Colonoscopy is utilized to provide direct visualization of the gastrointestinal tract in the evaluation, diagnosis, and management of gastrointestinal bleeding, colonic polyp(s)/dysplasia screening, and examination of the intestinal mucosa. This chapter reviews the equipment, endoscopic technique, indications, preparation, and the associated therapeutic interventions to effectively perform colonoscopy in pediatric patients. This chapter includes recent advances in the field of colonoscopy and serves as an essential reference for pediatric gastroenterologists.

Esophagogastroduodenoscopy (EGD) provides direct visualization of the gastrointestinal tract and is utilized for diagnostic and therapeutic procedures. This technique provides direct visualization of the esophagus, stomach and distal duodenum. EGD is utilized in the diagnosis and treatment of numerous gastrointestinal disorders in the pediatric population. This chapter outlines the indications, contraindications, technique, sedation, therapeutic interventions and potential complications associated with this procedure.

From the *Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania the †Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Children’s, Cleveland, OH. Received June 9, 2022; accepted June 13, 2022. The authors report no conflicts of interest. Address correspondence and reprint requests to Marsha Kay, MD, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Children’s, Cleveland, OH 44195 (e-mail: [email protected]).

Introduction: Our hospital implemented universal pre-operative COVID-19 screening in April 2020 to reduce risk of transmission to caregivers as well to avert a potential anesthetic risk in COVID positive patients. The aim of this project was to determine the prevalence of asymptomatic COVID- 19 infection among pediatric patients undergoing ambulatory procedures and surgeries, overall and for Pediatric Gastroenterology (GI) cases specifically. Methods: A retrospective chart review identified pediatric patients (≤21 years) who underwent ambulatory pre-operative COVID-19 testing between April 1, 2020-March 31, 2021. Demographic and health-related data was collected to identify asymptomatic COVID-19 positive patients scheduled for GI procedures and other ambulatory surgeries. We compared the proportion of patients who tested positive by age group, co-morbid condition, and surgical specialty. We also compared pediatric case rates to Ohio case rates. The study was IRB approved. Results: 4,663 asymptomatic pediatric patients underwent pre-operative COVID-19 testing by PCR and 81 patients were identified as positive (1.73%). In COVID-19 positive patients, 56% were male and 44% were female. Mean age was 12 years and patients 13-18 years were the age group with the highest fraction of positive tests (35%). 11% of patients screened were undergoing a GI-related procedure with a positivity rate of 1.3%. The peak in asymptomatic positives across all procedures occurred in November 2020 (30%), which preceded the peak in COVID-19 cases in Ohio by several weeks. Most prevalent co-morbid condition was asthma (15%) and 8% had inflammatory bowel disease. 5 patients were undergoing chemotherapy and none were on biologic therapy. 94% of cases were deferred. 25% of cases that proceeded required post-operative admission. Conclusion: Asymptomatic COVID-19 positive patients were identified before 1.73% of pediatric ambulatory procedures and before 1.3% of GI procedures. These case rates were higher than the concurrent adult case rate at our institution. The higher rate of asymptomatic COVID-19 infection in pre-operative pediatric ambulatory patients may reflect the milder disease in this age group. The peak in pediatric asymptomatic case positivity seemed to predict the subsequent peak case rate in the state of Ohio by a few weeks. As the pandemic continues with a large percentage of pediatric patients unvaccinated, pre-operative COVID-19 testing has important implications for pediatric GI and other ambulatory procedures..

Percutaneous endoscopic gastrostomy (PEG) is a feasible and safe technique for patients who need long-term feeding and cannot eat orally. With the increasing maturity of PEG technique, a large number of patients receive PEG tube placement every year in the world. However, PEG tube placement is not necessary in some patients, and some other patients are not evaluated strictly, leading to serious complications. In a broad sense, the mainly two indications for PEG include long-term enteral nutrition and gastric decompression. On the other hand, the main contraindications of PEG are distal intestinal obstruction, severe coagulation abnormalities, and severe infection at the PEG site. In the first section of this review, the indications and contraindications of PEG are introduced. Although PEG tube placement is a relatively safe technique, it can still cause a number of complications, including minor and major complications. Through standard management and treatment, the outcome of most patients is very good. In the second section of this review, we describe a variety of minor and major tube-related complications, and the treatment and prevention of these complications. In addition, the preparation and post-insertion care are also very important for PEG, which can reduce the incidence of complications. In the last section of this review, we describe related issues about the preparation and post-insertion care of PEG. In conclusion, PEG tube placement is a widely accepted technique that can bring benefits to the right patients.

BACKGROUND Hypertrophy of visceral adipose tissue (VAT) is a hallmark of Crohn disease (CD). The VAT produces a wide range of adipokines, biologically active factors that contribute to metabolic disorders in addition to CD pathogenesis. The study aim was to concomitantly evaluate serum adipokine profiles and VAT volumes as predictors of disease outcomes and treatment course in newly diagnosed pediatric patients with CD. METHODS Pediatric patients ages 6 to 20 years were enrolled, and their clinical data and anthropometric measurements were obtained. Adipokine levels were measured at 0, 6, and 12 months after CD diagnosis and baseline in control patients (CP). The VAT volumes were measured by magnetic resonance imaging or computed tomography imaging within 3 months of diagnosis. RESULTS One hundred four patients undergoing colonoscopy were prospectively enrolled: 36 diagnosed with CD and 68 CP. The serum adipokine resistin and plasminogen activator inhibitor (PAI)-1 levels were significantly higher in patients with CD at diagnosis than in CP. The VAT volume was similar between CD and CP. Baseline resistin levels at the time of diagnosis in patients with CD who were escalated to biologics was significantly higher than in those not treated using biologic therapy by 12 months (29.8 ng/mL vs 13.8 ng/mL; P = 0.004). A resistin level of ≥29.8 ng/mL at the time of diagnosis predicted escalation to biologic therapy in the first year after diagnosis with a specificity of 95% (sensitivity = 53%; area under the curve = 0.82; P = 0.015 for model with log-scale). There was a significantly greater reduction in resistin (P = 0.002) and PAI-1 (P = 0.010) at the 12-month follow-up in patients on biologics compared with patients who were not treated using biologics. CONCLUSIONS Serum resistin levels at diagnosis of pediatric CD predict the escalation to biologic therapy at 12 months, independent of VAT volumes. Resistin and PAI-1 levels significantly improved in patients with CD after treatment using biologics compared with those not on biologics. These results suggest the utility of resistin as a predictive biomarker in pediatric CD.

Autoimmune enteropathy is an extremely rare condition characterized by an abnormal intestinal immune response which typically manifests within the first 6 months of life as severe, intractable diarrhea that does not respond to dietary modification. Affected individuals frequently present with other signs of autoimmunity. The diagnosis is made based on a characteristic combination of clinical symptoms, laboratory studies, and histological features on small bowel biopsy. Autoimmune enteropathy is associated with a number of other conditions and syndromes, most notably immunodysregulation polyendocrinopathy enteropathy X-linked (IPEX) syndrome and autoimmune polyglandular syndrome type 1 (APS-1). Diagnosis and treatment is challenging, and further research is needed to better understand the pathogenesis, disease progression, and long-term outcomes of these conditions.

Colonoscopy with polypectomy is frequently performed in pediatric patients based on symptoms, with the majority of polyps identified being benign juvenile pedunculated polyps with a vascular stalk. This is in distinction to adults where polypectomy is often performed as part of a colon cancer screening and prevention strategy and a higher fraction of polyps are sessile and or dysplastic. In adults, polypectomy techniques emphasize a need for deeper resection to ensure complete resection of adenomas or potential carcinoma in situ. Adenomatous polyps can occur in the pediatric age group and may be associated with an underlying polyposis, hereditary or chronic inflammatory conditions. Polypectomy techniques include use of cold biopsy forceps for very small polyps, cold snare polypectomy for small sessile polyps and hot snare polypectomy for the majority of polyps in the pediatric age group. Adjuvant techniques include epinephrine volume reduction, saline-assisted polypectomy and hemostatic techniques including injection, clip application and loop application to prevent or treat post-polypectomy bleeding. Electrosurgical principles guide the settings and type of current utilized during hot snare polypectomy. Polypectomy utilizing thermal techniques is associated with a higher risk of complications compared with diagnostic colonoscopy.

Objectives: Colonoscopy with terminal ileal (TI) intubation is an important diagnostic and therapeutic tool in the care of children with digestive diseases, especially in those with inflammatory bowel disease. Ileal intubation rate is a recognized quality indicator for pediatric colonoscopy. Our primary aim was to identify our single-center ileal intubation rate and to secondarily identify specific factors, including bowel preparation quality, procedure duration, and cecal intubation rates which affect successful ileal intubation and by extension, complete colonoscopy. Methods: A retrospective chart review of all colonoscopies in 2015 was completed, identifying 458 procedures. Sixty-seven patients were excluded, resulting in 391 colonoscopies reviewed. Results: We analyzed 391 colonoscopy procedures with a mean patient age of 14.4 ± 5.3 years. The most frequent primary indications for colonoscopy included abdominal pain with “red flag” symptoms (35.5%), known inflammatory bowel disease (25.1%), and isolated abdominal pain (11.5%). Ileal intubation was achieved in 91% of all colonoscopies, with a 94.4% cecal intubation rate. Failure of ileal and cecal intubations was classified into 4 categories: disease-related conditions, bowel preparation, technical aspects, and miscellaneous issues. Potentially modifiable factors accounted for the majority of cases of failed TI intubation. The mean colonoscopy time with and without successful TI intubation were 39 and 48.1 minutes, respectively. Conclusions: Completion of colonoscopy to the TI is an essential part of a complete colonoscopy. TI intubation was possible in 91% of patients. This rate could potentially improve to 95% with optimization of modifiable factors such as improving bowel preparation or further refinement of endoscopic skills.

Serum Adipokines and Increased Abdominal Visceral Adipose Tissue at Diagnosis Predict Need for Biologic Therapy in Pediatric Inflammatory Bowel Disease Pediatric GI Award Jacob A. Kurowski, MD1, Rishi Gupta, MD2, Iulia Barbur3, Sarah Worley, MS1, Erick M. Remer, MD1, Tracey Bonfield, PhD3, Jean-Paul Achkar, MD, FACG1, Claudio Fiocchi, MD1, Satish E. Viswanath, MS, PhD3, Marsha Kay, MD1 1Cleveland Clinic, Cleveland, OH; 2University of Maryland Medical Center, Baltimore, MD; 3Case Western Reserve University, Cleveland, OH Introduction: Adipokines are thought to play a role in the inflammatory response derived from abdominal visceral adipose tissue (VAT). Pediatric patients with inflammatory bowel disease (IBD) have higher VAT volumes than healthy controls. We sought to evaluate the correlations between the abnormal VAT volumes in pediatric IBD with serum adipokines and their 12-month disease-related outcomes. Methods: Pediatric patients with suspected IBD were prospectively enrolled at time of initial colonoscopy. Clinical, laboratory, endoscopic, and anthropometric data were obtained at enrollment and 6and 12-month follow up for patients with IBD. Analysis included adipokines and cytokines. Abdominal MRI and CT sequencing was analyzed for VAT volumes if obtained within 3 months of diagnosis. Statistical analysis was performed with a p value of ≤0.05 determining statistical significance. Results: A total of 108 patients were recruited, 66 healthy controls (HCs) and 42 with newly diagnosedIBD, 83% with Crohn’s disease (Table 1). HCs had higher body mass index (BMI)-for-age percentiles than patients with IBD. Imaging was obtained on 44 patients and the ratio of VAT to total abdominal fat mass was higher in patients with IBD versus HCs (26.8% vs 22.6%, p=0.21). Patients with IBD had significantly higher baseline levels of resistin, PAI-1, HGF, and IL-6 at diagnosis compared to HCs. Resistin levels also correlated with VAT volumes (rho=0.48; p=0.027). Patients who required biologic therapy by 12 months following diagnosis had significantly higher baseline levels of resistin (27.3 ng/mL vs 13.8 ng/mL, p=0.04) and VAT volumes (822 cm3 vs 585cm3, p=0.05) compared to patients with IBD not on

Crohn’s Disease is a relapsing and remitting disease involving chronic intestinal inflammation that is often characterized by hypertrophy of visceral adipose tissue (VAT). While an increased ratio of VAT to subcutaneous fat (SQF) has previously been identified as a predictor of worse outcomes in Crohn’s Disease, bowel-proximal fat regions have also been hypothesized to play a role in inflammatory response. However, there has been no detailed study of VAT and SQF regions on MRI to determine their potential utility in assessing Crohn’s Disease severity or guiding therapy. In this paper we present a fully-automated algorithm to segment and quantitatively characterize VAT and SQF via routinely acquired diagnostic bowel MRIs. Our automated segmentation scheme for VAT and SQF regions involved a combination of morphological processing and connected component analysis, and demonstrated DICE overlap scores of 0.86±0.05 and 0.91±0.04 respectively, when compared against expert annotations. Additionally, VAT regions proximal to the bowel wall (on diagnostic bowel MRIs) demonstrated a statistically significantly, higher expression of four unique radiomic features in pediatric patients with moderately active Crohn’s Disease. These features were also able to accurately cluster patients who required aggressive biologic therapy within a year of diagnosis from those who did not, with 87.5% accuracy. Our findings indicate that quantitative radiomic characterization of visceral fat regions on bowel MRIs may be highly relevant for guiding therapeutic interventions in Crohn’s Disease.

BACKGROUND & AIMS: Up to 30% of patients with Crohn's disease (CD) require surgery within the first 5 years from diagnosis. We investigated the recent risk of bowel surgery in an inception cohort of pediatric patients with CD and whether early use of biologics (tumor necrosis factor antagonists) alters later disease course. METHODS: We collected data from the Pediatric Inflammatory Bowel Disease Collaborative Research Group registry on 1442 children (age, <= 16 y) diagnosed with CD from January 2002 through December 2014. Data were collected at diagnosis, 30 days following diagnosis, and then quarterly and during hospitalizations for up to 12 years. Our primary aim was to determine the 10-year risk for surgery in children with CD. Our secondary aim was to determine whether early use of biologics (<3 mo of diagnosis) affected risk of disease progression. RESULTS: The 10-year risk of first bowel surgery was 26%. The 5-year risk of bowel surgery did not change from 2002 through 2014, and remained between 13% and 14%. Most surgeries occurred within 3 years from diagnosis. The only predictor of surgery was disease behavior at diagnosis. CD with inflammatory behavior had the lowest risk of surgery compared to stricturing disease, penetrating disease, or both. We associated slowing of disease progression to stricturing or penetrating disease (but not surgery) with early use of biologics, but this effect only became evident after 5 years of disease. Our results indicate that biologics slow disease progression over time (hazard ratio, 0.85; 95% CI, 0.76-0.95). CONCLUSIONS: In an analysis of data from a registry of pediatric patients with CD, we found that among those with significant and progressing disease at or shortly after presentation, early surgery is difficult to prevent, even with early use of biologics. Early use of biologics (<3 mo of diagnosis) can delay later disease progression to stricturing and/or penetrating disease, but this affect could become evident only years after initial management decisions are made.

A 2-year-old girl with a 5-month history of early satiety, dyspepsia, and intermittent bilious emesis presented to the emergency room with a day's history of persistent vomiting and abdominal pain. Vital signs were stable but physical examination revealed abdominal distention with absent bowel sounds. She had mild leukocytosis and imaging revealed the findings above.Image 1: Chest x-ray: gastric distention with an air-filled loop of bowel in the thoracic cavity.Image 2: Computed tomograph coronal view of abdomen/chest: diaphragmatic hernia with stomach (arrow) above right hemidiaphragm in horizontal plane, consistent with organoaxial gastric volvulus. An emergent surgical consultation was obtained and exploratory laparotomy revealed a giant congenital posterior hiatal hernia, chronic incarcerated stomach with organoaxial volvulus, and massive perihiatal inflammation with fibrosis. Hiatal hernia was repaired primarily and buttressed with biological prosthetic patch (alloderm). She also underwent a Thal fundoplication to minimize postoperative gastroesophageal reflux disease as a result of impaired lower esophageal sphincter function. We present a case of acute organoaxial gastric volvulus, secondary to congenital hiatal hernia in a 2-year-old girl, with a complicated repair because of chronic fibrosis and scarring that most likely had been occurring over time. Our case adds to the literature on gastric volvulus, which is rare in the pediatric population and can be a life-threatening emergency. An upper gastrointestinal series should be considered in a child with persistent vomiting of unclear etiology before the development of acute complications as seen in this case (1-6).

Children inevitably swallow foreign material accidentally or intentionally. Each type of ingestion carries their own set of risks and complications, short and long term, some requiring immediate attention while others close monitoring. Alkalotic household cleaning products and lithium button batteries are increasingly common and damage the esophagus quickly. While many toys with rare-earth metals are banned, they are already present in many households and can cause necrosis of bowel that is between the magnets. This article reviews the incidence and assessment along with current literature to provide guidelines for management of pediatric patients with suspected caustic or foreign body ingestion.