Pediatric Colonoscope Research Articles

S1833 Single Operator Cholangioscopy in a Patient With Pancreaticoduodenectomy

Introduction: Cholangioscopy in patients with surgically altered anatomy can be technically challenging. In most patients with pancreaticoduodenectomy undergoing single operator cholangioscopy, the most common approach is through a percutaneous biliary drain placed by interventional radiology. We present a case in which a modified therapeutic upper endoscope (1T scope) was used for single operator cholangioscopy in a patient with pancreaticoduodenectomy. Case Description/Methods: A 64-year-old female with Gardner syndrome requiring colectomy and classic pancreaticoduodenectomy for an ampullary adenoma 10 years prior presented for surveillance endoscopy. She previously underwent endoscopic mucosal resection and intraductal radiofrequency ablation (RFA) of adenomatous tissue at the hepaticojejunal (HJ) anastomosis. She subsequently developed a stricture at the HJ anastomosis needing sequential dilations. A 1T scope was used and advanced to the HJ anastomosis. After balloon dilation of the HJ anastomotic stricture, cholangioscopy was performed and revealed abnormal biliary mucosa (Figure) approximately 2 cm below the hilum raising concern for intraductal extension of adenomatous tissue. Cholangioscopy directed biopsies were obtained and pathology revealed tubular adenoma without high-grade dysplasia. Intraductal RFA is planned in the future. Discussion: ERCP in patients with pancreaticoduodenectomy can be challenging. Different endoscopes have been used to overcome some challenges of ERCP in altered anatomy, each offering certain advantages and limitations. Commonly used endoscopes for ERCP in patients with pancreaticoduodenectomy include the adult and pediatric colonoscopes and single balloon enteroscope. These endoscopes do not allow for performing single operator cholangioscopy due to the length of the scope or the width of the accessory channel. Our report highlights that the 1T endoscope allows for performing single operator cholangioscopy in patients with prior pancreaticoduodenectomy when the HJ anastomosis can be reached.Figure 1.: Intraductal extension of adenomatous tissue seen on cholangioscopy.

S2184 A Case of Colonic Perforation After CT Colonography

Introduction: CT colonography is increasingly used in patients with failed initial colonoscopy. Although it is relatively considered a safe procedure but can have serious rare complications with significant morbidity and mortality. We present a case of a patient with failed colonoscopy due to severe diverticular disease who was referred for a CT colonography. Case Description/Methods: 70 years old male with the history of hypertension, dyslipidemia and recurrent diverticulitis who underwent colonoscopy for diagnostic purposes after recent episode of diverticulitis 3 months ago. Patient last colonoscopy 5 years ago showed extensive diverticular disease and one benign colonic polyp. Colonoscopy was attempted however despite using pediatric colonoscope we were not able to pass the sigmoid colon because of severe angulation and luminal narrowing. After discussion with the patient, decision was made to refer for CT colonography which was performed 2 months later which showed severe sigmoid diverticulosis. Note that the colon was insufflated with carbon dioxide gas.One day after the procedure, patient presented to the outside hospital with worsening abdominal pain and was found to have sigmoid perforation & air under diaphragm (Figure). He was taken to the OR urgently and underwent sigmoid resection with creation of colostomy with reversal later. Pathology was negative for malignancy but showed diverticulosis, diverticulitis and serosal adhesions. Discussion: CRC is the third most common cause of cancer and second leading cause of death from cancer. There are range of screening tests available for CRC screening including stool test, colonoscopy and radiological test including CT colonography. Although CT colonography is relatively a benign procedure but occasionally can cause serious complications. A retrospective analysis by Burling et al. found incidence of colonic perforation 0.08% after analysis of 17067 colonography examinations, while symptomatic perforation rate was 0.03%. (1) The data on colonic perforation after CTC is low (0.005%-0.03%) compared to colonoscopy (0.06%-0.19%) (2). Although CTC is a safe procedure we suggest that prior to referral for this procedure, a detailed risks benefits discussion should be held between the patient and physician.Figure 1.: Left: Sigmoid colon perforation. Right: Free air under diaphram.

S2890 A Case for Endoscopic Ultrasound-Directed TransGastric ERCP (EDGE) Procedure: Removal of Choledocholithiasis in Gastric Bypass Patient

Introduction: Due to rise in obesity, there has been an increased number of gastric bypass surgeries. Around 36% morbidly obese patient develop cholelithiasis or choledocholithiasis (CDL) in their lifetime. Due to the anatomy, a conventional Endoscopic Retrograde Cholangio Pancreatography (ERCP) is often challenging and not possible. We present a case of an altered anatomy ERCP in a patient with CDL and Roux-en-Y gastric bypass (RYGB) who underwent Endoscopic ultrasound Directed trans-Gastric ERCP(EDGE) procedure. Case Description/Methods: A 69-year-old female with a history of RYGB admitted for Hartmann’s procedure. During the hospitalization, she complained of RUQ pain and CT abdomen showed a distended gallbladder with cholelithiasis and CBD dilation of 8.3mm; MRCP confirmed five or more CDL. A traditional attempt at an ERCP using a pediatric colonoscope was unsuccessful in reaching the papilla. She underwent cholecystectomy with an intraoperative cholangiogram re-demonstrating the CDL. Options were to do a laparoscopy assisted ERCP v/s double balloon assisted ERCP v/s EDGE. Due to already multiple surgeries patient opted for EDGE procedure. For stage 1 of the EDGE, the excluded stomach was identified under EUS and punctured using a 19-gauge-needle followed by a radiocontrast dye injection into the excluded stomach confirmed under fluoroscopy. Subsequently, a guidewire was advanced through the needle into the pylorus and duodenum to verify the patency of pylorus. After confirming access to the excluded stomach, a 20 x 10 mm (AXIOSTM) lumen apposing metal stent (LAMS) was placed and a gastro-gastric fistula between the gastric pouch and the excluded stomach was formed. The lumen of the stent was subsequently dilated using a CRE balloon confirming the direct visualization of the gastric rugae. (Figure). The LAMS was left for 4 weeks for the tract to mature. Stage 2 of the EDGE procedure was then completed by passing the duodenoscope through the LAMS and completion of the traditional ERCP followed by removal of the LAMS. Overall patient did well. Discussion: EDGE is a minimally invasive EUS guided technique for doing an ERCP in patients with RYGB. Comparison studies have shown EDGE to have similar or better technical success when compared to laparoscopy-assisted ERCP and balloon Enteroscopy-assisted ERCP. Due to the high technical skill required in doing an EDGE, it is best advisable to offer this at institutions where a trained advanced endoscopist well versed with a therapeutic EUS is available.Figure 1.: A: EGD showing gastric pouch post-RYGB B: EUS suggests decompressed excluded stomach C: Injecting contrast into the excluded stomach - to make cystic cavity D: 20 x 10 mm(AXIOS) lumen apposing metal stent placement E: CRE Baloon dilation of LAMS F: Confirmed visualization of excluded gastric mucosa - gastrogastric fistula

S2486 Chilaiditi’s Sign: Should You Give Up or Persist?

Introduction: Chilaiditi’s sign is an incidental radiographic finding of the interposition of the bowel loop between the liver and the diaphragm. With an estimated worldwide prevalence of 0.028 - 0.25 %, this is commonly associated with older age and men. Below, we describe an unusual case of Chilaiditi’s sign incidentally found during a routine colonoscopy in a female patient Case Description/Methods: A 73-year-old asymptomatic woman was referred to the Endoscopy Unit for a surveillance colonoscopy. On physical examination, the patient had no abdominal pain or distension. CBC and CMP were unremarkable. Pediatric colonoscope was inserted via the rectum and reached the hepatic flexure. However, due to an acute angulation, the scope was not able to be advanced further and the procedure was therefore aborted prematurely. A CT scan of the abdomen and pelvis performed the same day identified interposition of the distal transverse colon and proximal ascending colon between the liver and the anterior abdominal wall, which explained the difficulty encountered in advancing the colonoscope beyond the hepatic flexure (Figure). She is being rescheduled for repeat colonoscopy. Discussion: Acute angulation of the bowel and technical difficulty in completing a colonoscopy may be indicative of Chilaiditi’s sign. Predisposing factors include: cirrhosis, COPD, or presence of ascites. When this anatomical distortion becomes symptomatic, it is referred to as Chilaiditi’s syndrome. These symptoms are secondary to elevation of the diaphragm and/or bowel obstruction, perforation, or ischemia. It can be confirmed with CT imaging, which typically demonstrates an interposition of the transverse colon between the liver and the abdominal wall. While no intervention is usually required for asymptomatic patients with Chilaiditi’s sign, awareness of the condition is important for physicians. Forceful pressure against the interposed bowel can trap air in the colon segment and increase intra-luminal pressure, potentially causing perforation. To decrease the risk of perforation, carbon dioxide can be administered in patients with known Chilaiditi’ sign during colonoscopy as an insufflating agent. Limited case reports are available on the management protocol for patients with Chilaiditi’s sign; however, according to a previous case report, carbon dioxide is safe and effective in the GI tract. It is imperative that endoscopists are aware of this condition and exercise extreme caution while performing a difficult colonoscopy.Figure 1.: CT scan of abdomen showing the interposition of the distal transverse colon and proximal ascending colon between the liver and the anterior abdominal wall.

De Novo Diagnosis of Lymphocytic Colitis After SARS-CoV-2 Vaccination

ABSTRACTSARS-CoV-2 mRNA vaccines are safe and effective for most patients. Gastrointestinal complications reported after vaccination have included gastroparesis and inflammatory bowel disease flares. In this study, we present a unique case of lymphocytic colitis that occurred in a healthy middle-aged man after Moderna SARS-CoV-2 mRNA vaccination. This reveals an unexpected complication of a mRNA vaccine that presented as worsening diarrhea after vaccination in a dose-dependent pattern. Caregivers should be aware of lymphocytic colitis as a possible complication of the Moderna vaccine and monitor those patients closely for symptom resolution.

Three Lumens Full of Blood—An Unusual Case of Gastrointestinal Bleeding

Question: A 58-year-old man was initially referred to our gastroenterology outpatient clinic for investigation of iron-deficiency anemia and positive fecal occult blood test (FOBT). His medical history was significant for simultaneous pancreas-kidney transplants 9 years earlier in the context of type 1 diabetes, for which he remained on triple immunosuppressive therapy with prednisolone, mycophenolate, and tacrolimus. His transplants were complicated by biopsy-proven chronic antibody-mediated rejection 4 years earlier, for which he received 6 months of intravenous immunoglobulin. There was no history of chronic liver disease or nonsteroidal medication use. Investigations demonstrated iron-deficiency anemia with a hemoglobin of 88 g/L, ferritin 14 μg/L, transferring saturation 5%, and a positive FOBT (1 of 3 samples). The patient underwent further evaluation with gastroscopy and colonoscopy, which were both unremarkable and did not identify a cause for iron-deficiency anemia. One month later, the patient re-presented to the emergency department with several days of melena and symptomatic anemia with a hemoglobin of 78 g/L. The patient underwent repeated gastroscopy, which did not reveal a cause for his symptoms. He received a blood transfusion and was referred for outpatient capsule endoscopy. Several weeks later, the patient represented with 3 days of melena and symptomatic anemia with a hemoglobin level of 45 g/L. The patient underwent an urgent push enteroscopy. What are the differential diagnoses of gastrointestinal bleeding in this patient? Look on page 335 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. A pediatric colonoscope was inserted 60 cm beyond the pylorus. There was no evidence of esophageal varices, esophagitis, or gastric varices. There was no ulceration or stigmata of recent hemorrhage found in the stomach or duodenum. At 55 cm distal to the pylorus, the anastomosis of the pancreatic transplant was encountered. It demonstrated a side-to-side duodenojejunostomy with 2 short blind duodenal limbs and the native efferent jejunal limb (Figure A). At the anastomosis, multiple varices were noted, of which one vessel was actively bleeding (Figure B). Hemostasis was achieved with the injection of adrenaline (2 mL, 1:10,000) and 2 through-the-scope hemostatic clips (Figure C). The patient then underwent a computed tomographic scan with pancreas protocol to characterize the anatomy and vasculature at the duodenojejunal anastomosis. Multiple venous varices were identified that communicated with a distended transplant pancreatic vein (Figure D). The transplant pancreatic vein anastomoses with the proximal right common iliac vein, and therefore the varices were not due to portal venous hypertension. There was no anastomotic stenosis, no venous thrombosis, and no arteriovenous fistulae. The hemoglobin remained stable after endoscopy and the patient was discharged home 3 days later. At outpatient follow-up 2 months after discharge, there was no evidence of further gastrointestinal bleeding and the hemoglobin level was stable. The patient will continue to be closely observed in the outpatient setting, with a view to endovascular intervention if further gastrointestinal bleeding occurs. Ectopic variceal bleeding from anastomotic varices between the donor duodenum and recipient small bowel are rare, with only 3 cases reported in the literature.1Gopal J.P. Jackson J.E. Palmer A. Taube D. Rathnasamy Muthusamy A.S. Gastrointestinal bleeding in a pancreas transplant recipient: a case to remember.Am J Case Rep. 2020; 21e923197Crossref PubMed Scopus (3) Google Scholar, 2Rostambeigi N. Shrestha P. Dunn T.B. et al.Recurrent ectopic variceal bleed after pancreas transplantation with no portal hypertension: case report and outcomes of endovascular onyx embolization.Vasc Endovasc Surg. 2019; 53: 415-419Crossref PubMed Scopus (5) Google Scholar, 3Fontana I. Bertocchi M. Di Domenico S. et al.Percutaneous embolization of periduodenal varix due to portal hypertension in a patient with kidney-pancreas transplantation: a case report.Transplant Proc. 2010; 42: 2162-2163Crossref PubMed Scopus (5) Google Scholar The mechanism by which ectopic varices develop after pancreas transplantation are not clear. Potential explanations include portal hypertension secondary to cirrhosis, increased vascular resistance, rejection of pancreatic transplant, and chronic venous obstruction. In our case, the mechanism was not elucidated.

Serrated Polyposis Syndrome in a Young Adolescent Patient.

Serrated polyps are pathological neoplastic lesions in the colon with subtle gross morphology leading to underreporting during colonoscopy. While detection rates are increasing in average-risk adult screening colonoscopy, the rate of detection during pediatric colonoscopy is unknown. Serrated polyposis syndrome is characterized by the presence of multiple serrated polyps in the colon and an increased risk of developing colorectal cancer. Cancer prevention relies on early recognition, endoscopic clearance of all polyps > 5 mm, and continued interval surveillance or prophylactic colectomy. We report the diagnosis and management of serrated polyposis syndrome in a young adolescent patient and highlight the subtle features of serrated polyps that may go unrecognized leading to underreporting in childhood.

Colonoscopy Quality Assurance and Maintenance of Competency Among Pediatric Gastroenterology Staff Members: A Canadian Center Experience.

IntroductionColonoscopy quality indicators and maintenance of competency skills are relatively well established in the adult literature as compared to the pediatric gastroenterology. One of the suggested quality assurance measures is cecal intubation rate, which is suggested to be >90% in all colonoscopies as per American Society of Gastrointestinal Endoscopy (ASGE) guidelines. Terminal ileum (TI) intubations are essentially required for diagnostic reasons in pediatric colonoscopies as compared to the screening reasons in adults. Maintenance of competency in pediatric colonoscopies has been described in the literature but in smaller studies contrary to the adult ones. The aims of this study are to compare our center’s individual and group cecal intubation rates and compare it with the published literature, assess the group’s terminal ileal intubation rates in comparison with the published literature, assess the most common reasons for failure to intubate the cecum and/or terminal ileum, and to assess whether the presence of a trainee affects the intubation rates and the duration of the procedure.MethodsA retrospective chart review was performed on all pediatric patients (0-18 years). Colonoscopies performed over a two-year period at our single center were included in the study. Patients scheduled for sigmoidoscopy and with altered anatomy of their colon were excluded from the study. The endoscopy and pathology reports were reviewed to ascertain whether the cecum and TI were reached. Quality of bowel preparation and any other stated reasons for incompletion were obtained. Clinical charts were reviewed to obtain indication for colonoscopy. Skin-to-skin time, which is the time from starting to the finishing of the procedure, was recorded for each procedure.ResultsA total of 391 colonoscopies were performed during the two-year study period by six gastroenterologists. The number of colonoscopies per staff ranged from 57 to 89 procedures. The overall cecal intubation rate was observed to be 98.5% (range: 95.9%-98.9%). TI intubation rate was lower at a rate of 83.1% (range: 63.3%-92.1%). The main stated reason for the inability to attain cecum/TI was technical difficulty and poor bowel prep. Daytime colonoscopies were shorter (39.5 minutes vs 50.3 minutes) compared to after-hours ones and had a higher TI intubation rate (84.5% vs 62.5%). No complications were encountered in the procedures.ConclusionDespite relatively low volumes, cecal intubation rates are very high, exceeding suggested standards. TI intubation rates were low, and there was noted to be a high degree of variability. However, multicentric collaborative evaluations are required over a longer period of time to establish relevant parameters for quality assurance and competency in pediatric endoscopy.

Percutaneous endoscopic jejunostomy: when, how, and when to avoid it.

The current review summarizes current evidence regarding the indications, contraindications, and technical aspects of placing a direct percutaneous endoscopic jejunostomy (DPEJ), as well as procedure-related and patient-related outcomes. DPEJ is indicated for patients who require long-term (>4 weeks) jejunal nutrition due to existing altered foregut anatomy (e.g., previous gastrectomy) or because the gastric route is not an option (e.g., due to high risk of aspiration, intolerance, gastroparesis). DPEJ may also offer decompression of the gastrointestinal tract in cases of small bowel obstruction (e.g., peritoneal carcinomatosis). Absolute contraindications include active peritonitis, uncorrectable coagulopathy, and ongoing bowel ischemia. Technically, the 'pull' technique using a paediatric colonoscope will be sufficient for most cases. Recent publications demonstrate high rates of technical success (>85%), while patient outcomes do not differ among patients undergoing percutaneous endoscopic gastrostomy (PEG) and those undergoing DPEJ. Obesity is a risk factor for technical failure, while age more than 80 years, diabetes mellitus, and ongoing inflammatory status may be considered risk factors for DPEJ-associated mortality. DPEJ is a safe and efficacious modality for long-term jejunal nutrition with an acceptable risk of mild complications. Careful patient selection and respect of preprocedural, periprocedural, and postprocedural precautions are of the utmost importance to ensuring a favourable outcome.

A206 GALLSTONE IMPACTION IN THE DESCENDING COLON WITH SUCCESSFUL ENDOSCOPIC REMOVAL

BackgroundGallstone impaction in the colon is a rare complication of cholelithiasis, typically because of gallstones migrating into the colon via a cholecystocolonic fistula. Gastrointestinal obstruction from gallstones only develops in 0.3–0.5% of patients with cholelithiasis and accounts for 0.095% of all mechanical bowel obstruction. Successful treatment has been described with endoscopic and surgical techniques.AimsThis report aims to present a case of colonic obstruction from gallstone that was successfully treated endoscopically.MethodsWe conducted a retrospective chart review on one patient including assessing the history of presenting illness along with biochemical, radiographic, and endoscopic results. We then conducted a narrative literature review on this subject matter.ResultsAn 85-year-old male with known cholelithiasis complicated by prior cholecystitis presented with a 2-day history of generalized abdominal pain. Computed tomography (CT) showed fistulisation between the gallbladder and hepatic flexure. Follow-up CT with rectal contrast showed lack of contrast beyond an impacted gallstone in the descending colon (Figure 1A, 1B). The patient was deemed a poor surgical candidate thus endoscopic gallstone extraction was attempted. With a pediatric colonoscope, the 41mm x 51mm gallstone was visualized 70cm from anal verge (1C). The stone was too large to be extracted en-block with snare or basket. Attempts to cut the stone at its surface with a polypectomy snare and other tools were unsuccessful because of the roundness and smoothness of the stone. Although we could chip away at the surface, we were unable to break the seal of the stone against the colon mucosa. We found the most effective method was tunneling through the stone’s centre using a closed rat-tooth forceps, then angling the tip of the scope and pulling the scope back to break off fragments from within. A polypectomy snare was used to further breakup larger fragments to prevent repeat impaction (1D). There was underlying diverticular disease and mild ischemic changes to the mucosa but no stricture. The patient did well post-procedure and was able to tolerate oral intake, pass flatus, and pass bowel movements. He was discharged 3 days later.A recent systematic review found a total of 38 cases of gallstone obstruction of the colon. Majority of patients (73.6%) ultimately required surgical intervention. Overall mortality is 13.1%.ConclusionsGallstone impaction in the colon is uncommon with successful endoscopic treatment seldomly described. This report describes a rare complication of gallstone disease that was successfully treated with widely available endoscopic tools. Funding AgenciesNone

A113 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS WITH SURGICALLY ALTERED ANATOMY IN A CANADIAN TERTIARY REFERRAL CENTRE

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) has become a mainstay of diagnosis and treatment of pancreatobiliary conditions. Surgically altered anatomy presents unique challenges in the procedure, necessitating creative solutions such as different types of endoscopes and tools. Distinct from regular anatomy, forward viewing scopes are often required for successful cannulation and therapy of the pancreaticobiliary system. To our knowledge, there is limited data on the practice of ERCP in altered anatomy in Canada. Aims Our aim is to present outcomes from a large series of patients with surgically altered anatomy who underwent ERCP at a large Canadian referral centre. Methods All ERCP procedures at a tertiary referral centre in Vancouver, Canada from Oct 2020 to Oct 2021 were reviewed retrospectively. Inclusion criteria required surgically altered anatomy and attempted ERCP. Liver transplant patients with duct-to-duct anastomosis were not included in the series. Patients with incomplete procedure documentation were excluded. Demographic, procedural and outcome data were collected. Results are presented descriptively and as median + IQR for quantitative data. Procedural success was defined as cannulation and performance of a cholangiogram and/or pancreatogram Results A total of 34 procedures met the inclusion criteria during the study period. Twenty-four procedures were on male patients (71%). Nineteen patients (56%) had had previous ERCP. Sixteen patients (47%) had choledocholithasis as the indication for the procedure, 9 patients (26%) had cholangitis and 5 patients (15%) had concerns of neoplasia. Some patients had multiple indications. Seventeen patients (50%) had roux-en-Y anatomy, 8 patients (24%) were post Whipple’s and 6 patients (18%) had Billroth II type anatomy. Other altered anatomy included duodenal switch, and post gastrojejunostomy bypass. The most commonly used endoscope was the adult or pediatric colonoscope (74% of cases). Single balloon enteroscope was used in 5 cases (15%). Overall success rate was 74%. The breakdown of success rate by anatomy is shown in Table 1. One (3%) complication was noted in the form of mild cholangitis, requiring only outpatient antibiotics. Conclusions Experience in ERCP in patients with altered anatomy is becoming more pertinent in tertiary care. Cannulation and therapy is more difficult in this cohort, but still successful in the majority of cases. Adverse events remain uncommon. Knowledge of forward viewing ERCP techniques is critical in surgically altered anatomy. Future studies will aim to expand the retrospective cohort for more quantitative analysis. Funding Agencies None

Impact of pediatric versus adult colonoscope on terminal ileum intubation: a retrospective study.

BackgroundVarious possible predictors of successful terminal ileal intubation (TII) have been explored but the role of the type of colonoscope is unclear.MethodsWe carried out a retrospective review of a prospectively collected database of all colonoscopies performed at a single endoscopy unit between May 2015 and July 2020. The primary outcome measure was successful TII in patients with specific indications for ileal examination. The primary predictor was the type of endoscope, pediatric or adult, used during the procedure. Univariate and multivariate analyses were performed.ResultsIn 5845 colonoscopies fulfilling the study criteria, the overall TII rate was 67.8%. In univariate analysis, the use of a pediatric colonoscope was associated with a higher TII rate (72.1% vs. 58.8%, P<0.001). Other variables associated with successful TII based on univariate analysis included the patient’s age, male sex, body mass index, endoscopists’ specialty, place of training, shorter colonoscope insertion time, shorter duration of the procedure, longer withdrawal time, procedures performed in the afternoon, type of sedation administered during colonoscopy, and cleanliness of the colon. Multivariate analysis yielded an adjusted odds ratio (OR) of 1.40 (95% confidence interval [CI] 1.21-1.62) for the use of a pediatric colonoscope. Propensity score-matching analysis also showed superiority of the pediatric colonoscope in achieving TII compared to an adult colonoscope, OR 1.35 (95%CI 1.17-1.57).ConclusionsPediatric colonoscope increases the success of TII during colonoscopy. For endoscopists performing colonoscopy with intent to examine the terminal ileum, it is recommended to choose a pediatric colonoscope to maximize the success rate.

Prospective comparison of an adult, an intermediate pediatric and a long pediatric colonoscope in the training process of gastrointestinal fellows to achieve high-quality practice in colonoscopy.

BackgroundFew data are available on the influence of colonoscope type on the training process and quality of colonoscopy. We conducted this prospective observational cohort study to investigate scope suitability for starting colonoscopy training, in relation to technical competence, quality indicators, and the patient’s comfort during diagnostic colonoscopy.MethodsA total of 126 consecutive patients were enrolled in the study and assigned to one of 3 groups: adult colonoscope ([AC], n=41); intermediate pediatric colonoscope ([IPC], n=43); and long pediatric colonoscope ([LPC], n=42). Primary outcomes were completeness of the examination and minutes to the cecum. Secondary outcomes included patient tolerance, position change, use of abdominal compression, loop formation, kind of loop, and overall difficulty of the procedure.ResultsCecal intubation rates were not statistically different between the groups: AC/87.8%; IPC/81.4%; and LPC/92.8%. Terminal ileal intubation rate differed significantly among the 3 groups (P=0.015) with LPC having the higher rate (66.7% vs. 60.9%/AC and 37.2%/IPC). There were significant differences in positional changes (fewer with LPC/1.36 vs. AC/2.15 and IPC/2.09, P=0.027) and midazolam administered doses (lower with LPC/0.52 vs. AC/1.07 and IPC/0.93, P=0.032). Loop formation with subsequent resolution was significantly associated with more pain for the patient with all of the 3 colonoscope types.ConclusionsThe LPC performs better in trainee hands than AC and IPC in terms of reaching competency, and quality indicators show less discomfort for the patients during colonoscopic procedures (lower midazolam dose and fewer positional changes). It could be considered the most suitable scope for starting high-quality colonoscopy training.

Assessment of Practice of Colonoscopy in Pediatrics in Brazzaville, Congo

Background: In Congo, there is no pediatric gastroenterology department and the activity of colonoscopy has never been evaluated. The aim of this study is to report the indications and the results of pediatric colonoscopy in Brazzaville. Methods: A retrospective study was conducted from January 2016 to August 2017 by analyzing reports of colonoscopy performed in the gastroenterology department in Brazzaville. Sex, prescribers, indications and results of colonoscopy were the variables study. Results: over the 19-month period, 489 colonoscopies have been performed, in which 13 (2.7%) colonoscopies were performed in children under 17 years, with an average age of 9.8 ± 4.6 (8 males and 6 females) and the extreme ranging from 1 - 17 years. The sex ratio (H/F) was 1.6. The prescribers were gastroenterologist (n = 4), pediatrician (n = 4), surgeons (n = 2), general practitioners (n = 2), pediatric students (n = 1). Chronic bowel inflammatory diseases and polypectomy was the most frequent conditions for colonoscopy indication. Seven (7) colonoscopies were normal. 4 cases were recto-polyps, and 2 cases were ulcerative colitis. Conclusion: pediatric colonoscopy is a powerful diagnostic and therapeutic means. The pediatricians should think about it to improve the management of children with digestive symptoms that meet the indications of pediatric colonoscopy.

Use of intravenous lidocaine for dose reduction of propofol in paediatric colonoscopy patients: a randomised placebo-controlled study

BackgroundPropofol, a widely used sedative in endoscopic procedures, sometimes causes cardiopulmonary complications. Intravenous lidocaine can diminish visceral pain and decrease the dose of propofol. The purpose of this study was to assess the efficacy and safety of intravenous lidocaine in reducing propofol dosage during paediatric colonoscopy.MethodsForty children who underwent colonoscopy were divided into two groups. Lidocaine hydrochloride (1.5 mg/kg induction and 2 mg/kg/h maintenance) was given intravenously to the lidocaine group, and the same amount of saline was given to the control group after they received lidocaine induction. Propofol initial plasma concentration of 5 μg/mL was targeted, and the procedure was performed after the bispectral index value reached 55. The primary outcome was propofol requirement.ResultsThe propofol requirement in the lidocaine group was decreased by 35.5% (128.6 ± 30.4 mg vs. 199.4 ± 57.6 mg; p < 0.001; 95%CI: − 100.60, − 41.02). The incidence of involuntary body movements was significantly lower in the lidocaine group (p = 0.028; OR = 0.17; 95%CI: 0.03, 0.92). The awakening time (p < 0.001; 95%CI: − 7.67, − 5.13) and recovery times (p < 0.001; 95%CI: − 7.45, − 4.35) were significantly lower in the lidocaine group. Pain was significantly less at 30 min and 60 min after the procedure in the lidocaine group (0 [0–4] vs. 3 [0–5], p < 0. 001; 0 [0–2] vs. 1 [0–3], p = 0.001). There was no difference in the incidence of bradycardia, hypotension, or hypoxia between the two groups.ConclusionsFor colonoscopy procedures in paediatric patients, intravenous lidocaine reduces the amount of propofol needed, provides better sedation and postprocedural pain management, as well as a reduction in recovery time.Trial registrationThe trial was registered on November 6, 2020 at China Clinical Trials Registration Center (www.chictr.org.cn) ref.: ChiCTR 2,000,039,706.

Continuous infusion of lidocaine in pediatric colonoscopy: A randomized double-blind placebo-controlled study.

Background:Propofol is commonly used for providing procedural sedation during pediatric colonoscopy. Intravenous (i.v.) lidocaine can mitigate visceral pain and reduce propofol requirements during surgery. The aim of this study is to investigate the effect of i.v. lidocaine on perioperative propofol and sufentanil dose, pulse oxygen saturation, postoperative pain score, and recovery time during pediatric colonoscopy.Methods:We designed a randomized, double-blind, placebo-controlled study and enrolled 40 children aged from 3 to 10 years who underwent colonoscopy. After titration of propofol to achieve unconsciousness, the patients were given i.v. lidocaine (1.5 mg/kg later 2 mg/kg/ hour) or the same volume of saline. Sedation was standardized and combined propofol with sufentanil. The primary outcome variables were intraoperative propofol and sufentanil requirements, and the number of oxygen desaturation episodes. Secondary outcome variables were recovery time after colonoscopy and post-colonoscopy pain.Results:Lidocaine infusion resulted in a significant reduction in propofol requirements: (median (quartile) 1.8 (1.5-2.0) vs. 3.0 (2.8-3.3) mg/kg respectively; P < 0.001) and sufentanil requirements: (median (quartile) 0.06 (0.05-0.08) vs. 0.1 (0.1-0.1) μg/kg respectively; P < 0.001). The number of subjects who experienced oxygen desaturation below 95% in the lidocaine group was also significantly less than that in the control group: 1 vs. 6 (P = 0.04). The mean (SD) recovery time was significantly shorter in the lidocaine group: (19.2 (2.6) vs. 13.3 (2.6) min respectively; P < 0.001). There was no significant difference in post-colonoscopy pain.Conclusion:Continuous infusion of lidocaine resulted in reduction of propofol and sufentanil requirements, recovery time, and risk of hypoxemia during pediatric colonoscopy.

Image: Colonic Hematoma Complicating Pediatric Colonoscopy

Image: Colonic Hematoma Complicating Pediatric Colonoscopy

Diagnostika a endoskopická intervence u raritního MALT lymfomu proximálního jejuna

Summary: Extranodal lymphoma from the marginal zone mucosa-associated lymphoid tissue (MALT lymphoma) is one of the primary extranodal non-Hodgkin‘s lymphomas with low degrees of malignancy but with the risk of spreading to distant locations in the body. B-lymphomas are sometimes associated with other diseases (eg. Helicobacter pylori and Campylobacter jejuni infections or inflammatory bowel disease). B-lymphomas may manifest with a variety of clinical signs, from dyspeptic syndrome with malabsorption and weight loss to ileus or massive gastrointestinal bleeding. Dia­gnosis is based on the clinical condition and the results of laboratory tests and imaging techniques, while endoscopy is the essential procedure for visualizing the tumor mass and collecting a bio­psy sample to determine the definitive histopathological dia­gnosis. MALT lymphoma treatment is managed by oncologists and includes chemotherapy and/or radiotherapy, with resection indicated in rare cases. In this case report we present an elderly female patient who was referred to our IBD centre for non-specific abdominal pain with a positive fecal occult blood test. Computed tomography (CT) examination was used before endoscopy and showed an infiltration of the splenic flexure by an unspecified mass, a subsequent colonoscopy showed intact mucosa of the colon, including the terminal ileum. In the second reading of the CT scan the location of the infiltrate was identified more specifically as the area of the proximal jejunum and jejunal mesentery. Subsequent upper endoscopy revealed a stenosing exulcerated tumor in the proximal jejunum, with the stenosis impassable even for a pediatric colonoscope. The dia­gnosis of MALT lymphoma was confirmed by a histological examination of the bio­psied tissue. A follow-up upper endoscopy was performed after the patient had completed her oncological treatment (chemotherapy in combination with radiotherapy), showing the presence of stenosis at the proximal jejunum, still impassable for the endoscope. In clinical terms, the patient experienced weight loss, which was to some extent caused by intermittent pseudo-obstruction when on a solid diet, therefore we decided to enrich her oral intake with high-calorie sip feed. The next follow-up CT scan of the abdomen showed a regression of the infiltrate, but the stenosis of the proximal jejunum, about 7 centimeters long, persisted. To respect the patient‘s wishes, no surgical resection of the stenotic section of the intestine was performed, but we proceeded with endoscopic dilatation of the stenotic section of the jejunum with a balloon. After the first two endoscopic dilatations of the stenotic area the patient experienced a temporary improvement in solid food tolerance. Because of restenosis, a third endoscopic dilatation was performed, with the development of complications that included short-term circulatory instability with abdominal pain and eventually required an urgent surgical solution. Key words: marginal zone B-cell lymphoma – stenosis – dilatation – intestinal perforation – jejunum – MALT

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