POSTER SESSION I THURSDAY, OCTOBER 2, 2003 5:00 PM–7:00 PM

A PROSPECTIVE STUDY TO ASSESS THE EFFICACY OF BOWEL PREPARATION IN PEDIATRIC PATIENTS WITH THE USE OF A BOWEL CLEANSING PREPARATION AND A NUTRITIONAL FOOD PACKAGE COMPARED WITH ORAL SODIUM PHOSPHATE. Mohammad F El-Baba, Mary Padilla, Shailender Madani, Chuan-Hao Lin, Ronald Thomas, Vasundhara Tolia, Children's Hospital of Michigan, Wayne State University, Detroit, MI A clean colon is essential for adequate visualization during colonoscopy. The inability of children to comply with preparation regimens requiring restricted diets and the intake of cleansing medications can result in poorly cleansed colon and sub optimal visualization of the colon. Aim of this study is to evaluate the adequacy and acceptance of the bowel cleansing prep and nutritional food package for colonoscopies in children. The pre-packaged low residue liquid and solid foods in combination of magnesium citrate, Bisacodyl tablets and suppository (E-Z-EM®), was compared with oral sodium phosphate (Fleet Phospho-Soda®). Patients were randomly assigned to one of two study preparations: group 1 received magnesium citrate, oral bisacodyl tablets and a pre-packaged low residue solid and liquid foods on the day prior to colonoscopy, and bisacodyl suppository administered on the day of the procedure at least one hour prior to departure. Group 2 received clear liquids and fleet phospho-soda on the day prior to colonoscopy. There were 36 patients in group 1 (Age 6–20 yr,16 males), and 26 patients in group 2 (age 4.5–18 yr, 12 males). The adequacy of bowel preparation was graded by the blinded endoscopist performing the procedure. The preparations were rated by patients for tolerance, compliance, side effects and desire for food. Summerized in table TABLETableE-Z-EM bowel cleansing preparation and nutritional food package resulted in a superior colon cleansing, decreased amount of retained stool, and less desire for food as compared to oral sodium phosphate. Both regimens did not significantly differ in adequacy of colon visualization, preparation tolerance, side effects or compliance. DIAGNOSTIC YIELD OF PUSH ENTEROSCOPY IN CHILDREN IS DEPENDANT ON THE CLINICAL INDICATION FOR THE PROCEDURE. Anil Darbari, Anthony Kalloo, Carmen Cuffari, Johns Hopkins University, Baltimore, MD; Johns Hopkins University, Baltimore, MD Despite widespread safe and effective use of push enteroscopy for several years in adult patients, reports on push enteroscopy in children are scarce. The aim of our study was to assess the diagnostic value of push enteroscopy in children according to indication. Between January 2001 and June 2003, 33 consecutive patients (M:F 19:14) underwent push enteroscopy. The median age (range) of the patients was 12.8 (8.2–18.6) years. Push enteroscopy was performed using enteroscope SF-100(Olympus America, Inc.) or pediatric colonoscope. The indications were radiological abnormalities of small bowel, heme positive stools with prior normal endoscopy ±colonoscopy, chronic diarrhea/ failure to thrive (FTT), abdominal pain and unexplained iron deficiency anemia. All patients had underwent prior negative etiological investigations. The proximal small bowel was explored 80–148 cm (Figure). Overtube was not used in any patient; fluoroscopy was used in one to confirm the location of anastamotic ulcer. The push enteroscopy was reported beyond the ligament of Treitz in all patients. Radiological small bowel abnormalities: push enteroscopy provided a diagnosis or modified the interpretation of radiological findings in 18/20 cases (90%). The common histologic diagnoses were Crohn's disease (55%), eosinophilic gastroenteropathy (25%) and post-transplant lymphoproliferative disease (15%). Heme positive stools: lesions of the small bowel were found in 5/7 of patients (71.4%). All patients had therapeutic procedures performed during/after push enteroscopy. Chronic diarrhea/ FTT: push enteroscopy yielded explanatory findings in 1/3 cases (33.3%). Abdominal pain (2 cases) and unexplained iron deficiency anemia (1 case): Push enteroscopy provided no diagnosis. Push enteroscopy was of particular value in investigating children with radiological abnormalities of the small bowel, and heme positive stool (prior normal upper endoscopy ±colonoscopy). It was of some value in the exploration of children with chronic diarrhea/FTT, but not of abdominal pain or unexplained iron deficiency anemia. The diagnostic yield of push enteroscopy in children appears to be dependant on the clinical indication of the procedure. Prospective trials are needed to confirm our findings. ENDOSCOPIC MANAGEMENT OF ESOPHAGEAL AND GASTRIC FOREIGN BODIES IN CHILDREN. Shivinder Narwal, Graciela Wetzler, Sundeep Arora, Maimonides Medical Center, Division of Pediatric GI, Brooklyn, NY Foreign body (FB) ingestion is a common problem in children and endoscopic removal of FB is an important therapeutic endoscopic application. Frequently ingested FBs are coins, pins, round stones, marbles, nails, batteries and jewelry. Coins are the most frequent FB ingested in all age groups. In the past 7 years, 130 children underwent endoscopic removal of FB at Maimonides Medical Center. Endoscopic removal of FBs and urgency of the procedure was decided upon by the gastroenterologist based on the location, size and the type of the FB. A chest and abdominal radiograph was obtained in all the patients prior to the procedure. Indications for the removal of FBs were: 1) Esophageal FBs 2) sharp or pointed FBs 3) FBs longer than 4 cm and wider than 25 mm and 4) alkaline and disc batteries. All procedures were performed in the endoscopy suite. Sedation was provided by pediatric anesthesiologist in all the cases. Twenty-five children with FBs in the proximal esophagus were intubated to secure the airway. Disc and alkaline batteries were removed within 4 hours of notification to avoid corrosive injuries. Sharp objects from esophagus and stomach were removed immediately. FBs in the stomach, which remained over four weeks were also electively removed because of parental anxiety and abdominal pain. All FBs which met the criteria of endoscopic removal were successfully removed endoscopically by using fiberoptic flexible endoscope, rat tooth forceps, alligator forceps and the stone/polyp retrieval baskets. No complications were observed during or after the procedure. The frequency of occurrence of various FBs were: Coins(112), Magnet(1); Food bolus(5); Safety pin(1); Bracelet (1); Hairclip(1); Plastic toy(1); ring(1); Fruit pits(2); Pin(3); Sharp screw(1); Thumb-tack(1). Multiple FB ingestion was noted in 5 children. Accidental foreign body ingestion is a common pediatric emergency necessitating intervention. Fiberoptic flexible endoscopic removal is a safe and successful technique, which allows the removal of the FB under direct visualization without any complications. PATTERNS OF USE IN PEDIATRIC ENDOSCOPY. Mark A Gilger, Mai El Mallah, Craig L Dietrich, Benjamin D Gold, Eric G Hassell, Melvin B Heyman, Baylor College of Medicine, Houston, TX; Emory University School of Medicine, Atlanta, GA; British Columbia Children's Hospital, Vancouver, BC, Canada; University of California at San Francisco, San Francisco, CA Endoscopy is a common procedure in pediatric practice, but why is it performed in children? PEDS-CORI (Pediatric Endoscopy Database System – Clinical Outcomes Research Initiative), was developed to promote scientific inquiry into the need, efficacy, costs & outcomes of pediatric endoscopy. The database was queried to characterize the practice of endoscopy in children. PEDS-CORI stores information on 14,142 endoscopies from 15 children's hospitals. The database was used to determine the type, frequency, indication & findings of all procedures. 8768 (62%) of all procedures were EGDs (esophago-gastro-duodenoscopy), 3394 (24%) were colonoscopies, 1061 (7.5%) were flexible sigmoidoscopies, 212 (1.5%) were ERCPs (endoscopic retrograde cholangiopancreatography) & 5% were other procedures. The M:F ratio was about 1:1. 83% of the procedures were outpatient. The mean age for subjects undergoing endoscopy was 10.2 years (1 m/o to 19 y/o), with 40% between 5–10 y/o. The most common indications for EGD were abdominal pain (38%), vomiting (20%) & reflux (16%). 4948 (56%) of EGDs had a significant finding including mucosal abnormalities (e.g. erosions, erythema, friability) (38%), esophageal inflammation (23%), hiatal hernia (7%), foreign body (5%), ulcer (4%), stricture (4%) & other (e.g., chronic disease, deformity, etc.)(16%). The most common indications for colonoscopy were abdominal pain (31%), hematochezia (31%) & diarrhea (24%). 2062 (60%) of colonscopies had significant findings including mucosal abnormalities (e.g., erosions, granularity, vascular irregularities, etc.) (32%), colitis/Crohn's (17%), polyps (14%), erythema/edema (7%) & other (e.g., fissure, hyperplasia, etc.)(30%). EGD is the most common endoscopic procedure performed in children. Most procedures are performed on children 5-10 y/o. Both EGD (56%) & colonoscopy (60%) have a remarkably high yield of significant findings, supporting the diagnostic role of endoscopy. PEDS-CORI is available to all NASPGHAN members as a powerful tool to explore the patterns of use in pediatric endoscopy & to develop valid, evidence-based guidelines for the care of digestive disease in children. SENSITIVITY OF ENDOSCOPY FOR THE DIAGNOSIS OF GRAFT VERSUS HOST DISEASE. Khalid Khan, Sally S Schindele, Rajaram Nagarajan, University of Minnesota, Minneapolis, MN Post hematopoietic stem cell transplant (HSCT) in children, gastrointestinal (GI) biopsies provide important information regarding infectious processes and graft vs. host disease (GVHD). The site of biopsy is dependent on the patient's symptoms, with most patients expressing both upper and lower GI complaints. Despite their usefulness, endoscopic biopsies are not without risk or limitations. Furthermore anesthesia is often required for upper endosocopy in small children. Flexible sigmoidoscopy while being less invasive gives little access to the intestine as a whole. We examine endoscopic yield from from upper endoscopy and sigmodioscopy for GVHD. We have reviewed the pediatric endoscopy database at the University of Minnesota to identify children who have undergone both upper and lower GI procedures post-HSCT, within 7 days of each other between 1995 and 2001. Only those who had a differential diagnosis of GVHD were included. Chi-square was used for statistical comparison. Forty-seven procedures (combined upper endoscopy and flexible sigmoidoscopy) were performed in 41 individuals (23 males/18 females), the majority of procedures (45/47) being performed on the same day. Pre-transplant diagnoses included; ALL (n=10), AML (n=7), Fanconi's Anemia (n=4), Adrenoleukodystrophy (n=3), Hurler's Syndrome (n=3), and Mucopolysaccharidosis (n=3). The mean age at transplantation was 7.3 years ±5.8 years. The average time from transplantation to endoscopic biopsy was 113 days ± 84 days. Histological abnormalities were found in 31/47; esophagus n=8, stomach n=16, duodenum n=18, rectum n=20. Graft versus host disease was diagnosed in 17/47 based on histology; esophagus n=2, stomach n= 6, duodenum n=14, rectum n=15. When results are combined for histological diagnosis of GVHD on upper endoscopy it is equivalent to rectal biopsy i.e., 15/17. TABLETable: Sensitivity (%) of Intestinal BiopsiesSigmoidoscopy should be considered as the initial procedure for children post HSCT being assessed for gastrointestinal symptoms. Apart from safety issues it has the greatest sensitivity for positive histological findings and particularly the diagnosis of GVHD. URGENT ENDOSCOPY IN CHILDREN WITH DISEASES OF THE UPPER GASTROINTESTINAL TRACT. Toledo ME Trujillo, Gonzalez E Sagaro, Franco M Oduardo, Arbelo T Fragoso, R Acosta, S Anaya, Department of Gastroenterology, “Juan Manuel Marquez” Children's Hospital, Havana Univ., Cuba With the development of new endoscopIes and techniques, urgent endoscopy for the diagnosis and treatment of diseases of the upper gastriontestinal tract in children has become a frequent procedure. The endoscopic reports of 677 patient with 16 years or less, of both sex, that were submitted to an urgent endoscopy in the Pediatric Hospital “ Juan Manuel Marquez” in Havana from January 1990 to December 2001 were reviewed. All the endoscopies were performed under general anesthesia with a pediatric flexible endoscope. The most frequent indication for the procedure were: caustic ingestion, 444 (65.5%), gastrointestinal hemorrhage, 217 (32%), and foreign body ingestion, 16 (2,5%). The corrosive more frequently ingested was alkali in 265 patients (59.8%) and the ingestion was accidental in 99.5% of the cases. 208 patients (33%) had bucofaringeal burns (48%) and in the skin 25 (5,6%). 200 patients had esophageal lesions (45,1%) classified as grade I 57 (12,8%), grade II 44 (9,9%), grade III 61 (13,7%) and grade IV 38 (8,5%). Children with gastrointestinal hemorrhage had Acute Hemorrhagic Gastritis 85 (39%), esophageal varices 42 (19,3%) and Peptic Ulcer 24 (11%). The 93% of the foreign bodies were extracted endoscopically, being coins the most frequently found. Urgent endoscopy is a useful procedure for the diagnosis and treatment of the diseases of the upper gastriontestinal tract in children. There were no complications, so the procedure is a safe one. As in our setting accidents are frequent we must insist in the prevention of them and education of the population. USEFULNESS AND ACCURACY OF DUODENAL ENDOSCOPIC BIOPSY IN LEUKEMIC OR BONE-MARROW TRANSPLANTED PATIENTS? Emmanuel MAS, Pierre Brochu, Steven Martin, Hopital Sainte-Justine, Montreal, QC, Canada The complication rate of esophagogastroduodenoscopy (EGD) is less than 2%, essentially with minor cardiopulmonary events. Intramural duodenal hematoma (IMDH) has been described, although the incidence is unknown. While trauma remains the main cause of IMDH, 16 cases were reported after EGD and duodenal biopsy (7 more after per-oral capsule biopsy); half of these occurred in hematology patients. We report 3 new cases of IMDH, occurring in our institution between 2000/10 and 2002/12. Moreover, we performed 11 EGD in hematology patients between 2001/04/01 and 2002/03/31, including 3 BMT recipients. The patients include a 3 month-old girl with bone-marrow transplant (BMT) for CD11-CD18 deficiency, a 10 year-old boy with Burkitt leukemia and a 7 year-old boy with BMT for acute leukemia relapse. The indications for EGD were suspected GVHD or vomiting. The platelet counts before EGD were 46000, 185000 and 52000/mm3 (post-transfusion). INR was normal in all. Between 12 and 16 hours after EGD, the patients developed severe abdominal pain and vomiting, with hematemesis in 2. US and CT scan showed IMDH with intestinal obstruction. Conservative management (gastric suction, TPN) was chosen as reported in the literature. Two patients required red cell or platelet transfusion. The course was complicated by pancreatitis (2/3), cholestasis (2/3). The first patient required TPN for 2 months; the second was discharged 11 days later on oral intake and the third died one month later from ARDS related to infection, while IMDH remained associated with dilated biliary and pancreatic ducts. At EGD, macroscopic findings included respectively: gastric corpus petechiae, mild esophagitis, esophageal ulcers. The only specific change in esophageal, gastric and duodenal biopsies was esophageal HSV culture positive for the last patient. Excessive depth of the biopsy and vascular trauma were retrospectively eliminated by our pathologist. In hematology patients, a normal clotting time and platelet count of at least 50000/mm3 do not guarantee the safety of duodenal biopsy, suggesting that it should be avoided to reduce the risk of IMDH. Some authors report that antral biopsy is more often positive than duodenal biopsy in GVHD. But if there is an indication for a duodenal biopsy, more conservative limits of coagulation and platelet function are certainly necessary. WIRELESS CAPSULE ENDOSCOPY FOR GASTROINTESTINAL BLEEDNG DUE TO INTESTINAL VASCULAR ANOMALIES. Bradley A Barth, Steven J Fishman, Victor L Fox, Children's Hospital, Harvard Medical School, Boston, MA Gastrointestinal vascular malformations (GIVM) are rare anomalies of embryonic vascular morphogenesis that often present with either chronic low-grade bleeding or acute massive hemorrhage. Treatment options depend on accurate determination of the location and extent of bowel involvement. Wireless capsule endoscopy (WCE) is an ideal tool for evaluating patients with GIVM since it affords non-operative evaluation of the entire small bowel. We present our initial experience and the first pediatric and young adult series of WCE for GIVM and rectal bleeding. Eight patients were studied, age 4-24 years (median =12), after with acute or chronic bleeding and of a vascular from to All patients underwent prior to WCE including with scan (n=7), scan small bowel (n=4), and (n=3). Endoscopy gastric antral vascular with bleeding duodenal mild gastric and vascular patients underwent small duodenal normal small bowel findings (n=4), and vascular were endoscopically in 5 patients to young age or inability to was used in two patients after endoscopic WCE was in all patients and GIVM of the small bowel in 5 of 7 were or dilated and (n=4), with a or capsule into the stomach it remained for the of the after endoscopic It the day. bowel time from one patient has undergone successful by WCE findings. WCE appears to be a safe and more tool than for small bowel vascular about location and extent of lesions be used to therapeutic intervention. The optimal and for WCE in small children WIRELESS CAPSULE STUDY IN PEDIATRIC AND G University of Montreal, Montreal, QC, Canada Wireless capsule endoscopy is a diagnostic for small bowel to the and safety of capsule endoscopy in pediatric and adult patients. The for all patients to our for a capsule endoscopy to were reviewed and into pediatric and adult age groups. The were in of gastric and small bowel time and diagnostic endoscopy was performed in and In the pediatric group the indications were disease and or bleeding In bleeding was the most common indication with Crohn's disease suspected in the The capsule to the stomach in only 3 all of the pediatric patients required any 10 of the received a liquid (1 and capsule was to any in a All 4 of these were the 3 adult patients with severe required endoscopic of the capsule into the to the capsule also had it into the The small bowel was to the in of pediatric and of The mean was in the pediatric group vs. A capsule was retained in the small bowel for an to an in 2 cases 1 in each age A small bowel performed prior to capsule to the stricture in either The without after treatment with The and in pediatric and adult groups. the of the small bowel were in both of of The capsule lesions in of pediatric and of the was normal in all No were endoscopy is a safe and in pediatric patients over the age of 5 is to adult and not bowel

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