an update on pediatric endoscopy - cip...
TRANSCRIPT
An Update On Pediatric
Endoscopy
Jie Chen , MD, phD
The Chidren’s Hospital of Zhejiang University School of Medicine
2016-3-4 Xi’an 2016CIP
Indication
• Diagonostic endoscopy
– Esophagogastroduodenoscopy (EGD)
– Colonoscopy
Routeine
•Acid peptic disease
•Suspion of mucosal inflammation
•Chronic diarrhea/malabsorption
•Chronic abdominal pain (with anemia,weight loss, vomiting)
•Hematemesia or enema,hematochezia
•Dsphagia or odynophagia
•Caustic ingestion,forgein body ingestion
•Recuurent vomiting
•GER,faliure for thrive…….
•Lower GI hemorrhage
•Chronic diarrhea
•Suspected IBD
•Cancer survellance(IBD, polyposis syndrome)
•Low GI tract lessions seen on imaging study
•Others:anemia unexplained, faliure to thrive, abdominal
pain…..
Indication
• Diagonostic endoscopy
– Esophagogastroduodenoscopy (EGD)
– Colonoscopy
– Double ballon enteroscopy
– Wireless capsule endoscopy
Routeine
Investigation of the small intestine
Indication
• Therapeutic endoscopy – Polypectomy
– Foreign bodies removal
– Hemostasis
– Ligation of esophageal varices
– Reset(gastric vovulus,intessuception)
– Dilation of strictures
– Stent placement
– Catheter placement (nasogastrojejunal tube, PEG,PEGJ,PEJ)
– POEM
– ERCP
• Evaluation & Followup
Contraindication_ absolute
• Severe heart and pulmonary disease
• Shock
• gastrointestinal perforation
• Suspected Aneurism of thoracic aortic
• Stroke
Contraindication_relative
• Bleeding disorders
• Recent histroy of bowel surgery
• Toxic dilation of the bowel
• Partial or complete bowel obstruction
• Aneurism of abdoninal or ileac aorta
• Acute inflammation with errosive of mouth,
throat, and GI tract
• Mental illness
Personnel
• Physician: Pediatric gastoenterogists
• Assistant specially trained
– Meet , explain to child & hold, reasurre child
throughout procedure
– Abtain ,process tissure & assist other equipments
• Competent physician in anesthesia and
resusitation
Facilities and Equipment
• Routine endoscopy :outpatient setting,
Hospital bedside or operating room
• Occasionally, more invasive and therapeutic
procedure
• Equipment for monitoring: BP , pulse,SpO2
• emergency medication + resussitation
• Good endoscopy system with size and type
approptiated for pediatric use
Diagnostic Endoscopy
Duodenal ulcer & gastric ulcer
1.Peptic ulcer 2.Hemorrhagic gastritis
3 Deulifoy disease 4.Esophegeal varices
GI Bleeding
Colon polyps
Intestinal lymphangiectasis (duodenum)
Pseudomembranous colitis
‘’ ‘’
Eosinophilic esophagitis
Eosinophilic gastroenteritis
Ulcerative Colitis
UC & CD
HSP
gastric autrum spotting Spotting in duodenum
erosion&ulcer in duo Blue plaques in duo
Endoscopic diagnosis of small bowel
diseases
Diagnosis rate via routine techniques
• Radiology (KUB、SBFT)
• Abdominal ultrasound
• ECT
• Agiography
• EGD/Colonscpy
Diagostic rate
10%-15%
Endospopy for investigation of SBD
• EGD、colonoscopy
• Small bowel enteroscopy (SBE)
– Push enteroscopy
– Double ballon enteroscopy
• WCE
• EUS
• Intraoperative endoscopy
• Laparoscopy
EGD & colonoscopy in the diagnosis of
intestinal diseases
• EGD
– For observation of upper jejunum lesions in
patients with gastrojejunostomy
• Colonoscopy
– Be able to investigating the terminal ileum
EUS in the diagnosis of intestinal
diseases
• Valuable at duodenal lesions
– To identification of the inner wall and the outer
wall of the duodenum disease
– To investigation of duodenal periampullary tumor
SBE techniques
• Push enteroscopy
• 2.5 meter long push
eneroscopy
• Sona & rope way enteroscopy
• Bougie enteroscopy
• SBE
• DBE
In China better value in
unexplained intestinal
bleeding and small
bowel obstruction
Valuable to determine
the treatment options
DBE
• Oral or transanal
• Entire small bowel examination
• Indication – Obscure GI Bleeding
– Suspected crohns disease
– Angiography / GI imaging abnormality
– Chronic diarrhea or abdorminal pain _suspected SBD
– Multiple intestinal polypus
– Suspeted small intestine cancer
– Therapeutic intervention in small intestine
Ileum erosion Jejunum erosion Cobblestone levy (CD)
CD: Jejunum ulcer Intestinal bachet’s disease
Mechel’s diverticulum Diverticular ulcer
Disadvantages
• Technically difficult procedure
• Very time consuming (Procedure can take > 3 hours)
• Higher risk of small bowel perforation
• Case reports of pancreatitis and intestinal necrosis
• Reported incidents of aspiration and pneumonia
WCE evaluation of small intestine
• Obscure gastrointestinal bleeding and /or
anemia
• Evaluation of extent of small intestinal
disorders such as Crohn’s disease
• Small-intestinal abnormalities on SBFT or CT
• Suspected malabsorption
• Surveillance of polyposis syndromes
involving small intestine
Contraindications
Absolute:
• Suspected small intestinal obstruction
• Pregnancy
Relative:
• Motility disturbances: Gastroparesis/ Achalasia
• Small bowel diverticulosis
• Poor surgical candidates
Types of endoscopic capsule
Imaging rapid viewing system
QuickView v5
Setting Selectable:
High/Normal/Low
Image Adjustment
One-click on/off
IA button
Lewis
Score
Study Manager
A–Mode or M-
mode
(when RAPID
is M-mode
enabled)
(CapsuleEndoscopy.org, 2008)
WCE in pediatric patients
• The detection rate 50%
– New diagnosis: 49%
• Complication :
– Retention of capsule 1.5-2.2%
– Aspitation: rare
CD：83.3%
Obscure GI bleeding :73.3%
Phlebectasia Hemangioma
HSP Jejunum Bleeding
lymphoma GIST
Polypoid mass polyps
Meckel’s
diverticulum Intestinal lymphangiectasis
Sprue malabsorption
Crohn`s disease
Linar erosions
Linar erosion
ulceration
ileutitis
Inflammato
ry polyp
WCE for Crohn`s disease
• Diagonosis determination
• Management options
• Mucosal healing detection
0
1
2
3
4
5
6
7G
astr
ic
Duoden
Jeju
num
Ileum
J +
I
CD (n 21)
UC/IC (n 7)
Cohen et al. JPGN 2008;47(1):31-36.
Detection of new lesions
•5/7 (71%) UC/IC is CD
•13/21 (62%) CD
extesive small
intestine involved
•Modified medical cures
for the CD cases new
diagnosed
0
10
20
30
40
50
60
70
80
90
100
UC/IC CD
Reclassified
Cohen et al. JPGN 2008;47(1):31-36.
Reclassified diagnosis
0102030405060708090
100
diag
nosi
sde
cisi
ons
man
agem
ent
CE
N = 18
Gralnak et al, Digest Dis Sci 2011
Modified management option
Detection of mucosal healing
PRE PCDAI 30;
12Wks afte treatment PCDAI 10;
AZA
Proposed Algorithm For Diagnosis of
Suspected Crohn’s Disease
Colonoscopy/Ileoscopy +
Stop
_
Obstructive Symptoms?
_
Capsule Endoscopy
+
SBFT +
Stop
_
• WCE vs push enteroscopy
– 2 meta analysis：
• 63% vs. 28%
• 87% vs. 14.8%
• WCE vs SBFT
• 42% vs. 6%
• 87% vs. 9.9%
• CE vs DBE
• 60%vs 57%
Value of WCE for investigation of obscure
GI Bleeding
Treister et al. Am J Gastroenterol. 2005;39:684-8.
Lewis et al. Endoscopy. 2005;37:960-5.
Pasha et al. Clin Gastroenterol Hepatol. 2008;6:671-6.
Endospopy for investigation of SBD
• EGD、colonoscopy
• enteroscopy
– Push enteroscopy
– Double ballon enteroscopy
• WCE
• EUS
• Intraoperative endoscopy
• Laparoscopic
Therapeutic endoscopy
Polypctomy
Types of intestinal polyps
Indication
• Polyp on stalk , small or large
– Larger polyps can be divided into sub-removal
– Multiple polyps ,from distal to proximal, once or
more times
• Flat board polyp < 2cm
Contraindication
• Flat board polyp 2cm
• Familial adenomatous polyposis
• Intesive adema
• Endoscopy contraindication
complication
• Bleeding
• Burns
• Perforation
Cause of foreign body ingestion
• swallow 80% -90%
– (coins, button battery, keys, needle, clips。。。。。 )
• Gastrointestinal stenosis
• Iatrogenic
• Diospyrobezoar
• Other: mental illness, abuse
Endoscopic foreign body removal
• Indication
– At Upper GI foreign body or At large
intestine but cannot be discharged
– Emergency ,especially for sharp or toxic
• Contraindication
– Suspected perforation
– Huge forgein mass
– Endoscopy contraindication
Coins in esophagus
Date nutlet incarcerated in esophagus
Stapler nail in stomach
Duodenum_ needle
Upper GI bleeding control
• Non-variceal upper gastrointestinal bleeding
– PU
– Hemorragic gastritis
– Others
• Dieufoy disease, HSP, mellory-weiss
syndrom。。。
• Gastroesophageal varices
•Spout Hemostatic agents
•Ingection (histoacryl。。。)
•clips
Scelotherapy or ligation
Tetanium folder hemostasis
Esophageal varices sclerotherapy
Esophageal varices ligation
preoperative intraoperative
1 wk postoperative 4 months postoperative
Endoscopic treatment of
esophageal stenosis
• Dilation
– Ballon dilator
– Water ballon dilator
– Savary bougies
• Stent placement
• Laser
• Heat
• High frequency electrocoagulation
Water ballon dialation
Savary-Gilliard bougie dilation
Heat treatment for webbed esophagus
POEM for achalacia
(Peroral endoscopic myotomy)
— Fang Y, et al. 2015
Percutaneous Endoscopic gastrostomy
(PEG)
• Indication : Malnutrition due to various feeding
difficulty need long term nutritional support with
normal gastrointestinal function
– Dysphagia caused by Nervous diseases and
systemic disease
– Long term PN with infection
– Severe biliary fistula leading bile back to the
gastrointestinal tract
– EN more than 1 momths
PEG/PEGJ
Percutaneous Endoscopic Gastro-Jejeunostomy
(PEGJ)
• Not torelate gastric tube feeding
– Gastric relaxation
– Gastroesophageal reflux
• PEG ajusted to PEGJ
• Enteral Feeding tubes inserted into the
duodenum through the stomach feeding tube
PEGJ
Endoscopic retrograde
cholangiopancretography (ERCP)
ERCP
• To confirm duct stone
• To clear the cause and nature site of
obstruction judice
• To diagose chronic pancreatitis
• To get pacreatic juice for gene detection
• Only way to diagnose pancreas
schizophrenia
EST
• EST lithotomy
• Acute obstructive suppurative
cholangitis
• Acute gallstone pancreatitis
• Biliary obstruction
• Biliary stent placement
pancreas schizophrenia
Normal Chronic
pancreatitis
Chronic pancreatitis，duct cyst
In the future
• Standardization of pediatric endoscopy
• Actively expand the field of endoscopic therapy
• Improve the diagnosis and treatment of small bowel diseases
• Strictly regulate the endoscope cleaning and disinfection processes
• To find and issue the guideline and trainee program for improing medical care
Conclusion
• Endoscopic procedure in the pediatric
population is safe and effectiveness
• Consideration for appropriate indication
• Be ware of potetial risk and complication
