Predictors of positive esophagogastroduodenoscopy outcomes in children and adolescents: a single center experience

Since its inception in the 1960s, the field of pediatric gastroenterology has experienced rapid growth. Pediatric gastroenterology is now an American Board of Pediatrics certified subspecialty that emerged from earlier training of pediatricians in adult gastroenterology units and an increased recognition of gastrointestinal disorders that are unique to children. Over the past 30 years, the number of pediatric gastroenterologists has greatly increased. While there used to be only a few specialists based out of select centers around the world, pediatric gastroenterology is now an ever-growing specialty with approximately one pediatric gastroenterologist per 100,000 children in the United States [1]. With the development of a subspecialty focused on the disorders of the pediatric gastrointestinal tract, new technologies were also developed to aid in diagnoses such as pediatric esophagogastroduodenoscopy (EGD). Pediatric EGD was first introduced in the 1970s [2]. Over the past 30 years, pediatric EGD has evolved from an infrequent procedure performed in the operating room with a monocular viewing of the intestinal lining to a routine outpatient procedure that makes use of intravenous sedation and large viewing screens.

With the increase usage of pediatric EGD procedures the incidence of diseases that require EGD for diagnosis in children has also increased. Franciosi et al. showed that the characteristics of children undergoing EGD, as well as endoscopy practices, changed in the 20-year period from 1985 to 2005 [3]. During this time, there was a 12-fold increase in the number of first-time EGDs performed. This may have also led to an increase in disease incidence rates. An increase of disease rates, however, may instead reflect increasing rates of disease diagnosis rather than a true rise of disease occurrence. The inclusion of children with less severe clinical presentations and the collection of greater numbers of biopsies per procedure might have played a role in increasing rates of disease diagnosis. During this 20-year interval, the number of patients referred for EGD because of gastrointestinal bleeding decreased from 34 to 5%, while the number of patients with abdominal pain increased from 23 to 43%. Additionally, the rate of complete EGD (in which biopsies were taken from the esophagus, stomach, and duodenum) increased from 18% in 1985 to 95% in 2005.

Studies report positive findings in more than 50% of endoscopies performed in children [4–11]. The complication rates associated with these procedures are 1.3% for EGD and less than 1% for colonoscopy [12–18]. These procedures, however, are invasive in that they require intravenous sedation or general anesthesia. Concerns for neurobehavioral disorders and abnormalities in brain function caused by environmental chemical exposure during early brain development have recently been extended to anesthetics and sedatives, which are administered to millions of young children worldwide [19]. They are also associated with significant anxiety for both the patient and the patient’s family [20–23]. Given the invasiveness and anxiety associated with EGD, predictors that could accurately identify children with diseases otherwise only diagnosable by EGD would be useful; however, there is little existing knowledge of such predictors. Thus, the objective of the present study was to identify which predictors could accurately determine the outcomes of diagnostic EGD performed in children and adolescents without known gastrointestinal disease.

The ability to perform diagnostic EGD in adults and children has been one of the defining characteristics of the current era of gastroenterology. It has undoubtedly expanded our understanding of the pathophysiology of common gastrointestinal disorders in children and has been a tremendous tool in the management of patients. As the availability and utility of EGD in the pediatric population has increased over the past three decades, the volume of procedures performed has paralleled that rise. Consequently, decisions regarding the appropriate indications and timing of EGD in children have evolved over time and arguably remain more of an art than a science. More critical review of the use of this tool is needed to maximize efficacy and minimize risk.

This study illustrates the limitations of diagnostic EGD in the workup of many of the most common GI complaints in children. In 55% of cases, there were no EGD abnormalities. The data recorded demonstrated only 30% for histologically confirmed diagnosis in children less than 4 years of age. These findings are similar to those in the few studies reporting EGD outcomes in children and adolescents, and further research is needed to identify patients with the highest risk for treatable etiologies diagnosed by EGD [4–11]. Furthermore, greater discussion is needed to reach a consensus regarding what is an acceptable diagnostic yield for EGD in children and adolescents that takes into account the costs and the risks of the procedure, especially in very young children. Although there will be a wide spectrum of opinions regarding what constitutes an acceptable rate of normal EGD, with greater focus on this issue, quality measures may be established similar to those regarding rates of normal appendectomies in pediatric surgery [27].

In our population of children and adolescents, several clinical characteristics and laboratory variables were found to be independently predictive of positive EGD outcomes, and these predictors differed across the age spectrum. Patients who were older than 12 years of age, African–American race and positive celiac antibodies were significant overall, and these findings are similar to those in the few studies reporting EGD outcomes in children and adolescents; age above 13 years, vomiting, and hypoalbuminemia were significant predictors of positive EGD outcomes [9], and vomiting and duration of symptoms less than 1 year were risk factors for mucosal inflammation in a highly selected group undergoing EGD for symptoms of dyspepsia [28].

Our results are promising and indicate that the clinical utility of predictive factors for positive EGD outcomes merit further exploration. However, we recognize the limitations of a retrospective study. Firstly, the definitions of charted clinical variables and endoscopy findings are not standardized, in that clinician may have a slightly different definition of, for example, diarrhea. This would increase the inconsistency associated with these variables and subsequently increase the sample size required to maintain adequate study power. Secondly, there can be substantial inter-observer variation in identifying mild endoscopic abnormalities such as erythema due to operator experience and the lack of systematic endoscopic assessment. Thirdly, there was no reliable method to control for pre-endoscopy medical treatment, which may have altered the EGD findings, resulting in a discrepancy between a patient’s presenting signs and symptoms and the EGD outcome. Lastly, our database did not identify isolated erythema or other mild abnormalities on EGD. The clinical significance of such findings, similar to isolated mild inflammation on histology, is not clear. Therefore, the inclusion of mild endoscopic abnormalities in the definition of a positive EGD outcome may have resulted in some misclassification of the EGD outcomes.

In conclusion, in our population of children and adolescents, several predictors were found for positive EGD outcomes. Given the low diagnostic yield of EGD in very young children, we believe that an initial noninvasive workup is reasonable to identify a likely diagnosis prior to any endoscopic evaluation. Prospective studies with standardized definitions of the clinical variables and endoscopy outcomes are expected to improve the clinical significance of EGD prediction.