Diagnostic role of upper gastrointestinal endoscopy in pediatric inflammatory bowel disease.
BACKGROUND
Discrimination between ulcerative colitis (UC) and Crohn disease (CD) may be difficult on ileo-colonoscopy alone because of a lack of definitive lesions. Retrospective studies show upper gastrointestinal endoscopy may be helpful in confirming diagnosis in such cases.


OBJECTIVE
To prospectively determine importance of upper gastrointestinal endoscopy in diagnosis of inflammatory bowel disease (IBD) and assess factors predictive of upper gastrointestinal involvement in IBD.


METHODS
All pediatric patients were enrolled prospectively and consecutively over a 2-year period and investigated with an ileo-colonoscopy and barium meal follow-through. Children with procto-sigmoiditis, later confirmed histologically to be typical of UC, were excluded from the study. The remainder underwent upper gastrointestinal endoscopy. The protocol and methodology were determined a priori.


RESULTS
65 children suspected of IBD underwent colonoscopy. Of the total, 11 had recto-sigmoiditis with typical macroscopic appearances of UC; once this was confirmed on histology these patients were excluded from the study. Of the 54 children (males, 31; median age, 11.1 years) remaining, 23 were initially diagnosed with CD on ileo-colonoscopy and 18 (33%) were diagnosed with UC. The diagnosis remained ambiguous in 13 (six colonic, four ileo-colonic, three normal colon) on clinical, radiologic and histologic grounds. Upper GI endoscopy helped to confirm CD in a further 11 (20.4%). Two patients were diagnosed with indeterminate colitis. Upper gastrointestinal inflammation was seen in 29 of 54 (22 CD; 7 UC ). Epigastric and abdominal pain, nausea and vomiting, weight loss and pan-ileocolitis were predictive of upper gastrointestinal involvement (P < 0.05). However, 9 children with upper gastrointestinal involvement were asymptomatic at presentation (31%). Overall upper gastrointestinal tract inflammation was most common in the stomach (67%), followed by the esophagus (54%) and duodenum (22%).


CONCLUSIONS
Upper gastrointestinal tract endoscopy should be part of the first-line investigation in all new cases suspected of IBD. Absence of specific upper gastrointestinal symptoms do not preclude presence of upper gastrointestinal inflammation.
University Department of Paediatric Gastroenterology, Department of Histopathology, Royal Free Hospital, London, UK.
S P
SP
Castellaneta
N A
NA
Afzal
M
M
Greenberg
H
H
Deere
S
S
Davies
S H
SH
Murch
J A
JA
Walker-Smith
M
M
Thomson
Anshu
A
Srivistrava
D000293:Adolescent; D002432:Cecum / Q000473:pathology; D002648:Child; D002675:Child, Preschool; D003093:Colitis, Ulcerative / Q000175:diagnosis* / Q000473:pathology; D003106:Colon / Q000473:pathology*; D003113:Colonoscopy; D003424:Crohn Disease / Q000175:diagnosis* / Q000473:pathology; D003937:Diagnosis, Differential; D004386:Duodenum / Q000473:pathology; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D004947:Esophagus / Q000473:pathology; D005260:Female; D006801:Humans; D007082:Ileum / Q000473:pathology; D007223:Infant; D008297:Male; D011446:Prospective Studies; D012007:Rectum / Q000473:pathology; D013270:Stomach / Q000473:pathology