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COME L’ENDOSCOPIA HA TRASFORMATO LA

GASTROENTEROLOGIA PEDIATRICA

Salvatore Cucchiara,

Department of Pediatrics - Sapienza University of Rome

Pediatric Gastroenterology and Liver Unit

University Hospital Umberto I, Rome

TECHNICAL AND SCIENTIFIC EVOLUTION OF GASTROENTEROLOGY

HOW ENDOSCOPY INTEGRATES WITH TRADITIONAL AND

MODERN DIAGNOSTIC TOOLS

HOW ENDOSCOPY INTEGRATES WITH TRADITIONAL

AND MODERN DIAGNOSTIC TOOLS

STOOL

CULTURE

MOLECULAR

MICROBIOTA

PROFILE

HISTOLOGY

MUCOSA

CYTOKINE

SCENARIO

MUCOSA

SPECIMEN

CULTURE

GI ENDOSCOPY IN PEDIATRIC GASTROENTEROLOGY: ITEMS

The indications for upper endoscopy in the pediatric age group are similar

to those for adult endoscopy, but…..

all infants, many children, and some adolescents cannot verbalize or

describe symptoms accurately

PEDIATRIC PECULIARITIES:

Training (acquisition and maintenance)

Equipment

Circumstances: i.e. ingestion of foreign bodies, caustic substances

Rigorous definition of indications

Preprocedure health evaluation

Sedation, analgesia and monitoring

Postprocedure monitoring and discharge

TRAINING IN PEDIATRIC GI ENDOSCOPY IS CRUCIAL !!!

UPDATING TRAINING OF PEDIATRIC GI ENDOSCOPISTS JPGN 2004;39:S589-S595

Use of GI and hepatobiliary-pancreatic endoscopy in children has

advanced during the past decades

Specific techniques for diagnosis and interventional procedures.

Training in pediatric endoscopy must keep pace with these

developments

Responsibility of national and international PEDGI

organizations to guide its membership in the skill acquisition during

fellowship training and in the maintenance-enhancement of those

skills.

Procedures are an integral

part of the practice of

pediatric gastroenterology

(trainees expected to demonstrate

competency in the performance of a

wide array of procedures).

Endoscopy and related procedures (eg, motility procedures), in continual state of evolution (technological advances in equipment, changes in other diagnostic disciplines, i.e. imaging, and shifts in the health care delivery system).

It remains important to establish

guidelines for pediatric

gastroenterology training

programs so that trainees are up to

date in the most current techniques

available.

………essential aspect of all

training programs is to

ensure that each trainee is

adequately exposed to

relevant procedures….

i.e. diagnostic and therapeutic upper

and lower GI endoscopy, percutaneous

endoscopic gastrostomy tube

placement, diagnostic and therapeutic

colonoscopy, endoscopic examination

of the SB (capsule endoscopy and/or

SB enteroscopy), ERCP, percutaneous

liver biopsy, rectal biopsy………………...,

manometry (esophageal,

antroduodenal, colonic and

anorectal), esophageal pH and

impedance monitoring, and breath

test analysis….

After completion of a training program in Pediatric Gastroenterology, Level 1

trainees should be able to do (JPGN 2013;56: S1-S38):

Recommend procedures on the basis of personal consultation and consideration

of specific indications, contraindications, and diagnostic and therapeutic

alternatives

Counsel the patient and family on bowel preparation and other pre-procedure

requirements as indicated

Select and apply appropriate sedation as indicated

Identify age-, size-, and condition-appropriate endoscopy equipment

Perform each indicated procedure safely, completely, independently, and

expeditiously

Interpret and describe endoscopic findings accurately

Integrate endoscopic findings or therapy into the management plan

After completion of a training program in Pediatric Gastroenterology, Level 1

trainees should be able to do (JPGN 2013;56: S1-S38):

Understand the inherent risks of endoscopic procedures, and counsel the patient

and family on the expected risks of benefits of, and alternatives to various

procedures

Recognize personal and procedural (including equipment) limitations and know

when to request assistance

Recognize and manage complications, including requesting assistance from

colleagues in related disciplines such as pediatric anesthesia, critical care,

pediatric surgery, or adult gastroenterology as required

Know how to clean and maintain endoscopic equipment and be familiar with the

Joint Commission and institutional standards for quality improvement, infection

control, sedation, and monitoring

Understand how an endoscopy unit is run, including how the unit interfaces with

the inpatient and outpatient gastroenterology practice and other services

(including pediatric anesthesiology)

GASTROINTESTINAL ENDOSCOPY AND GUIDELINES OF THE

MOST COMMON PEDIATRIC GI DISORDERS-CONDITIONS

FUNCTIONAL GASTROINTESTINAL DISORDERS

HELICOBACTER PYLORI

GASTROESOPHAGEAL REFLUX DISEASE

EOSINOPHILIC ESOPHAGITIS

CELIAC DISEASE

INFLAMMATORY BOWEL DISEASE

INTERVENTIONAL ENDOSCOPY

OBJECTIVES: appropriateness of indications for upper gastrointestinal (UGI)

endoscopy in children with dyspepsia.

CONCLUSIONS: UGI endoscopy appropriate only for cases with a family history of

peptic ulcer and/or HP infection, > 10 year age, with symptoms persisting > 6 months

and affecting activities of daily living.

A) INDICATIONS TO UPPER GASTROINTESTINAL ENDOSCOPY IN CHILDREN WITH

DYSPEPSIA. Guariso G et al. JPGN 2010;50:493-9

VALIDATION OF PEDIATRIC ROME III CRITERIA OF FUNCTIONAL DYSPEPSIA

B) IMPACT OF PEDIATRIC ROME III CRITERIA OF FUNCTIONAL DYSPEPSIA ON THE

DIAGNOSTIC YIELD OF UPPER ENDOSCOPY AND PREDICTORS FOR A POSITIVE

ENDOSCOPIC FINDING. Tam YH et al. JPGN 2011;52:387-91

Rome III recommendations in dyspeptic children for alarm features and investigation

for HP: effective to identify children with a higher likelihood of organic diseases and

require upper endoscopy before a diagnosis of FD (HP and nocturnal pain)




HELICOBACTER PYLORI



CELIAC DISEASE



EVIDENCE-BASED GUIDELINES FROM ESPGHAN AND NASPGHAN FOR

HELICOBACTER PYLORI INFECTION IN CHILDREN. JPGN 2011;53:230-243

Recommendation 1:

Primary goal of clinical investigation of GI symptoms is to determine the

underlying cause of the symptoms (not solely HP infection presence)

Recommendation 6:

For the diagnosis of HP infection during EGD, gastric biopsies (antrum and

corpus) for histopathology must be obtained

Recommendation 7:

The initial diagnosis of HP infection should be based on either positive

histopathology + positive rapid UBT or a positive culture

Recommendation 14:

A “test and treat” (T&T) strategy is not recommended in children.

Primary goal of testing is to diagnose the cause of clinical symptoms…….a “T&T” strategy will not

provide this information in children…….current evidence does not support this practice in children.




HELICOBACTER PYLORI



CELIAC DISEASE



European Society for Pediatric Gastroenterology, Hepatology and Nutrition:

GUIDELINES FOR THE DIAGNOSIS OF CELIAC DISEASE, JPGN 2012;54:136-60




HELICOBACTER PYLORI



CELIAC DISEASE



Am J Gastroenterol. 2013 Apr 9. doi: 10.1038/ajg.2013.71. [Epub ahead of print]

ENDOSCOPIC FEATURES OF EOSINOPHILIC ESOPHAGITIS

furrowing and

vertical lines

mucosal rings and

whitish exudates

ACG Clinical Guideline: Evidenced Based Approach to the Diagnosis and Management of

Esophageal Eosinophilia and Eosinophilic Esophagitis (EoE). Am J Gastroenterol 2013 Epub




HELICOBACTER PYLORI



CELIAC DISEASE



Reflux esophagitis as the presence of endoscopically visible breaks in the

esophageal mucosa at or immediately above the GEJ.

Visible breaks in the esophageal mucosa: signs of greatest interobserver

reliability (operator experience is a component of interobserver reliability).

Grading severity of esophagitis useful for grading esophagitis and

response to treatment (the LA classification generally used for adults, but

suitable for children).

Endoscopically normal esophageal mucosa does not exclude NERD or

esophagitis of other etiologies

PEDIATRIC GERD CLINICAL PRACTICE GUIDELINES: JOINT

RECOMMENDATIONS OF THE NASPGHAN AND ESPGHAN. JPGN 2009; 49:498-547

Diagnostic yield of endoscopy greater if multiple samples of good size and

orientation are obtained from biopsy sites

Variables influencing validity of histology as a diagnostic tool for RE:

sampling error (patchy changes); no standardization of biopsy location,

tissue processing, and morphometric interpretation.

Histology may be normal or abnormal in NERD because GERD is an

inherently patchy disease. Histologic findings of eosinophilia, elongation

of papillae (rete pegs), basal hyperplasia, and dilated intercellular spaces

(spongiosis) are neither sensitive nor specific for RE

PEDIATRIC GERD CLINICAL PRACTICE GUIDELINES: JOINT

RECOMMENDATIONS OF THE NASPGHAN AND ESPGHAN. JPGN 2009; 49:498-547




HELICOBACTER PYLORI



CELIAC DISEASE



IBD 1 IBD 2 IBD 3 IBD….. UC CD

DEFINING IBD: current vs future

Names vs Mechanistic subsets

From Dermot McGovern

20th CENTURY 21st CENTURY

Target therapy to pathogenesis

Multiple homogeneous disease phenotypes based on

mechanisms………..serology, genotype,microbioma,

mucosal cytokine scenario……..

IBD-U

DIAGNOSTIC ALGORITHM OF INFLAMMATORY BOWEL DISEASE (IBD)

Symptoms and signs of IBD DIFFERENTIAL DIAGNOSIS Infections

vasculitides

immunodeficiencies

food allergy,

lymphoma,

malabsoprtion,

chronic liver disease,

arthritis,

etc…….

Indexes of nutrition, activity,

absorption, stool culture (Yearsinia

etc. Cl. difficile, ASCA, pANCA, stool

calprotectine, ………….

IMAGING (non invasive)

ULTRASOUND (SICUS) +++

MRI GADOLINIUM +++

Contrast x-ray + (?) Scintigaphy + (?)

I. Ileo-colonoscopy, Esophagogastroduodenoscopy, Histology,

II. Videocapsule, Device Assisted Enteroscopy

Crohn’s disease

Ulcerative colitis

IBD-unclassified

Follow up

Control symptoms

Mucosal healing (reduce inflammation)

Deep remission

Change disease course

Prevent relapse

Reduce complications

Optimize growth potential

Prevent surgery

Preserve bowel

Maintain adequate nutritional status

Improve quality of life

Short-Term

Long-Term

OLD & NEW THERAPEUTIC GOALS IN PEDIATRIC IBD

SURROGATE MARKERS FOR

MUCOSAL HEALING

AND DEEP REMISSION

• Fecal markers: calprotectin,

lactoferrin

• Serum markers: CRP

• Imaging methods: colonic US

• Capsule endoscopy: colonic WCE

• ………….HMGB1…

DDW 2013

Orlando, USA

DDW 2013

Orlando, USA

DDW 2013, Orlando, USA

DIAGNOSTIC ALGORITHM OF INFLAMMATORY BOWEL DISEASE (IBD)

Symptoms and signs of IBD DIFFERENTIAL DIAGNOSIS Infections

vasculitides

immunodeficiencies

food allergy,

lymphoma,

malabsoprtion,

chronic liver disease,

arthritis,

etc…….

Indexes of nutrition, activity,

absorption, stool culture (Yearsinia

etc. Cl. difficile, ASCA, pANCA, stool

calprotectine, ………….

IMAGING (non invasive)

ULTRASOUND (SICUS) +++

MRI GADOLINIUM +++

Contrast x-ray + (?) Scintigaphy + (?)

I. Ileo-colonoscopy, Esophagogastroduodenoscopy, Histology,

II. Videocapsule, Device Assisted Enteroscopy

Crohn’s disease

Ulcerative colitis

IBD-unclassified

Follow up

SIGENP MULTICENTER STUDY

2011;43:220-4

Rome Sapienza University, Naples Federico II University, Pescara PED-GI Hospital

Usefulness of wireless capsule endoscopy in paediatric inflammatory bowel disease. Dig Liver Dis

2011;43:220-4.

PATIENTS WITH SUSPECTED CROHN’S DISEASE (16) (GROUP A) (median age: 12.3 years; range: 7-18 years)

MRI – WCE: investigation of small intestine

CROHN’S DISEASE proximal jejunum (7), distal jejunum (4), proximal ileum (4), distal ileum (6)

Stricturing

Crohn’s disease,

successful EBD

Self-limited

enteropathy

Eosinophilic

Enteropathy in 2,

NSAID in 1

SINGLE BALLOON ENTEROSCOPY

10 patients - MRI: 7 with IWT and TE,

3 with IWT and SE; WCE: diagnostic of

CD in 3, suggestive of CD in 7

2 patients - MRI:

strictures (WCE

not performed)

3 patients - MRI:

normal; WCE:

unspecific

1 patient - MRI:

IWT and TE;

WCE: unspecific

Figure legend. CD: Crohn’s Disease; WCE: wireless capsule endoscopy; EBD: endoscopic balloon dilatation; NSAID: non steroid anti-inflammatory drugs; MRI: magnetic resonance imaging; MRI features: IWT= increased wall thickness; TE=transmural enhancement; SE=stratified enhancement.

Successful endoscopic

balloon dilatation

THERAPY: a) introduction of biologics in 10 patients on maintenance therapy with thioprine, b)

change of biological agent in 4 patients (from infliximab to adalimumab)

5 patients: IWT

and NSCE

3 patients: IWT and SE

3 patients: IWT and TE

3 patients:strictures

(2 with NSCE and 1 with SE)

SINGLE BALLOON ENTEROSCOPY

Inability to pass anastomosis

stricturoplasty in 4

(severe inflammation in areas

proximal to the MRI features)

Evidence of severe

inflammation

MRI: investigation of small intestine; WCE: not performed

Figure legend: MRI= magnetic resonance imaging; MRI features: IWT= increased wall thickness;

TE=transmural enhancement; SE=stratified enhancement; NCSE=non significant contrast enhancement

PATIENTS WITH ESTABLISHED CROHN’S DISEASE (14) (GROUP B) (previous surgery in 13) - (median age: 15.7 years; range: 12-18 years)

THE FUTURE OF PEDIATRIC GI ENDOSCOPY




HELICOBACTER PYLORI



CELIAC DISEASE



ADVANCES IN MODERN ENDOSCOPIC THERAPEUTICS

Important factors in performing successful

therapeutics

• Accessories

• Scope handling and experience

How often do we perform therapeutics and can we

predict what we will do ?

Interventions

• Haemostasis

• Injecting

• Argon plasma coagulation

• Heater probe or contact cautery

• Gluing

• Clipping and endolooping

• Polypectomy

• Stenting

• Dilatation

• Feeding tubes

• ERCP

Thank you for your

attention

Yesss, finally over !

come l’endoscopia ha trasformato la gastroenterologia ... · pdf filecome...

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