A young child who presents with fatigue and anemia may have a nonemergent problem, or may require an expensive, multispecialty, multi-imaging evaluation. One of the most challenging problems to evaluate is an occult gastrointestinal bleed (GIB). Visualizing the entire small bowel is often crucial in diagnosing a cause for occult GIB.
Two techniques to visualize the small bowel include push enteroscopy and double balloon enteroscopy (DBE). Push enteroscopy visualizes only a part of the proximal small intestine and may have a higher risk of perforation (1). DBE uses an overtube that does not have a small caliber designed for young children (2). DBE may not visualize the entire small intestine even when used via both anterograde and retrograde routes (2). The previous 2 techniques are still fairly novel methods in the young pediatric patient.
A third technique to visualize the small bowel is video capsule endoscopy (VCE). The focus of this report is using VCE in a young child. VCE was approved by the Food and Drug Administration in 2003 for pediatric patients ages 10 years and older (3). VCE uses the use of Given Imaging's PillCam Small Bowel capsule (Given Imaging, Yoknaem, Israel), which is 26-mm long, 11-mm wide, weighs 3.4 g, records images at a rate of 2 frames per second (fps), and has a battery life of about 8 hours (4). VCE has been used extensively since 2001 in adults for evaluating GIB, inflammatory bowel disease, polyposis, and gastrointestinal neoplasms.
VCE has thus far been well-tolerated in pediatric patients in diagnosing telangiectasias (5), polyps (6), inflammatory bowel disease (1), and hemangioma (7). In this report, VCE was used successfully to diagnose the cause of obscure GIB in a 22-month-old.
An African American female presented initially at 21 months of age with microcytic, normochromic anemia. She did not have hematemesis, epistaxis, bruising, rashes, cutaneous hemangiomas, abdominal pain, or weight loss. There were no bleeding disorders in the family history, although the mother had anemia that required iron supplementation. The patient's hemoglobin ranged from 6 to 9.4 g/dL on oral iron supplementation and 1 packed red blood cell transfusion.
Evaluation included a normal coagulation panel, and a normal Meckel scan. After the patient had 1 episode of passing bloody clots in her diaper, she was referred to a gastroenterologist for a colonoscopy and upper endoscopy. The upper endoscopy to the distal duodenum and the colonoscopy to the cecum were normal, including biopsies of the colon, duodenum, stomach, and esophagus.
Nine months after the initial presentation, the patient began having dark black stools and presented to the emergency department. Her hemoglobin was 3.9 g/dL with a reticulocyte count of 12.4% and platelets were 284,000 K/mm (4). A Meckel scan and upper endoscopy and colonoscopy were repeated at this time and were a negative for an obvious bleeding source. A CT scan with oral and intravenous contrast was also done and was normal. VCE was also performed at the time of repeat endoscopy. An Olympus GIF-160 endoscope was used and advanced into the stomach and the capsule was advanced into the duodenum and released using the advanced capsule endoscope delivery device AdvanCE (US Endoscopy, Mentor, OH). The small bowel transit time was 224 minutes and the capsule was evacuated within 48 hours. There were no complications. The video capsule identified a single hemangiomatous lesion in the mid-small bowel (Fig. 1).
The finding led to an exploratory laparoscopy combined with intraluminal enteroscopy, with localization of the lesion in the small intestine. Segmental bowel resection with primary anastomosis was performed. The lesion was identified as a 3.5-cm hemangioma (Fig. 2). Within 3 months of surgery, the patient's hemoglobin and mean corpuscular volume (MCV) normalized. There have been no further episodes of GIB in the 1 year since resection of the lesion (Fig. 2).
VCE has been used since its approval in 2001 in adults mostly for evaluation of inflammatory bowel disease, lymphomas, and polyp syndromes. The video capsule is a noninvasive way of examining the entire small bowel mucosa. A study of 97 adult patients by van Tuyl et al (8) published in 2007 showed that in cases of occult gastrointestinal bleeding, VCE led to a definitive diagnosis in 26% and a probable diagnosis in 41%, leading to a change in management in 31%. In the same study (8), VCE used for overt bleeding gave a definitive diagnosis in 71% and led to change in management in 62%. A study published by Lewis and Swain (4) in 2002 included 20 adult patients with occult GIB who underwent VCE. VCE visualized bleeding sites in 55% patients (4). The average transit time through the small intestine was 257 minutes (4).
Limitations with VCE have been studied by Rondonotti et al (9) in 2005 in a retrospective study of 733 adult patients. Limitations include gaps in the recording, failure to download VCE recordings, short duration of capsule batteries <6 hours, difficulty in swallowing the capsule, and failure to reach the ileocecal valve. The limitations prevented or hampered finding the diagnosis in 2.9% and occurred in the initial phase of VCE use (9). Preschool- and kindergarten-age children who have swallowed coins, ranging from pennies to quarters and thus larger in diameter than the PillCam, have been able to pass the coins beyond the esophagus (1). Ingested coins may become impacted, but only 1% will require surgery (10). As long as these children are asymptomatic, we generally observe them and await passage. In another study, capsule retention occurred in 0.01%, especially in adult patients with Crohn disease, nonsteroidal anti-inflammatory drug-induced lesions, and radiation therapy (11). If there is a concern for capsule retention, a patency capsule may be used. In the study by Herrerias et al (12) of 106 adult patients, the rate of retention mentioned was between 0% and 13%. In the study it was mentioned that performing small bowel follow-through studies and receiving normal results did not rule out strictures. Performing small bowel follow-through exposes the patient to radiation and may not be as accurate as a patency capsule in detecting small bowel narrowing. As technology improves, there should be fewer problems with recording gaps and downloading recordings from the capsule. In a case report by Kavin et al (7), the capsule took just over 2 hours to enter the cecum from the duodenum. In our case report, the small intestine transit time took 3 hours and 44 minutes, well below the 6 to 8 hour average battery life.
Currently, Food and Drug Administration approval for use of VCE is for children 10 years and older. There have been relatively few cases when this technology has been used on children younger than 10 years. Seidman et al (1) evaluated obscure small bowel disorders in a 5-year-old, Holden et al (13) evaluated a 3-year-old for occult GIB and an 8-year-old for Crohn disease, Kavin et al (7) diagnosed a hemangiomatosis in a 2.5-year-old, and in Italy, de'Angelis et al (14), evaluated small bowel disease in an 18-month-old. Our case report documents one of the youngest children to have successfully undergone VCE in the United States.
Small children have to undergo general anesthesia or deep sedation to use VCE because they are usually unable to swallow the pill. To decrease the risk of capsule retention, care should be taken in obtaining a history of problems with delayed gastric emptying, small bowel obstruction secondary to previous surgical changes, pyloric stenosis, Crohn disease, or Meckel diverticulum. VCE is more sensitive than esophagogastroduodenoscopy (1) in detecting small bowel pathology and may help tremendously in evaluating causes of obscure gastrointestinal bleeding, small bowel inflammation, and abdominal pain. In a noninvasive manner, the entire small bowel can be visualized. This case suggests that children as young as 22 months old may be able to safely undergo this useful diagnostic test. In some cases, including this one, VCE is the only method by which to make a definitive diagnosis, thereby saving the patient from the additional morbidity associated with hospitalization, transfusion, and additional invasive procedures.
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