SYMPOSIUM: GASTROENTEROLOGY

When to do paediatric
gastrointestinal endoscopy?

the development of a sub-specialty focused on disorders of the

paediatric GI tract, new technologies such as paediatric endoscopy were developed to aid diagnoses. Paediatric oesophagogastroduodenoscopy (OGD) began in the 1970s and since that
time, it has evolved from an infrequent procedure in the operating room with a single ocular operator view for macroscopic
inspection of the GI-tract to a routine day case procedure. There
is a structured grid training programme for prospective trainees
in the United Kingdom (UK) that has emerged from earlier
training of paediatricians in adult gastroenterology units and an
increased recognition of GI disorders that are unique to children.
Endoscopists these days also enjoy macroscopic views using
large high definition viewing screens with the option of video
recording and obtaining still pictures.

Mansoor Ahmed
Ashok Karupaiah

Abstract
Over the last few decades, paediatric gastroenterology has rapidly developed into a well-established sub-specialty. Improvements in training and
equipment have led to enhanced safety with fewer complications
following endoscopies. In specialized units, diagnostic and therapeutic
upper gastrointestinal endoscopy and proctosigmoidoscopy/colonoscopy
are regularly performed under conscious sedation or general anaesthesia.
Emerging guidelines and new advances in the diagnostic tools are being
incorporated into routine paediatric gastrointestinal endoscopy practice.

GI endoscopy
The most frequently performed GI endoscopies in children are
diagnostic OGD and proctosigmoidoscopy/colonoscopy. Other
diagnostic and therapeutic interventions include endoscopic
retrograde cholangiopancreatography, dilatation of oesophageal
strictures, vascular ligation or sclerotherapy for bleeding varices,
foreign body retrieval, insertion of percutaneous endoscopic
gastrostomy (PEG) and polypectomy. Moreover, new disorders
such as Eosinophilic Oesophagitis (EO) have been established as
well-known entity.
New and emerging modalities like video capsule endoscopy,
balloon assisted enteroscopy and narrow band imaging are being
established in paediatric GI practice and may be incorporated
into routine diagnostics in the future. Despite an increase in the
number of GI endoscopies over the years, diagnostic yield with
abnormal histology results remains constant at 62e67%. This
suggests that the increase in number of paediatric endoscopies
performed is due to increased demand rather than lower
threshold for the procedure. Small number of negative/normal
endoscopies is important to ensure satisfactory pick up rate of all
significant pathologies. Normal endoscopy may also influence
management decisions by reassuring patient/parents as well as
clinicians.

Keywords children; colonoscopy; criteria; endoscopy; gastrointestinal

tract

Introduction
The field of paediatric gastroenterology has evolved into a defined
sub-specialty over the last few decades. The number of paediatric
gastroenterologists has increased steadily worldwide. Over the
recent years, dramatic improvements in the equipment including
fibre optic and video technology, greater availability of dedicated
sessions, nursing support, approved training curriculum and
enhanced training opportunities have improved successful and
safe execution of paediatric gastrointestinal (GI) endoscopy. GI
endoscopy remains one facet of a thoughtful and judicious use of
investigations undertaken by a clinician who is competent in
making informed decisions while taking into consideration its
benefits vs risks, safety aspects, patient/parent preference and
availability of alternative investigation modality. Like any investigation requested, paediatric GI endoscopy is only useful when it
is likely to influence management, resulting in an improved
outcome. Worldwide, the decision to perform GI endoscopy may
also be influenced by its availability, cost and necessary expertise.

Patient preparation and consent

Historical perspective

Preparation for gastrointestinal endoscopy involves providing

adequate verbal and written information to parents/child. It is
crucial to provide sufficient information (e.g. potential risks and
benefits of the procedure using an age-appropriate language) in
good time before the actual date of procedure. Physiological,
psychosocial and emotional needs of paediatric patients and their
parents should be taken into consideration. Prior to elective
procedure, informed consent from parents or guardians should
be obtained. It is equally important to document key elements of
this consultation in patient notes.

Since its inception in the 1960s, paediatric gastroenterology has

rapidly established itself into a recognised sub-specialty. With
Abbreviations: GI, Gastrointestinal; OGD, Oesophagogastroduodenoscopy; UK, United Kingdom; PEG, Percutaneous Endoscopic Gastrostomy;
EO, Eosinophilic Oesophagitis; PPI, Proton Pump Inhibitor; GORD, GastroOesophageal Reflux Disease; HP, Helicobacter Pylori; ESPGHAN, European
Society of Paediatric Gastroenterology Hepatology and Nutrition;
BSPGHAN, British Society of Paediatric Gastroenterology Hepatology and
Nutrition; EMA, Endomysial Antibody; IBD, Inflammatory Bowel Disease;
UC, Ulcerative Colitis; FAP, Familial Adenomatous Polyposis; PJS, PeutzJeghers Syndrome; APC, Adenomatous Polyposis Coli.
Mansoor Ahmed

MBBS FRCP FRCPCH

Risks/complications of GI endoscopy
Rare risks of GI endoscopy include bleeding, infection and
perforation. Bleeding after colonoscopy is usually minimal and
self limited (may occur after mucosal biopsy or polypectomy).
Depending on the case series, bleeding has been documented to
occur in 0.26%e2.5% of patients after colonoscopy. Colonic

is a Consultant Paediatrician at

Queens Hospital, Burton Upon Trent, UK. Conflicts of interest: none.

Ashok Karupaiah MBBS MRCPCH is an ST-5 Paediatrics at Queens
Hospital, Burton Upon Trent, UK. Conflicts of interest: none.

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SYMPOSIUM: GASTROENTEROLOGY

administered to control behaviour to allow safe completion of

endoscopic procedure. During conscious sedation, there remains
a risk of aspiration and occasional patients may progress to deep
sedation with respiratory depression, hypoventilation, apnoea,
airway obstruction, laryngospasm, and cardiopulmonary
impairment. Some of the patients given midazolam may develop
paradoxical excitement and aggression during the procedure.
It is recommended that all patients having conscious sedation
during GI endoscopy should be monitored by an appropriately
skilled professional (other than endoscopist/operator) who is
competent in monitoring and maintaining the airway in case of
airway compromise. General anaesthesia, on the other hand,
provides a more conducive environment for the endoscopist and
a well protected airway. It also provides a pain/distress free
experience for the patient.

perforation is the most serious complication of colonoscopy in

children and is either during polypectomy or related to forceful
insertion of colonoscope while negotiating acute bends (especially in a child with macroscopic evidence of moderate/severe
colitis). Its risk ranges from 0.06% to 0.3%. Risk of bacteraemia
is quite rare even after polypectomy and multiple biopsies.

Pre-procedural assessment
Pre-procedural assessment includes a thorough evaluation
including history of previous sedation/anaesthesia, medication
and allergies. Focussed physical examination involves special
focus on the airway/breathing system. It is important to examine
and document any relevant findings such as loose teeth, oral
piercings and enlarged tonsils. Loose teeth can be accidentally
dislodged when entering the airway. Significantly enlarged tonsils and adenoid hypertrophy can result in breathing difficulties
and obstructive apnoea in sedated patients.
Laboratory tests may include coagulation screening and full
blood count (especially prior to therapeutic endoscopies). However, in the absence of significant past medical history, the significance of pre-endoscopic routine blood tests such as
coagulation screening is limited. It is natural for young children
and teenage youngsters to be anxious prior to the procedure.
Presence of parents during pre-procedural preparation and use of
premedication with benzodiazepines has been shown to reduce
anxiety and fear prior to the procedure. Midazolam has also been
shown to reduce the emotional stress and makes the patient feel
more comfortable during intervention.

Upper GI endoscopy
An upper GI endoscopy is the most useful resource for evaluating
oesophageal, gastric and duodenal pathology. Majority of the
OGDs are performed for diagnostic purposes. The endoscopist is
able to perform macroscopic evaluation of upper GI mucosa up
to and including 2nd part of duodenum in all the cases. During
OGD, biopsies are usually taken from various parts of upper GI
tract for histological evaluation. Insertion beyond 2nd part of
duodenum is also achievable in some patients.

Diagnostic OGD
Diagnostic OGD is the standard method of detecting and diagnosing many GI disorders. The threshold for examination varies
with personal practice and ease of availability. Table 1 outlines
common diagnostic indications for OGD in infants/children. One
of the most frequent indication for OGD has been to confirm the
diagnosis of coeliac disease. Other indications include upper
abdominal pain and/or discomfort (mostly epigastric) with red
flags in history or on examination (e.g. weight loss, anorexia,
anaemia). In many instances, OGD is undertaken for epigastric/
retrosternal pain or discomfort which persists despite a course of
Proton Pump Inhibitor (PPI) therapy. Intermittent episodes of
vomiting, complicated gastro-oesophageal reflux disease (GORD)
and suspected symptomatic Helicobacter Pylori (HP) gastritis
may also warrant an OGD. Disaccharidase enzyme evaluation
(e.g. lactase test) may also be carried out during OGD.

Advice on dietary restrictions and bowel preparation

Pre-procedural fasting and bowel preparation depends on patients age, type of sedation or general anaesthesia and the
planned procedure (e.g. OGD or colonoscopy). Agents used for
sedation have the potential to impair protective airway reflexes,
particularly during deep sedation. Although a rare occurrence,
pulmonary aspiration may occur if the child regurgitates during
sedation due to inability to protect his or her airway. Usual
recommendation is to fast from solids/formula feeds for 6 hours,
breast milk for 4 hours and clear fluids (e.g. water) for 2 hours
before the procedure. However, one should follow local guidelines and policies.
Since there is no ideal bowel cleansing regimen in children,
various protocols have been developed and followed in different
institutions. There is no consensus on the use of an ideal pharmacological preparation for bowl cleansing prior to colonoscopy.
Polyethylene glycol based solutions with electrolytes or stimulant laxatives are used in various combinations to achieve
desirable results. In infants, adequate preparation can usually be
obtained with cautious use of small-volume enemas.

Diagnostic paediatric OGD-indications

Coeliac disease
Vomiting/intractable or chronic GORD
HP infection
Chronic abdominal pain with significant morbidity or signs
of organic disease
Anorexia/weight loss/faltering growth
Unexplained anaemia
Crohns disease/IBD
Chronic diarrhoea/malabsorption
Unexplained melaena

Sedation vs general anaesthesia

OGD and colonoscopy in children are generally performed either
under moderate (conscious) sedation or general anaesthesia.
This largely depends upon local facilities and arrangements.
Advantages of conscious sedation include maintaining protective
airway reflex, spontaneous breathing during the procedure and
quick recovery afterwards. Sedation in children is often

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Table 1

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OGD and coeliac disease

from adults with respect to HP infection in terms of its prevalence, complication rate, near-absence of gastric malignancies,
age-specific problems with diagnostic tests/drugs and higher rate
of antibiotic resistance. Compared with adults, peptic ulcer disease is found less often in infected children undergoing OGD.
ESPGHAN recommends that the initial diagnosis of H pylori
infection should be based on either positive histopathology and
positive rapid urease test or a positive culture. For the diagnosis
of H pylori infection during OGD, ESPGHAN also recommends
that 2 biopsies should be obtained from both the gastric antrum
and the corpus for histopathology. Because the density of HP
may be patchy, the sensitivity increases with the number of biopsies taken. The suspicion of an infection is often based on the
macroscopic findings of a nodular mucosa in the antrum
(Figure 1) or bulbus and/or gastric or duodenal erosions or ulcerations. Clinicians should wait at least 2 weeks after stopping
PPI therapy and 4 weeks after stopping antibiotics to perform
biopsy-based and non-invasive tests (urea breath test, stool test)
for HP.

The prevalence of coeliac disease is estimated to be 1:100 in the UK.

Since the introduction of recent European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) guideline on the management of coeliac disease (2012) and its
endorsement by British Society of Paediatric Gastroenterology,
Hepatology and Nutrition (BSPGHAN) and Coeliac UK (2013),
there has been a decline in OGD for this indication. Current
recommendation suggests that the presence of raised tissue
transglutaminase antibodies (>10 times the upper limit of normal)
in a symptomatic patient with normal immunoglobulin A levels
warrants a further blood sample to check endomysial antibody
(EMA) level and determination of HLA-DQ2/HLA-DQ8 typing. If
EMA is positive and patient is either DQ2 or DQ8 positive then the
diagnosis of coeliac disease is confirmed without the need for a
duodenal biopsy. For other patients requiring OGD for the diagnosis of coeliac disease, BSPGHAN recommends at least 4 biopsies
from 2nd part of duodenum or beyond in addition to 1e2 biopsies
from first part of duodenum/duodenal cap.
Even though mosaic pattern and scalloping of the mucosal
folds have been described in duodenal mucosa in coeliac patients, normal looking macroscopic duodenal mucosa does not
rule out coeliac disease. The histological features of the small
intestinal enteropathy in coeliac disease have a variable severity,
may be patchy and in a small proportion of patients with coeliac
disease, appear only in the duodenal bulb. One should ensure
adequate gluten intake prior to testing with advice from dietician
if necessary. OGD is also carried out to explore the aetiology of
unexplained iron deficiency anaemia which may or may not
represent coeliac disease.

OGD and EO
In the last 10e15 years, EO has received considerable attention as a
new disease entity, with the first consensus report being published in 2007. EO is a disorder that requires OGD with biopsy for
diagnosis and is restricted to the oesophagus. It represents a
chronic, immune/antigen-mediated oesophageal disease characterized clinically by symptoms related to oesophageal dysfunction
and histologically by eosinophil-predominant inflammation and
requires detection of 15 eosinophils per high-power field in 1
biopsy specimens. Other causes of oesophageal eosinophilia
should be excluded, specifically PPI responsive oesophageal
eosinophilia. Sensitivity of detecting EO is dependent upon the
number of oesophageal biopsies taken at the time of diagnosis with
94% sensitivity if four or more biopsies are taken.

OGD and Crohns disease

National surveys of inflammatory bowel disease (IBD) in children
aged <16 years in the UK have showed the incidence to be 5.2e5.4
per 100,000 individuals per year. Routine OGD as well as ileocolonoscopy during the initial evaluation for IBD were not commonly
practiced until the 1990s. Now, there is general consensus amongst
paediatric gastroenterologists to perform OGD as well as colonoscopy during the initial diagnostic evaluation in all suspected
Crohns disease/IBD patients. In children, histological evidence of
Crohns disease in the upper GI tract can be present in up to 30% of
cases even in the absence of upper GI symptoms.
The presence of upper GI tract involvement has long been
considered as a sign of Crohns disease and not UC. However, this
is no longer held to be true as mild ulceration and microscopic
involvement of the stomach are well documented in UC and may
occur in 4e8% of patients. ESPGHAN as well as BSPGHAN
recommend that all children suspected of having IBD should have
upper and lower GI endoscopy preferably with intubation of terminal ileum and multiple biopsies from all segments in the upper
(oesophagus, stomach, duodenum) and lower intestinal tract
(ileum, caecum, ascending colon, transverse colon, descending
colon, sigmoid and rectum) for histological diagnosis.

OGD and HP gastritis

HP infection is usually acquired during the first years of life in
both developing and industrialized countries. Children differ

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Figure 1 Marked nodularity of gastric body (HP gastritis).

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In EO, mucosal abnormalities are well described. However,

none of these are pathognomonic and can be seen in other
pathological conditions. Similarly, presence of a normal esophageal mucosa on endoscopy does not rule out EO. In EO with
active inflammation, macroscopic findings include diminished
vascular pattern, mucosal linear furrowing, thick mucosa and
surface exudates (white plaques). In chronic disease with tissue
remodelling, mucosal abnormalities include crepe-paper mucosa
(mucosal fragility), transient/fixed rings with corrugated mucosa
or trachealization (Figure 2) and strictures. Oesophageal dilatation is an option in children with EO who have oesophageal
stenosis unresponsive to drug therapy.

Therapeutic paediatric OGD-indications

Caustic ingestion (diagnostic  therapeutic)
Dysphagia/Odynophagia (diagnostic  therapeutic)
Haematemesis (diagnostic  therapeutic)
Control of upper GI bleeding/oesophageal variceal banding
Foreign body removal
Dilation of oesophageal strictures
PEG/naso-jejunal tube insertion
Table 2

be treated endoscopically with endoluminal gastroplication in

specialized centres with good outcome.

Therapeutic (diagnostic) OGD

Table 2 delineates some of the universal therapeutic indications
for OGD in infants/children. In many instances, it is difficult to
clearly demarcate diagnostic from therapeutic OGDs. For instance,
after acute volume resuscitation for gastrointestinal bleeding,
endoscopy may be considered for active, persistent or recurrent
bleeding to distinguish between variceal and nonvariceal bleed
and to perform sclerotherapy or banding of oesophageal varices
during or following a bleeding episode. In many centres, OGD for
this indication is carried out by paediatric surgeons.
Depending upon the local arrangements, paediatric gastroenterologist or paediatric surgeon may perform OGD for PEG
insertion or insertion of transpyloric feeding tubes (nasoduodenal or naso-jejunal feeding tube placement). Therapeutic
upper endoscopy is also indicated for removal of selected
polypoid lesions. Dysphagia, odynophagia and/or persistent
refusal to eat may also warrant an OGD. Furthermore, OGD is
carried out following known or suspected ingestion of a caustic
material. Identification of oesophageal stricture warrants oesophageal dilatation during OGD. Severe gastro-oesophageal reflux
disease (refractory to maximal medical therapy) in children can

OGD and foreign body ingestion

Ingested foreign bodies, which have passed beyond the oesophagus, are likely to pass through the rest of the GI tract uneventfully in most circumstances. Most ingested foreign bodies are
coins, batteries and small toy pieces. OGD is carried out urgently
for removal of ingested oesophageal foreign bodies (relatively
large objects which are unlikely to pass through gastrooesophageal junction) and for sharp or toxic foreign bodies
such as button batteries, especially when the battery is lodged in
the oesophagus or when the battery has not passed beyond the
pylorus after an appropriate time.
Ingested button batteries which are retained in the oesophagus are most dangerous as the risk of tissue necrosis is particularly high, leading to severe oesophageal damage and fistula
formation even days after their removal indicating the urgency of
foreign body retrieval. Urgent retrieval is indicated after ingestion
of multiple magnets due to risk of intestinal obstruction and
perforation. OGD is also indicated if other objects are retained in
the stomach for longer than a couple of weeks as harmless
appearing objects might induce tissue damage.

Surveillance OGD
Follow up of selected ulcerated lesions or mucosal abnormalities in
upper GI mucosa may require surveillance OGD. Similarly, follow
up for adequacy of prior sclerotherapy or other variceal treatment
(e.g. banding, shunting procedure in chronic liver disease/portal
hypertension) also warrants surveillance OGD. Other indications
include surveillance for gastric or duodenal polyps in the polyposis
syndromes, transplant rejection (graft Vs host disease) or other
complications following intestinal transplantation. Surveillance
OGD is also indicated for proven Barretts oesophagitis.

Colonoscopy
Over the last couple of decades, safety and efficacy of colonoscopy in establishing lower GI tract pathology in children has
advanced to the point that both diagnostic and therapeutic colonoscopies (e.g. polypectomy) are now routinely performed by
most paediatric gastroenterologists. The improvement in equipment has permitted examination across all paediatric age groups.
However, successful completion including ileal intubation in
100% of cases remains a technical challenge among paediatric
patients. This is mainly due to smaller intestinal lumen,

Figure 2 Multiple ring like lesions with white plaques in mid-oesophagus

(EO).

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difficulties in sedating a frightened or otherwise uncooperative

child (during conscious sedation), acute angulations at splenic/
hepatic flexures and loop formation (mainly within sigmoid
colon) thus leading to potentially increased risk of perforation.
Furthermore, an additional level of complexity in paediatric patients is poor bowel preparation (compliance with the necessary
bowel cleansing or failure to achieve desired result).

Diagnostic colonoscopy
Table 3 summarizes common diagnostic indications for colonoscopy in infants/children. Diagnostic colonoscopy is indicated for
evaluation of unexplained anaemia, unexplained gastrointestinal
bleeding such as melaena of unknown origin or haematochezia,
for clinically significant prolonged diarrhoea of unexplained origin
with suspicion of inflammatory bowel disease (red flags in Table 3)
and evaluation of an abnormality on radiographic imaging which
is likely to be significant (e.g. filling defect, stricture). Diagnostic
colonoscopy is not indicated in acute/self-limited diarrhoea, rectal
bleeding associated with constipation/anal fissure, functional
abdominal pain and irritable bowel syndrome. Similarly, it is
contraindicated in fulminant colitis/toxic megacolon, suspected
bowel perforation and acute peritonitis.

Figure 3 Multiple aphthous ulcers in colon (Crohns disease).

Colonoscopy and IBD

backwash ileitis and without epithelioid granulomas on biopsy.

Other macroscopic findings include ulcers, erythema, easy
mucosal friability, loss of vascularity, granularity, purulent
exudate (Figure 4), spontaneous bleeding, pseudo-polyps and
continuous abnormalities with variable proximal extension from
rectum.

Colonoscopy is the most important investigation to differentiate

between Crohns disease and Ulcerative Colitis (UC). It identifies
localization and extent of IBD. Histology of terminal ileal biopsies
may help to exclude other diagnoses (e.g. tuberculosis, Behcets
syndrome, lymphoma, vasculitis). Sigmoidoscopy does not have
a role except in severe UC where the risk of bowel perforation is
higher. Unlike adults, over 90% of children with UC have pancolitis making full colonoscopy advisable. The majority of IBDunclassified (previously known as indeterminate colitis) behave
like UC but a few are later diagnosed as Crohns disease. In case
of incomplete ileocolonoscopy as the result of technical difficulties, an attempt should be made to complete the work-up by
repeat ileocolonoscopy in patients with suspected CD or when
the type of inflammatory colitis can not be determined.
In Crohns disease, aphthous (Figure 3), linear, or stellate
ulcers, cobble-stoning, skip lesions with segmental distribution,
fistulae, strictures and abnormalities in oral and/or perianal region are seen. The most important reliable feature of typical UC is
continuous mucosal inflammation of the colon, starting distally
from the rectum, without small bowel involvement other than

Therapeutic colonoscopy
The most common therapeutic category in paediatric lower
gastrointestinal disorders is polyps. Isolated juvenile rectal
polyps are common in paediatric age group. Narrow base polyps

Diagnostic paediatric colonoscopy-indications

Chronic diarrhoea with red flags (clinically significant diarrhoea with
weight loss, rectal bleeding, recurrent oral ulcers, worsening lethargy, unexplained anaemia, hypoalbuminaemia, raised inflammatory markers and high faecal calprotectin levels)
Haematochezia/melaena
Inflammatory bowel disease
Clinically significant chronic abdominal pain with red flags
Rejection of intestinal transplant
Lower GI tract lesions in imaging studies (filling defect, stricture)
Table 3

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Figure 4 Diffuse mucopus with loss of vascularity in colon (UC).

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throughout the colon as well as extraintestinal manifestations.

FAP and related syndromes (attenuated FAP, Gardner and Turcot
syndromes) are linked to mutations in the adenomatous polyposis coli (APC) gene. Patients with the APC gene mutation are at
risk of more aggressive phenotype. Adenomatous polyps (or
adenomas) are precancerous lesions with inevitable progression
to colorectal cancer by the fifth decade (100%). Children at risk
for FAP should be screened annually starting at age 10e12 years.
Colectomy is the only effective therapy that eliminates the
inevitable risk of colorectal cancer.
PJS is a rare autosomal dominant disorder characterized by
hamartomatous polyps occurring anywhere in the GI tract and
accompanied by characteristic muco-cutaneous pigmentation on
the lips and oral mucosa. There is potential of malignant
degeneration within GI polyps and development of extraintestinal malignancies. Patients with PJS may develop significant GI bleeding, intussusception, and rectal prolapse.
Familial juvenile polyposis is characterized by multiple inflammatory polyps throughout the colon that are associated with
painless rectal bleeding (rarely serious haemorrhage), rectal
prolapse, and failure to thrive. This entity is different to solitary
juvenile polyps, which are common in children and do not have
the lifetime risk of malignancy. Video capsule endoscopy is an
emerging modality used to evaluate small bowel polyps.
Approximately 50% of patients with familial juvenile polyposis
develop GI cancer.

can easily be cauterized/snared and removed during colonoscopy. However, caution should be exercised in cases of wide
based polyps. Presence of multiple polyps in the colon may
represent polyposis syndrome. Other indications for therapeutic
proctosigmoidoscopy/colonoscopy are rare and include treatment of bleeding vascular anomalies and placement of seton
suture to treat perianal Crohns disease. In most cases, this is best
left to paediatric surgeons.

Surveillance colonoscopy
In patients with increased risk of colonic malignancy, surveillance colonoscopy is carried out periodically. This usually includes patients with polyposis syndromes. Surveillance
colonoscopy may also be carried out for rejection or other
complications following intestinal transplantation.

Colonoscopy and polyposis syndrome

Intestinal polyposis syndromes are relatively rare. Awareness of
the future health risks is important for patients and their families.
All patients with polyposis syndromes require serial screening
including OGD and colonoscopy to evaluate the degree of polyposis and survey for malignant transformation. Intestinal polyposis syndromes can be divided into Familial Adenomatous
Polyposis (FAP), hamartomatous polyposis syndromes such as
Peutz-Jeghers Syndrome (PJS) and other rare polyposis syndromes such as hereditary-mixed polyposis syndrome.
FAP (Figure 5) is the most common genetic polyposis syndrome. It is characterized by numerous adenomatous polyps

Conclusion
Paediatric GI endoscopy has evolved into a well-established subspecialty in the last decades. It provides a safe and effective
diagnostic tool for many GI disorders. Advances in training and
improved equipment means that children of all ages can be
scoped thus confirming the diagnoses of well-known diseases
such as IBD, coeliac disease and OE. New diagnostic tools, such
as wireless capsule endoscopy have been proven to be safe and
effective. Numerous National and International guidelines and
training programmes have been developed to train emerging
trainees for higher specialist training in paediatric gastroenterology which is likely to improve medical care for children with
disorders of the GI tract.
A
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3 Franciosi JP, Fiorino K, Ruchelli E, et al. Changing indications for upper
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4 Friedt M, Welsch S. An update on pediatric endoscopy. Eur J Med Res
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documented findings in paediatric gastrointestinal endoscopies. WPJ
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6 Cote CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006; 118: 2587e602.

Figure 5 Multiple sessile polyps (FAP).

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and adolescents. JPGN Publish Ahead of Print. http://dx.doi.org/10.
1097/MPG.0000000000000239.
18 Koletzko S, Jones NL, Goodman KJ, et al. Evidence-based guidelines
from ESPGHAN and NASPGHAN for helicobacter pylori infection in
children. JPGN 2011; 53: 230e43.
19 Papadopoulou A, Koletzko S, Heuschkel, et al. Management guidelines
of eosinophilic esophagitis in childhood. JPGN 2014; 58: 107e18.
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Practice points
C

512

OGD and colonoscopy can be safely and effectively performed in

children of all ages.
Over the past decades, due to increased demand, the number of
endoscopies carried out in children has increased steadily.
Common diagnostic indications for OGD and colonoscopy are
coeliac disease, complicated GORD, rectal bleeding and IBD.
Common therapeutic indications for OGD and colonoscopy are
control of variceal bleed, foreign body retrieval, PEG and
polypectomy.
OGD and colonoscopy in children are either performed under
general anaesthesia (preferable and default level) or conscious
sedation. All children having the procedure under conscious
sedation should be monitored by an appropriately qualified
practitioner (other than the endoscopist) who is sufficiently skilled to provide rescue in case of airway compromise.

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