Common Indications and The Diagnostic Yield of Esophagogastroduodenoscopy in Children with Gastrointestinal Distress

Abstract

Background The number of inconspicuous results of esophagogastroduodenoscopies (EGDs) in childhood appears to be disturbingly high. The aim of this study was to analyze the diagnostic yield of EGD and to determine its relevance of specific clinical indications.

Methods We performed a retrospective analysis of 380 consecutive pediatric patients who underwent diagnostic EGD in two German level I pediatric gastroenterology departments in 2015 and 2016.

Results 44% of the 380 patients were male and 17% were younger than 5 years old. 55% of all EGDs (n=210) did not yield a pathological result. 27% (n=104) of all EGDs were performed due to nonspecific symptoms (epigastralgia, nausea). Strikingly, in this group, 88% (n=91) showed normal results and in only 12% a diagnosis was made: reflux esophagitis (n=5), Helicobacter pylori (HP) gastritis (n=6) or hemorrhagic gastritis (n=1). Fewer inconspicuous EGDs were performed in patients with dysphagia (68%) or heartburn and reflux (61%). 59 patients were examined due to serologically elevated celiac antibodies. Here, the diagnosis could be confirmed histopathologically in 78% (n=46). Of the 37 patients with abdominal pain and a previously positive non-invasive HP test, EGD served to establish the diagnosis of HP gastritis in 84%.

Conclusions The diagnostic yield for EGDs is increased in patients with more specific symptoms (i. e. dysphagia, heartburn, HP, celiac disease). Consequently, as an invasive procedure, EGD warrants a strict indication.

Zusammenfassung

Hintergrund Die Zahl der unauffälligen Befunde der Ösophago-Gastro-Duodenoskopien (ÖGDs) im Kindes- und Jugendalter scheint beunruhigenderweise hoch zu sein. Das Ziel der folgenden Studie war es, den diagnostischen Stellenwert von ÖGDs bei Kindern zu analysieren und die Relevanz von spezifischen, klinischen Indikationen für auffällige ÖGD-Befunde zu ermitteln.

Methoden Wir führten eine retrospektive Studie von insgesamt 380 durchgeführten ÖGDs bei pädiatrischen Patienten in 2 großen pädiatrischen gastroenterologischen Abteilungen in den Jahren 2015 und 2016 durch.

Ergebnisse 44% der 380 Patienten waren männlich und 17% der Patienten waren jünger als 4 Jahre alt. 55% aller durchgeführten ÖGDs (n=210) ergaben keine pathologischen Befunde. 27% (n=104) aller ÖGDs wurden aufgrund von nicht-spezifischen Symptomen wie Oberbauchschmerzen oder Übelkeit durchgeführt. Interessanterweise hatten in dieser Gruppe 88% (n=91) der Patienten einen unauffälligen Befund und in nur 12% konnte eine eindeutige Diagnose gestellt werden: Refluxösophagitis (n=5), Helicobacter pylori (HP) Gastritis (n=6) oder hämorrhagische Gastritis (n=1). Weniger unauffällige ÖGD-Befunde waren v. a. bei Patienten mit Dysphagie (68%) oder Sodbrennen und Reflux (61%) vorkommend. 59 Patienten wurden einer ÖGD aufgrund serologisch erhöhter Zöliakie-Autoantikörper unterzogen. Hier konnte die Diagnose histopathologisch in 78% (n=46) bestätigt werden. Von den 37 Patienten mit Bauchschmerzen und einem positiven nicht-invasiven HP-Test, konnte mittels ÖGD die Diagnose einer HP-Gastritis in 84% der Fälle nachgewiesen werden.

Schlussfolgerung Der diagnostische Nutzen von ÖGDs ist v. a. bei Patienten mit spezifischen Symptomen hoch (Dysphagie, Sodbrennen, HP, Zöliakie). Die Indikation zur ÖGD als invasives diagnostisches Instrumentarium sollte v. a. bei Kindern streng gestellt werden

Key words

esophagogastroduodenoscopy - indication - Helicobacter pylori - dysphagia - reflux - abdominal pain

Schlüsselwörter

Ösophago-Gastro-Duodenoskopie - Indikationsstellung - Helicobacter pylori - Dysphagie - Reflux - Bauchschmerzen

• References

• 1 Belsha D, Bremner R, Thomson M. Indications for gastrointestinal endoscopy in childhood. Arch Dis Child 2016; 101: 1153-1160
• 2 D’Agostino J. Common abdominal emergencies in children. Emerg Med Clin North Am 2002; 20: 139-153
• 3 Dhroove G, Chogle A, Saps M. A million-dollar work-up for abdominal pain: is it worth it?. J Pediatr Gastroenterol Nutr 2010; 51: 579-583
• 4 Di Lorenzo C, Colletti RB, Lehmann HP. et al. Chronic abdominal pain in children: a clinical report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastreonterol Nutr 2005; 40: 245-248
• 5 Di Lorenzo C. EGD for children with abdominal pain: the jury is still out. Nat Rev Gastroenterol & Hepatol 2013; 10: 701-703
• 6 Drossmann AD. Functional gastrointestinal disorders: History, pathophysiology, clinical features, and rome IV. Gastroenterology 2016; 150: 1262-1279
• 7 El-Serag HB, Balley NR, Gilger M. et al. Endoscopic manifestations of gastroesophageal reflux disease in patients between 18 months and 25 years without neurological deficits. Am J Gastroenterol 2002; 97: 1635-1639
• 8 Gilger MA, Gold BD. Pediatric endoscopy: new information from the PEDS-CORI Project. Curr Gastroenterol Rep 2005; 7: 234-239
• 9 Guariso G, Meneghel A, Dalla Pozza LV. et al. Indications to upper gastrointestinal endoscopy in children with dyspepsia. J Pediatr Gastroenterol Nutr 2010; 50: 493-499
• 10 Husby S, Koletzko S, Korponay-Szabo IR. et al. European society for pediatric gastroenterology, hepatology, and nutrition guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr 2012; 54: 136-160
• 11 Hyams JS, Burke G, Davis PM. et al. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr 1996; 129: 220-226
• 12 Jones NL, Koletzko S, Goodman K. et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr 2017; 64: 991-1003
• 13 Kaitha SR, Salem G, Zhao YD. et al. The impact on endoscopic resource utilization after a targeted intervention for cost-minimization of egd and colonoscopy. Am J Gastroenterol 2016; 111: 1559-1563
• 14 Koletzko S, Jones NL, Goodman KJ. et al. Evidence-based guidelines from ESPGHAN and NASPGHAN for Helicobacter pylori infection in children. J Pediatr Gastroenterol Nutr 2011; 53: 230-243
• 15 Lane MM, Weidler EM, Czyzewski DI. et al. Pain symptoms and stooling patterns do not drive diagnostic costs for children with functional abdominal pain and irritable bowel syndrome in primary or tertiary care. Pediatrics 2009; 123: 758-764
• 16 Lee WS, Zainuddin H, Boey CC. et al. Appropriateness, endoscopic findings and contributive yield of pediatric gastrointestinal endoscopy. World J Gastroenterol 2013; 19: 9077-9083
• 17 Nelsen EM, Lochmann-Bailkey A, Grimes IC. et al. Low yield and high cost of gastric and duodenal biopsies for investigation of symptoms of abdominal pain during routine esophagogastroduodenoscopy. Dig Dis Sci 2017; 62: 418-423
• 18 Quitadamo P. Di Nardo Giovanni Miele E. et al. Gastroesophageal reflux in young children and adolescents: Is there a relation between symptom severity and esophageal histological grade?. JPGN 2015; 60: 318-321
• 19 Rasquin A, Di Lorenzo C, Forbes D. et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology 2006; 130: 1527-1537
• 20 Rippel SW, Acra S, Correa H. et al. Pediatric patients with dyspepsia have chronic symptoms, anxiety, and lower quality of life as adolescents and adults. Gastroenterology 2012; 142: 754-761
• 21 Sandler RS, Everhart JE, Donowitz M. et al. The burden of selected digestive diseases in the United States. Gastroenterolgy 2002; 122: 1500-1511
• 22 Sharma VK, Nguyen CC, Crowel MD. et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc 2007; 66: 27-34
• 23 Sherman P, Hassall E, Fagundes-Neto U. et al. A global evidence-based consensus on the definition of gastroesophageal reflux disease in children. Am J Gastroenterol 2009; 104: 1278-1295
• 24 Starfield B, Hoekelman R, Mc Cormick M. et al. Who provides health care to children and adolescents in the United States?. Pediatrics 1984; 74: 991-997
• 25 Thakkar K, Chen L, Tatevian N. et al. Diagnostic yield of oesophagogastroduodenoscopy in children with abdominal pain. Aliment Pharmacol Ther 2009; 30: 662-669
• 26 Thakkar K, Chen L, Tessier ME. et al. Outcomes of children following esophagogastroduodenoscopy for chronic abdominal pain. Clin Gastroenterol Hepatol 2014; 12: 963-969
• 27 Thakkar K, Dorsey F, Gilger MA. Impact of endoscopy on management of chronic abdominal pain in children. Dig Dis Sci 2011; 56: 488-493
• 28 Thakkar K, El-Serag HB, Mattek N. et al. Complications of pediatric EGD: a 4-year experience in PEDS-CORI. Gastrointest Endosc 2007; 65: 213-221
• 29 Thakkar K, Gilger MA, Shulman RJ. et al. EGD in children with abdominal pain: a systemic review. American J of Gastroenterology 2007; 102: 654-661
• 30 Trovato CM, Montuori M, Anania C. et al. Are ESPGHAN “biopsy-sparing” guidelines for celiac disease also suitable for asymptomatic patients?. Am J Gastroenterol 2015; DOI: 10.1038/ajg.2015. 285.
• 31 Uc A, Hyman PE, Walker LS. Functional gastrointestinal disorders in African American children in primary care. J Pediatr Gastroenterol Nutr 2006; 42: 270-274
• 32 Werkstetter KJ, Korponay-Szabo IR, Popp A. et al. Accuracy in diagnosis of celiac disease without biopsies in clinical practice. Gastroenterology 2017; DOI: 10.1053/j.gastro.2017.06.002,. [Epub ahead of print]