| Abstract|| |
Background: Biopsy of the small bowel is frequently obtained by endoscopic forceps instead of the classical suction capsule, yet reports from developing countries are scarce. Aim of the study: to report our experience on the diagnostic value of this procedure in our community.
Patients and methods: A retrospective analysis of all endoscopic duodenal biopsies (EDB), performed on all patients below 18 years of age. Data retrieved from the records included age, gender, nationality, indication for biopsy, the endoscopic findings, and the results of histopathology.
Results: From 1993 to 2002, 241 endoscopic biopsies were performed on 241 consecutive children. Most of the children (96%) were Saudi nationals, the age range between six weeks to 18 years, and male to female ratio was 0.7: 1. All of the biopsy material was adequate for routine histopathology. The commonest indications for biopsy were short stature and chronic diarrhea in 116/241 (48%) and 102/241 (43%) of the children respectively. Refractory rickets accounted for 11/241 (5%) of the indications. The prevalence of villous atrophy was highest in children presenting with chronic diarrhea (40%), compared to short stature (22%). Other less common, but important findings were villous atrophy in three unusual conditions (one refractory rickets, one unexplained anemia, and one polyendocrinopathy), two cases of intestinal Giardia lamblia infestation, three cases of intestinal lymphangiectasis and one case of Mycobacterium avium intracellulare. Unexpected endoscopic findings were documented in 34/241 (14%) of the children.
Conclusions: Endoscopic duodenal biopsy is adequate not only for the diagnosis of villous atrophy, but also for the detection of other gastroenteropathies.
Accordingly, when expertise and equipments are available, EDB should be the procedure of choice not only in industrialized but also in developing countries.
Keywords: Endoscopy, duodenal biopsy, villous atrophy.
|How to cite this article:|
El Mouzan MI, Abdullah Assiri AM, Al Herbish AS, Al Sohaibani MO. Endoscopic duodenal biopsy in children. Saudi J Gastroenterol 2006;12:31-3
It is universally recognized that biopsy of the small bowel is important for the evaluation of intestinal pathology in adults and children. The technique of biopsy has evolved over the last several decades from various types of plain or directable suction biopsy capsules, but all were time consuming and required fluoroscopy. ,,,,,,,,, In the meantime, suitable equipment and technique of gastrointestinal (GI) endoscopy for infants and children became available in the 1970's, with subsequent improvements making an important contribution to the evaluation of children with suspected GI pathology. ,, In an attempt to reduce time and avoid exposure to radiation, Sullivan et al introduced a technique of using an endoscopy-guided suction capsule.  Subsequently, endoscopic small bowel biopsy gradually developed and evolved over the last three decades. Earlier concerns about the adequacy of the size of endoscopic forceps biopsy material for histopathologic assessment have been gradually alleviated over the years. ,, It has been shown that the biopsy material obtained from either the jejunum or the duodenum by a forceps of any size is adequate for histopathologic evaluation. ,,, Furthermore, it was found that disaccharidase activity in endoscopic duodenal biopsy (EDB) was equivalent to those obtained by capsule biopsy.  In many developing countries, although gastrointestinal endoscopy is performed routinely on pediatric patients in most tertiary care centers, reports on the experience with EDB are scarce. , In this paper, we report our experience in the use of standard endoscopic forceps biopsies in the evaluation of children with suspected small intestinal disease.
| Patients and Methods|| |
This is a retrospective analysis of all EDB's performed on all patients from birth to 18 years of age at King Khaled University Hospital (KKUH) in Riyadh, Kingdom of Saudi Arabia, over a period of 10 years. In our institution, children under six months of age are examined without sedation and older children are sedated with midazolam alone or in combination with pethidine depending on the preference of the endoscopist. Esophagogastroduodenal inspection is performed routinely before biopsy and any abnormality is described and sampled as indicated. Subsequently, two to four forceps biopsies are taken from the second or third part of duodenum, put in 10% formaline solution and sent to the Pathology Department for further processing and examination. Data retrieved from the records included age, gender, nationality, indication for biopsy, the endoscopic findings, and the results of histopathology. Simple descriptive statistics were performed to define the indications and yield of endoscopy and histopathology.
| Results|| |
From 1993 to 2002, 241 children were referred to the gastroenterology service for EDB. Most of the children (96%) were Saudi nationals, age ranged between 6 weeks to 18 years with 188/241 (78%) of the children below 12 years of age. The male to female ratio was 0.7: 1. All of the EDB were adequate for routine histopathology. The commonest indications for biopsy were short stature and chronic diarrhea in 116/241 (48%) and 102/241 (43%) of the children respectively. Refractory rickets accounted for 11/241 (5%) of the patients. Other indications in 12/241 (5%) included protein-losing enteropathy in two patients, polyendocrinopathies in three, iron deficiency anemia in three, and polyarthritis, unexplained weakness, hypocalcemia, and Crohn disease in one patient each. The pattern of histopathologic diagnosis in relation to indications is shown in the table indicating that the prevalence of villous atrophy is highest in children presenting with chronic diarrhea (40%), compared to short stature (22%). Mild chronic non-specific duodenitis was the only finding in 100/241 (41%). Other less common, but important findings were the presence of villous atrophy in three unusual conditions (One refractory rickets, one unexplained anemia, and one polyendocrinopathy), two cases of intestinal Giardia lamblia infestation, three cases of intestinal lymphangiectasis and one case of Mycobacterium avium intracellulare. All of the latter four patients had creamy material covering the duodenal mucosa. Evaluation of the esophagus, stomach and duodenum before taking biopsies revealed abnormal endoscopic findings in 34/241 (14%) of the children, all of which were unexpected clinically. There were three cases of esophagitis, 15 cases of gastritis (five erosive and two nodular), of which seven were Helicobacter pylori e. Endoscopic duodenitis was diagnosed in 16 patients.
| Discussion|| |
Although our hospital provides free care to patients referred from almost all regions of the Kingdom, the children are selected for intestinal biopsy by gastroenterologists and in cases of short stature by endocrinologists. Compared to the classical capsule suction biopsy technique, the EDB is faster, avoids exposure to radiation, allows examination of the esophagus, stomach and duodenum, directs biopsy site under vision, eliminates the problem of failure of the suction capsule to fire, and provides adequate tissue sample for most diagnostic purposes. ,, All our samples were considered adequate as judged by the histopathologists, a finding consistent with the experience of others who reported that not only the quality but also the quantity is more than that obtained by suction biopsy. , The pattern of indications for biopsy in this report reflects the prevalent pattern of clinical presentations in our community with predominance of cases of chronic diarrhea and short stature. Similarly, the high diagnostic yield in these two presentations probably reflects the high selection of patients for biopsy. The 22% prevalence of villous atrophy in our children with short stature is within the range reported in the literature: between 8% for unselected,  to almost 60% for highly selected cases. 
Mild chronic non-specific duodenitis, a controversial entity, was the only histopathologic finding in 27% of the patients. In addition to villous atrophy, the EDB provided enough material for the diagnosis of other enteropathies such as lymphangietasia and tuberculosis. Another advantage of EDB is the opportunity to examine the upper GIT during the same procedure. Following this approach, we were able to diagnose conditions that required specific therapy, such as erosive and nodular gastritis, some of which were Helicobacter pylori positive. In conclusion, our experience indicates that EDB is adequate not only for the diagnosis of villous atrophy but also for the detection of other gastroenteropathies. Accordingly, wherever proper equipment and expertise are available, endoscopic duodenal biopsy should be the procedure of choice not only in industrialized but also in developing countries.
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Mohammad Issa El Mouzan
College of Medicine and KKUH. King Saud University, P.O. Box 2925, Riyadh 11461
Source of Support: None, Conflict of Interest: None
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