Pediatric Endoscopy Research Articles

Improving the Timeliness of Procedures in a Pediatric Endoscopy Suite

Pediatric endoscopic procedures are essential in the evaluation and treatment of gastrointestinal diseases in children. Although pediatric endoscopists are greatly interested in increasing efficiency and through-put in pediatric endoscopy units, there is scarcely any literature on this critical process. The goal of this study was to improve the timeliness of pediatric endoscopy procedures at Children's Hospital at Montefiore. In June 2010, a pediatric endoscopy quality improvement initiative was formed at Children's Hospital at Montefiore. We identified patient-, equipment-, and physician-related causes for case delays. Pareto charts, cause and effect diagrams, process flow mapping, and statistical process control charts were used for analysis. From June 2010 to December 2012, we were able to significantly decrease the first case endoscopy delay from an average of 17 to 10 minutes (P < .001), second case delay from 39 to 25 minutes (P = .01), third case delay from 61 to 45 minutes (P = .05), and fourth case delay from 79 to 51 minutes (P = .05). Total delay time decreased from 196 to 131 minutes, resulting in a reduction of 65 minutes (P = .02). From June 2010 to August 2011 (preintervention period), an average of 36% of first endoscopy cases started within 5 minutes, 51% within 10 minutes, and 61% within 15 minutes of the scheduled time. From September 2011 to December 2012 (postintervention period), the percentage of cases starting within 5 minutes, 10 minutes, and 15 minutes increased to 47% (P = .07), 61% (P = .04), and 79% (P = .01), respectively. Applying quality improvement methods and tools helped improve pediatric endoscopy timeliness and significantly decreased total delays.

The Next Novelty in Pediatric Endoscopy

The Next Novelty in Pediatric Endoscopy

Pediatric Endoscopy in Calabar, an Emerging Trend – Challenges and Prospects: A Report of Two Cases.

Data on pediatric endoscopy in Nigeria is almost non-existent. This may be due to lack of trained pediatric endoscopist or lack of facilities. Upper gastrointestinal(GI) endoscopy is thegold standard for evaluating upper GI symptoms/diseases. The majority of gastroscopies in Nigeria are done in adults but children also present with symptoms that require it,hence the need to develop pediatric endoscopy in Nigeria. This is a report of two cases done in the only private high definition video endoscopy facility in Calabar (JIL ENDOSCOPY), Nigeria. Two female children aged 10 years and 8 years had gastroscopy for swallowed foreign body (an office pin) and upper GI bleeding respectively. These patients were referred to JIL endoscopy by Pediatricians from the University of Calabar Teaching Hospital,Calabar. Conscious sedation was administered by the same anesthetist in the two cases. In the first patient, no foreign body was seen at gastroscopy while marked duodenitis was found to be responsible for the upper GI bleed in the second child. The choice of anesthesia for pediatric endoscopy has remained a topic of debate in many fora. A lot needs to be done to develop pediatric endoscopy in Nigeria. Keywords: Pediatric endoscopy, anesthetic challenges, Calabar, Nigeria.

Sedation for Pediatric Endoscopy

It is more difficult to achieve cooperation when conducting endoscopy in pediatric patients than adults. As a result, the sedation for a comfortable procedure is more important in pediatric patients. The sedation, however, often involves risks and side effects, and their prediction and prevention should be sought in advance. Physicians should familiarize themselves to the relevant guidelines in order to make appropriate decisions and actions regarding the preparation of the sedation, patient monitoring during endoscopy, patient recovery, and hospital discharge. Furthermore, they have to understand the characteristics of the pediatric patients and different types of endoscopy. The purpose of this article is to discuss the details of sedation in pediatric endoscopy.

Current status and clinical impact of pediatric endoscopy in Korea.

In pediatrics, endoscopic examination has become a common procedure for evaluation of gastrointestinal presentations. However, there are limited data on pediatric endoscopy in Korea. The aim of this study was to analyze the current status and clinical impacts of endoscopic examination in children and adolescents. We retrospectively reviewed the medical records of outpatients who visited the tertiary hospital. Patients under 18 years of age who underwent endoscopy were included. Endoscopic findings were classified as specific and normal based on gross findings. Specific endoscopic findings were reflux esophagitis, peptic ulcers, and Mallory-Weiss tear. Other findings included acute gastritis classified according to the updated Sydney system. In 722 of 330,350 patients (0.2%), endoscopic examination (554 esophagogastroduodenoscopies [EGDs], 121 colonos-copies, 47 sigmoidoscopies) was performed between January 2008 and January 2013. In EGD, abdominal pain was the most frequent presentation (64.1%). The most common diagnosis was gastritis (53.2%), followed by reflux esophagitis. The frequency of peptic ulcer disease was 12.8%. Frequent symptoms leading to colonoscopic examination were abdominal pain, diarrhea, and hematochezia. In colonoscopy, a negative result was more likely in children younger than 7 years old. After the procedure, the diagnostic yield of EGD and colonoscopy was 88.1% and 45.8%, respectively, and the rate of change in management was 67.1%. In pediatrics, endoscopic examination was useful for the choice of therapeutic strategy and it would be a standard method for evaluation of gastrointestinal presentation.

Novel Methods for Training Future Pediatric Gastroenterologists

See “Challenge of Meeting Fellowship Procedural Guidelines in Therapeutic Endoscopy and Liver Biopsy” by Lentze on page 3 and “Challenges in Meeting Fellowship Procedural Guidelines in Pediatric Therapeutic Endoscopy and Liver Biopsy” by Lerner et al on page 27. Endoscopic procedures play important diagnostic and therapeutic roles in the practice of pediatric gastroenterology. The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)'s guidelines for training in pediatric gastroenterology, published in 1999, were updated in 2013 (1,2). These guidelines include recommendations about the minimum number of procedures that should be performed to achieve competency during fellowship training. In this issue of the Journal of Pediatric Gastroenterology and Nutrition, Lerner et al (3) discuss challenges in meeting the number of recommended procedures. The authors collected data from 12 pediatric gastroenterology fellowship programs in the United States and used CPT codes and endoscopy databases to determine the number of procedures performed at each institution during a 3-year period (2009–2011). They divided the number of procedures by the number of fellows at the institution to estimate the number of procedures performed by each fellow, and then compared these estimates to the NASPGHAN guidelines. From this sample of 12 fellowship programs, many did not have sufficient procedural volume to meet the requirements of the training guidelines. None of the programs met the minimum numbers from the 1999 guidelines. Although some of the requirements in the 2013 guidelines are less stringent, only 1 center met the thresholds for all procedures. This article highlights the challenges in meeting the minimum number of procedures recommended during training, which is 1 step in achieving competence. As the guidelines note, many people will need to exceed these minimum numbers before they are competent in a given procedure. Objectively assessing competency is an unmet need, which theoretically could be accomplished through direct observation using an assessment tool. The well-known surgeon Atul Gawande wrote in The New Yorker about the importance of coaching and direct observation of surgeons in the operating room (4). Presumably, this concept could be adapted to procedural skills in gastroenterology. The NASPGHAN guideline from 2013 includes an assessment tool for endoscopy and colonoscopy. Quality metrics in adult gastroenterology include at least a 90% cecal intubation rate. As discussed in the NASPGHAN guidelines, these standards are based on studies of the learning curve in adult gastroenterology. For example, after 50 colonoscopies, trainees had cecal intubation rates exceeding 80% (5), but other studies have shown cecal intubation rates of 84% after 120 colonoscopies (6) and 90% after 140 colonoscopies (7). A larger regression analysis of 10 studies in adult gastroenterology fellows (n = 189) reported a 90% cecal intubation rate after 341 colonoscopies (8); however, little is known about the learning curve for procedural competence in pediatric gastroenterology, and defining competency in therapeutic endoscopy techniques is difficult. In light of the challenges in meeting the minimum number of procedures suggested by NASPGHAN, the authors offer several suggestions to increase procedural experience. These include rotations with adult gastroenterologists, computer simulators, ex vivo animal models, and hands-on endoscopy courses. Only 25% of the pediatric gastroenterology fellowship programs they surveyed had a computer simulator, and logistical and scheduling constraints may make use difficult. Another instrument to complement traditional patient-based procedural training is the partial-task box trainer that has been developed and tested to teach endoscopy skills. This mechanical simulator is validated in pediatric gastroenterology and contains 5 elements that involve key endoscopic maneuvers (9). The modular system allows compartments to be interchanged to include additional skills, including advanced endoscopy and therapeutic techniques. The partial-task box trainer is affordable, as well as mobile, allowing fellows to use it when time permits. The box trainer is also useful in teaching basic endoscopic skills before novice fellows begin performing procedures on patients. In the future, simulators or the partial-task box trainer may be used to maintain procedural skills, improve skills for those who already have a more advanced skill set, or assess skills for licensing or credentialing purposes. Because therapeutic endoscopic procedures are adapted to pediatric patients, fellowship training must use innovative methods to learn, maintain, and assess skills. The article by Lerner et al raises concerns that pediatric gastroenterology fellows may not be performing enough procedures during their training. We must be innovative and critically evaluate how best to provide high-quality, safe patient care for children who may benefit from endoscopic evaluation and therapy as well as assess the skills of individuals who are providing endoscopic care.

Challenges in Meeting Fellowship Procedural Guidelines in Pediatric Therapeutic Endoscopy and Liver Biopsy

The aims of this study were to assess the opportunities for therapeutic endoscopy, liver biopsies, and percutaneous endoscopic gastrostomy (PEG) placements available to fellows during a 3-year pediatric gastroenterology fellowship, and to evaluate access to ancillary procedural-training opportunities. Data were collected from 12 pediatric gastroenterology fellowship programs in the United States. Procedures completed in the years 2009-2011 were queried using CPT codes and endoscopy databases. The maximal opportunity for procedures was based on the total procedures performed by the institution in 3 years divided by the total number of fellows in the program. The centers completed a questionnaire regarding ancillary opportunities for endoscopic training. There is significant variability in pediatric endoscopic training opportunities in specialized gastrointestinal (GI) procedures. Under the 1999 guidelines, no centers were able to meet the thresholds for polypectomy and control of nonvariceal bleeding. The 2013 guidelines allowed the number of programs reaching polypectomy thresholds to increase by 67% but made no difference for control of bleeding despite a decrease in the threshold. Training in PEG placement was not available in 42% of the surveyed centers. Elective ancillary procedural training is offered by 92% of the surveyed centers. Most training programs do not have the volume of therapeutic endoscopy procedures for all of the fellows to meet the training guidelines. Training in therapeutic endoscopy, PEG placement, and liver biopsy in pediatric GI fellowships should be supplemented using all of the possible options including rotations with adult GI providers and hands-on endoscopy courses. A shift toward evaluating competency via quality measures may be more appropriate.

Informed consent in pediatric gastrointestinal endoscopy

Informed consent has become a major, but also mandatory component in medical praxis nowadays. A great number of forums and publications emphasize its ethical and psychological commands, the most adequate way to obtain it and especially its legal implications. In pediatrics, the implications of this procedure are complex, sometimes confusing or not well understood. Thus, in clinical consultations or simple medical acts, the consent could be seen as implicit; when we talk about maneuvers that lead to psychological or physical discomfort, invasive investigations, including endoscopy or therapeutic acts with possible risks or complications, informed consent from parents or legal tutors, respectively an intellectually, psychologically and socially evolved, educated child’s consent (acceptance) becomes mandatory. We must, however, clarify the nuances between consent and acceptance, not only from the semantic point of view, the proportion of either of the two terms in the final decision, the minor patient’s ability to discern at different age stages and finally the role and the importance of the doctor in such decision makings.

Sedation and analgesia for gastrointestinal endoscopy in children

Different sedation or anesthesia protocols are available to enable gastrointestinal endoscopic examinations in children. None is optimal. Sedation is organized according to the medical system, resources and the availability of personnel and medication (sedatives, anesthetics, analgesics). If anesthesiologist’s sedation teams for children are not available, strong evidence supports sedation safety and efficiency when it is performed by specially educated non-anesthesiologists and registered nurses. This review is a brief synthesis of main guidelines and position papers of procedural sedation in children and, when unavailable, in adults, who are eligible for pediatric gastrointestinal endoscopy sedation by non-anesthesiologist. Published data are supplemented by clinical experience and the findings of author’s research on ketamine sedation. Other established sedative combinations are benzodiazepine and opioid or propofol as a sole agent or in combination with analgesics. Special stress is given on a proper choice of the sedation protocol for specific examination or procedure in accordance with institution’s policy. Whole endoscopic team has to be engaged in the implementation of new evidence and continuous education to achieve the highest possible safety and quality standards.

Delivery of Key Elements of the Informed Consent Process to Parents in Pediatric Endoscopy

Delivery of Key Elements of the Informed Consent Process to Parents in Pediatric Endoscopy

Current Status and Clinical Impact of Pediatric Endoscopy in Korea

Current Status and Clinical Impact of Pediatric Endoscopy in Korea

An update on pediatric endoscopy

Advances in endoscopy and anesthesia have enabled gastrointestinal endoscopy for children since 1960. Over the past decades, the number of endoscopies has increased rapidly. As specialized teams of pediatric gastroenterologists, pediatric intensive care physicians and pediatric endoscopy nurses are available in many medical centers, safe and effective procedures have been established. Therefore, diagnostic endoscopies in children are routine clinical procedures. The most frequently performed endoscopies are esophagogastroduodenoscopy (EGD), colonoscopy and endoscopic retrograde cholangiopancreaticography (ERCP). Therapeutic interventions include variceal bleeding ligation, foreign body retrieval and percutaneous endoscopic gastrostomy. New advances in pediatric endoscopy have led to more sensitive diagnostics of common pediatric gastrointestinal disorders, such as Crohn’s disease, ulcerative colitis and celiac disease; likewise, new diseases, such as eosinophilic esophagitis, have been brought to light.Upcoming modalities, such as capsule endoscopy, double balloon enteroscopy and narrow band imaging, are being established and may contribute to diagnostics in pediatric gastroenterology in the future.

DIAGNOSTIC BRONCHOSCOPY IN CHILDREN

In recent years there has been significant progress in pediatrics, including pediatric pulmonology and endoscopy, which led to marked achievements in diagnostics, treatment and prophylaxis of respiratory tract disorders in children. The wide spectrum of various questions of anatomical and physiological peculiarities of the children respiratory tract is discussed in this article. The authors give a systematical review of indications and contraindications for bronchoscopy and offer the algorithm of choice of the optimal and most informative method of investigation. The modern conceptions of preparation and anesthesia methods for the bronchoscopic procedures in children are shown. The importance of complex analysis of the revealed during bronchoscopy structural and functional disorders of the respiratory tract depending on the nosological issue and characteristics of the disease clinical course is accentuated. The article contains descriptions of endoscopic patterns of the most common trachea and bronchi abnormalities in children, as well as detailed techniques of the bronchoalveolar lavage, forceps and brush-biopsy. The unique original data on newest endoscopy method — confocal laser endomicroscopy (alveoscopy) in older children, which had never previously used before neither in the Russian Federation, nor in the other countries, are of the most interest. The article is illustrated by demonstrative endoscopic images.

Three-Dimensional Direct Laryngoscopy and Bronchoscopy

This is the first description of 3-dimensional (3D) pediatric airway endoscopy in the otolaryngology literature detailing the superior visualization with this technology. Ultimately, enhanced optics may further improve the treatment of airway pathology. To report the first case series examining the use of 3D direct laryngoscopy and bronchoscopy (DLB) in the diagnosis and management of laryngotracheal pathology. Case series. Tertiary care pediatric hospital. Three patients underwent both telescopic 2-dimensional (2D) and 3D DLB for comparison purposes: a 12-year-old boy for visualization of complete tracheal rings, a 23-year-old man for dilation of tracheal stenosis, and a 4-month-old boy for resection of subglottic cysts. Enhanced visualization of laryngotracheal pathology and facilitated endoscopic surgery. To our knowledge, this is the first case series in the otolaryngology literature examining the use of 3D DLB for the resection of subglottic cysts, dilation of tracheal stenosis, and visualization of complete tracheal rings. We believe that the 3D view offers qualitatively improved depth perception, accuracy of balloon placement, and appraisal of subglottic cyst resection margins. This emerging technology has vast potential for improving endoscopy, surgical precision in airway interventions, tissue preservation, and methods of teaching. More research is needed in this area regarding the benefits and advantages of 3D compared with 2D endoscopy.

Incidence of perforation in pediatric GI endoscopy and colonoscopy: an 11-year experience

Incidence of perforation in pediatric GI endoscopy and colonoscopy: an 11-year experience

Functional gastrointestinal diseases in children: Facing the rising tide

However, looking at the overall picture, this study suggests that use of romiplostim is safe and effective as it raised platelet count in 33/35 of the patients, with the majority peaking platelet count between two to three weeks since the first peptide injection. This may help raise platelet counts in CHC patients undergoing antiviral treatment. Currently, most of adverse effects of antiviral therapy with pegylated interferon, ribavirin, and protease inhibitors, such as anemia, leucopenia, fever, body ache, etc can be managed with supportive treatment such as erythropoietin, G-CSF injection, paracetamol, and nonsteroidal anti-inflammatory drugs. Yet no good treatment exists for thrombcyopenia. This study brings hope for CHC patients with thrombocytopenia who are in need of antiviral treatment. Understandingly, this is a phase II study, and the authors rightly caution in the concluding paragraph that further studies in larger group of patients over a longer period of time are warranted in defining the optimal treatment schedule and dosage of romiplostim. Nevertheless, studies on romiplostim will be closely watched by hepatologists like me, as this may bring hope to many patients with advanced fibrosis or cirrhosis from CHC who are excluded from current antiviral treatment due to pre-existing thrombocytopenia.

Harmony of Duet over Solo: Use of Midazolam or Propofol for Sedative Endoscopy in Pediatric Patients

See versus Midazolam for Sedation during Esophagogastroduodenoscopy in Children by Ji Eun Oh, Hae Jeong Lee, Young Hwan Lee, on page 368-372 The aims of the sedation during endoscopic procedures are to increase the comfort of patients, to improve endoscopic performance, and to increase the satisfaction of both patient and performing endoscopist. The optimal level of sedation for endoscopy is conscious sedation, moderate degree of sedation, that is, a drug-induced depression of consciousness during which patients can respond purposefully to verbal commands. Therefore, adequate spontaneous ventilation and cardiovascular function is usually maintained.1 Midazolam is the drug most commonly used for sedation during gastrointestinal endoscopy (GIE) procedures. To date, several data have shown that when propofol is compared with midazolam in terms of their effectiveness, propofol is acknowledged to be superior for action time and recovery time. However, dark aspect of coin also exists that propofol has more serious cardiopulmonary depression compared to midazolam and more respiratory distress, apnea and hypotension than other sedatives.2,3 Endoscopic procedure is a well-established tool for diagnosis and treatment in pediatric gastroenterology as much as for adult patients. Majority of pediatric esophagogastroduodenoscopy performed under sedation using sedative drugs, such as midazolam, propofol, and ketamine, to avoid restraining and the recall of unpleasant GIE, because procedural sedation guarantee optimum comfort for and cooperation from children undergoing GIE.4 Endoscopic procedures with sedatives provide comfort not only for the patient but also for the endoscopist. As much as benefits, the safety should be the first priority to be considered during the endoscopy, especially for younger pediatric patients. Propofol has limitations, when used in sedative endoscopy, in its narrow safety zone, which makes moderate sedation rapidly shift to deep sedation and general anesthesia without antidote. For this reason, propofol was permitted to be used only by anesthesiologist in the early period of sedative endoscopy; however, American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy denoted that propofol administered by endoscopists is effective and safe irrespective of the patient's age.5 Recent data showed that not only anesthesiologists but endoscopists could control propofol safely during endoscopy.6-8 Complications, such as local pain from propofol injection and unpleasant feeling after recovery,2,3 may be overcome by decreasing the dose of propofol. Several studies reported that premedication with midazolam could ameliorate the level of patient discomfort compared to when using propofol alone.5,9,10 A study from Canada demonstrated that sedation with propofol alone or propofol combined with fentanyl or midazolam in children was safe and effective. Propofol in combination with fentanyl or midazolam provided better sedation and ease of endoscopy than propofol alone.11 In this issue of Clinical Endoscopy, Oh et al.12 compared midazolam and propofol for the sedative endoscopy in children, revealing that propofol had shorter recovery time and little increment of heart rate compared to midazolam. These results are similar to a previous report.13 According to the data, local pain occurred only in 17.6% of the propofol group, much lower compared to 60% reported in a previous study,14 but no difference was found in terms of respiratory distress. As limitations of the study by Oh et al.,12 the study was retrospective and single center experience with relatively small sample size, possibly causing a selection bias. Total dosage of sedatives associated with the incidence of complications, especially for the respiratory distress, was not mentioned at all. Moreover, as the authors stated in the discussion, data on induction time and patient's satisfaction in each sedation group are lacking. Nonetheless, this report might be the first one which compared the efficacy and safety of intravenously administered midazolam and propofol for sedation in children during endoscopy in Korea. These data support that the use of propofol under the supervision of an endoscopist in the pediatric endoscopy setting is safe compared to midazolam. In contrast to adult patients, the necessity for sedative endoscopy in children is much higher and a prerequisite to achieve the purpose of GIE. Traditional enema sedation or restraint yielded quite lower level of satisfaction to both parents and doctors. Considering the incidence of diseases associated with social stress and early puberty, no way to avoid sedation for pediatric endoscopy is secured from this study. However, prospective study with considerable number of patients with subcategory evaluation using combination of midazolam and/or propofol with other sedatives is required to minimize complications of propofol. As harmony of duet over solo, appropriate combination of propofol and midazolam might reduce the existing risks of respiratory distress and others.

The safety and efficacy of remifentanil compared to fentanyl in pediatric endoscopy

To compare propofol combinations with low induction doses of remifentanil and fentanyl in respect to the complication frequency and efficiency in ease of procedure in children undergoing esophagogastroduodenoscopy. Materials and methods: Sixty-four patients, aged 3-14 years and undergoing elective esophagogastroduodenoscopy, were included in the study. The patients received an induction dose of 0.25 µg kg-1 remifentanil and 2 mg kg-1 propofol (group R), or 0.5 µg kg-1 fentanyl and 2 mg kg-1 propofol (group F) before the procedure. The procedure began with a sedation score of >=5. Hemodynamic values, movement, ease and duration of the procedure, the time to awakening, and any requirement for additional doses of propofol/opioids and adverse events were recorded. Results: Although frequency of apnea after induction was higher and the duration of apnea was longer in group R, during procedure and postprocedure follow-up, there were no apnea episodes in either group (P 0.05). Intraoperative respiratory rate, time to eye opening, opioid consumption, and duration of recovery were significantly shorter in group R (P < 0.05). Conclusion: Remifentanil, when combined with propofol, can provide as efficient and safe anesthesia as fentanyl propofol combination for procedures like esophagogastroduodenoscopy.

General Anesthetic Versus Light Sedation: Effect on Pediatric Endoscopy Wait Times

Wait times are an important measure of health care system effectiveness. There are no studies describing wait times in pediatric gastroenterology for either outpatient visits or endoscopy. Pediatric endoscopy is performed under light sedation or general anesthesia. The latter is hypothesized to be associated with a longer wait time due to practical limits on access to anesthesia in the Canadian health care system. To identify wait time differences according to sedation type and measure adverse clinical outcomes that may arise from increased wait time to endoscopy in pediatric patients. The present study was a retrospective review of medical charts of all patients <18 years of age who had been assessed in the pediatric gastroenterology clinic and were scheduled for an elective outpatient endoscopic procedure at McMaster Children's Hospital (Hamilton, Ontario) between January 2006 and December 2007. The primary outcome measure was time between clinic visit and date of endoscopy. Secondary outcome measures included other defined waiting periods and complications while waiting, such as emergency room visits and hospital admissions. The median wait time to procedure was 64 days for general anesthesia patients and 22 days for patients who underwent light sedation (P<0.0001). There was no significant difference between the two groups with regard to the number of emergency room visits or hospital admissions, both pre- and postendoscopy. Due to the lack of pediatric anesthetic resources, patients who were administered general anesthesia experienced a longer wait time for endoscopy compared with patients who underwent light sedation. This did not result in adverse clinical outcomes in this population.

Appropriateness, endoscopic findings and contributive yield of pediatric gastrointestinal endoscopy.

To determine the predictability of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and American Society for Gastrointestinal Endoscopy (ASGE) guideline with regard to appropriate endoscopic practice in children, positive endoscopic findings and contributive yield in clinical practice. This was a descriptive, retrospective analysis, conducted at the Department of Paediatrics, University Malaya Medical Centre, Malaysia. All children who had esophagogastroduodenoscopy (EGD) and colonoscopy from January 2008 to June 2011 were included. An endoscopy was considered appropriate when its indication complied with the NASPGHAN and ASGE guideline. All endoscopic findings were classified as either positive (presence of any endoscopic or histologic abnormality) or negative (no or minor abnormality, normal histology); effecting a positive contributive (a change in therapeutic decisions or prognostic consequences) or non-contributive yield (no therapeutic or prognostic consequences). Overall, 76% of the 345 procedures (231 EGD alone, 26 colonoscopy alone, 44 combined EGD and colonoscopy) performed in 301 children (median age 7.0 years, range 3 months to 18 years) had a positive endoscopic finding. Based on the NASPGHAN and ASGE guideline, 99.7% of the procedures performed were considered as appropriate. The only inappropriate procedure (0.3%) was in a child who had EGD for assessment of the healing of gastric ulcer following therapy in the absence of any symptoms. The overall positive contributive yield for a change in diagnosis and/or management was 44%. The presence of a positive endoscopic finding was more likely to effect a change in the therapeutic plan than an alteration of the initial diagnosis. A total of 20 (5.8%) adverse events were noted, most were minor and none was fatal. The NASPGHAN and ASGE guideline is more likely to predict a positive endoscopic finding but is less sensitive to effect a change in the initial clinical diagnosis or the subsequent therapeutic plan.