Gastrointestinal endoscopy involves examining the inside of the gastrointestinal tract using a lighted flexible or rigid instrument called an endoscope. An endoscope is generally introduced into the body through the mouth or anus. As a medical procedure, endoscopy has been performed since the early nineteenth century, and originally involved the use of alcohol or turpentine lamps as light sources for rigid instruments.1 The birth of modern endoscopy can be dated to the 1960s with the development of flexible fiberoptic instruments. These allowed visualization of areas beyond the reach of rigid instruments and greatly improved patient comfort. The development of fiberoptic illumination further improved endoscopic safety by removing thermal and electrical complications from the procedure. Flexible fiberoptic endoscopes were further modified in the 1980s by replacing fiberoptic image bundles with a charge-coupled device (CCD) video camera, which provided greater image detail and display on a video screen. CCD chip size has become smaller over time, further allowing the size of endoscopes to become smaller.

In the 1970s, the diameter of endoscopes became small enough to allow investigation of children.2 Prior to the use of endoscopy, gastrointestinal diseases were diagnosed mostly by fluoroscopic contrast studies. Over the past four decades, gastrointestinal endoscopy has been shown to be safe and effective in diagnosis and treatment of children. In the 1980s, endoscopes were designed specifically for use in children, thereby cementing the importance of endoscopy in the field of pediatric gastroenterology.

Today, the diagnosis of gastrointestinal diseases in children can be made more accurately and quickly as a result of direct visualization of tissue and targeted tissue biopsies. In addition, therapeutic endoscopy has allowed for safe, minimally invasive treatments that were once only performed by open surgical techniques with longer recovery periods. As a result of endoscopy, the field of pediatric gastroenterology has grown tremendously. The contributions of endoscopy to pediatric gastroenterology will continue to grow as technology continues to progress.

In this chapter, we review the fundamentals of pediatric endoscopy. In particular, we describe the endoscopy unit as a clinical resource for children with gastrointestinal disease, as well as necessary steps that must be followed by both clinicians and families in preparation for endoscopic procedures. We also provide descriptions of different diagnostic and therapeutic procedures, as well as indications for their performance, and discuss post-endoscopy care.

Generally speaking, a pediatric endoscopy unit is comprised of a reception and waiting area, preprocedure preparation facilities, procedure rooms, and a recovery suite.3 The waiting area allows patients to check in and families to gather while their child is having a procedure. This area should be a fun and inviting place where young children will feel comfortable. Most units have an initial preparation area where the patient will undress and informed consent is obtained. The next area of the unit is the procedure area (see Figure 10–1). This is often composed of multiple rooms where multiple providers can be performing endoscopic procedures simultaneously. After their procedure, patients will be taken to a recovery area where they are closely monitored. An endoscopy unit also must have facilities for endoscope and equipment storage, as well as an area for scope cleaning and disinfecting. Endoscopy units may be exclusively for pediatrics or a shared unit, where both adult and pediatric endoscopies are performed. Pediatric endoscopy may also be performed in operating rooms; this procedure location may be preferable for patients with high anesthesia risk. In acute medical situations, procedures may also be performed in intensive care settings.

The endoscopy procedure room should also be child-friendly. Equipment consists of an endoscopy station with a video processor and endoscope light source (see Figure 10–2), an air, water, and suction pump, and at least one video monitor, although two monitors, preferably on boom towers, are preferable. The procedure room should have an examining table as well as anesthesia capabilities, ideally allowing for anesthetic gas administration. In addition, an electrosurgical generator should be present for therapeutic procedures, such as polypectomy or hemostasis. Although not mandatory, it is helpful if at least one procedure room also has fluoroscopic capabilities with either a fixed fluoroscopy table or a fluoroscopic C-arm unit.

Preparing children and their families for an endoscopic procedure ideally begins well ahead of the procedure day.3 Both electively and urgently scheduled procedures should involve a careful explanation by the patient’s primary gastroenterologist about indications that warrant its performance, as well as basic information about endoscopy itself. The gastroenterologist should also communicate with the child’s primary care provider. Gastrointestinal endoscopy, as a concept, can be introduced to patients by describing the endoscope as a camera that allows the inspection of the lining of the gastrointestinal tract, thereby providing a unique means of imaging this part of the body. It is also appropriate for physicians to discuss early on in the planning process that small biopsies from multiple sites in the inspected intestinal tract will likely be obtained.

Once the procedure has been scheduled, the patient’s family will be contacted by the procedural unit staff. Initial contact by unit staff often occurs via telephone for electively scheduled procedures, and serves to allow the endoscopy unit personnel to: (1) determine individual needs of the patients, (2) obtain a medical history, and (3) review prior procedural experiences. The preprocedure telephone call is also important for expanding upon anticipatory guidance for children and their families regarding the day of the procedure, including what monitoring equipment will be applied, the need for intravenous line placement, and the patient’s sedation plan.

Children undergoing colonoscopy will require complete cleansing of stool from the colon before the day of the procedure. Cleansing of the colon can take up to 3 days and involve a number of different preparation regimens. Most regimens use a combination of osmotic laxatives, such as magnesium citrate or polyethylene glycol (PEG), and stimulants, such as biscodyl tablets, to aid in the efficiency of purging. Rectal irrigation with saline or phosphosoda enemas may be used on the morning of the procedure to further prepare the bowel. In general, the goal of any colonoscopy prep is to have watery output on the day of the procedure that is clear with no sediment apparent in the toilet bowl or diaper.

Preprocedure information with specific instructions for bowel cleansing may be provided in person, or over the telephone, and is increasingly available on institutional websites. This information is often also reiterated in an information packet that is mailed to the patient’s home. Generally speaking, bowel cleansing involves asking children to follow a clear diet for at least 1–2 days prior to the procedure, and to take specific doses of laxatives at defined intervals in advance of the procedure. A clear diet consists of broth, clear fruit juices (without pulp or sediment), popsicles, and flavored gelatin desserts (without added fruit). In general, it is best if children can avoid eating red-colored liquids, popsicles, and gelatin, as these tend to transiently stain the mucosa red and make it difficult for the endoscopist to identify true erythema or hemorrhage.

Ensuring safety of preparation regimens is paramount. All bowel cleansing approaches carry some risk of electrolyte imbalance and dehydration, and must be employed carefully in ill patients. If patients are significantly ill, unstable, at significant risk for dehydration, or at risk for hypoglycemia, it may be appropriate to perform bowel preparation in the hospital, where intravenous fluids can be administered simultaneously. Inability of patients to tolerate the bowel preparation, because of an inability either to comply with the instructions or to tolerate the preparation, may also be identified as indications for admission for bowel cleansing. Nevertheless, most children are able to prepare for ambulatory colonoscopy at home, as regimens have become increasingly more palatable and well tolerated in recent years.

Sedation

A careful plan for sedation is also fundamental to preparing for pediatric gastrointestinal endoscopy.4 The primary goals of sedation regimens for pediatric endoscopic procedures are to ensure a patient’s safety, comfort, and cooperation continuously throughout the procedure. Secondary and often desirable goals of sedation are to provide periprocedural amnesia, maximize procedural efficiency, minimize recovery times, and maintain cost-effectiveness.

The two primary types of sedation available for children undergoing gastrointestinal procedures are general anesthesia and intravenous sedation. Both are considered safe and effective, especially when patient’s physical status, age, and cognitive development are taken into account. Institutions may vary in which sedative regimens are standard for otherwise healthy children undergoing endoscopy. In many institutions, intravenous sedation may be administered by either an anesthesiologist or the endoscopists themselves. Most intravenous sedation combines a fast-acting anxiolytic, such as the benzodiazepine, midazolam, with a narcotic, such as fentanyl. Alternatively, some institutions prefer to use ketamine, a dissociative hallucinogenic that is fairly effective at rendering children quiet and still. Anesthesiologists may choose to work with fast-acting inhalational anesthetics, such as sevofluorane, or use a total intravenous propofol sedation regimen, often in combination with midazolam. Propofol is a fast-acting sedative hypnotic that can be used to induce a full spectrum of sedation depths, from light sedation to general anesthesia. In children undergoing gastrointestinal procedures, propofol is generally administered as a constant infusion (by a pump), which allows for careful drug titration.

To aid in guiding which patients should receive anesthesiologist-administered sedation, the American Society of Anesthesiologists (ASA) has designed a patient classification system that ranges from Status 1 (healthy patient) to Status 5 (moribund patient) (Table 10–1). Children who are Status 1 and 2 and thus either healthy or known to have a systemic illness (i.e., asthma) that is under good control can be considered good candidates for endoscopist-administered sedation. All ASA Status 3 patients with severe or unstable systemic diseases should be evaluated carefully, on an individual basis, for either sedation or general anesthesia. Many of these are safe for sedation in the endoscopy suite, and may not require the operating room. Status 4 and 5 patients with either a severe systemic disease that is a threat to their life or who are moribund should receive general anesthesia, generally in an operating room setting.

One increasing practice trend among pediatric endoscopists is the employment of anesthesia support to perform endoscopy in children outside of the main operating room, often in a dedicated outpatient endoscopy suite, using propofol. This approach is again used in children who would be classified as ASA I or II, and are stable and otherwise healthy. Very small infants, very ill children, and those with significant co-morbidities, including cardiac or respiratory diagnoses, are best served with general anesthesia in the operating room.

Prophylactic Use of Antibiotics Prior to Endoscopy

All children with congenital heart disease should receive cardiac clearance prior to undergoing gastrointestinal procedures, as well as guidance as to whether or not they require prophylactic antibiotics to prevent subacute bacterial endocarditis (SBE). In recent years, the American Heart Association (AHA) has altered their recommendations. They no longer recommend antibiotic prophylaxis in patients undergoing gastrointestinal procedures for the sole purpose of preventing infective endocarditis.5 This departure of the AHA from previous guidelines refers to the fact that no data exist demonstrating a link either between endoscopy and endocarditis or between antibiotic prophylaxis and the prevention of endocarditis. Nevertheless, a cardiologist may recommend that some children with cardiac disease receive a dose of amoxicillin or other antibiotic prior to the procedure.

Upper gastrointestinal endoscopy allows for the direct inspection of the esophagus, stomach, duodenal bulb, and the second and third portions of the duodenum.6 Upper gastrointestinal endoscopy is therefore otherwise known as esophagogastroduodenoscopy (EGD). An EGD is the most common procedure performed in pediatric gastroenterology, and can be performed in children of all ages, including premature neonates.

Instruments

Endoscopes are commercially available by Olympus, Pentax, and Fujinon and in general are similar in design, with only subtle differences. Today’s modern gastroscopes have four-way directional tip control that ranges from 180˚ to 210˚ in the up direction and 90˚ to 120˚ in the down direction with 100–120˚ deflection in both the left and right directions (see Figure 10–3). This tip mobility allows a complete inspection of the upper GI tract. The endoscope diameter size can vary from 6 to 9.8 mm in diameter. The 9.8-mm scope can provide high-definition quality images; both have a fiberoptic light source, an instrument/suction channel that ranges in size from 2 to 2.8 mm in diameter, and an air/water nozzle. Larger diameter endoscopes geared for therapeutics are also available, and have a diameter from 11 to 13 mm. Larger instruments also have larger instrument/suction channels, as well as separate suction and instrument channels. Therapeutic endoscopes are the ideal scopes to use for gastrointestinal bleeding. However, their large size makes them difficult to use in young children.

Indications for Upper Endoscopy

Indications for upper endoscopy can be divided by diagnostic and therapeutic purposes (Table 10–2). It is important to note that, in many cases, diagnostic endoscopy is indicated only after medical therapy has failed, or if symptoms relapse after discontinuation of medical therapy.

Contraindications for Upper Endoscopy

There are relatively few contraindications to upper endoscopy. In children, the size of the patient is rarely a contraindication. The only absolute contraindication for endoscopy is when bowel perforation is suspected. Most other conditions that might give an endoscopist pause before starting a procedure represent relative contraindications, and should be weighed in terms of whether the benefits of performing a procedure outweigh its risks. Coagulopathy is only a relative contraindication for diagnostic endoscopy, although extra care is certainly required and biopsies would be contraindicated until the coagulopathy is corrected.