Pattern of pediatric upper gastrointestinal disease: A teaching hospital experience

A Lardhi; A Al Sultan; M Al Fadel Saleh; A Al Quorain; A Adel; R Al Baradie

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Year : 1996 | Volume : 2 | Issue : 1 | Page : 15-18

Pattern of pediatric upper gastrointestinal disease: A teaching hospital experience

A Lardhi¹, A Al Sultan², M Al Fadel Saleh¹, A Al Quorain², A Adel¹, R Al Baradie¹
¹ Department of Pediatrics, King Fahd Hospital of the University, Alkhobar, Saudi Arabia
² Department of Internal Medicine, King Fahd Hospital of the University, Alkhobar, Saudi Arabia

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Abstract

During the period 1983-1993, 166 pediatric patients(91 females and 75 males) were subjected to upper gastrointestinal endoscopy. Epigastric pain or heart burn and vomiting were the indications in 115 (69 %)patients. Gastritis. duodenitis, and esophagitis were diagnosed in 63 (38 %), and duodenal ulcer in seven (4.2%)patients. Bleeding sites were identified in 10 out of 21 (47.6% )patients with a history of hematemesis. Helicobacter pylori was identified in 12 (48%) of 25 patients with chronic gastritis. Endoscopic removal of foreign bodies (FB) was required in nine patients. Endoscopic small bowel biopsy provided sufficient material to confirm the diagnosis in seven out of 13 patients with chronic diarrhea. Endoscopic findings were normal in 78 (47%)patients. The procedure was safe and well tolerated.

How to cite this article:
Lardhi A, Al Sultan A, Saleh M A, Al Quorain A, Adel A, Al Baradie R. Pattern of pediatric upper gastrointestinal disease: A teaching hospital experience. Saudi J Gastroenterol 1996;2:15-8

How to cite this URL:
Lardhi A, Al Sultan A, Saleh M A, Al Quorain A, Adel A, Al Baradie R. Pattern of pediatric upper gastrointestinal disease: A teaching hospital experience. Saudi J Gastroenterol [serial online] 1996 [cited 2020 Oct 23];2:15-8. Available from: https://www.saudijgastro.com/text.asp?1996/2/1/15/34036

Upper gastrointestinal (UGI) endoscopy has become a corner stone in the diagnosis and management of gastrointestinal diseases. Since it was introduced in pediatric practice, the experience gained over the last three decades, along with the development of special pediatric endoscopes have alleviated the concerns about its safety in children ^{[1],[2],[3],[4],[5],[6],[7]} . The direct visualization of different sites, with the facility to obtain histological materials, makes endoscopy superior to other gastrointestinal diagnostic procedures^[5],[8],[9] . The aim of this communication is to present our analysis of common upper gastrointestinal disorders seen at King Fahd Hospital of the University.

Patients and methods

The medical records of all pediatric patients, subjected to UGI endoscopy at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia, during the period January 1983 to December 1993,were retrieved and retrospectively analyzed.

The endoscopic procedure was performed generally under basal sedation using olympus-pediatric gastroduodenoscope (GIF-XP). In some infants and older children, general anaesthesia was required, average duration was 15-20 minutes. A biopsy was taken where indicated and feasible. Based on the indications, patients were classified into five groups: Group A: patients with epigastric pain, heart burn and vomiting. Group B: patients with hematemesis. Group C:patients with chronic diarrhea/malabsorption syndrome. Group D: patients with history of FB ingestion. Group E: patients with other conditions.

Results

There were 166 patients, of which 88% are Saudis, 91 females (54.8%)and 75 males (45.2%) with a mean age of 11.4 ± 4.6 SD (ranging between three months and 16 years). The presenting symptoms for which endoscopy was indicated were abdominal pain, heart burn and vomiting. Physical examination revealed upper abdominal tenderness in 79 (47.6%), pallor in 25 (15%), signs of malnutrition in 10 (6%) and hepatosplenomegaly in four (2.4%) patients. The endoscopic findings are illustrated in the [Table - 1].

Of the 115 patients in group A, endoscopy revealed gastritis in 30 (26%), duodenitis in 20 (17%), esophagitis in 13 (11%) and duodenal ulcer in seven (6%) patients. In the remaining 45 patients (40%) in this group, endoscopy was normal. Gastric biopsies were obtained from 34 patients. The histologic diagnosis showed superficial chronic active gastritis in 25 (73.5%) patients and it was normal in the remaining nine patients. Of the 25 patients with chronic gastritis, H. pylori was identified pathologically in 12 (48%)patients. An eight-year-old boy with abdominal pain, who showed normal endoscopic finding developed typical purpuric rash and joint swelling diagnosed later as Henoch-Schonlein purpura.

Of the 21 patients in group B, the source of bleeding was identified in 10 (47.6%) patients. Erosive gastritis was the cause of bleeding in six (31.6%), duodenal ulcer in two (10.5%) patients and one each (5.3%) with gastroesophageal reflux disease and esophageal varices.

There were 13 patients in group C. The endoscopic findings in seven patients showed mild to moderate nonspecific inflammation in the duodenum and the upper part of the jejunum. The small bowel biopsy in these patients revealed celiac disease in three (21%), subtotal villous atrophy due to giardiasis in two (15.4%) and one each (7.7%) with intestinal lymphangiectasia and eosinophilic gastroenteritis. In the six patients with normal endoscopic findings (46%), cystic fibrosis was diagnosed in two; intestinal duplication, abetalipoproteinemia, ulcerative colitis and Addison's disease in one each. Patients with accidental ingestion of FB (Group D) had routinely-plain abdominal x-ray prior to endoscopic procedure to confirm the presence of the FB and to identify its approximate location. The FB were successfully removed in all of them. These FB consisted of coins (25 halala) in six, hair clips in two and a fish bone was removed from the lower part of the esophagus in one.

Of the eight patients in group E, four with hepatosplenomegaly were subjected to UGI endoscopy to confirm esophageal varices suspected on barium meal study. Esophageal varices due to schistosomiasis were present in two patients. The hepatosplenomegaly in the remaining two patients was related to hematologic disease, namely sickle cell disease. In the remaining two patients, the endoscopy of the first one showed circumferential necrosis and moderate to severe stenosis of the middle and lower part of the esophagus caused by accidental ingestion of a caustic substance. This patient required repeated endoscopic dilatation. Tuberculous esophagitis, which was suspected in the second patient, was confirmed histologically (granulomatous esophagitis). This patient was treated, and responded to antituberculous drugs. The UGI endoscopy in two patients with colonic polyposis was free of any abnormality.

The laboratory tests showed moderate hypochromicmicrocytic anemia in 39(23.5%) patients, which was caused mainly by UGI-bleeding, iron deficiency and sickle cell disease. In 16(9.6%) patients, the occult blood test was positive. Stool analysis showed giardia intestinalis infestation in four (2.4%) patients. The other tests were generally within normal limits. No complications related to endoscopy were encountered in any patient.

Discussions

Pediatric UGI endoscopy is proven to be a preferred diagnostic and therapeutic tool in various gastrointestinal disorders. The concerns about its safety and efficacy have been alleviated by the introduction of special pediatric endoscopes that facilitate excellent visualization and better tolerability by children. The procedure is generally carried out under basal sedation in most cases ^[9],[10] . Some authors, however, recommend general anesthesia in young children ^[2],[6],[11] .

The indications in the majority of our patients were abdominal pain, heart burn and vomiting which were comparable with other reports ^[5],[11] . Endoscopic diagnoses of esophagitis, esophageal varices, gastritis, duodenitis and peptic ulcer disease were made according to the accepted standard criteria ^[12] . Gastritis was by far the most common endoscopic and histologic diagnosis followed by duodenitis and esophagitis. The frequency of gastritis in our patients is higher than that reported from the central region of Saudi Arabia ^[13] . Of interest was the identification of H. pylori in a relatively high percentage (48%) of patients with chronic gastritis. This is in agreement with other reports that the acquisition of H. pylori occurs in about 10% of children per annum between the ages of two and eight years ^[14]. Duodenal ulcer, which was seen in 4% of our patients, is similar to other reports ^[6],[13] . However, Hagrove reported a figure of 8% in his series ^[15] . Gastric ulcer was not seen in our study. This is in contrast to the 5% reported by Al-Mofleh et al ^[13] . A low incidence of gastric ulcer has also been reported in adults from this institution where the ratio of duodenal to gastric ulcer was 7.6:1 ^[16] . The source of bleeding was identified in about half of the patients with hematemesis and the commonest cause was erosive gastritis. This is in contrast to other reports where peptic ulcer disease is the common cause of bleeding ^{[5],[13],[15]} . The delay of presentation in some patients with hematemesis may explain the low diagnostic yield in this group. In our patients with chronic diarrhea and malabsorption syndrome, UGI endoscopy was very helpful in obtaining adequate small bowel biopsy material for the diagnosis of small bowel disorders, such as celiac disease and intestinal lymphangiectasia. The removal of foreign body through UGI endoscopy is safe; avoids radiation exposure and reduces hospital admission ^[9],[17] .

In conclusion, the common endoscopic abnormalities observed in this study were gastritis associated with H. pylori infection, followed by duodenitis and esophagitis. We confirm previous findings that UGI endoscopy in infants and children is a safe and acceptable diagnostic, as well as therapeutic procedure.

References

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