Endoscopy in pediatric patients with upper gastrointestinal bleeding

Yuzo Akasaka, Fumio Misaki, Takayuki Miyaoka, Masatsugu Nakajima, Keiichi Kawai,

MD MD MD MD MD

Kyoto, Japan

In 25 pediatric patients with hematemesis or melena, early or urgent endoscopy was performed with no complications. In children older than 10 years, endoscopy can be done in the same way as in adults. In patients younger than 1 year, both general anesthesia and a small caliber peroral endoscope are necessary. Endoscopy can be done usually without general anesthesia if a small caliber endoscope is used in patients from 2 to 9 years of age. Endoscopy has been done within 7 days after hematemesis and/or melena in 420 patients with upper gastrointestinal bleeding, seen in our clinic since 1963. The value of early or urgent endoscopy for adult patients with upper gastrointestinal bleeding has been well established.Hln pediatric patients, however, early or urgent endoscopy has not become routine yet, though several reports describe the evaluation of pediatric endoscopy.4-12 This paper intends to emphasize and illustrate the safety and effectiveness of early or urgent endoscopy in pediatric patients. MATERIALS AND METHODS Since 1969, 25 pediatric patients (18 boys and 7 girls), ranging in age from 3 months to 15 years, have undergone endoscopy within 7 days after hematemesis or melena. In 11 endoscopy was done within 24 hours after manifest bleeding, and in 6 it was done within 72 hours. Blood transfusions were given to 5 before endoscopy. Radiographic examinations were performed before or after endoscopy in 19 of the 25 patients. The main sources of bleeding identified by endoscopy included duodenal ulcers 12 erosions or erosive gastritis,S gastric ulcers" esophageal varices,2 and esophagitis. 2 The esophagus, stomach, and duodenal cap were observed endoscopically in all patients without significant complications. The procedures usually required less than 15 minutes. RESULTS Instrumentation and Anesthesia. Before the development of a pediatric peroral endoscope (Olympus GIF-P), the adult fiberscopes were used by us in several pediatric patients over 5 years of age. Small caliber fiberscopes such as Olympus GIF-P and GIF-P2 are now used commonly in pa-

tients younger than 9 years. In older pediatric patients the ordinary adult fiberscopes are used (Table I). Pharyngeal anesthesia and an appropriate amount of antispasmodic agent were given to all11 ofthe children older than 10 years and to 10 of 13 younger children, 2 t09 years of age. In a few unruly patients, diazepam (Valium) was administered for sedation. General anesthesia was performed in only 2 patients, a 3-month-old girl and a 4-year-old girl whose general conditions were judged too poor to permit examination under pharyngeal anesthesia. In 2 patients endoscopy was accomplished safely and quickly without anesthesia. Identification of Bleeding Sources. In 12 of the 25 patients, bleeding sources were identified by radiography as well as by endoscopy (Table 1/). In 7 patients whose bleeding sources could not be identified radiographically, small superficial lesions of the esophagus or stomach were detected endoscopically (Figure 1). In the remaining 6 patients, radiography was not done but the bleeding sites were identified endoscopically. Table I.

Instruments used for early or urgent endoscopy in pediatric patients with upper gastrointestinal bleeding. AGE

GIF-P2

>1

1 2 2

1-5

5-9

ENDOSCOPE GIF-P JF-B2 GIF-K

5

TOTAL

1

7

1 2

2

2

1 6

10-15 TOTAL

SIF-B

4

9

1

o

6

2 3

3

11 25

4

From the Kyoto Prefectural University of Medicine, Department of Preventive Medicine, Kyoto, Japan. Reprint requests: K. Kawai, MD, Kyoto Prefectural University of Medicine, Department of Preventive Medicine, Kyoto, Japan. VOLUME 23, NO.4, 1977

199

Table II.

Relative accuracy of endoscopy and fluoroscopy in pediatric patients with upper gastrointestinal bleeding age

1 1-5 5-9 9-15 total

gastric ulcer

duodenal ulcer

erosive lesions

esophageal varices

esophagitis

(b)

(a)

(b)

(a)

(a)

4

(a) (a) (a) (a)

(a) (a) (a) (c)

(b)

(b)

(c) (a) (c)

(c) (c)

12

(a)

5

(b)

(c)

(b)

(b)

2

2

(a): fluoroscopy correct, endoscopy correct. (b): fluoroscopy equivocal, endoscopy correct. (c): only endoscopy correct.

DISCUSSION It has been stressed by us that endoscopy should be done as soon as possible after hematemesis or melena to detect bleeding sources and to decide the need for early surgical operation.1-3 Furthermore, multiple superficial lesions are often detected endoscopically.' In pediatric patients, pediatric endoscopy had only rarely been done before the introduction of small caliber peroral endoscopes, except for the use of the flexible fiberbronchoscope in pediatric patients older than 5 years.·,7,'

Figure 1. Endoscopic photographs of (left) mucosal erosions in the body of the stomach of a 3-month-old girl and (right) bleeding from esophageal varices in a 9-year-old boy.

REFERENCES 1. AKASAKA Y, KAWAI K: The early application of endoscopical examination for the upper G-I bleeding, 1 st Asian-Pacific Congress of Endoscopy (Symposium) Kyoto, Japan, 1973 2. KAWAI K, IDA K, AKASAKA Y: Clinical evaluation of endoscopy for the upperG-1 bleeding, urgent endoscopy of digestive and abdominal diseases. Int Symposium (Prague/Carlsbad), 39, 1971 3. KAWAI K, TaRlE 5, AKASAKA Y: Emergency endoscopy for bleeding in the digestive tract. Stomach and Intestine Uapan) 8:871, 1973 4. AMENT ME, GANS Sl, CHRISTIE Ol: Experiences with esop!lagG-gastrGduodenoscopy in diagnosis of 79 pediatric patients with hematemesis, melena or chronic abdominal pain. Gastroenterology 68:858- 1975 5. CREMER M, PETERS)P, EMONTS P, RODESCH P, CARDRANEL 5: Fiberscopy of the gastrointestinal tract in children. Endoscopy 6:186,1974

200

Since 1973, the Olympus GIF-P, a prototype of pediatric peroral endoscope,'2 has been used commonly in infants and children with upper gastrointestinal bleeding. In 1975, the Olympus GIF-P2 was developed as a new, small caliber endoscope with a much better view and better maneuverabi Iity but with a greater outer diameter than those of GIF-P. This instrument permits accurate visualization from the esophagus to the second portion of the duodenum; the gastric cardia and angle can be seen by retroflexion. Many endoscopists prefer to use general anesthesia in pediatric endoscopy.·,7 As experience extends, pediatric gastrointestinal endoscopy has been performed safely without general anesthesi~s,12 In our clinic, patients from 2 to 9 years of age are examined only with pharyngeal anesthesia, with the addition of sedatives in a few unruly chi Idren. However, in the patients younger than 5 years, the most appropriate premedication must be decided individually. In children younger than 1 year, general anesthesia is employed because these infants cannot cooperate and are liable to the risk of tracheal compression by the fiberscope. Early or urgent endoscopy in infants and children, as in adults, is far superior to radiography in detecting bleeding sources, especially superficial lesions which do not have sufficient depth or contour to be identified by barium outline or contrast.

6. FREEMAN NV: Pediatric gastroscopy. Lancet 26:1351,1971 7. FREEMAN NV: Clinical evaluation of the fiberoptic bronchoscope (Olympus 8F-58) for pediatric endoscopy.} Pedialt Surg 8:213, 1973 6. GLEASON WA, TEDESCO Fl, KEATlNG)P, GoLDSTEIN PO: Fiberoptic gastrointestinal endoscopy in infants and children.} Pedialt 65:610,1974 9. GANSSl, BERCI G: Advances in endoscopy of infants and children.} Pedialt Surg 6:199,1971 . 10. KAWAI K, MURAKAMI K, MISAKI F: Endoscopical observation on gastric ulcers in teenagers. Endoscopy 4:206, 1970 11. NAMIKI M, NAKAGAWA K: Gastric ulcers in the field of pediatrics and the aged. Stomach and Intestine (Japan) 9:968, 1974 12. TEDESCO Fl, GOlDSTEIN WA, KEATING lK: Upper gastrointestinal endoscopy in the pediatric patient. Gastroenterology 70:492, 1976 GASTROINTESTINAL ENDOSCOPY