endoscopy in pibd - appspghan.org · what is special in pediatric endoscopy •size of devices...

ENDOSCOPY IN PIBD

Katsuhiro Arai, MD, PhDCenter for Pediatric Inflammatory Bowel Disease

Division of GastroenterologyNational Center for Child Health and Development

Tokyo, Japan

https://appspghan.org

COI disclosure

I have no conflict of interestrelated to this lecture.

Katsuhiro Arai

APPSPGHAN PIBD MASTERCLASS


IS CHILDREN SMALL ADULTS?

No! Yes!


WE ARE THE SPECIALISTS FOR PEDIATRIC ENDOSCOPY!

I APPSPGHAN - PIBD Materclass4


What is special in pediatric endoscopy• Size of devices• Vulnerability• Extent of the attached D/C• Available devices and equipment• Requirement of sedation or anesthesia

with their risk• Etc….

Attached to

the

retroperitoneu

m

D/C


HAVE YOU EXPERIENCED THE SITUATION LIKE…

That UC patient did not have gastric or small intestinal lesion before. But he is

having trouble with fistula and abscess…

Could he have Crohn?

I believed he had typical UC, and I did evaluate his upper and small bowel. Now, he is not gaining weight, and I see his CRP is somewhat going up…. Could he have Crohn?

I should have done

EGD..

I should have done capsule endoscopy..


WHOLE BOWEL EVALUATION IS ESSENTIAL IN DIAGNOSING PEDIATRIC IBD

Revised Porto Criteria

Levine et al. JPGN 2014

Ileocolonoscopy and EGD

should be performed for

all children suspected to

have IBD!

Capsule endoscopy or

MRE should be performed

unless you have no doubt

he/she has UC….


138100 120 114 113 119 138

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2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

EGD Colonoscopy Small bowel(stoma, baloon) Capsule Others

PEDIATRIC ENDOSCOPIES AT NCCHD (2010-2019）

Balloon Assisted Endoscopy

Small Bowel Transplantaion

Capsule Endoscopy

（/Year）

270


➢Evaluating the whole gastrointestinal tract is essential for accurate diagnosis of IBD



SCORING SYSTEM FOR ENDOSCOPY

Ulcerative Colitis

◆Mayo score

◆DAI score

◆Rachmilewitz index

◆Baron index

◆Puchitis disease activity Index (PDAI)

◆Ulcerative colitis endoscopic index of disease activity (UCEIS)


Crohn’s Disease

◆Simple endoscopic score for Crohn’s disease (SES-CD)

◆Crohn’s disease endoscopic index of severity (CDEIS)

◆Rutgeerts score

◆Capsule endoscopy Crohn’s disease activity index (CECDAI)

◆Lewis scoreScoring of endoscopic finding is useful for clinical trial or

objective evaluation of disease activity!


MAYO ENDOSCOPIC SCORE



ATYPICAL FINDINGS OF UC

• Skip lesion

• Rectal sparing

• Deep ulceration

• Backwash ileitis

• Upper GI lesions

Don’t get caught with a diagnosis!


CHILDREN WITH UC AT NCCHD

110

Dx’ed as UC

(IBD-U is not included)

11 (9.9%)

Change the diagnosis as Crohn’s disease

6 (54.5%)

Dx’ed as UC by colonoscopy only

@ referring hospital

5 (45.5%)

Dx’ed as UC @NCCHD after total GI tract

evaluation99

Remain as UC


Follow up over

6-160 months

Risk factors (p<0.05)Hypoalbuminemia and

Anemia at diagnosis as well as

requirement of biologics

(Submitted for publication)

Diagnosis may change during the course!


ENDOSCOPIC FINDINGS OF CROHN’S DISEASE!

Aphthous Ulcers Longitudinal Ulcers

Cobble Stone Appearance


SIMPLE ENDOSCOPIC SCORE FOR CROHN’S DISEASE (SES-CD)

SES-CD values

Variable 0 1 2 ３

Ulcers None Aphthous ulcers

(Diameter 0.1-0.5cm)

Large ulcers

(Diameter 0.5-2cm)

Very large ulcers

(Diameter >2cm)

Ulcerated surface None <10% 10-30% >30%

Affected surface Unaffected

surface

<50% 50-75% >75%

Stenosis None Single, can be passed Multiple, can be

passed

Cannot be passed


TI Rt. C T. C Lt. C R Total

Ulcers 0 2 1 1 1 5

Ulcerated surface 0 1 1 1 1 4

Affected surface 0 2 1 1 1 5

Stenosis 0 1 0 0 0 1

SES-CD=15Mild: 3-6, Moderate: 7-15, Severe: ≧16

Daperno M. Gastrointest Endosc 2004;60:505

Khanna R. Inflamm Bowel Dis 2014;20:1850


CAPSULE ENDOSCOPY CROHN’S DISEASE ACTIVITY INDEX(CECDAI)

A Inflammation 0: None

1: Mild to Moderate (edema, hyperemia, or denudation)

2: Severe (edema, hyperemia, or denudation)

3: Bleeding, exudate, erosion, aphthae, ulcer<0.5cm

4: Pseudopolyp, ulcer 0.5-2cm

5: Ulcer >2cm

B Extent of Disease 0: None

1: Single segment (focal disease)

2: 2-3 segments (patchy disease)

3: >3 segments (diffuse disease)

C Stricture 0: None

1: Single, traversed

2: multiple, traversed

3: obstraction


CECDAI=proximal segment

(AXB+C) + distal segment (AXB+C)

Mild-moderate ≧3.5

Severe ≧5.8

Melmed GY. Gastrointest Endosc 2018;88:947


VARIOUS ENDOSCOPIC FINDINGS IN PIBD

Leopard Sign of CGD colitis（Obayashi N, Arai K. JPGN 2016)

XIAP deficiency IL-10 signaling defect Autoimmune enteritis(Jimbo K, Arai K. JPGN 2015)

You will sometimes find very interesting findings


BIOPSIES

• At least 2 biopsies from each section

• Work together with pathology team

• Understand the limitation of pathology


SMALL BOWEL ENDOSCOPYhttps://appspghan.org

CAPSULE ENDOSCOPYhttps://appspghan.org

Capsule Endoscopy in Children with IBDCan we do it?－

Higher risk of retention with narrow tract and possible stenotic lesion…

Can children swallow the big capsule?


EVALUATING THE PATENCY OF INTESTINAL TRACT

Excretion within 33 hours confirms the patency of the GI tract. Need evaluation if no excretion in 30 hours.


• Clear hood, retrieval net, and snare can be used to guide the capsule to the duodenum

Oikawa-Kawamoto M, World J Gastro. 2013

ENDOSCOPIC PLACEMENT OF CAPSULE


ENDOSCOPIC PLACEMENT OF CAPSULE

• A few 6 year-old can swallow the capsule

• Majority of 10 year-old or older can swallow the capsule

• Patency capsule can be used to evaluate the necessity of endoscopic placement


Post-pyloric placement of capsule is another benefit of AdvanCE

Capsule endoscopy is feasible in infants more than 8-10kghttps://appspghan.org

CAPSULE ENDOSCOPY@NCCHD

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2011 2012 2013 2014 2015 2016 2017 2018 2019

（件）

Introduction of

Capsule Endoscopy

Introduction of

Patency Capsule

Introduction of

Delivery Device (AdvanCE)


Always think about how you complete the studies in children who would not swallow the capsule!

I want to complete all the endoscopic exams efficiently

I do not want to anesthetize kids multiple times

How do you proceed endoscopies with minimum burden for the patients?


PROCESS OF CAPSULE ENDOSCOPY FOR CHILDREN SUSPECTED TO HAVE IBD @ NCCHD

Patency Capsule

Swallow the Capsule

Endoscopy

EGD and Colonoscopy if IBD is suspected

EGD, Colonoscopy and endoscopic

duodenal placement of

Patency Capsule

Endoscopic duodenal placement of Capsule

Endoscopy under sedation or anesthesia

Consider alternative small bowel imaging

study or postponing the Capsule Endoscopy

Able to swallow the capsule

& patency confirmed

Unable to swallow

the capsule

Patency confirmed

Patency not confirmed


THE POWER OF CAPSULE ENDOSCOPY IN PEDIATRIC GI PRACTICE

10y.o M Lymphangiectasia

22y.o.F Peutz-Jeghers syndrome

6y.o. M Pyogenic Granuloma


BALLOON ASSISTED ENTEROSCOPY

Diagnostic and Therapeutic!


(Yokoyama . JPGN 2016)

（Yokoyama K. JPGN 2016;63:34）


(Yokoyama . JPGN 2016)

◆Total complication rate was 5.4%, however, the rate without DBERC was 1.9％, which was as low as adult DBE procedure

◆The risk of pancreatitis was higher in those who underwent DBERC or whose procedure took over 120 minutes

（DBERC: Double balloon enteroscopy assisted endoscopic retrograde cholangiography)

（Yokoyama K. JPGN 2016;63:34）


ENDOSCOPY FOR CHILDREN WITH IBD

• Diagnosis of IBD

• Evaluate the response to current treatment• Aim for mucosal healing

• Evaluate the disease activity and extent when recurrent

• Therapeutic endoscopy for bleeding and stenosis



Invention and development in

endoscopy started from adult side

THE INNOVATION OF ENDOSCOPY IN CHILDREN

Smaller diameter and enhanced

resolution

Development of Patency Capsule

and AdvanCE

Increasing number of pediatric endoscopists

More diagnostic and therapeutic

endoscopies in infant and children

More children would receive the benefit of

small bowel endoscopies (Capsule & Balloon)


IS CHILDREN SMALL ADULTS?

No! Yes!No!• Procedure can be hard with

smaller size of the GI tract, higher risk of complication and inability to swallow the capsule.

• Devices and equipment may not be available for their smaller body size.

• Sedation or anesthesia may be necessary

• Differential diagnosis can be different

Yes!• Children, even young

infants, should be able to receive the appropriate endoscopic evaluation and treatment.

• Pediatric endoscopists and our societies should be creative and contributive for the sake of safe and effective endoscopy for children.


For the Better Care of Children with IBD

Children First!


endoscopy in pibd - appspghan.org · what is special in pediatric endoscopy •size of devices...

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