Peculiarities of paediatric digestive endoscopy.

1. Introduction 1.1. What is the role of paediatric endoscopy nowadays? Which are the main indications and contra-indications? An increased knowledge of normal and pathologic endoscopic patterns in paediatric patients has been increasing in the last decades. Besides, the availability of flexible instruments with narrow diameter and elevate qualitative resolution allows Paediatric Gastroenterologists to investigate small infants too. An adequate setting including endoscopic equipment, endoscopic room, support area and dedicated caregivers is fundamental to perform appropriate procedures. Diagnostic endoscopy comprehends fiber-endoscopy, capsule endoscopy, confocal microendoscopy and echo-endoscopy. Roles of Digestive Endoscopy • Visualisation of the mucosa; • Evaluation of architecture and vascularisation; • Evaluation of mucosal secretions; • Availability to take biopsy samples for histological examination with optic microscopy, ultra-structural examination with electronic microscopy, cultures, CRP methods, dissecting microscopy, chromo-endoscopy, vital staining, enzymatic studies, brushing; • Endoscopic treatments. Functions of Digestive Endoscopy © 2013 Gasparetto and Guariso; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. • Morphologic diagnosis of structural congenital and acquired alterations (optic microscopy, immune-histochemistry, electronic microscopy, confocal microendoscopy, brushing); • Identification of infective processes (CRP techniques of molecular biology) and cultural examination; • Morphological, chemical and microbiological evaluation of endoluminal secretions; • Endoscopic treatment in case of gastrointestinal bleeding, varices, polyps, stenoses, tumors. Appropriateness. Indications and contraindications to endoscopic examinations [1-2] An endoscopic exam is indicated when the expected benefits (longer life survival, pain contention, reduction of anxiety, increase in functional capacity) exceed the potential negative consequences (mortality, morbidity, anxiety, pain, disability). An endoscopic exam is necessary when it is unavoidable and mandatory for the care of the patient. Signs and Symptoms of Indication for Upper Gastrointestinal (GI) Endoscopy • GI bleeding; • Disphagia, odinophagia, persistent feeding refusal, persistent chest pain; • Upper abdominal pain with signs and symptoms suggesting organic diseases (red flags); • Suspect of peptic disease; • Persistent vomit; • Suspected alterations at upper GI imaging; • Suspected caustic ingestion; • Iron deficiency anaemia. Pathologic Conditions for which Diagnostic Upper GI Endoscopy is indicated: • Peptic esophagitis, hemorrhagic gastritis, peptic ulcers in stomach, bulbus and duodenum; • Gastrointestinal opportunistic infections i.e. Cytomegalovirus, Fungi; • Eosinophilic esophagitis; • Caustic ingestion; • Atrophic gastritis; • Helicobacter pylori (HP) gastritis; • Coeliac disease; • Inflammatory bowel disease (IBD) with localisation at the upper GI tract; 268 Endoscopy of GI Tract • Patients with liver cirrhosis, disphagia, malnutrition, oesophageal varices; • Congestive gastropathy; • Chronic diarrhoea of unknown nature; • Structural alteration of the mucosa (Microvillus Inclusion Disease, Tufting Enteropathy); • Benign or malignant lesions in common bile duct or duodenum; • Graft Versus Host Disease (GVHD) after bone marrow transplantation; • Lymphoproliferation after organ transplantation i.e. EBV-related gastric lymphoma after liver transplantation. Pathologic Conditions for which Therapeutic Upper GI Endoscopy is indicated: • Polypectomy; • Treatment of oesophageal varices; • Placement of ostomies; • Treatment of GI bleeding (i.e. bleeding ulcers) non responsive to medical therapy; • Removal of foreign bodies; • Oesophageal stricture. Absolute Contraindication to Upper GI Endoscopy • Suspect of Gastrointestinal Perforation. Relative Contraindications to Upper GI Endoscopy • Non complicated gastro-oesophageal reflux; • Functional uncomplicated abdominal pain; • Congenital hypertrophic stenosis of the pylorus; • Isolated spasm of the pylorus; • Follow-up controls for ulcers, mucosal abnormalities, Barrett oesophagus; • Surveillance of benign healed lesions. Upper GI endoscopy is not appropriate for all children with dyspeptic symptoms, but only for cases [3]: • With a family history of peptic ulcer and/or HP infection; • Over 10 years of age; • With symptoms persisting for more than 6 months; • With symptoms severe enough to affect activities of daily living; Peculiarities of Paediatric Digestive Endoscopy http://dx.doi.org/10.5772/52523 269 Pathologic Conditions for which Diagnostic Lower GI Endoscopy is indicated: • Inflammatory bowel disease (IBD); • Infective colitis; • Allergic colitis; • Neutrophil disfunction associated colitis i.e. Glycogenosis; • Immune mediated diseases; • Vascular abnormalities (venous ectasia secondary to portal hypertension, angiodysplasia, haemangiomas, vasculitis); • Polyps and polyposes (juvenile polyps, adenomatous polyps, hyperplastic polyps, hamartomatous polyps, hereditary polyposic syndromes as Peutz-Jeghers Syndrome, Cowden Syndrome); • Pseudopolyps of the colon; • Neoplastic lesions i.e. leiomyosarcoma, lymphoma, carcinoma; • Screening of displasia; • Surveillance after bowel transplantation (rejection, complications); • Obscure iron deficient anaemia; • Structural alteration of the mucosa (Microvillus inclusion disease, Tufting enteropathy); • Chronic diarrhoea of unknown nature; • Suspect of filling defects or stenoses at radiographic-ultrasonographic images; • Rectal trauma; • Necessity of ileal or colonic bioptic samples. Pathologic Conditions for which Therapeutic Lower GI Endoscopy is indicated: • Polypectomy; • Post-polypectomy complications; • Mucosal resections; • Ablation of vascular malformations (i.e. Dieulafoy Lesion); • GI bleeding (i.e. Bleeding ulcers); • Placement of percutaneous ostomies; • Dilatations of colonic stenoses; • Removal of foreign bodies; Absolute Contraindications to Lower GI Endoscopy 270 Endoscopy of GI Tract • Suspected intestinal perforation; • Severe acute colitis with toxic megacolon; Relative Contraindications to Lower GI Endoscopy • Acute self-limiting diarrhoea; • Gastrointestinal bleeding with demonstrated origin at the upper GI tract; • Recent intestinal resection; • Irritable bowel syndrome; • Chronic abdominal pain without significant morbidity; • Simple constipation and encopresis.