain (abstract). Gastroenterology 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. Pediatrics 1979;63:408-13. 4. Cremer M, Peeters JP, Emonts P, et al. Fiberendoscopy of the gastrointestinal tract in children. Experience 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 J GastroenteroI1978;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 ulcer disease: a clinical study in 73 children. Can Med Assoc J 1974;1111:225-8.

Authors and Correspondents

The editor's new address, as of November 1, 1983, is as follows: Bernard M. Schuman, MD Department of Medicine Gastroenterology Medical College of Georgia Augusta, Georgia 30912

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