Video capsule endoscopy: Update to guidelines (May 2006)
Consensus on digestive endoscopy
Guidelines of the SFED
Indications for gastrointestinal biopsies during upper digestive endoscopy or screening of oeso-gastro-duodenal neoplasia
Head of project: D. Heresbach,
Working group: B. Napoléon, P Burtin, J.-C. Delchier
Reading group: E. Vaillant, D. Lamarque, R. Laugier and the Board of the Société Française d’Endoscopie Digestive (SFED)
According to the annual survey ”2 jours d’endoscopie en France (2 days of endoscopy in France)”, 1.1 million of upper digestive endoscopies are performed each year, of which 70% reveal an abnormality. Nevertheless, the observed abnormalities lead to biopsies in only 15% of oesophageal lesions against 95% of gastric lesions and 84% of duodenal lesions. Carrying out biopsies on the gastrointestinal mucosa during upper digestive endoscopic exploration allows a macroscopic examination and a pathological analysis at the same time. Biopsies are essential when the endoscopic aspect of the mucosal lesion is insufficient to lead to a precise and complete diagnosis, which impacts therapy as well as surveillance rhythm or prognosis.
Performing biopsies is a low-risk procedure, but its ”indirect” cost is not negligible. It is thus justified:
to define this practice with recommendations in terms of indications and quality criteria;
to specify when and how they must complete or be associated with mucosal chromendoscopy to target these biopsies.
Gastrointestinal mucosal biopsies are carried out with disposable forceps as reuse of gastrointestinal endoscopic biopsy forceps is no longer allowed (AFSSAPS, Official Jounal of 2001, June 6th). Use of large jaws forceps is preferred to small-sized forceps because of a better quality pathological analysis, although there is no significant improvement in diagnostic yield. The advantage of forceps enabling multiple biopsies in a single passage through the operating channel of the endoscope has not yet been established. Sampling by biopsy forceps should be targeted with precision. It should ideally be carried out perpendicularly to the mucosal surface. When the incidence of the forceps is particularly tangential, as is the case in the oesophagus, the highest biopsy quality can be obtained with a continuous succion while applying the forceps onto the mucosa. Presence of an endoscopic assistant is necessary when performing biopsies as the forceps is triggered by this assistant. The method of collecting samples is not codified, but it is recommended to collect tissue fragments in the jaws of the forceps with the help of a fine metallic forceps (tweezers); use of a needle, source of contamination by accidental jab, should be prohibited. Samples should immediately be put in a recipient containing a fixing agent, generally supplied by the pathological laboratory. Diluted and coloured formalin or alcohol without Bouin’s fluid should be preferred as they denature nucleic acids, even if some pathologists found that Bouin’s fluid enables an easy morphological analysis. The jar should immediately be labelled. In case of sampling on different anatomical sites, each jar is clearly identified by a number. As soon as endoscopy is finished, the operator fills in a request for a precise morbid anatomical examination by indicating at least the sampling site, with reference to jar numbers in case of multiple sites, macroscopic aspects and the objective of the endoscopy.
Vascular lesions (oesogastric varices, angiodysplasia and angiomas) should not be biopsied, except dyschromic and iodo-negative areas in the inferior third of the oesophagus, if located on a varix before their treatment. In case of active gastrointestinal bleeding, the haemorrhagic lesion should not undergo biopsy at the site of haemorrhage but biopsies may be performed at a distance.
In case of acquired or induced coagulation disorders, arising from antithrombotics intake (anti-vitamin K, platelet anti-aggregants, heparins, etc.), it is not recommended to perform an antithrombotics relay or interruption (except if a recent INR is below 1.5 in case of anti-vitamin K treatment), uniquely for performing biopsies. Loop macrobiopsy or nasoendoscopy is, on the other hand, contra-indicated under platelet anti-aggregant, anti-vitamin K or heparin therapy and necessitates an interruption and relay according to recommendations and underlying thrombotic risk (cf. specific SFED recommendation guidelines).
Definitive indications for oesophageal biopsies are:
Any abnormality of relief or dyschromatic pattern of the oesophageal mucosa.
In patients at risk for squamous cell carcinoma of the oesophagus, the search for abnormalities should be facilitated by chromoendoscopy with Lugol® a 2% iodine-potassium solution,; only iodo-negative areas would thus undergo biopsy.
It must be used in patients having:
– a personal history of head and neck carcinoma or previous oesophageal squamous carcinoma;
– a Plummer-Vinson syndrome (sideropenic hypochromic anaemia and annular stenosis of the upper third of the oesophagus);
– a history of ingestion of caustic product, especially after a delay > 15 years whatever accompanying oesophageal stenosis or symptoms;
– a more than 15-year past history of achalasia;
– a genetic predisposition revealed by specific syndromes ie, palmoplantar keratosis or tylosis in its form with late onset between 5 and 15 years;
– an history of alcohol and/or tobacco intoxication.
The surveillance rhythm is currently being subject to debate, but may rely upon indications mentioned in [Table 1].
In case of ectopic oeso-gastric mucosal junction (Z line) it is necessary to perform biopsies to confirm the presence of intestinal metaplasia which defines Barrett’s oesophagus (BE) (prevalence : 1–3% in the general adult population) whereas it frequency reaches up to 5–10% during repeat upper digestive endoscopies for gastro-esophageal reflux disease (GERD).
– biopsies are first performed on abnormalities of relief or dyschomic area and their location should be well described (height and quadrant) within Barrett’s oesophagus. Then, systematic sampling according to the Seattle protocol is performed to complete the targeted biopsies: One biopsy per quadrant every 2 cm in height, in separated jars ; the cartography is reproduced on a diagram (example: BE 10 cm high = 20 biopsies); endoscopic pathological analysis of biopsies and length of BE measured by endoscopy lead to present surveillance recommendations. According to lesions observed (intestinal metaplasia, low- or high-grade dysplasia), this surveillance rhythm is detailed in a specific SFED guideline. In case of gastro-oesophageal reflux, systematic biopsies of the mucosal junction (Z line) are performed to screen intestinal metaplasia of the cardia, equivalent to an ”ultra short” BE without endoscopic abnormality. However, this indication that has not been validated yet, since estimation of the risk of cancer of the cardia remains controversial in this case.
It is also accepted:
a) to perform biopsies:
– on all elevated tumoral lesions of the oesophageal mucosa (papilloma, carcinoma);
– on all mucosal lesion of uncertain nature, especially in immunodepressed patients;
– on all esophageal ulceration, in the squamous cell mucosa as well as in the glandular mucosa;
– on all glandular heterotopic foci in the upper oesophagus in case of ulceration or associated oesophageal symptoms;
– systematically, especially in the upper third of the oesophagus and in the absence of visible lesion, in case of herpetiformis dermatitis and in case of oesophageal symptoms without obvious lesions or with discrete mucosal modifications, suggestive of oesinophilic oesophagitis (at least five stepped biopsies and presence of 15 oesinophils per field showing important swelling on at least one biopsy).
b) biopsies are not required:
– on sub-mucosal tumours: superficial biopsy with forceps is not contributive in this case but it would be necessary to perform a real sub-mucosal biopsy or fine needle aspiration to obtain a relevant pathological analysis. In fact, this type of biopsy is achievable only after incision of the mucosa for a deep sampling, which increases the risk of bleeding or even perforation due to its blind nature. It is thus preferable, when a confirmation diagnosis is absolutely necessary, to perform an EUS-guided biopsy;
– on vascular lesions;
– on typical peptic lesions at the time of the diagnosis ; in the case they should be sampled, biopsies would be performed during a repeat upper digestive endoscopy after proton pump inhibitor therapy.
Currently, there is no validated technique enabling a precise targeting of biopsies on areas exclusively at risk for dysplasia: among the techniques daily accessible, chromoendoscopy with methylene blue or 2% acetic acid enables identifying areas of intestinal metaplasia, and sometimes of high-grade dysplasia, only if it is performed during a zoom endoscopy . Electronic techniques for processing images using narrow spectral bands (FICE or NBI systems) also enable identifying areas of intestinal metaplasia and detecting high-grade dysplasia in a manner identical to chromoendoscopic staining. None of these methods detect low-grade dysplasia. If their diagnostic yield for lesions of high-grade dysplasia or carcinoma is identical to that of stepped biopsies in some expert centres, the absence of inter-observer and large-scale reproducibility has not yet allowed them to replace stepped biopsy protocols.
Definitive indications for oesophageal biopsies are:
Biopsy carried out on a lesion identified by endoscopy
any tumoral lesion concerning the gastric mucosa; biopsies of the tumour should be associated with biopsies of the surrounding mucosa so as to ensure that possible adjoining dysplasia areas are not left out;
any gastric ulcer; biopsy protocols should include biopsy on the fundus and a minimum of eight biopsies carried out especially on the borders of the ulcer, spread on the whole circumference of the lesion;
enlarged folds, so as not to miss a lymphoma or gastric linitis. It is then mandatory to perform either multiple deep biopsies by repeating the sampling on the same location or to perform a macro-biopsy of a fold with a diathermic loop.
Biopsies in search of Helicobacter pylori (Hp)
They should concern areas of apparently normal gastric mucosa at the level of the antrum and fundus on the small and large flexure.
They are mandatory in case of gastric or duodenal ulcers and are recommended (in the absence of contra-indication), although debatable, in case of a NSAID induced lesions in which prolonged treatment with Proton Pump Inhibitor is envisaged. They are recommended in cases of personal history of operated gastric cancer if the search has not been carried out before gastric surgery or in case of first degree or multiple family history of gastric cancer. Performing at least two antral biopsies, two fundic biopsies and one biopsy at the angle of the small flexure enables the search for Hp infection and the correct evaluation of intestinal atrophy and metaplasia at the same time.
Search and surveillance of pre-neoplastic lesions of the stomach
Two types of situations increasing the risk of gastric cancer or pre-cancerous lesions may be distinguished:
those for which an association is certain and where the importance of an endoscopic surveillance is suggested by several trials. It concerns
a) personal history of intestinal metaplasia with low- or high-grade dysplasia to:
– confirm the diagnosis;
– establish a cartography of the lesions through serial biopsies;
– search for a potential relationship with an H. pylori infection. Monitoring is motivated by an incidence of gastric cancer of the order of 0.6–6% according to the degree of dysplasia without clear recommendation of a follow-up rhythm based on evidence based data. Expert opinion agree for a follow-up at 3 to 5 years intervals; in cases of ”confirmed” high-grade dysplasia, endoscopic or surgical treatment might be discussed.
b) gastric polyps
The rule is to perform biopsies on the polyps to specify their nature that cannot always be determined by their endoscopic shape and mucosal pattern. A resection procedure by polypectomy or mucosectomy is recommended in case of adenoma and for hyperplastic polyps > 5 mm. Fundic gland polyps may be left on site if they are off the context of a familial adenomatous polyposis. When gastric polyps diagnosis is made within the scope of a familial adenomatous polyposis, an endoscopic follow-up of the stomach is recommended after resection at 1 year and then every 5 years; large fundic gland polyps (> 1 cm) should be removed and the small ones monitored through perendoscopic biopsies every 3 years.
c) personal history of gastric resection for gastric carcinoma : no recommendation of a rhythm based on scientific data.
those for which a search is justified despite the impact of surveillance is still debated:
a) chronic atrophic gastritis with fundic intestinal metaplasia : monitoring is debated since the incidence of gastric cancer may reach 0.25% to 1%.
b) HNPCC syndrome.
c) history of gastrectomy for gastric or duodenal ulcer 15 to 20 years after surgery.
d) Biermer’s anaemia.
e) first-degree family history of gastric cancer.
When upper digestive endoscopy is performed in these latter cases, at least two antral biopsies, two fundic biopsies and one biopsy at the ungulus of the small flexure enables the correct evaluation of intestinal atrophy and metaplasia at the same time as well as to detect the presence of H. pylori.
During the course of dyspepsia with normal oeso-gastro-duodenal endoscopy, biopsies usually detect the presence of H. pylori and preneoplastic lesions as mucosal atrophy type or intestinal metaplasia. Performing at least two antral biopsies, two fundic biopsies and one biopsy at the angle of the small flexure enables the search for infection by H. pylori and the correct evaluation of intestinal atrophy and metaplasia at the same time. The advantage of this approach is associated with the fact that eradication of the bacteria has a weak but established role in the control of symptoms and that, in addition, it would stop the progression of possible lesions with low or exceptional neoplastic risk. However, in the absence of clear dyspeptic symptoms there is no indication to recommend systematic upper digestive endoscopy as a screening test to research Hp infection or pre-neoplastic lesion.
Gastropathies are characterised by the presence of endoscopically visible mucosal lesions without patholologic inflammation. Except for gastropathies induced by portal hypertension where biopsies are contra-indicated, biopsies are always useful to confirm a diagnosis for gastritis or gastric disease and to eventually detect an infection by H. pylori even in the presence of an apparently normal mucosa. The biopsy protocol always includes two fundic biopsies, two antral biopsies and one biopsy at the antro-fundic transition zone.
Culture of H. pylori
In case the treatment of H. pylori is a failure, it is recommended to carry out a culture with a antibiogram before establishing a new line of treatment. In such a case, two fundic biopsies and two antral biopsies should be performed for bacteriological tests. Samples should be placed in physiological saline serum and rapidly dispatched to a centre specialised in the culture of the bacterium. Molecular screening methods of mutations associated with resistance against antibiotics would soon enable obtaining rapid results from samples dispatched immediately and without any particular precautions.
Etiologic evaluation of a chronic colitis
Within the scope of the evaluation of a chronic colitis or inflammatory bowel disease, in particular lymphocytic or collagenous colitis, celiac disease, or Crohn disease, multiple biopsies should also be performed in healthy areas and stepped at the esphageal, gastric and duodenal levels for the search of a focal foveolar gastritis characterised by a lymphocytic and macrophagic infiltrate, particularly in H. pylori-negative patients. This gastritis is more common at the antral level than at the fundic level without any specific macroscopic translation or in the form of tiny erythematous bands.
Their main advantage is to confirm the sub-mucosal character of the tumour as seen through endoscopy, since the biopsies generally look normal. Thus EUS-guided FNA is preferable when a confirmation of the diagnosis of the nature of a sub-mucosal tumour is absolutely necessary. These biopsies are not necessary in case of typical aberrant pancreas.
Even in the case of iron deficiency anaemia, fundic biopsies may enable identifying an atrophic gastritis. Macrocytosis may be masked by an association to martial deficiency and induced by malabsorption of iron as a consequence of the hypochlorhydria.
Definitive indications for duodenal biopsies are:
– anaemia with iron deficiency without known cause, whatever the age of the patient (the yield of biopsies is not decreased in elderly patients, particularly past 65;
– folate deficiencies: duodenal biopsies need to be associated with gastric biopsies;
– chronic diarrhoea : associated with colonic and ileal biopsies;
– suspicion of celiac disease, even if the diagnosis is set by positive circulating antibodies. at initial endosocopy, biopsies should be multiple in the first duodenum and more distal in the third duodenum; villous atrophy is maximal in the distal duodenum whereas associated signs (increase in intra-epithelial lymphocytes, cryptic hyperplasia) are more frequent at the level of the proximal duodenum. The number of biopsies to be performed is at minimum 4 for an optimal diagnosis (two distal and two proximal);
– assessment of the response to a gluten-free diet during the course of celiac disease, one year after the implementation of the diet;
– resistance to a well conducted gluten-free diet: search for a type I or type II refractory sprue (in this case, request for a CD3 and CD8 immunomarking on the usual biopsies and make samples for frozen biopsies for a molecular or cytometry test of clonality of lymphocytes on biopsies);
– suspicion of specific parasites (giardiasis, strongyloidiasis);
– villous pattern lesions, before deciding on the type of treatment, particularly endoscopic, or establishing a score for lesions within the scope of a familial adenomatous polyposis with, in case of a normal duodenum or low score for lesions (Spigelman grade I or II), a recommendation for endoscopic duodenal surveillance every 2 years;
– suspicion of Crohn’s disease or chronic colitis without proof of its diagnosis, where duodenal biopsies should be performed. The presence of granuloma is not constant and varies from 5% to 15% according to the series. However, granulomas are more frequently identified in the duodenum, even in the duodenal bulb, rather than in the stomach.
Indications under evaluated are:
– systematic duodenal biopsies during upper digestive endoscopy whatever the indication: according to some expert centers, this policy may multiply, the endoscopic prevalence of celiac disease by 4 (1.0–3.9%) and of giardiasis by 5 (0.8–0.45%) by increasing the number of duodenal biopsies by 65%;
– regular hypertrophic papilla of Vater.
1 Ribeiro U, Posner MC, Safatle-Ribeiro AV, Reynolds JC. Risk factors for squamous cell carcinoma of the oesophagus. Br J Surg 1996; 83: 1174–1185
2 Gehanno P. Cancers associated with cancer of the esophagus. Rev Prat 1999; 49: 1177–1179
3 Brucher BLDM, Stein HJ, Bartels H et al. Achalasia and esophageal cancer: incidence, prevalence, and prognosis. World J Surg 2001; 25: 745–749
4 Risk JM, Mills HS, Garde J et al. The tylosis oesophageal cancer (TOC) locus: more than just a familial cancer gene. Dis Eosophagus 1999; 12: 173–176
5 Dikshit RP, Boffetta P, Bouchardy C et al. Risk factors for the development of second primary tumors among men after laryngeal and hypopharyngeal carcinoma. Cancer 2005; 103: 2326–2333
6 Dubuc J, Seyrig JA, Barbier JP et al. Endoscopic screening for esophageal squamous-cell carcinoma in high-risk patients: a prospective study conducted in 62 French endoscopy centers. Endoscopy 2006; 38: 690–695
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8 Allum WH, Griffin SM, Watson A, Colin-Jones D on behalf of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, the British Society of Gastroenterology, and the British Association of Surgical Oncology. Guidelines for the management of oesophageal and gastric cancer. Gut 2002; 50 (Suppl. V): v1–v23
Table 1 Predisposition and risk factors for oesophageal squamous cell carcinoma (OSCC) which may justify gastroscopic screening and surveillance with iodine-potassium iodide (i/i or Lugol) colouration.
OSCC predisposing factors
Incidence or prevalence
Time lag for OSCC onset/risk factor and average age of onset
Recommendation for Upper digestive endoscopy
Head and neck carcinomas
10 years/diagnostic head and neck carcinomas
Every year for 10 years, then at a less frequent rhythm (every 3 or 5 years?)
× 15 to × 120
20 years/diagnostic achalasia
15 years/diagnostic of achalasia
Intake of caustic product
30 years/intake of caustic product
15 years/diagnostic of caustic-induced lesions
Incidence at 45 years:
Mean age: 30
Commission recommandation de la SFED
Service des Maladies de l’Appareil Digestif, CHU Pontchaillou,
F-35033 Rennes Cedex 9, France
Consensus on gastrointestinal endoscopy
Dilation of benign stenoses of the oesophagus in adults and children
Head of project: D Heresbach
Working group: C Boustière, L Michaud, D Lachaux, P Burtin
Reading group: A Dabadie, F Prat, R Laugier
Benign stenoses of the oesophagus are less frequent than stenoses of neoplastic origin and are generally treated by endoscopy either through dilations or, more recently, through the use of temporary or extractable prostheses.
The objective of dilatation is the disappearance or improvement of dysphagia or, in stenoses of unknown origin, to enable the progression of the endoscope.
All symptomatic stenoses may be dilated through the endoscopic procedure, which may be proposed as first-line treatment because of its good tolerance and simplicity to implement. Surgical treatment of stenoses (oesopahgectomy or resection of a stenosis with anastomosis) is an alternative burdened with morbidity.
In daily practice, three main procedures are used for the dilatation of the oesophagus: the Savary-Gilliard bouginage in polyvinyl (used on a guide wire), hydrostatic balloon passing into an endoscope or through the scope (TTS) and pneumatic balloons over the scope.
Stenoses due to extrinsic compression cannot be improved by endoscopic dilatation.
Virtually, all intrinsic benign stenoses of the oesophagus may be subject to endoscopic dilation with bouginage or hydrostatic balloon. In adults, with a decreasing frequency, the following aetiology may be mentioned:
peptic stenoses, generally located at the inferior third of the oesophagus;
post-therapeutic endoscopic stenoses (laser, sclerosis of oesophageal varices, photodynamic therapy);
stenoses due to eosinophilic oesophagitis;
anastomotic or post-surgical stenoses, i.e. stenoses due to oeso-jejunal anastomosis after total gastrectomy or stenoses of the cardial orifice after a too tight installation of an anti-reflux assembly;
congenital stenoses of diaphragm type or within the context of the Plummer-Vinson syndrome.
In children, the major concerns are anastomotic stenoses occurring after surgical treatment of an oesophageal atresia, and caustic stenoses or stenoses due to eosinophilic oesophagitis. Post-infection (cytomegalovirus or herpes, generally occurring with an immunodepressed patient) or peptic stenoses and those following a sclerosis of oesophageal varices or congenital oesophageal stenosis are among the less frequent aetiologies.
Achalasia is also an indication for dilatation of the lower oesophageal sphincter (LOS). Spastic-like motor disorders of the oesophageal may occasionally necessitate a dilatation of the oesophagus.
Conditions to peeform the procedure
The patient should have been fasting for at least 6 hours. In case of achalasia, a 12-hour fast is necessary so as to ensure that the oesophagus is empty. It is sometimes associated with an oesophageal aspiration and especially with a tracheal intubation during the procedure.
Oesophageal dilatation should be performed under sedation or general anaesthesia (the rule for children).
The use of fluoroscopy to check the position of the guide wire and the dilatation device is recommended in case of complex, tortuous or angulated stenosis and in case of any doubt concerning the correct positioning of the guide wire.
Oesophageal dilatation is classified as a bleeding risk procedure and requires discontinuation of anti-coagulants, as a function of the grade of thromboembolic risk involved. The treatment is relayed with intravenous heparin, needs to be stopped 6 hours before the dilatation, and may be restarted 4–6 hours after the dilatation. Anti-aggregating agents should also be stopped, but some publications suggest that aspirin may be continued on a case-by-case basis.
Dilatation is classified as a moderate risk for endocarditis. An antibioprophylaxy should be discussed for patients having a high risk for endocarditis (see SFED guidelines on antibioprohylaxy during endoscopy).
Dilatation of the oesophagus in adult patients may often be performed in an ambulatory mode. However, each case should be evaluated individually and the possibility of hospitalisation for post-procedure surveillance should be explained to the patient. Because of anaesthesia, a hospital follow-up of 24 hours is strongly recommended in children.
Risks and complications
Endoscopic dilatation of benign stenoses of the oesophagus is a simple operation, at low cost and rapidly available; it allows an immediate symptomatic improvement and can be repeated on-demand.
The two main drawbacks are:
a frequent transient efficacy which necessitates repeated dilatation procedures in particular for benign stenosis, or the choice between a calibration strategy with multiple procedure for treatment with extractible prosthesis and in case of failure, a surgical treatment;
the risk of complication (perforation) is low in a majority of indications but more frequent in complex stenoses. Some aetiologies are subject to an increased risk: caustic stenoses, eosinophilic oesophagitis, post radio-therapy or recent oesophageal anastomosis (usually less than 3 months).
Thus, the rate of perforation was estimated at about 3% by a British audit, reporting a 1% mortality rate. Perforations are rare in cases of benign stenoses (1%) compared with malignant ones (6%); the mortality rate is also low (0.5% versus 2.3%).
Perforation risk is also increased in case of achalasia (3% to 4%, mortality rate: < 1%). The majority of perforations occur during the first dilatation session, and in case of achalasia, a gradual dilatation starting with a 30-mm balloon may reduce this risk.
The choice of the technique (bouginage, hydrostatic dilatation or pneumatic balloon) depends on personal experience. In fact, no study has demonstrated the superiority of a particular technique and no technique seems more particularly adapted for a specific indication except for achalasia. In fact, in this latter case, only pneumatic dilatation is indicated.
For other indications, in case of technical failure, an alternative procedure should be proposed.
Endoscopy enables locating the level of the stenosis against the oesophageal opening, evaluating the degree of stenosis in millimetres, its angle and whether it is possible to go through it or not. This step is essential to define the equipment to be used for the dilatation procedure. In certain difficult cases, passing through the stenosis with an ultra-thin endoscope as a ”naso-gastro-scope” enables securing the dilatation. A radiographic imaging study (contrast CT) is not required before a dilatation, but may be useful in complex stenoses and is advised in upper dysphagia to rule out a disease at a high risk of perforation (pharyngeal diverticulum, post-cricoid ring). It is preferable to obtain biopsies prior to dilatation and to search for an eosinophilic infiltration of the oesophageal mucus. Bbrushing or biopsies do not contra-indicate the dilatation during the same process.
Patients suspected of achalasia should obtain an evaluation before the dilatation including, at least, an oesophageal manometry to confirm the diagnosis. Other explorations (endoscopic ultrsonography, and CT) should be performed in case of suspected carcinoma of the oeso-cardiac junction.
Technique of dilatation with bouginage
Savary-Gilliard polyvinyl bougies are the most commonly used. They are rigid with diameters ranging from 5 to 20 mm and with a flexible streamlined extremity 20 cm long. A radio-opaque ring is present at the maximal diameter zone, and enables to assert that the dilatatorhas crossed the stenosis.
Installation of the guide wire: Usually, a guide wire known as “Savary’s guide” is chosen. It is made of metal and is reusable (autoclave sterilisation at 134°C), equipped with a flexible portion 5 cm long at its distal tip; a semi-rigid disposable guide wire should be used in the case where an esophageal prosthesis should be inserted during the same process. In case of tight or tortuous stenosis (rare in benign stenosis) or in acute-angulated anastomotic locations, a disposable hydrophilic wire of 0.035 inch may be used. These guide wires, being less rigid, require careful manoeuvres during the bouginage.
Once the stenosis is passed by the guide wire , the endoscope will be withdrawn by pushing forward the guide wire that should not be moved during this manoeuvre. If fluoroscopy is not used to check the intra-gastric position of the distal tip of the guide wire, then one should pay particular attention to the absence of movement of the guide wire.
Progressive dilatation is performed by passage of the bougies over the guide wire, with the help of an assistant who maintains a fixed tension on the wire so as to avoid any curvature of the dilatatorin the oesophagus, as this may be the source of parietal tear or perforation. Fluoroscopic control is strongly recommended. The first dilatatorto be used should have a diameter slightly greater than the tighter part of the stenosis (ex: start with a 7-mm dilatatorto dilate a stenosis evaluated at 5mm). A correct feed without significant dysphagia may be obtained with a 12 to 13 mm diameter in adults; a normal feed often requires a 15 mm calibre. In case of a tight stenosis, dilatation should be limited to 13 mm during the first session. The ”rule of three bougies” is cited, without being an evidence based recommendation. It consists in limiting the use of three bouges with increasing diameters during the same session and taking the diameter that gave a spasm sensation as the reference. The cervical position in extension may help in the introduction of bougies over a guide wire especially for those of a diameter superior to 13 mm.
In case of an initial non traversable stenosis, it is recommended to reintroduce the endoscope parallel to or over the guide wire so as to examine the aspect of the stenosis and the lower part of the oesophagus after dilatation (when the dilatation is sufficient to let the endoscope pass, generally after having passed a 11-mm bougie).
Technique of dilatation with hydrostatic balloon
Oesophageal cuffs usually have a diameter ranging from 5 mm to 20 mm. They can be used through the operator channel of most endoscopes (but not in naso-fiberscopes or neonatoscopes) without prior positioning of a guide wire. The balloon has a flexible extremity of around 15 mm length or a short guide wire that facilitates passage within the stenosis. Recent models have a diameter, adjustable a a function of the inflation pressure. A diameter of 15–18 mm is generally well adapted for hydrostatic dilatation of the oesophagus; a dilatation of up to 16–20 mm is often necessary to dilatate Schatzki’s rings.
In children, the diameter of the bougies as well as of cuffs should be adapted to the weight of the child and severity of the stenosis. Whatever the type of stenosis, the choice of bougies or cuffs remains debated. Only one retrospective paediatric series favours dilatation with balloons which are reported to be less traumatising and more efficient . The number and frequency of dilatation depends on the type of stenosis, on its tightness, and on duration and efficiency of the previous dilatation session. In case of multiple sessions required, repeat sessions may be proposed every 2–4 weeks.
The endoscope is positioned a few centimetres above the upper pole of the stenosis and the dilatation cuff is introduced into the operator channel of the endoscope. The median part of the cuff (of 5–8 cm length) is saddled on the stenosis under endoscopic control. In case where traversing proves to be difficult or if the stenosis is complex, tortuous or angulated with doubt concerning the right positioning of the cuff, a guide wire should be inserted through the stenosis under fluoroscopic control and the cuff is slid on the guide wire.
The cuff is connected to a syringe filled with water or physiological saline solution (to which a radiopaque product may be added to enhance the visualisation of the imprint of the stenosis) and mounted on a manometer.
The assistant blows the cuff to its optimal diameter by following the pressure recommendations mentioned in the user manual or on the cuff itself (from 3 to 8 atm or 30 to 45 psi according to the size of the cuff). The blown cuff may be left there for 20–60 seconds before deflation and removal. The 3 mm rule, initially used during the first session, is still applicable and allows to performing several sessions. A study on peptic stenoses reported the lack of difference in terms of results or complications between a progressive dilatation with hydrostatic cuff or performed outright at 15 mm.
Dilatation with pneumatic balloon for achalasia
Several types of dilatators are available, and dilatation with pneumatic balloons has become a classical method of achalasia treatment. The Rigiflex® system is a polyethylene balloon mounted on a fine flexible dilatatorwhich is positioned after insertion of a guide wire. Balloons are available in three sizes: 30, 35 and 40 mm diameter, and are marked with radiopaque rings at the centre and extremities of the balloon. A gradual dilatation, starting with the 30-mm balloon is recommended.
Following the positioning of the guide wire, the balloon, mounted on the thin bougie, is positioned on this guide wire, usually under fluoroscopic control but a dilatation under endoscopic control is also possible. The optimal pressure used is not based on comparative studies but is classically between 7 and 20psi . The endoscopist slowly inflates the balloon to ”prop” it on the cardial orifice while firmly keeping it at the mouth or by slightly pulling it up; then, the balloon takes a sandglass pattern and does no longer move . Then the balloon is fully inflated until disappearance of the notch or of the cardiac spasm. An initial 30-mm balloon dilatation for 20 seconds is as efficient as a dilatation with a bigger balloon for a longer duration.
In case of achalasia, a satisfactory clinical result is reported in 60–95% of cases, but young adults experience poorer results compared with older subjects. A second or third pneumatic dilatation session may be performed before a surgical treatment (cardioplasty) is discussed. In older patients the injection of botulinum toxin in the four quadrants is an alternative to pneumatic dilatation or after its failure. Despite botulinum toxin injection effectiveness is up to 85% of cases, the rate of relapse of symptoms at 6 months is frequent (50%). This was confirmed in a randomised trial with a high rate of relapse compared to pneumatic dilatation (70–89% versus 32–38%).
Immediately after dilatation
An oesophago-gastro-duodenoscopy enables evaluation of the calibration of the oesophagus, ease of passage of the endoscope, absence of parietal impairment and abnormality (a slight parietal injury and moderate bleeding are usual and proves the efficacy of the dilatation). In case of uncertain aetiological diagnostic of stenosis, biopsies should be taken and endoscopic ultrasonography should be programmed a few weeks latter.
Surveillance and post-dilatation care
Following an oesophageal dilatation, the patient should be examined upon waking up in the recovery room. In case of thoracic pain or when the post-procedure endoscopic examination, has shown an open laceration of the wall or an abundant bleeding, clinical examination will search for a sub-cutaneous emphysema through palpation of the abdomen and thorax up to the greater supraclavicular fossa. In such a case, imaging studies (contrast upper gastrointestinal study or CT tomodensitometry) will enable ensuring the absence of perforation and/or mediastinal injury. At any doubt, a thoraco-abdominal scan will be performed as a matter of priority.
Perforation risk is higher during dilatation of an achalasia, and a 24-h post-procedure hospital stay is recommended by some experts. Food (liquid followed by semi-liquid followed by normal diet) will be progressively taken during the same night or on the next day. Relapse of the stenosis after dilatation is often observed in children. It depends on the type of stenosis but also on the persistence of acid reflux which will systematically be prevented with proton pump inhibitors. Several techniques, not commonly used in children, are available to avoid relapse of stenosis after dilatation: insertion of an oesophageal covered stent, infiltration of corticoids or packing with mitomycin C . The aim of topical treatment with drugs is to avoid the occurrence of fibrosis and relapse of the stenosis. Their feasibility and efficacy are under study.
Usefulness of temporary or extractable prostheses
Short term clinical improvement is obtained in close to 100% of cases.
Long-term results seem to be better for peptic stenoses compared to radiotherapy-induced or caustic stenoses. However, a better long-term result is obtained in more than half of cases with successive dilatation sessions.
In some cases, a rapid symptomatic relapse and relapse of the stenosis would lead to the insertion of an extractable endoprosthesis. Several prostheses (generally completely covered on both surfaces) are presently available as refundable for benign stenoses (Polyflex, HV-Stent, Niti-S and HV-stent): their extraction is always possible after a varying time limit (6–12 weeks, not validated) according to the type of prosthesis. The commercialisation of completely covered and biodegradable prostheses would probably be of use in the treatment of difficult cases of stenosis.
Perendoscopic dilatation is now frequently used and is a therapy of choice in benign stenosis of the oesophagus, with good effectiveness and a low complication rate.
Because of easier handling and good effectiveness, the use of through-the-scope hydrostatic balloons is progressively replacing bouginage.
Pneumatic dilatation remains the standard for achalasia and has a higher risk of complication and a lower effectiveness, especially in younger patients.
In the future, new extractible or biodegradable stents will probably improve the management of recurring stenoses.
1 Kozarek RA. Gastrointestinal dilation. In: Tadataka Yamada, ed. Textbook of Gastroenterology. 3rd ed. Philadelphia: JB Lippincott Co; 1999: 2811–2822
2 Lang T, Hummer HP, Behrens R. Balloon dilation is preferable to bouginagenage in children with esophageal atresia. Endoscopy 2001; 33: 329–335
3 Uhlen S, Fayoux P, Michaud L. Mitomycin C as an alternative to stent for conservative management of esophageal strictures in children. J Pediatr Gastroenterol Nutr 2005; 40: 235–6
4 Lew RJ, Kochman M. A review of endoscopic method of esopahgeal dilations. Clin Gastroenterol 2002; 35: 117–126
5 Holm AN, de la Mora Levy JG, Gostout CJ et al. Self-expanding plastic stents in treatment of benign esophageal conditions. Gastrointestinal Endosc 2008; 67: 2025
6 Zerbib F, Thefiot V, Richy F et al. Repeated pneumatic dilations as long term maintenance therapy for esophageal achalasia. Am J Gastroenterol 2006; 101: 692–697
Commission recommandation de la SFED
Service des Maladies de l’Appareil Digestif, CHU Pontchaillou,
F-35033 Rennes Cedex 9, France
Head of project: B. Védrenne
Working group: D. Heresbach1, P Burtin, D. Soudan2
Reading group: B. Napoléon1, F. Devulder2,
1 SFED, 2 SNFCP
This consensus was reached with the participation of the Société Nationale Française de Colo-Proctologie (French national society for colo-proctology) and under supervision of the Board of SFED.
Radiation-induced proctitis results from the irradiation of the pelvic region (prostate cancer, anal epidermoid carcinoma). It may lead to different symptoms (rectal bleeding, false nature’s call). Bleeding associated with telangiectasia may prove to be substantial and lead to significant anaemia. The objective of the endoscopic treatment is to destroy this neovascularisation and thus obtain a quasi-disappearance of the rectal bleeding. On the other hand, there is no evidence that the treatment is efficient against the emission of mucus or incontinence. The reference method is the argon plasma coagulation (APC) treatment. If some other treatments described in literature (coagulation with bipolar electrocoagulation catheter (Bicap) or Nd-YAG laser) have not been sufficiently evaluated to be actually proposed, the local application of formalin represents a conceivable alternative. A total prior coloscopy should always be necessary to eliminate any other causes of bleeding.
Practical modalities for APC treatment
Prior precautions and circumstances for achievement
The existence of moderate haemostatic disorders is not a contraindication, within the limits of an INR > 1.5 and platelets > 50000/mm3. In case of anti-coagulant or anti-platelet treatment, the corresponding SFED recommendations should be followed because APC endoscopic treatment is at high risk for bleeding.
Achievement of an APC may be possible in an ambulatory mode. Anaesthesia is not absolutely necessary. An oral preparation with PEG or dibasic sodium phosphate is recommended. It reduces the risk of a wrong preparation likely to generate an ignition as well as explosion. The patient should be informed of possible complications (cf. infra), particularly pain and secondary bleeding due to a loss of eschar.
The ignition power should be low to allow the creation of an electric arc without contact with the wall. On the ERBE ICC 200 generator, it should be more than 40 watts to allow good triggering of the ignition. It should remain less than 50–60 watts to avoid complications. The precise choice between these two extreme values is guided by the findings during examination. At present, new generators authorise the delivery of modulable electricity. With the VIO 200D-APC (ERBE) generator, electricity may be delivered in three modes: precise, pulse or forced. Treatment of radiation-induced proctitis calls for the precise mode. The level of power in this mode should be as low as possible, while allowing triggering of ignition. It is thus, if possible, necessary to use level 1 among the eight levels proposed. The eight levels correspond to increasing voltages inducing increasing coagulation depths and are depicted on a pictogram of the generator. However, this recommendation of the manufacturer has not been validated through published clinical trials. Also, the new ”MAXIUM” APC generator, manufactured by the Martin company, possesses an ”argon endo” mode that resembles the ”precise” mode of the ERBE VIO 200 D-APC 2 equipment. A power of 30 watts seems sufficient to trigger an efficient ignition with this generator, but the lack of data in literature does not permit the validation and recommendation of this adjustment.
The gas output should be between 0.8 and 1.2 L/min. It can be increased beyond this level if it helps in triggering the arc towards areas that are difficult to access. However, above 1.5 L/min, turbulences result on withdrawal of the catheter and this very often limits the relevance of increasing the output for triggering the ignition. In this case (difficulty of ignition in some poorly accessible areas in spite of a high gas output), the pulse mode may be chosen instead of the precise mode on the new ERBE VIO 200 D-APC generator. It is thus necessary to choose the level 1 voltage among the two levels proposed in this mode, with the lowest power possible and, a priori, at 40 watts.
Two lesion destruction and application modalities are possible: by ”spots” on lesions that are well separated from each other or by ”scanning” in the case of diffuse lesions. In case the wall is fragile, it is necessary to avoid:
contact of the catheter with the wall by following the technical and adjustment advices;
several coagulation repeats on the same point; this would, however, be necessary when bleeding appears in an already treated area;
circumferential treatment, particularly on the lower part of the rectum, which has to be balanced with the abundance and extent of bleeding observed during examination.
It is necessary to avoid too little spread-out spot coagulations that favour bleeding at the periphery of lesions during the procedure. These peripheral bleedings would necessitate a second application close to the first one and run the risk of deep and painful ulcerations or perforation. On the contrary, a coagulation surface that is slightly larger than the telangiectatic area to be treated allows avoidance of bleeding at the periphery of the coagulated area and risks associated with iterative ignitions in the same area.
Regular exsufflations are necessary to avoid rectocolic distension due to the liberation of argon gas and improve tolerance.
The use of a gastroscope and the practice of retrovision allow treating lower lesions that are located close to the anorectal junction: this location may also be treated through direct vision with the help of a handpiece attached to a proctoscope. These very low located lesions have, however, to be treated with great care because it is at this level that the risk for complications is at the maximum. In case of uncontrolled induced bleeding following a second or third ignition of APC focused on the same haemorrhagic lesion, it is possible to perform haemostasis by injecting an adrenalin isotonic saline serum at 1:10 000 dilution.
Rythm and management after an APC
Sessions are to be performed every 4 weeks. The minimum time lag between two sessions is 3 weeks to allow sufficient healing. Prescription of a step 1 analgesic is recommended. Morphinics are sometimes necessary.
Results and Complications [1–5]
They stem from seven series, of which three are prospective, totalling 158 cases:
Success is obtained in 76% to 100% of cases after two to three sessions.
They are rare:
perforations (two cases), the management of which was surgical;
explosions without perforation (two cases);
haemorrhage through emission of eschar, treated with sclerosing injection in case of prolonged bleeding (one case);
microproctitis or stenosis (three cases);
extensive necrosis due to antibiotherapy and analgesic treatment (1 case).
Alternatives to APC treatment
Treatment with formalin (aqueous formaldehyde solution)
It has shown its efficiency in the case of bleeding-induced anaemia within the framework of prospective studies [6–10]. Formalin induces superficial coagulation necrosis, followed by healing. Application, under visual control (anal retractor), of compresses impregnated with formalin (4% dilution) on the haemorrhagic lesions for 1–4 minutes is the most commonly used method. Its tolerance is good on the whole. Only one series  describes continence disorders, the mechanism of which is not univocal (numerical importance of cancers of the irradiated anus and/or prolonged installation of retractors to perform applications). Performance of enema instillations in certain small series and the use of 2% to 3% dilutions seem to give identical results; however, the most severe complications have been described after the enemas . The global efficiency, in published series, ranges from 70% to 100% following an average of 1.5 sessions . In spite of the absence of a randomised prospective study on the treatment of radiation-induced proctitis, there is sufficient argument to consider that the application of formalin is an efficient treatment. It may be proposed as an alternative to APC or in case of failure of the latter. The risk for continence disorders secondary to a prolonged application of anal retractors will weigh in favour of APC in patients with risk of incontinence.
Treatment with sucralfate
Another reported treatment possibility is the twice daily administration of sucralfate enemas (2 g in 20 ml water) for 4–16 weeks. Only one study showing a significant effect has however been published . This simple and cheap treatment necessitates other studies, particularly of long-term follow-ups, so that it may be recommended as first-line intervention.
Coagulation with argon plasma is the standard treatment of post-radiation symptomatic rectal telangiectasia. Local application of formalin may represent an alternative to be chosen on a case-to-case basis. The potential complications of these treatments make an adapted technique necessary.
The key points
Coagulation with argon plasma is the standard treatment of radiation-induced proctitis. It necessitates an oral preparation with PEG or NaP.
It may be performed in an ambulatory mode without general anaesthesia.
The usual adjustment is 50 watts (maximum 60 watts) at an output of 1 L/min (maximum 1.5 litres) on the first-generation ERBE ICC generators. On more recent generators, the precise mode would be used with a minimal power level (level 1 for ERBE or 30 watts for Martin equipment). The minimum time lag between two argon plasma coagulation sessions should be 3 weeks. The alternative treatment is 4% formalin with tamponage via proctoscopy. This alternative should be avoided in patients with risk of incontinence.
1 Canard J-M, Védrenne B. Clinical application of Argon Plasma Coagulation in gastrointestinal endoscopy: has the time come to replace the Laser? Endoscopy 2001; 33: 353–357
2 Canard J-M, Védrenne B, Bors G et al. Résultats à long terme du traitement des rectites radiques hémorragiques par la coagulation au plasma d’argon. Gastoentérol Clin Biol 2003; 27: 455–459
3 Rolachon A, Papillon E, Fournet J. L’électrocoagulation au plasma d’argon est-elle un traitement efficace des malformations vasculaires digestives et des rectites radiques? Gastroentérol Clin Biol 2000; 24: 1205–1210
4 Kaasis M, Oberti F, Burtin P, Boyer J. Argon plasma coagulation for the treatment of hemorrhagic radiation proctitis. Endoscopy 2000; 32: 673–676
5 Postgate A, Saudners B, Jtjandra I, Vargo J. Argon plasma coagulation in chronic radiation proctitis. Endoscopy 2007; 39: 361–365
6 Ismail MA, Qureshi MA. Formalin dab for haemorrhagic radiation proctitis. Ann R Coll Surg Engl 2002; 84: 263–264
7 Luna-Pérez P, Rodríguez-Ramírez SE. Formalin instillation for refractory radiation-induced hemorrhagic proctitis. J Surg Oncol 2002; 80: 41–44
8 de Parades V, Etienney I, Bauer P et al. Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis – an effective but not risk-free procedure: a prospective study of 33 patients. Dis Colon Rectum 2005; 48: 1535–1541
9 Parikh S, Hughes C, Salvati EP et al. Treatment of hemorrhagic radiation proctitis with 4 percent formalin. Dis Colon Rectum 2003; 46: 596–600.
10 Haas E, Bailey HR, Farragher I. Application of 10 percent formaline for treatment of radiation-induced hemorrhagic proctitis. Dis Colon Rectum 2007; 50: 213–217
11 Denton A, Forbes A, Andreyev J, Maher EJ. Non surgical interventions for late radiation proctitis in patients who have received radical radiotherapy to the pelvis. Cochrane Database Syst Rev 2002; CD003455
Dr. Bruno Védrenne
rue Saint Sauveur 1
Head of project: A. Lachaux
Working group: L. Michaud, A. Lachaux, S. Violla, P. Burtin
Reading group: D. Heresbach, R. Laugier
This consensus was reached by the Board of SFED and the GFHGNP
Recommendations made for adult patients are, in principle, applicable to infants and children. Nevertheless, it is necessary to emphasize specificities associated with age and diseases observed in children [1 4].
Performing a gastrointestinal endoscopy in a newborn, infant or child is an invasive procedure that should be carried out ideally by a pediatric gastroenterologist who masters endoscopy or by a gastroenterologist within the scope of a close collaboration with a pediatric team. Management modalities are partly dependent on the operator’s experience and centre technical possibilities. This procedure should be carried out by an experienced operator within a structure assuring safety of the child before, during and after the endoscopy.
Taking into consideration children’s specificities, the GFHGNP and the SFED recommend that the prescription of an endoscopy for a child should be done by a pediatric gastroenterologist who masters endoscopy or by a gastroenterologist within the scope of a close collaboration with a pediatric team [1 4].
As in adults, contra-indications are similar [1 3]. Absolute contra-indications are suspicion of gastrointestinal perforation, recent gastrointestinal surgery and shock state; relative contra-indications are respiratory or cardiac insufficiencies.
In case of orofacial malformation or in poly-disabled patients (spinal, thoracic and abdominal deformity), carrying out an endoscopic examination may become problematic and is open to specific evaluation.
Special precautions need to be taken in case of anticoagulants treatment or haemostasis disorders
Information and consent
It is essential to deliver prior oral and/or written information to parents and, if possible, to the child (in a manner adapted to his/her age) and to obtain parental and if it is possible the child consent.
Key technical issues
The presence of medical and nursing staff with strong technical skills on pediatric endoscopy is required for the management of young children in particular. Also, endoscopy equipment and environment (rooms, beds) should be adapted to the child.
Related to age
Duration of the fasting period before carrying out the examination depends on how old the child is: 4 hours from 0 to 6 months, 6 hours from 6 to 36 months and 8 hours for older children [1,2].
Accidents and incidents are more often observed in newborns and young infants [3,5 6]. In these patients, it is necessary to identify specific risks generally due to the presence of an associated condition (metabolic disease, poly-disability, etc.) and be particularly careful with the fasting tolerance (hypoglycemia), dehydration risks (colonic preparations) and hypothermia. Hypoxia secondary to tracheal compression by the endoscope is possible even in an intubated child; insufflation may be poorly tolerated and may lead to respiratory distress. These two complications justify surveillance of transcutaneous oxygen saturation during pediatric endoscopy.
Biopsies may be at the origin of haematomas formation on the duodenal wall and perforations. Unstable milk teeth increase the risk of inhalation.
Related to equipment
Rooms: A pediatric environment that competes with the quality of the patient management. The room should be adapted to this activity and, in particular, be correctly heated and equipped with resuscitation equipment adapted for any age.
Endoscopes [1,2]: They should be adapted to the weight of the child and, when existing, pediatrics equipment should be preferred. We remind that equipment for adults can often be used and the operator’s experience is one of the main elements that condition the safety and quality of this type of examination. However, the use of large-diameter endoscopes may lead to hypoxia associated with tracheal compression even in an intubated child.
Newborn and premature babies from 1200 g to 3200 g: neonatoscope or nasofiberendoscope (diameter less than 6mm)
Full-term newborn from 3.2 to 25 kg: neonatoscope or paediatric gastroscopes (5–8 mm)
More than 25 kg: neonatoscope, paediatric gastroscope or, failing which, adult gastroscope
Newborns and infants: exploration of the colon with a pediatric gastroscope. Colonoscopes adapted to these age classes do not exist.
From 2 to 12: Use of a pediatric colonoscope (diameter less than 11mm)
After 12: possible use of an adult colonoscope.
Related to sedation or anaesthesia
The use of sedative drugs requires the use of resuscitation equipment and skills, which enables to palliate any secondary effect of these drugs, in particular loss of permeability of upper airways and cardio-respiratory depression.
The most frequent complication to dread when performing an upper endoscopy is the occurrence of a hypoxia with desaturation, sometimes associated with disorders of the cardiac rhythm . Young age, excessive insufflation, use of a large-diameter endoscope, and pharyngeal anesthesia are contributing factors .
Monitoring of vital constants (SaO2, heart and respiration rates, body temperature) before, during and after achievement of endoscopic procedure is absolutely necessary. The monitoring should be reinforced in infants under 6 months .
Ideally, the majority of gastrointestinal endoscopies should be performed under anaesthesia . In fact, the choice of using sedation rather than anaesthesia depends on several factors, namely local organization modalities including the availability of anaesthesia slots, state of the patient, nature of the act, and in particular its duration and its more or less aggressive character.
In case of endoscopy under anaesthesia
In this case, anesthesia is conducted in accordance with regulatory texts and recommendations of societies involved in anesthesia and resuscitation (7). Except in case of emergency, an anesthesia clinic should be carried out at least 48 hours before the procedure. During this clinic, the anesthetist should specify the duration of pre-operative fasting and possible pre-medication. The choice of anesthesia protocol is under the anesthetist responsibility. After the anesthesia, all patients should be transferred to the recovery room before being sent back to their original hospital as soon as the responsible anesthetist considers that their clinical state allows it. Patients who are exempted from this rule are those who are, for whatever reason, directly transferred to the resuscitation room.
In case of endoscopy under sedation
Sedation represents a continuum ranging from light sedation to deep sedation; thus, there is always a risk of involuntarily switch from a ”too light” level of sedation (to perform the act in good conditions) to a deep (too much) loss of consciousness with loss of airway protective reflexes . This type of complication may arise in case of an accidental overadministration of drugs, an unexpected potentiation of drug-induced association, a particular sensitivity of the patient to agents used or an association of these different causes.
In addition, sedation is usually used to obtain the cooperation of the child . More often, children younger than 6 and those presenting psychomotor retardation would necessitate deep sedation to become cooperative, even if they are the most vulnerable to the harm caused by sedating agents on the permeability of airways, respiratory command or protective reflexes .
Because a deep state of sedation, expected or not, may occur in children after the administration of sedative agents, the physicians and paramedical staff in charge of the patient should have adequate skills and equipment to ensure the safety of this procedure and face complications inherent to this type of situations (hypoxemia, etc.). In particular, they must be trained to be able to perform a potential pediatric cardio-pulmonary resuscitation.
The choice of sedatives has always been subject to debate. The most commonly used are hypnotics such as benzodiazepin (e.g. midazolam) or barbiturates (e.g. pentobarbital) as well as other agents from their own pharmacological class (e.g. chloral hydrate, propofol). These agents are however devoid of analgesic effects and this is troublesome in a painful procedure and may thus necessitate the association to an analgesic. However, it is necessary to keep in mind the risk of potential secondary effects, namely respiratory depressors. For simple procedure (gastroscopic diagnosis, for example), some use an equimolar mixture of oxygen-nitrous oxide (Kalinox®), which may be associated with a oro-pharyngeal anesthesia (xylocain spray, etc.) after the age of 2. However, the analgesic potency of EMNO being weaker in infants than in older children, the probability of a failure is higher in younger patients and the rate of complications similar.
The following points must be considered to use sedation before a gastrointestinal endoscopy in children and to have good chance of success in the best conditions of safety:
A full medical checkup before the sedation, including an evaluation of the cardio-pulmonary state and airways (permeability, possible intubation difficulty, etc.).
A fasting period before sedation, adapted to age and possibility of emptying of gastric contents.
Supervision of the sedation by a physician enough trained to perform airways and cardio-pulmonary resuscitation in children.
A qualified medical staff able to ensure cardio-pulmonary monitoring of the child during and after sedation. In case of deep sedation, the staff should not be in charge of other responsibilities and/or activities, outside the collection of vital signs at least every 5 minutes.
Continuous follow-up including monitoring of arterial saturation in oxygen by pulse oximetry during and after the procedure, and if possible, also including measurement of heart and respiratory rates and arterial pressure.
Rooms furnished with resuscitation equipment and immediately available drugs adapted to the age and weight of the child.
Post sedation surveillance of the child, only by pediatric staff, in an adapted room and including a monitoring comparable to the one used during sedation.
Criteria for leaving hospital before returning home, confirming the absence of possible complications associated with the procedure, recovery of cardio-respiratory and neurological functions and the elimination of the effects of administered agents.
A sedation procedure describing the different stages, from pre-sedation evaluation to leaving hospital by specifying, namely, the drug protocol used and follow-up/monitoring implemented.
Examinations achieved without sedation
Upper endoscopy: Very small caliber endoscopes (neonatoscope) should be used to perform a gastroscopy in very young infants (< 6 months) without sedation or after a simple medication (saccharose- or glucose-containing infusion at 10–30%: 2 mL per kg) particularly if the gesture was performed rapidly, for example, for a diagnosis (search for an oesophagitis). This attitude enables skipping the rule imposing a 24-h cardio-respiratory monitoring following anesthesia in infants of less than 6 months (4 months for certain teams).
Rectosigmoidoscopy: It can be performed without sedation, with a premedication or simple sedation based on the use of an equimolar oxygen and nitrous oxide mixture (Kalinox®). Colonoscopy is always performed under general anesthesia.
Related to the disease
Poor tolerance to insufflation and to passage of the endoscope in patients having a pulmonary disease (cystic fibrosis, etc.) may occur.
Identification of possible haemostatic disorders (liver disease, malabsorption, thrombocytopenia, familial coagulopathy) possibly at the origin of parietal hematoma.
Performing biopsies is often necessary to establish a diagnosis. This information should, if possible, be evaluated before starting the endoscopy to avoid an increased duration of the examination and so to impose an optimal sedation.
Antibioprophylaxis is recommended in a systematic manner in case of invasive gestures such as percutaneous gastrostomy and in patients at risk of infectious endocarditis. In this case is recommended to follow the SFED  and SFAR  recommendations.
Colon preparation in paediatrics
There is no standardized preparation [1,2,10]. Only a few products have been tested in children and have a pediatric MA (Normacol enfant: MA >3 years; Klean Prep: MA > 3 years). In practice, commonly used are (expert advice):
Rectosigmoidoscopy: Up to 3 years old, enema with isotonic saline serum (5 to 10 cc/kg/enema) with or without polyethylene glycol should be done. Over 3 years old, it is generally performed after rectosigmoidal evacuation with one or several enemas (sodium phosphate).
Ileocoloscopy. Up to 3 years old, enema with isotonic saline serum (5 to 10cc/kg/enema) with or without polyethylene glycol. Over 3 years old, association of adapted dietetics on the days prior to the examination and polyethylene glycol per os 30–40 mL/kg of body weight in 2 hours and twice a day is sometimes sufficient. In case of fecal retention, osmotic laxatives and evacuation enemas are used. A clear liquid diet may also be used for 24 hours followed by 45 ml FLEET® Phospho-soda, administered twice a day on the evening and the morning of the coloscopy.
The achievement of a colonic preparation is generally difficult to perform in a satisfying manner in children and often necessitates a hospital setup sometimes with the help of a naso-gastric probe to administer the laxative solution.
The endoscopic technique
Technical achievement principles and modalities are the same as for adults. The operator’s experience is one of the main points that condition the quality of this kind of examination.
In infants and newborns, the mucosa is fragile and insufflation may be poorly tolerated.
The main indications
Upper endoscopy: In emergency and semi-emergency situations.
Gastrointestinal bleeding, most particularly in case of active or recurrent bleeding. It should be performed within the first 24 hours and enable diagnosis of a lesion in more than 80% of cases (peptic oesophagitis, gastritis, gastro-duodenal ulcer, oesophageal varice rupture, Mallory-Weiss syndrome).
Removal of blocked or pointed foreign bodies in the oesophagus (cf. SFED and GFHGNP sheet)
Ingestion of caustic products. In this situation, endoscopy should not be performed too early (< 6 hours) but not later than 24 hours (cf. SFED and GFHGNP notices) .
More often, it concerns programmed evaluations in case of:
Malabsorption: Duodenal biopsies to search for villous atrophy lesions for the diagnosis of celiac disease or for an enzymatic trial (carbohydrate intolerance).
Inflammatory bowel disease (IBD) of the digestive tract (Crohn’s disease and ulcerative colitis).
Upper abdominal pain and/or dyspeptic disorders to search for an organic disease: eosinophilic or peptic oesophagitis, gastroduodenal ulcer or Helicobacter pylori-induced gastritis.
Persistent vomiting: Search for a gastritis, ulcer, anti-pyloric or duodenal obstruction, etc.
monitoring of patients with: Barrett oesophagus, peptic oesophagitis, portal hypertension, etc.
In case of refusal of food, unexplained malaises of the newborn and infant (peptic oesophagitis?) and unexplained iron deficiency anemia, an endoscopy may be justified in limited indications.
Lower endoscopy: in children the search for an IBD and evaluation of rectal bleeding are the main indications.
Interventional endoscopy: In current practice, indications are limited
Extraction of foreign bodies (see GFHGNP and SFED common notice)
Endoscopic percutaneous gastrostomy (see GFHGNP and SFED common notice)
Endoscopic polypectomy (same modalities as for adults)
Except in emergency situations, other procedures should not be managed outside reference centre that are used to perform these examinations in children or adults. It particularly this concerns the endoscopic management of gastrointestinal bleeding, oesophageal stenosis, portal hypertension (sclerosis of oesophageal varices and banding) and indications of ultrasonography and ERCP.
1 Winter HS, Murphy S, Mougenot JF, Cadranel S. Pediatric Gastrointestinal Endoscopy: textbook and atlas. 1 st ed. Lewiston, NY: BC Decker Inc.; 2006
2 ASGE standards of practice committee, Lee KK, Anderson MA, Baron TH et al. Modifications in endoscopic practice for pediatric patients. Gastrointest Endosc 2008; 67: 1–9
3 Committee on Drugs. American Academy of Pediatrics. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: addendum. Pediatrics 2002; 110: 836–838
4 Mougenot JF, Faure C, Olives JP et al. Recommendations of the French Speaking Pediatric Hepatology, Gastroenterology and Nutrition Group. Current indications for digestive system endoscopy in children. Arch Pediatr 2002; 9: 942–944
5 Ament ME. Prospective study of risks of complication in 6,424 procedures in pediatric gastroenterology. Pediatr Res 1981; 15: 524 [Abstract]
6 Gilger MA, Jeiven SD, Barrish JO, McCarrol LR. Oxygen desaturation and cardiac arrhythmias in children during esophagogastroduodenoscopy using conscious sedation. Gastrointest Endosc 1993; 39: 392–395
8 Michaud L. Francophone Pediatric Hepatology, Gastroenterology, and Nutrition Group. Sedation for diagnostic upper gastrointestinal endoscopy: a survey of the Francophone Pediatric Hepatology, Gastroenterology, and Nutrition Group. Endoscopy 2005; 37: 167–170
10 Wexner SD, Beck DE, Baron TH et al. A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Gastrointest Endosc 2006; 63: 894–909
11 Barbi E, Petaros P, Badina L et al. Deep sedation with propofol for upper gastrointestinal endoscopy in children, administered by specially trained pediatricians: a prospective case series with emphasis on side effects. Endoscopy 2006; 38: 368–375
Service de Gastroentérologie, Hépatologie et Nutrition pédiatriques
Hôpital Femme Mère Enfant du CHU de Lyon
59, boulevard Pinel, 69677 Bron Cedex
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