Upper gastrointestinal endoscopy (UGIE) is useful in many situations in adults and children (1,2). During the past few years, learned societies have worked on criteria for selecting patients most likely to benefit from UGIE (3). Official recommendations about the appropriate use of UGIE in adults have been published in the United States (4) and the United Kingdom (5). Although few studies have compared the efficiency of UGIE versus other investigations in pediatric patients, recommendations were issued in 1996 by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) (6). In 2001 the Groupe Francophone d'Hépatologie Gastroentérologie et Nutrition Pédiatriques (GFHGNP) issued recommendations adapted to geographic factors (7). The GFHGNP recommendations distinguish between situations in which UGIE is “usually not appropriate,” such as in uncomplicated gastroesophageal reflux, diagnosis of pyloric stenosis, or functional abdominal pain, and those in which UGIE is “usually appropriate,” such as in cases of upper intestinal bleeding, caustic ingestion, or dysphagia, thus giving physicians latitude to decide on a case-by-case basis when UGIE is needed.
The main objective of the present study was to evaluate the appropriateness of UGIE performed in pediatric patients in a teaching hospital in France. Appropriateness was defined as compliance with GFHGNP recommendations. The secondary objectives were to look for factors potentially associated with inappropriate use of UGIE, to evaluate the overall diagnostic efficiency of UGIE, and to determine whether publication of the GFHGNP recommendations affected practice patterns regarding UGIE use.
PATIENTS AND METHODS
We identified all of the UGIE procedures performed at the Besançon Teaching Hospital in Besançon, France, between January 1, 2001 and June 30, 2003 in children younger than 18 years of age, by 2 senior pediatricians with more than 15 years of experience with pediatric endoscopy each. We excluded UGIE procedures performed by gastroenterologists for adults. In each patient the decision to perform UGIE was made by the family physician or by a hospital-based physician who evaluated symptoms reported by the patients or family. The UGIE procedures were done at 2 centers (Besançon Teaching Hospital and the Franche-Comté Polyclinic); in each patient, the choice of treatment center was based on availability of the endoscopists who worked in the 2 centers. Informed consent was obtained from the parents and from older children.
The UGIE procedures were performed in an endoscopy room (with or without sedation) or in an operating room under general anesthesia. The decision between these 2 modalities was based on patient age, reason for UGIE, and medical history, and also on the fact that the examination was performed on an inpatient or outpatient basis. Sedation, when used, consisted of midazolam intravenously or intrarectally if needed in combination with nalbuphine intravenously. The following endoscopes were used: the Olympus GIF-N-30 fiberoptic scope (Olympus, Hamburg, Germany) with a television set, the Olympus GIF-XP-20 fiberoptic scope with a television set, and the Pentax FG-24X videoendoscope (Pentax Imaging, Golden, CO). Findings were recorded using a 4-point scale to score the severity of esophageal lesions (1, hyperemia; 2, edema or superficial erosion; 3, erosion with hemorrhage; and 4, deep ulcers) and a 2-category grading system to score the severity of gastric and duodenal lesions (moderate or severe). As needed, ≥1 biopsies were performed for histological studies, with stains selected according to the nature of the specimen. Four histopathologists in the 2 centers were involved in the analysis of the biopsy specimens.
The following information was abstracted retrospectively from the endoscopy reports and patient records:
* Age, sex, address, symptoms, treatment center at which UGIE was performed, whether UGIE was on an inpatient or outpatient basis, and whether sedation or general anesthesia was given
* UGIE findings, number of biopsies, and histological findings
* Name of the endoscopist and final diagnosis based on the clinical, endoscopic, and histological data
Home residency of the child was used to calculate the distance from home to hospital using Mappy software (Mappy, Paris) (8). Based on the symptoms, the UGIEs were categorized as appropriate if GFHGNP criteria were met and as inappropriate if not. Regarding diagnostic efficiency, UGIE procedures were categorized as contributive or noncontributive.
The UGIE procedures were considered contributive if they had a direct impact on treatment (ie, gross abnormalities, clinically relevant biopsy findings such as celiac disease, and interventional endoscopies). The UGIE procedures were considered noncontributive if their findings were normal or showed abnormalities that did not affect the treatment (eg, incompetent lower esophageal sphincter, healed ulcer, histological abnormalities from macroscopically normal areas such as histological gastritis or esophagitis). To evaluate the effect of the GFHGNP recommendations on practices, we compared 2 periods: before and after September 30, 2002, when the recommendations were published in the Archives Françaises de Pédiatrie (7).
To look for an association between appropriateness of UGIE and diagnostic efficiency, we used the χ2 test. Variables associated with inappropriate use of UGIE were identified using univariate analysis (χ2 test) followed by backward variable selection for inclusion in a multivariate logistic regression model. P > 0.05 were considered statistically significant. Statistical analysis was performed with SAS software (version 8.2; SAS, Cary, NC).
During the study period, 301 UGIE procedures were performed in 258 patients. We excluded 8 UGIE procedures in 7 patients because of unavailable data. Thus, the present study was based on 293 UGIE procedures in 251 patients (Table 1) with a mean age of 2 years (range, 2 days–17 years) at the time of the UGIE. The mean home-to-hospital distance was 39 km (range, 2–149 km). The most common indication of fibroscopy was failure to thrive, which was noted in 89 patients (30%). Table 2 lists all of the reported symptoms.
Of the 293 UGIE procedures, 52 (18%) were inappropriate according to the GFHGNP recommendations. The most common reasons for UGIE in this patient subset were excessive crying in infants or isolated failure to thrive (Table 3). Of the 241 appropriate UGIE procedures, 122 (51%) were contributive, compared with only 9 (17.3%) of the 52 inappropriate UGIE procedures. This difference was statistically significant, with an odds ratio (OR) of 4.2 and a 95% CI of 2–8.7 (P < 10−3). In contrast, the proportion of inappropriate UGIE procedures was similar for the 2 endoscopists, and the distance from home to hospital did not influence the likelihood of undergoing an inappropriate UGIE (Table 4). In the multivariate analysis (Table 5) the only factor significantly associated with inappropriate UGIE was outpatient status (OR, 2.51; 95% CI, 1.24–5.08; P = 0.01). The proportion of inappropriate UGIE procedures was similar before and after publication of the GFHGNP guidelines (19% and 15%, respectively; OR, 1.31; 95% CI, 0.67–2.63; P = 0.41).
Of the 52 inappropriate UGIEs, 9 provided clinically relevant information, showing ulcerative esophagitis in 1 patient, hemorrhagic esophagitis in 4 patients, duodenitis in 1 patient, and malabsorption in 3 patients due in one case to cow's milk allergy and in 2 cases to fully documented celiac disease.
Since the introduction of endoscopy as a diagnostic investigation and subsequently as a therapeutic tool, millions of endoscopy procedures have been performed in adults and children throughout the world. Endoscopy is technically demanding in pediatric patients, and regular practice is crucial to acquiring the necessary level of expertise (9). In addition, current procedures for disinfecting endoscopy material are burdensome (10). Finally, endoscopy in pediatric patients requires optimal sedation, which can induce adverse effects (11–15).
To date, the degree of compliance with official recommendations for pediatric UGIE has not been determined. Evaluating practice patterns is a crucial step toward optimizing quality of care. Therefore, we conducted the present retrospective study in a medium-sized teaching hospital that is the referral center for the Franche-Comté region of eastern France. This region is 1 of the 52 regions of France and has a population of approximately 1 million.
We used a retrospective design because our objectives were to study everyday clinical practice and to compare the periods before and after publication of the GFHGNP recommendations. Of the 258 patients who underwent UGIE during the study period, only 7 patients were excluded because of missing data.
A potential source of error inherent in the retrospective design of our study is that some of the patients included may have had symptoms that were not recorded in the medical charts.
To improve the uniformity of our patient population, we included only patients whose UGIE procedure was performed by a pediatrician. In our hospital, recruitment differences exist between endoscopies in children performed by pediatricians and those performed by gastroenterologists in adults.
The overall diagnostic efficiency rate in our study was 45%. This seems acceptable when we compare it with what is found in series in adults (16–19). Because the identification of histological gastritis or esophagitis without gross abnormalities has no impact on treatment (15), UGIE procedures showing these findings were classified as noncontributive in our study.
The 17.7% rate of inappropriate UGIE may seem fairly high but is in line with the results of studies evaluating UGIE in adults (16–19). Reasons for inappropriate UGIEs fell into 3 main categories, as outlined in the forthcoming sections.
Follow-up After Neonatal Esophagogastroduodenitis
The pathophysiology and management of neonatal esophagogastroduodenitis (NNOGD) remain actively debated. In addition, the need for UGIE as part of the initial workup in babies with suggestive symptoms has been challenged. In the few series published to date, a full recovery was achieved in nearly all of the patients, including those with extremely severe lesions (20–23). Follow-up UGIE was done in 7 of 13 patients with NNOGD during this study period. Findings were normal in 6 patients and showed moderate esophagitis in 1 patient after H2-antagonist therapy.
Failure to Thrive
A gradual decrease or sudden dropoff in weight gain is common in pediatric patients, most notably those ages 1 to 2 years (24). This condition was present in 30% of our patients. Possible gastrointestinal causes are celiac disease or food allergies. When a gastrointestinal cause is suspected, UGIE may be performed with the goal of obtaining a biopsy specimen of the duodenal mucosa (1,25). However, the GFHGNP recommendations leave a considerable degree of latitude regarding the clinical and laboratory test abnormalities that should lead to a duodenal biopsy (7).
It is unclear whether failure to thrive without a clinical or laboratory test showing evidence of malabsorption and no other associate diseases requires a duodenal biopsy as part of the first-line workup. We included this presentation among the inappropriate reasons for the performance of UGIE. Of the 20 patients who had isolated poor weight gain and who underwent UGIE to obtain a duodenal biopsy specimen, 17 had normal results. The biopsy ensured the diagnosis of celiac disease in 2 patients and cow's milk allergy in 1 patient; however, none of these 3 patients had had appropriate laboratory tests before UGIE was performed.
Frequent crying is a common symptom in infants but more often denotes a functional disorder than an organic disease. Colic is by far the most common gastrointestinal cause, but it is sometimes misleading, with esophagitis often occurring as a complication of gastroesophageal reflux (26–32). The management of an infant with colic is often awkward because no adequately effective treatments are available (33) and the parents often respond to the crying with a high level of anxiety. This explains why UGIE is sometimes prescribed to support the physician's diagnosis and to reassure the parents. Our findings indicate that excessive crying without other symptoms fails to predict the presence of upper gastrointestinal lesions. In contrast, excessive crying with spitting up after feedings, vomiting, dysphagia, and poor weight gain may indicate esophagitis.
The only factor significantly associated with inappropriate UGIE performance in our study was outpatient status. Hospital-based physicians may be more likely to comply with recommendations than may office-based physicians. Alternatively, admitted patients may represent a selected patient subset with greater disease severity and more extensive investigations before UGIE compared with the outpatient population.
Most of the physicians who ordered UGIE in outpatients were pediatricians working in office practice or community hospitals. The proportion of general practitioners was extremely low, suggesting that general practitioners rarely prescribe UGIE in children or may tend to refer their pediatric patients to nonpediatric endoscopists.
We found no difference in the proportion of inappropriate UGIE procedures before and after the publication of the GFHGNP recommendations (7). However, this finding may be ascribable to the short duration of the second period (10 months) because the impact of recommendations on practices may take more time to develop.
We found that approximately 1 in 6 UGIE procedures was inappropriate according to GFHGNP recommendations (7). Only 9 Of 52 inappropriate endoscopies provided useful diagnosis, suggesting the usefulness of these guidelines despite no previous validated study. Inappropriate use of UGIE was more common among family physicians than among hospital-based physicians. Our data suggest that endoscopists may need to appraise the appropriateness of prescriptions for UGIE to target their efforts toward those patients most likely to benefit, avoiding underutilization of UGIE and unnecessary exposure of patients to the non-negligible adverse effects of UGIE. Constraints associated with sedation and anesthesia will probably have a major impact on the use of UGIE in the future.
The authors thank GALLIA Laboratories and the Association des Juniors en Pédiatrie for their support in this work.
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