Endoscopic Procedures In Children Research Articles

Temporary hypotension and ventilation difficulty during endoscopic injection sclerotherapy for esophageal varices in a child with Fontan circulation: a case report

BackgroundEndoscopic procedures are rarely performed in children with congenital heart disease (CHD); therefore, the associated complications are unknown. We report an abrupt change in circulatory and respiratory condition during endoscopic injection sclerotherapy for esophageal varices.Case presentationA 9-year-old boy with a history of total anomalous pulmonary venous connection (TAPVC) repair and Fontan procedure for asplenia and a single ventricle with TAPVC underwent endoscopic injection sclerotherapy under general anesthesia for esophageal varices. Systolic blood pressure decreased from 70 to 50 mmHg following a sclerosant injection; a second injection reduced his peripheral oxygen saturation from 93 to 79% secondary to ventilation difficulty. Although we suspected anaphylaxis intraoperatively, postoperative imaging suggested that balloon dilation performed to prevent sclerosing agent leakage caused compression of the pulmonary venous chamber and trachea owing to the anomalous intrathoracic organ anatomy.ConclusionThorough understanding of the complex anatomy is important before performing endoscopic procedures in children with CHD to preoperatively anticipate possible intraoperative complications and select the optimal therapeutic approach and anesthesia management.

Transient End-Tidal Carbon Dioxide Elevation During Pediatric Upper Endoscopy With Carbon Dioxide Insufflation: Is It True Hypercapnia?

Endoscopic insufflation, long performed using air, is being replaced by carbon dioxide (CO2) at many pediatric centers, despite limited published data on its use in children. We have previously demonstrated that CO2 use during esophagogastroduodenoscopy (EGD) in non-intubated children is associated with transient elevations of end-tidal CO2 (EtCO2). This observation raised concerns about possible CO2 inhalation and systemic absorption. Here, we investigate this concern by concurrently measuring both EtCO2 and transcutaneous CO2 (tCO2) during upper endoscopic procedures in children. To determine if elevations in EtCO2 levels seen in non-intubated children undergoing CO2 insufflation during EGD are associated with elevated systemic CO2 levels. Double-blinded, prospective, randomized clinical trial. Children were randomized 1:1 to receive either CO2 or air for endoscopic insufflation. EtCO2 was sampled with a CO2-sampling nasal cannula and tCO2 was monitored using the Radiometer transcutaneous monitoring device. Fifty nine patients were enrolled; 30 patients in the CO2 insufflation group and 29 in the air group. All patients underwent a procedure involving an EGD. Transient elevations in EtCO2 (defined as >60 mmHg) were observed only in the CO2 insufflation group. This contrasted with the similar elevations of tCO2 between the CO2 and air insufflation groups. None of these events were of clinically significant magnitude or duration. This study demonstrates that the observed transient elevations in EtCO2 seen during EGD in non-intubated children receiving CO2 insufflation are most likely measurements of eructated CO2 without evidence of excessive systemic absorption of CO2.

Serologic diagnosis of celiac disease: May it be suitable for adults?

The diagnosis of coeliac disease (CD) in adult patients requires the simultaneous assessment of clinical presentation, serology, and typical histological picture of villous atrophy. However, several years ago, the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition guidelines approved new criteria for the diagnosis in children: Biopsy could be avoided when anti-transglutaminase antibody (TGA) values exceed the cut-off of × 10 upper limit of normal (ULN) and anti-endomysium antibodies are positive, independently from value. This “no biopsy” approach is a decisive need for pediatric population, allowing to avoid stressful endoscopic procedures in children, if unnecessary. This approach relies on the correlation existing in children between TGA levels and assessment of mucosal atrophy according to Marsh’s classification. Several lines of evidence have shown that patients with villous atrophy have markedly elevated TGA levels. Therefore, we aim to perform a narrative review on the topic in adults. Despite that some studies confirmed that the × 10 ULN threshold value has a very good diagnostic performance, several lines of evidence in adults suggest that TGA cut off should be different from that of pediatric population for reaching a good correlation with histological picture. In conclusion, the heterogeneity of study reports as well as some conditions, which may hamper the serological diagnosis of CD (such as seronegative CD and non-celiac villous atrophy) and are much more common in adults than in children, could represent a limitation for the “no biopsy” approach to CD diagnosis in patients outside the pediatric age.

Evolution in the Practice of Pediatric Endoscopy and Sedation.

The fields of pediatric gastrointestinal endoscopy and sedation are critically important to the diagnosis and treatment of gastrointestinal (GI) disease in children. Since its inception in the 1970s, pediatric endoscopy has benefitted from tremendous technological innovation related to the design of the endoscope and its associated equipment. Not only that, but expertise among pediatric gastroenterologists has moved the field forward to include a full complement of diagnostic and therapeutic endoscopic procedures in children. In this review, we discuss the remarkable history of pediatric endoscopy and highlight current limitations and future advances in the practice and technology of pediatric endoscopy and sedation.

Effect of music on pediatric endoscopic examinations: a randomized controlled trial

Background and study aims The primary objective was to measure the effect of music as an adjunct to sedation in patient anxiety levels during pediatric endoscopic examinations. Patients and methods We performed a single-blind randomized controlled trial comparing music with no music in children aged 2 to 18 years. Anxiety was measured using the Modified Yale Preoperative Anxiety Scale (m-YPAS) and the Visual Analog Anxiety Scale (VAS-anxiety). Patient perception of pain was evaluated with the Wong-Baker Faces Pain Rating Scale (WBFPRS). Patient experience, family satisfaction, and endoscopist perception of difficulty were evaluated. Sedative doses were recorded. Results A total of 51 children were randomized to the experimental group and 49 children to the control group. The mean ages were 10.5 years and 12.3 years, respectively. There were 63 % female subjects with no differences between groups. Overall, there were 85 upper endoscopies and 15 colonoscopies. In the recovery unit, the experimental group had lower average m-YPAS scores (mean score 27.7 vs 34.7; P < 0.001), a higher proportion of them had low m-YPAS scores (80 % vs 49 % P < 0.001), had lower VAS-anxiety scores [mean score 0.55 vs 1.57 ( P = 0.003)], and had lower WBFPRS scores [mean score 2.7 vs 1.3 ( P = 0.001)]. There were no statistically significant differences found in the amount of standard sedation given to the groups, nor in additional sedation administered. In the experimental group, the patient-reported experience was significantly better. Conclusions The study results show that music reduces anxiety and pain associated with endoscopic procedures in children. It also facilitates these procedures and improves patient satisfaction.

Rigid and flexible ureteroscopy (URS/RIRS) management of paediatric urolithiasis in a not endemic country.

In the last years due to miniaturization of endoscopic instruments and percutaneous surgery, endourology has become very popular in paediatric urinary stone managment. We reported our single-centre experience in retrograde endoscopic procedures in children. Results and complications of URS/RIRS are discussed. We retrospectively reviewed our experience in patients ≤ 16 years old affected by urinary stones who underwent URS/RIRS procedures performed by two surgeons with expertise in endourology. A total of 30 renal Units (RUs) underwent endoscopic procedures (URS, RIRS or both). Surgical complications according to the ClavienDindo's classification and stone-free rate were evaluated at 3 months follow-up. Success of URS was defined as stone-free status after single procedure while RIRS success rate was considered as presence of residual stone fragments smaller than 4 mm at first procedure. The mean age of our patients was 8 years, range 2- 16 years. A total of 30 renal units (RUs) underwent 40 endourological procedures (23 URS and 17 RIRS; 10 children underwent both procedures at the same time). 17/30 (56.6%) RUs were pre-stented before surgery. The stone-free status was achieved in 23/30 renal units treated, with a 76.6% success rate. The remaining 7 patients had residual stones greater than 4 mm and underwent further treatments. After a second surgery the stone-free rate turned out to be 93.3% (28/30 renal units). Rigid and flexible ureteroscopy (URS/RIRS) is a reliable technique for treatment of < 2 cm urinary stones in paediatric age group. It shows low rate of major complications and promising results in terms of stone-free rate.

Diagnostic Yield of Endoscopic Procedures in Children: Experience of a Portuguese Center

Background: Over the last decades, the use of gastrointestinal (GI) endoscopic procedures has been increased in children worldwide, allowing the early diagnosis and therapeutic intervention in multiple GI diseases. Aims and Methods: In order to evaluate the appropriateness and the diagnostic yield of initial GI endoscopic techniques in children in a Portuguese tertiary hospital, we performed a retrospective cohort study during a 12-month period. Results:A total of 308 procedures were performed in 276 patients; the median age was 11 years and 50.4% were males. Esophago-gastro-duodenoscopy (EGD) corresponded to 81.8% of the procedures and ileo-colonoscopy (IC) to the remaining; 11.6% of the patients underwent both EGD and IC. Overall, 51.3% of the exams showed abnormal macroscopic findings, and 69.6% showed histopathological signs of disease, with IC showing significantly more positive results than EGD (p < 0.05). Considering the different indications independently, abnormal serology for celiac disease, suspected ingestion of foreign bodies, suspected inflammatory bowel disease, and food impaction were frequent in our population; and in the majority of the cases, the suspected diagnosis was confirmed: celiac disease, ingestion of foreign bodies, inflammatory bowel disease, and eosinophilic esophagitis, respectively. On the other hand, despite the high frequency of epigastric pain in this population, only nearly one-third of the patients showed abnormal histological findings. The final diagnosis was established in 63% of the patients, and 39.1% initiated the new treatment. Discussion:Our results emphasize the importance of endoscopic procedures, especially IC, in the diagnosis of GI diseases in pediatric patients, as well as the careful choice of the endoscopic techniques in those with less specific symptoms, as chronic abdominal pain. In this particular situation, given the proportion of cases that may be due to functional disease, good characterization of the clinical context is needed, and endoscopy should be reserved for a second-line approach. Conclusion: It is important to monitor and examine the endoscopic techniques as an index of quality criteria for clinical practice.

A Retrospective Multicenter Cohort Analysis of Complications Following Outpatient Therapeutic Endoscopic Procedures in Children: 2017 Presidential Poster Award

Introduction: The risk of complications following therapeutic endoscopic procedures in children is poorly understood, herein we analyzed a 44-center diagnostic-code based database for admissions, direct inpatient or ED-inpatient followig the commonest pediatric endoscopic therapeutic interventions. Methods: The study is a retrospective multi-institutional database analysis. PHIS was interrogated through ICD 9-CM principal procedure codes to identify patients undergoing therapeutic endoscopy in the ambulatory setting between 9/1/2005 and 8/30/2015 at 44 free-standing children's hospitals. Demographics, co-morbidities, and type of procedure were analyzed using the generalized linear mixed model framework. The R statistical package was used for analysis. Results: A total of 6,302 patients underwent therapeutic endoscopic procedures during the study period: 45.07% underwnt polypectomy, 21.61% underwent variceal sclerotherapy or banding and 33.32% underwent endoscopic control of bleeding. Of the 6,302 patients, 0.65% were readmitted (40 to ED, 13 to directly to inpatient) within 5 days with a gastrointestinal or pulmonary diagnosis. The mean age (SD) overall was 9.32 (5.36) years and 9.56 (5.29) years for readmissions. The majority of readmissions (33/53, 62.26%) were on the day of or the day after the procedure; 30.2% received abdomen imaging, 11.3% received chest imaging and none were reendoscoped. Readmissions were significantly associated with race (P = 0.010), being higher in minority children (OR 2.11, 95% CI: (1.19, 3.75)) but not age or gender (Age P=0.890; Gender P=0.947). Complex chronic conditions (CCC) conferred risk of readmission; each additional CCC increasing the odds by 44% (OR 1.44, 95% CI: (1.02,2.03), P=0.038). Type of procedure was significantly associated readmission (P=0.003). Endoscopic control of a bleed had higher odds than polypectomy / injection/banding (OR 2.26, 95% CI: (1.18, 2.26); OR 6.33, 95% CI: (1.85, 21.69)). Conclusion: This is the largest study, to date, reporting on adverse outcomes complicating elective therapeutic endoscopic procedures in children defined by ED or inpatient readmission postprocedure. It is limited by the inherent diagnostic constraints of a coding based database. We report a 0.65% readmission rate, with most readmissions on the day of procedure or the next day. Readmission is more likely in minority populations and in children with complex chronic comorbidities. Endoscopic hemostatic intervention entailed the highest risk of readmission.

A Retrospective Multicenter Cohort Analysis of Complications Following Outpatient Diagnostic Endoscopic Procedures in Children: 2017 Presidential Poster Award

A Retrospective Multicenter Cohort Analysis of Complications Following Outpatient Diagnostic Endoscopic Procedures in Children: 2017 Presidential Poster Award

55 Does the Presence of a Trainee Increase Adverse Events for Endoscopic Procedures in Children?

55 Does the Presence of a Trainee Increase Adverse Events for Endoscopic Procedures in Children?

Topical tranexamic acid as a novel treatment for bleeding peptic ulcer: A randomised controlled trial

Background:Peptic ulcers are among the most common causes of upper gastrointestinal (GI) bleeding in children. The standard care for GI bleeding is endoscopy for diagnostic and therapeutic purposes. We aimed to assess the effect of topical tranexamic acid (TXA) via endoscopic procedures in children with GI bleeding caused by bleeding ulcers.Procedure:In this randomised controlled trial, 120 children were evaluated by diagnostic procedures for GI bleeding, of which 63 (30 girls, 33 boys) aged 1-month to 15 years were recruited. The patients were randomly divided into case and control groups. In the case group, TXA was administered directly under endoscopic therapy. In the control group, epinephrine (1/10,000) was submucosally injected to the four quadrants of ulcer margins as the routine endoscopic therapy. In both groups, the patients received supportive medical therapy with intravenous fluids and proton pump inhibitor drugs.Results:The mean ± standard deviation age of the children was 5 ± 2.03 years. Rebleeding occurred in 15 (11.4%) and 21 (9.8%) patients in the case and control groups, respectively (P = 0.50). The frequency of blood transfusion episodes (P = 0.06) and duration of hospital stay (P = 0.07) were not statistically different between the groups.Conclusion:Using topical TXA via endoscopic procedures may be effective in cases of GI bleedings caused by active bleeding ulcers. In order to establish this therapeutic effect, a large number of clinical studies are needed.

Fecal calprotectin as a marker of the severity of mucosal inflammation in children with inflammatory bowel disease.

Inflammatory bowel disease (IBD) in children has a remitting and relapsing course. The aim of our study was to evaluate the value of fecal calprotectin (FC), C-reactive protein (CRP), and clinical scores in predicting endoscopic and histological lesions in children with IBD. A total of 68 children with IBD (29 with ulcerative colitis (UC), 39 with Crohn's disease (CD), mean age 14.2 years) were included in the study. We retrospectively reviewed clinical scores (PUCAI, PCDAI), CRP values, endoscopic, and histological data as well as FC values in all included children. In children with UC, the correlation between the histological lesions and FC (r = 0.609, p < 0.01), CRP (r = 0.390, n.s.), or PUCAI (r = 0.535, p < 0.05) was higher than for children with CD (FC r = 0.490, n.s.; CRP r = 0.269, n.s.; PCDAI r = 0.257, n.s.). The correlation between endoscopy scores and the same parameters yielded similar findings (UC: FC r = 0.628, p < 0.01; CRP r = 0.387, n.s.; PUCAI r = 0.256, n.s.; CD: FC r = 0.516, p < 0.05; CRP r = 0.238, n.s.; PCDAI r = 0.267, n.s.). The correlation between FC and PUCAI (r = 0.532, p < 0.01) was higher than that between CRP and PUCAI (r = 0.424, p < 0.01). However, the correlation between FC and PCDAI (0.384, p < 0.01) is lower than that between CRP and PCDAI (r = 0.447, p < 0.01). FC is a better predictor of the severity of endoscopic and histological lesions than CRP or disease activity scores, especially for UC. FC, as a noninvasive marker, could possibly be used to reduce the number of endoscopic procedures in children with a confirmed diagnosis of IBD.

The Diagnostic Yield of Upper Endoscopy Procedures in Children- Is it Cost Effective?

Upper endoscopy is an invaluable tool for the diagnosis and treatment of various gastrointestinal symptoms in children. Over the years, the number of endoscopic procedures performed in different medical centers has increased considerably and the cost associated with the procedure has become unsustainable. Recently, the US government has investigated this topic and has suggested steps to reduce the cost and use of endoscopic procedures in the adult population, changes that have not been accepted favorably by the American Gastroenterology Associations (AGA). In the present report, we evaluate the diagnostic yield of the procedure in children and suggest steps to reduce the annual number of upper endoscopic procedures in children. The diagnostic yield and the cost-effectiveness of the procedure are also discussed.

1134

Introduction: Endoscopic procedures in children and adolescents in the United States are uniformly performed with the patient under some form of sedation. Airway management in children can be challenging as they are more vulnerable to adverse events. Currently, large studies investigating pediatric endoscopy under sedation and adverse events do not exist. The sedation program at Helen DeVos Children’s Hospital (HDVCH) is delivered by pediatric Intensivists who provide non-intubated procedural sedation for large numbers of patients. Here, we evaluate our practice of sedating patients for esophagogastroduodenoscopy (EGDs). Hypothesis: Non-intubated intravenous sedation for pediatric endoscopy is both safe and effective. Methods: Single-center retrospective series of outpatient GI endoscopies performed from January 2008 to December 2011. Following IRB approval, relevant data such as demographic, medication, and adverse event data were obtained from patients’ sedation records. Results: 2314 (998 female) patients were sedated in an outpatient setting for various indications to undergo EGD. Average age was 9.2 ± 4.8 years and Median ASA class was 2 with Mallampati class 1. The main indications for EGD were 762 patients (33%) for dysphagia, 645 patients (28 %) for reflux and 368 (16 %) for eosinophilic esophagitis. The patients were screened by a sedation nurse for suitability for sedation and then by the Attending Intensivist prior to sedation. Propofol was the drug of choice in 2248 (97 %) patients, Methohexital, 60 patients, Ketamine, 4 patients and Versed/Fentanyl, 2 patients. Average propofol administered was 8.7 ± 17.8 mg/kg including and an average of 2.23 ± 1.2 mg/kg induction dose.Recorded Intra-sedation adverse events were 2 patients required intubation, bag/mask ventilation 19/2314 (0.82%) and 1 acute drug reaction. Overall adverse events were separated in those needing prolonged observation 44/ 2314 but discharged same day and those needing at least overnight Hospital stay 3/2314. Conclusions: EGD sedation can be safely delivered in the outpatient setting by a team that has been trained to provide such care in pediatric populations.

Spontaneous respiration during intravenous anesthesia in children

Maintaining spontaneous respiration during intravenous anesthesia for investigative and surgical procedures may avoid the need for airway instrumentation and reduce the risk of desaturation. In addition, when performing airway endoscopic procedures in children, maintaining spontaneous respiration while using intravenous anesthesia can reduce the need for endotracheal intubation. This facilitates improved access to the smaller airway, allows assessment of the dynamic function of the airway, and reduces exposure of personnel to inhaled anesthetic agents. Anesthetic hypnotic and analgesic agents are potent dose-dependent depressants of respiration. Infants have historically been considered to be at a higher risk of respiratory depression, especially from opioid analgesics. However, recent evidence suggests that infants and younger children outside the neonatal period are more resistant to the effects of remifentanil, even when combined with propofol. Spontaneous respiration can be maintained at doses adequate to suppress somatic responses to painful procedures. The large inter-individual variation in respiratory depressant effects necessitates individualized dose titration. The drug dose is more linearly related to variation in the respiratory rhythm and respiratory rate than to minute volume or end-tidal carbon dioxide. Apneic episodes are less likely when respiratory depressant drugs are administered slowly, as this allows time for the end-tidal carbon dioxide level to rise to a new apneic threshold. Hypnotic anesthetics and opioid analgesics act synergistically to cause respiratory depression and suppression of the somatic response. Spontaneous respiration can be maintained when anesthetizing children using intravenous anesthesia.

Sedation Versus General Anesthesia in Pediatric Colonoscopy - Effect On Rates of Complete Colonoscopy and Ileal Intubation

Ileoscopy is carried out to diagnose pathology limited to the small bowel and to more accurately diagnose inflammatory bowel disease. Endoscopic procedures in children require deep sedation because of their physical discomfort and emotional distress during the procedure. Many pediatric gastroenterologists have begun to prefer general anesthesia administered by a pediatric anesthesiologist. We compared the rates of complete colonoscopy and successful ileoscopy when carried out either under general anesthesia or sedation. Materials and Methods: We retrospectively reviewed the reports of all pediatric colonoscopies performed in our medical center between 2000-2007. Results: There was a total of 215 colonoscopies during the study period of which 127 were performed under general anesthesia (Group 1) and 88 under sedation (Group 2). The mean age of the children was 10.7 years (range: .5-18 years). The rates of complete colonoscopy were similar (65.1% in Group 1 and 65.9% in Group 2). In contrast, the rates of ileoscopy were significantly higher in Group 1 compared to Group 2 (36.5% versus 22.7%, respectively, P=.032). After eliminating examinations in which ileoscopy was not mandatory, the positive effect of general anesthesia on terminal ileum intubation rates was even higher (45.2% in Group 1 versus 23.9% in Group 2, P=.004). There were no major complications for either group. Minor complications included transient bradicardia which responded to a single dose of Atropin. Conclusions: Performing colonoscopy under general anesthesia allows a more comprehensive examination without increased risk for complications.

Endoscopic management of the liver transplant patient

Endoscopic management of the liver transplant patient

Propofol sedation for endoscopic procedures in children.

Propofol sedation has been used successfully in various outpatient minor procedures in children. Limited data are available on the usefulness of propofol sedation during gastrointestinal endoscopic procedures in children. The aim of this study was to evaluate our experience of propofol sedation in pediatric gastrointestinal endoscopic procedures. The charts of all children who had undergone diagnostic endoscopic procedures, and were sedated by propofol, were retrospectively reviewed. Demographic data, cardiovascular monitoring, and drug dosages were recorded. Patients evaluated their sedation efficacy by answering a questionnaire before discharge. A total of 104 children underwent 107 procedures. Propofol alone was given in 19 procedures and in combination with midazolam and/or fentanyl in 88 procedures. All procedures were completed and significant complication occurred in only one patient. No significant difference was observed in the amount of sedative drugs or recovery time between upper and lower endoscopic procedures. A lower propofol dosage was needed when a combination of drugs was given compared to propofol drug alone. Patients' assessment of their sedation showed that the vast majority had experienced postendoscopic amnesia. Propofol sedation for endoscopic procedures is safe and acceptable for children. Propofol sedation should be offered to young children, especially those who express significant anxiety.

7216 Propofol sedation for endoscopic procedures in children.

We routinely suggest Propofol sedation to children whose parents refused conscious sedation or general anaesthesia with intubation. Aim: To evaluate the sedative efficacy of Propofol sedation during endoscopic procedures in children at our facility. Methods: The charts of children who underwent endoscopic procedures with Propofol sedation between 4/1998 to 8/1999 were reviewed. Midazolam and Fentanyl were used in conjunction with Propofol, upon the anaesthesiologist's decision. Demographic, cardiovascular monitoring, and recovery time were recorded. Before discharge, children completed a questionnaire to evaluate their assessment of their sedation. Results: A total of 107 procedures were reviewed. Demographic, medication dose, and recovery time are shown in Table 1. Propofol dose was significantly reduced when Fentanyl (p=0.001), but not Midazolam (p=0.64), was added to the sedative protocol. No significant side effect from Propofol sedation was observed during the procedure. Sedation assessment by all participants was graded as excellent and none of the children had any recollection of the procedures. Conclusion: (1) Propofol sedation in children is adequate and safe. (2) Fentanyl has a synergistic effect to Propofol sedation. (3) Propofol sedation should be offered to children who are reluctant to have conscious sedation or tracheal intubation.

REUTILIZING NEGATIVE RAPID UREASE TESTS IN CHILDREN

9 CLOtests are routinely used in upper endoscopic procedures in children to detect the presence of H. pylori infection. Regardless of the test result, the CLOtest is discarded after one use. Aim: To investigate the accuracy of re-use of negative CLOtest kits with biopsies obtained from children and calculate the potential annual cost saving at a rural and an urban hospital. Methods: Children who undergo the first diagnostic upper endoscopy procedure were prospectively recruited into the study. Tissue samples were sent for routine histological examination and for each CLOtest; one new CLOtest, and the other was a negative re-used CLOtest. The time period between the first and second use of the negative CLOtest was less than 2 weeks. The average annual saving in rural and urban hospital was calculated as the # of negative kits (85%) × $3 × # procedure/year. Results: A total of 61 children were recruited between Sept. 97 & Feb. 98. The mean age was 10.2 ± 4.3 years, and Male/Female ratio was 1.2:1.0. Nine children were positive by CLOtest and 52 were negative. The concordance between new and re-used CLOtests was 98%. The average annual number of upper endoscopic procedures was 183±19 and 767±102 in rural and urban hospitals, resulting in an average cost saving of $265 at the rural hospital and $1958 at the urban Children's Hospital. Conclusion: Re-used negative CLOtest during endoscopy procedure is appropriate, and may significantly reduce supply costs in places with high volumes of endoscopic procedures.