Upper Gastrointestinal Endoscopy in Sudanese Infants and Children

Background: Upper gastrointestinal endoscopy [UGIE] in children is safe and useful. Pediatric gastrointestinal endoscopy was introduced relatively recently in Sudan. The indications and patterns of endoscopic findings of UGIE in Sudanese children were not reported before. Objectives: Our objective was to identify the indications and findings of UGIE among Sudanese children and to compare that with others’ findings. Patients and methods: The Demographic data of the first 200 children less than 15 years of age who underwent UGIE during January 2005 to December 2007 were retrieved from their files and analysed. Results: Two hundred children had UGIE. Their ages ranged between 6 months and 15 years. 80 and 20 had UGIE because of hematemesis and abdominal pain respectively. 50 children had esophageal varices while peptic ulcer disease was found in 19. 65 out of 100 children who presented with failure to thrive, short stature, and persistent diarrhoea were found to have macroscopic duodenal lesions. 65 duodenal biopsies showed total villous atrophy. H. pylori infection and gastritis were found in 165out of 180 biopsies [91.7%]. Ultrasound abdomen was performed in the 125 children who presented with hematemesis or abdominal pain. 20 out of the 52 who had ultrasonographic abnormalities were found to have cavernous transformation of the portal vein, whereas 10 children had features of liver cirrhosis. Conclusions: The patterns of upper GIT diseases in the study population were comparable to literature. However, H. pylori infection and cavernous transformation of the portal vein were higher than reports from other parts of the world.


Introduction
The safety and usefulness of upper gastrointestinal endoscopy [UGIE] in children were well established.Nevertheless, complications may arise [1][2][3][4] .With the recent advances in technology, endoscopy is becoming an essential component of modern diagnostic and therapeutic modalities in children.The widespread availability of non-invasive monitoring and short-acting sedatives facilitated the procedure.The indications for scoping children are more or less similar to those in adults 5 .However, unlike in adults, failure to thrive, persistent refusal to take food, limitation of usual activities and ingestion of a caustic material and foreign bodies are other common indications for UGIE in children.Sporadic UGIE for children were performed since the introduction of gastrointestinal endoscopy in Sudan in the fifties of last century.However, a dedicated unit for paediatric endoscopy was accomplished only recently.
Data on UGIE in Sudanese children were scanty.To the best of our knowledge there were no published reports concerning the indications or findings of UGIE in children in Sudan.In this paper we retrospectively reviewed the data of the patients who had UGIE in this relatively new unit and compared our findings with reports from other parts of the world.

Objectives
Our objective was to identify the indications and findings of UGIE among Sudanese children and to compare that with international literature.

Patients and methods
This study was conducted at Jafar Ibn Auf Children Hospital, Khartoum, Sudan, which is a tertiary care paediatric hospital and represents the only centre with established paediatric endoscopy unit in the country.The demographic data of the first 200 children less than 15 years of age who underwent UGIE during January 2005 to December 2007 were retrieved from their files and analysed.History, clinical examination, basic investigations and UGIE were reviewed.Endoscopic biopsies were taken when appropriate and ultrasound abdomen was done when indicated.

Pre endoscopic preparation
Informed consents from parents were taken.All children less than six months had preendoscopic fasting for four hours while those below three years of age and older children fasted for six and eight hours respectively according to the guidelines of The American Academy of Pediatrics 6 .
Intravenous midazolam [0.1mg/kg] and/or pethidine [1mg/kg] were given as pre-medication according to the need.All children had nasal oxygen throughout the procedure and were monitored with pulse oximetry.
Olympus paediatric gastroscopes [GIFP3] were used for the procedure.Gastric and small bowel biopsies were examined with light microscopy after staining with Heamatolexin and Gimsa Stain

Results
Two hundred children had UGIE.Sixty were less than two years of age and 140 were between two and fifteen years.Eighty children had gastroscopy because of hematemesis.Some had more than one indication for endoscopy [Table I].Of the 20 children who presented with abdominal pain eight were found to have reflux esophagitis, nine had gastritis, six had duodenitis and DU, and one had normal endoscopic findings.
Mallory Weiss tear was seen in two patients, whereas gastric mass was seen in only one patient.Fifty children had oesophageal varices and peptic ulcer disease was seen in 19 ones.More than one pathology were seen in some children.[Table II].One hundred and eighty biopsies were taken from the stomach and small bowel of the patients.

UGIE in Sudanese Infants and Children, Omayma M S& Gadour M O EH
Sixty-five duodenal biopsies showed total villous atrophy where as 45 had minimal mucosal changes.H. pylori infection was found in 165 [91.7%] of our patients.Table VI compares the prevalence of gastritis, H. pylori and duodenal ulcers in our study with some previous reports.Ultrasound abdomen was performed in the 125 children who presented with hematemesis or abdominal pain.Fifty out of them had splenomegally and eight had hepatomegaly, twenty children had cavernous transformation of the portal vein.Beaded portal vein and signs of periportal fibrosis were seen in five children each, whereas 10 children had frank signs of liver cirrhosis.Seventy-three children showed no abnormality.

Discussion
Video endoscopy in children became well established as a safe and effective procedure for evaluation and management of various abdominal problems in children 11 .In keeping with this, none of our patients had complications related to the procedure and we had good diagnostic yield.Half of the children in this study had UGIE because of failure to thrive, persistent diarrhoea and short stature.This high percentage is not consistent with reports from elsewhere 10 and could be explained by the relatively poor general nutritional status, infections and illiteracy.Nevertheless, a significant proportion of patients in this group proved to have total villous atrophy, which may point to celiac disease as an important cause for failure to thrive and short stature in Sudanese children.
Eighty (40%) patients presented with hematemesis.This is higher than the figures, which were reported by Okello 12 [8.9%]and Ayoola 10 [24%].Fifty of those 80 (63%) patients had oesophageal varices.This was not a surprise because schistosomiasis is endemic in Sudan.Nevertheless, only five patients had ultrsonographic pictures suggestive of per-portal fibrosis.
Cavernous transformation of the portal vein is an uncommon cause of portal hypertension in children.Its aetiology is not well understood and some believe that it is a congenital deformity rather than a transformation 13 .The existence of isolated cavernous transformation of portal vein in 20 out of 52 children who had ultrasonographic changes in this study was rather high.Thorough search failed to reveal any of the predisposing factors for this transformation.This high lights the importance of cavernous transformation/deformity as a common contributor to portal hypertension in children and questions the ranking of periportal fibrosis due to schistosomiasis as the commonest cause of portal hypertension.
Eighty patients (40%) were found to have reflux oesophagitis.The presence of hiatus hernia in fifty children had probably contributed significantly to that.However, we could not find a good explanation for the high [25%] presence of hiatus hernia.
In contrast to other reports, none of the studied population had presented with corrosive ingestion.This could be, in part, due to nonaccessibility to those products or families may not be aware of the existence and usefulness of the endoscopes in such cases.Only one patient had gastric mass and this goes with the rarity of solid upper GIT tumours in children 14 .H. pylori infection and gastritis were strikingly high in the study population.That was not in keeping with reports from UK or KSA 7,10 .However, similar results were seen regarding duodenal ulcer in Saudi Arabia and Greece 8 .The extremely high rate of infection with H. pylori and the associated gastritis in our children [91.7%] are alarming signs as infection at a young age is believed to result in chronic atrophic gastritis and gastric cancer in adult life 15 , which deserve immediate action.The role played by H. pylori infectiondirectly or via its associated diseases-in failure to thrive in this study has to be verified.Only 10% of our patients had UGIE because of abdominal pain.This is in keeping with reports from Uganda but contradicts reports from other parts of the world 12 .

Conclusions
UGIE is emerging as an important and safe diagnostic and therapeutic procedure in the practice of paediatric gastroenterology in Sudan.There is a good correlation between symptoms and endoscopic findings.The histopathology had confirmed the diagnosis in the majority of patients pointing to the good diagnostic yield of UGIE.The patterns of diagnosed upper GIT diseases in our population were comparable to literature despite few differences.However, H. pylori infection and cavernous transformation of the portal vein were higher than reports from other parts of the world.Is cavernous transformation of the portal vein ranks as the commonest cause of portal hypertension in children?This needs especial consideration and further studies.

Table I .
The indications for UGIE in 200 children.

Table II .
The endoscopic findings of the 200 patients.

Table III .
Endoscopic findings in 100 children presented with failure to thrive, short stature, and Persistent diarrhoea

Table IV :
H.pylori and endoscopic findings is our study compared to some other studies