What Is Known
- There is limited literature on duodenitis in children.
- Previous studies reporting duodenitis in children have small sample size.
- Duodenitis occurs in children with celiac disease and inflammatory bowel disease.
What Is New
- Prevalence of duodenitis in children undergoing endoscopy is 12.7%.
- There is a poor correlation of endoscopic appearance with histology in children with duodenitis.
- Gastritis is a frequent occurrence in children with duodenitis.
Upper gastrointestinal tract endoscopies are commonly performed in children for the evaluation of gastrointestinal symptoms. The procedure often includes obtaining biopsies from the esophagus, stomach, and duodenum. Common histopathological findings seen in children include esophagitis, gastritis, and duodenitis.
Gastritis and esophagitis have been well studied in children because they are more common than duodenitis. Previous studies have described different types of gastritis with specific etiology and clinicopathological features (1). There is also abundant literature on esophagitis, particularly reflux and eosinophilic esophagitis (2); however, there is limited literature regarding duodenitis in the pediatric population. We aimed to assess the prevalence, etiology, clinical, endoscopic, and pathological features in a large cohort of children with duodenitis.
At Yale-New Haven Children's Hospital, pediatric gastroenterologists perform all the upper gastrointestinal endoscopies in children. At all of the endoscopies, multiple mucosal biopsies from the esophagus, stomach, and duodenum are obtained routinely. The biopsies are reviewed either by a pediatric pathologist with expertise in gastrointestinal pathology or by a gastrointestinal pathologist. The diagnosis of duodenitis is based on the presence of neutrophilic infiltrate for acute/active duodenitis, or chronic changes inclusive of villous/crypt architecture changes or excess of either intraepithelial lymphocytes or mixed cell infiltration in the lamina propria (3). Gastritis is diagnosed by the presence of mixed inflammatory infiltrate, and esophagitis is diagnosed by the presences of eosinophils.
For this study, we retrieved the pathology reports of all the upper endoscopies performed in our institution during 5 years from January 2008 to December 2012. These reports were reviewed to identify children with duodenitis. The presence of associated gastritis and esophagitis was noted and compared between children with and without duodenitis. For cases with a diagnosis of duodenitis, all microscopic sections were retrieved and reviewed by 2 pediatric pathologists (S.H. and R.A.M.), and the diagnosis of duodenitis was confirmed in all.
We reviewed the medical charts of all of the patients with duodenitis and collected demographic, clinical, and laboratory data. The procedure reports were reviewed to assess the presence of endoscopic findings such as erythema, edema, erosions, ulcers, or any inflammatory changes. Etiology of duodenitis was correlated with the patient's clinical diagnosis. The diagnosis of inflammatory bowel disease (IBD) such as Crohn disease or ulcerative colitis was based on clinical, radiological, endoscopic, and pathological findings (including concurrent or preexisting biopsies of the lower gastrointestinal tract). The diagnosis of celiac disease was based on the presence of typical duodenal pathological features and positive celiac serology. The diagnosis of Helicobacter pylori infection was based on positive identification of the bacteria either on routine stains or immunostain of gastric biopsies. We also reviewed charts of children without duodenitis to assess common indications for endoscopy and diagnoses to compare with those in children with duodenitis.
Statistical analysis was performed using the χ2 test and the t test. The human investigation committee of Yale University approved this study.
In our institution, 2772 children had 3064 upper gastrointestinal tract endoscopies performed during a 5-year period. Out of 2772 children, 352 children had duodenitis (12.7%). In comparison, gastritis and esophagitis were seen in 48% and 21% of children, respectively. The annual prevalence of duodenitis had increased from 9% in the first year in 2008 to 14% in the fifth year in 2012.
The mean age of patients with duodenitis was 10.6 years (range 0.5–18.8), and 51% were boys. Out of 352 children, 56% were white, 24% were Hispanic, 15% were African-Americans, and 5% were of other racial origin. The common primary indications of endoscopy in children with duodenitis were abdominal pain (38%) and positive celiac serology (32%) (Table 1). In comparison, primary indications for endoscopy in children without duodenitis were abdominal pain (46%) and nausea/vomiting (14%). There was a significant difference in these primary indications for endoscopy in children with and without duodenitis (Table 1).
In 64% of children with duodenitis, we were able to attribute a specific etiology or a diagnosis, whereas in 36% of the cases, no obvious etiology could be identified. The most common etiology was celiac disease (32%), followed by Crohn disease (13%), ulcerative colitis (3%), H pylori infection (6%), and nonsteroidal antiinflammatory medications (3%). Duodenitis in 7% of children was associated with features of functional dyspepsia and functional abdominal pain. Interestingly, there was 1 patient with concomitant ulcerative colitis and celiac disease who has been described before by us as a case report (4). This patient was classified as a celiac disease patient. In comparison, children without duodenitis did not have celiac disease as per diagnostic criteria and had less prevalence of IBD compared with children with duodenitis (10% vs 16%, P < 0.01).
Review of procedure reports of children with duodenitis showed that in 63% of the endoscopies the duodenum appeared macroscopically normal despite the presence of duodenitis on histological examination. In 37% of endoscopies, macroscopic abnormalities such as edema, erythema, erosions, scalloping, or ulcers were evident. Three patients (1%) had duodenal ulcers. Histology showed various changes in duodenal mucosa such as neutrophil infiltrate, cryptitis, villous blunting/atrophy, excess of intraepithelial lymphocyte infiltrate, and mixed cell infiltrate in lamina propria. Duodenal granuloma was observed in 2 patients with Crohn disease.
Table 1 shows the presence of associated esophagitis and gastritis in children with and without duodenitis. Although there was no difference in the prevalence of esophagitis, the prevalence of gastritis was significantly higher in children with duodenitis compared with children without duodenitis (64% vs 46% respectively, P < 0.001).
Given the high prevalence of associated gastritis in children with duodenitis, we subdivided our cohort into 131 children with duodenitis and 221 children with gastroduodenitis. There was no significant difference in clinical symptoms in these 2 groups of children (Table 2). We also compared children with 2 common etiologies (celiac disease and IBD) for the presence of duodenitis and gastroduodenitis. Celiac disease presented almost equally as duodenitis and gastroduodenitis (51% vs 49%, respectively, P = NS); however, in children with IBD, gastroduodenitis was significantly more common than isolated duodenitis (87% vs 13%, respectively, P < 0.001).
We report the prevalence, etiology, clinical, endoscopic, and pathological features of duodenitis in a large cohort of children. Duodenitis has been described as a part of upper gastrointestinal tract lesions in children with IBD (5,6), but there is very limited literature on duodenitis in general unselected group of children. To the best of our knowledge, there are only 2 small pediatric studies on this topic. In 1987, Oderda et al (3) reviewed 320 endoscopies in children and reported 32 children with endoscopic duodenal abnormalities and 4 children with histological evidence of duodenitis (1%). In another study in 1998, Long et al (7) correlated radiological findings with endoscopic and pathological findings in 24 children with duodenitis and 51 healthy control subjects. In our study, the prevalence of duodenitis was 12.7% in children undergoing endoscopy. This increase in prevalence compared with the previous older study (3) could be because of multiple factors such as routine performance of endoscopies and rising incidence and recognition of celiac disease and IBD.
In our study, children with duodenitis were more likely to have positive celiac serology as indication for endoscopy and less likely to have abdominal pain, nausea, and vomiting compared with children without duodenitis. We could identify a specific diagnosis related to duodenitis in 64% of children. As expected, celiac disease and Crohn disease were the leading causes in our patients. A large number of children (36%) had nonspecific duodenitis. This finding is similar to the high percentage of nonspecific duodenitis (60%) that is reported in adults (8). Our study shows that children with duodenitis are more likely to have gastritis (64%) than esophagitis (22%). The cause of this association may be because of underlying causes of duodenitis such as celiac disease, IBD, H pylori, and NSAID ingestion, which are more likely to cause gastritis than esophagitis. We also observed that children with IBD are more likely to have gastroduodenitis than children with celiac disease.
Previous studies have shown a poor concordance between endoscopic findings and histological diagnosis of duodenitis in children. Long et al (7) reported 54% sensitivity of predicting histological duodenitis with endoscopic examination of the duodenum in 24 children. Our data shows an even lower sensitivity of 37%, highlighting the need for obtaining routine duodenal biopsies from normal-appearing duodenal mucosa. We observed a spectrum of histological features such as inflammatory infiltrate, granulomas, architecture changes involving villi, and crypts in our patients.
Duodenitis as a part of upper gastrointestinal involvement has been reported in 31% to 33% of children with Crohn disease and 3% to 23% in children with ulcerative colitis (5,6). Our group looked at our pathology database of 7 years and identified 421 children with duodenitis in our institution (9). We compared histopathological features of 50 children with duodenitis and IBD with those of 168 children with nonspecific duodenitis and celiac disease. We observed a significant overlap in duodenal histological features because of different etiology but a higher frequency of cryptitis in children with IBD (9).
Major limitation of this study is its retrospective nature. Although diagnosis of duodenitis was confirmed in all, diagnosis of gastritis and esophagitis was based on pathology reports. To the best of our knowledge, however, this is the first study describing prevalence, etiology, and clinical features in a large group of unselected children with duodenitis. We also report an interesting association of gastritis with duodenitis in children and a poor correlation of endoscopic appearance with histology for duodenitis.
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