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Year : 2016  |  Volume : 7  |  Issue : 3  |  Page : 104-109

Role of endoscopic ultrasound in pediatric gastrointestinal diseases

Institute of Digestive and Hepatobiliary Sciences, Medanta - The Medicity, Gurgaon, Haryana, India

Date of Web Publication10-Nov-2016

Correspondence Address:
Dr. Rajesh Puri
Institute of Digestive and Hepatobiliary Sciences, Medanta - The Medicity, Sector 38, Gurgaon - 122 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-5042.193738

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Endoscopic ultrasound (EUS) is a well-established diagnostic and therapeutic modality for adults. It is extremely helpful for a broad range of diagnostic indications including upper gastrointestinal (GI) malignancies, submucosal lesions, pancreatic lesions (masses, cystic lesions), chronic pancreatitis, etiological workup of recurrent acute pancreatitis, common bile duct evaluation (calculi versus tumor), gallbladder lesions/microliths, and rectal malignancy; well-established therapeutic roles include fine-needle aspiration of lesions/lymph nodes, pancreatic fluid collection drainage, pancreatic duct drainage, biliary drainage, gallbladder drainage, pelvic abscess drainage, celiac plexus block, or neurolysis. Some recent studies have reported the use of EUS in the pediatric population. EUS is safe and easy to perform in the pediatric population also. However, there is paucity of data on use of EUS in pediatric population. In contrast with its regular therapeutic use in adults, EUS is not commonly performed in children for therapeutic reasons and most of the data are available on diagnostic use only. All of studies have shown that EUS is safe and a useful modality with a positive impact on management in majority of study population. EUS is very useful in pediatric population for the evaluation of upper GI tract submucosal lesions or rectal masses, pancreaticobiliary disorders, characterization of esophageal strictures, and for evaluation of enteric duplication cysts. The advent of miniprobe that can be passed through conventional endoscopes has increased the applicability of EUS in infants and children. Although there are limited data regarding use of EUS in pediatric population, it appears to be a very promising diagnostic and therapeutic tool.

Keywords: Endoscopic ultrasound, gastrointestinal diseases, pediatric patients

How to cite this article:
Singh RR, Choudhary NS, Puri R. Role of endoscopic ultrasound in pediatric gastrointestinal diseases. J Dig Endosc 2016;7:104-9

How to cite this URL:
Singh RR, Choudhary NS, Puri R. Role of endoscopic ultrasound in pediatric gastrointestinal diseases. J Dig Endosc [serial online] 2016 [cited 2019 Jun 26];7:104-9. Available from: http://www.jdeonline.in/text.asp?2016/7/3/104/193738

  Introduction Top

Endoscopic ultrasound (EUS) is an evolving diagnostic and therapeutic modality that allows an accurate imaging of gastrointestinal (GI) tract and its periluminal structures. Since its advent in 1980, there has been progressive expansion of its domain owing to improvement in equipment design, endoscopic techniques, and development of better accessories.[1]

The role of EUS is well-established in adult population. However, it has not been adequately evaluated in pediatric GI and pancreaticobiliary disorders. It may be due to relatively low incidence of pancreaticobiliary and luminal GI cancers, absence of dedicated pediatric echoendoscopes, need for deep sedation or general anesthesia, and challenges of esophageal and duodenal intubation in small children; feasibility of endoscopy in children is shown in [Table 1].[2] Some studies have reported EUS being used for both diagnostic and therapeutic purposes in children, with excellent safety and significant impact on patient management.[3],[4]
Table 1: Feasibility of EUS in children (adapted from American Society for Gastrointestinal Endoscopy, 2012)[2]

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  Indications Top

In children, EUS is most commonly performed for evaluation of pancreatitis (recurrent acute, chronic), suspected choledocholithiasis, benign/malignant lymphadenopathy, benign submucosal lesions, for example, ectopic pancreas, esophageal and duodenal duplication cysts, and pancreatic solid/cystic lesions. The list of indications for EUS in pediatric age group is progressively expanding. It can be divided into pancreaticobiliary and intestinal indications [Table 2]. Impact of EUS in pediatric patients in various studies is shown in [Table 3].[3],[4],[5],[6],[7],[8],[9] Impact on patient management ranges from 35.5% to 98% in various studies.
Table 2: Indications of EUS in pediatric patients

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Table 3: Impact of pediatric EUS on patient management

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  Pancreaticobiliary Disorders Top

EUS has been most extensively studied for pancreaticobiliary indications, in both adults and children. It is the most accurate diagnostic modality for choledocholithiasis, biliary stricture, pancreaticobiliary solid, and cystic mass lesions.[10],[11] EUS-guided fine-needle aspiration (FNA) can be used to obtain tissue/fluid for cytopathological and histopathological examination, thus allowing a definitive diagnosis.[12] Representative images of pediatric EUS are shown in [Figure 1]. EUS also allows a better delineation of pancreatic morphology and its various structural changes due to proximity of probe to pancreatic parenchyma.[13]
Figure 1: (a) Linear endoscopic ultrasound image of mediastinal lymph node, fine-needle aspiration suggestive of chronic granulomatous necrotizing lymphadenitis due to mycobacterial organisms (b) linear endoscopic ultrasound image of posterior mediastinal mass in a 11-year-old girl, fine-needle aspiration suggestive of mesenchymal neoplasm (c) linear endoscopic ultrasound image of abdominal lymph node, fine-needle aspiration suggestive of reactive lymphadenopathy (d) linear endoscopic ultrasound image showing gall bladder microliths in a case of recurrent idiopathic pancreatitis

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A recent retrospective study reported the role of EUS performed for pancreaticobiliary indications in children.[6] The authors performed 52 diagnostic and therapeutic EUS procedures in 48 children, spanning over a period of 14 years and they demonstrated that EUS was technically feasible and safe procedure in children. The study showed a positive impact of EUS in 51 of 52 procedures. A recently published retrospective study from India reemphasized the safety and efficacy of EUS in children;[9] 123 diagnostic and 2 therapeutic EUS procedures were performed in 121 children. The most common indication was pancreaticobiliary (118 procedures in 114 children) followed by mediastinum (n = 5) and stomach (n = 2). EUS diagnosed chronic pancreatitis (n = 21), pseudocysts (n = 3), pancreatic necrosis (n = 1), pancreatic masses (n = 4 including 2 insulinomas), choledocholithiasis (n = 2), choledochal cysts (n = 2), portal biliopathy (n = 1), esophageal leiomyoma (n = 1), gastric varix (n = 1), gastric neuroendocrine tumor (n = 1), GI stromal tumor in stomach (n = 1), and splenic artery pseudoaneurysm (n = 1). EUS-guided FNA cytology was positive in four of seven patients (two had tuberculosis, one pancreatic solid pseudopapillary tumor, and one gastric neuroendocrine tumor). A positive clinical impact was documented in 43 (35.5%) patients with minor adverse events in three patients.[9]

Single session procedures combining EUS with endoscopic retrograde cholangiopancreatography (ERCP) in children with suspected biliary obstruction has been used for both diagnosis and relief of obstruction. It allows both procedures to be performed in same sedation. In a recent study,[6] 9 combined EUS-ERCP were safely performed in 7 children. It also avoided unnecessary ERCP in 13 patients with suspected biliary obstruction due to choledocholithiasis. EUS has much better sensitivity for biliary microlithiasis compared to conventional imaging techniques including computed tomography (CT), magnetic resonance cholangiopancreatography, and hepatobiliary scan.[14]

Pancreatic cystic lesions are incidentally detected in 2.6% of abdominal multidetector CT examinations and 20% of magnetic resonance imaging (MRI) studies[15],[16],[17] and they can be benign, premalignant, or frankly malignant. EUS allows characterization of cystic lesions as well as their drainage [Table 4].[18],[19],[20] EUS-guided cyst fluid aspiration and analysis (cytopathology, fluid carcinoembryonic antigen (CEA), mucin, and amylase levels) help in diagnosis and deciding on optimal management option.[21],[22],[23],[24],[25] A CEA concentration of 192 ng/mL provides 84% specificity in differentiation of mucinous from nonmucinous lesions.[25],[26],[27],[28],[29] Mucinous lesions detected with mucicarmine staining, cysts with high CEA and low-amylase levels are more likely to carry malignant potential.
Table 4: EUS guided pancreatic fluid collection drainage

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EUS can be used for evaluation of pancreaticobiliary malignancies detected by conventional imaging techniques. It allows staging and sampling of lesions and can guide management decisions.[30],[31] EUS-guided FNA has high diagnostic accuracy for solid pancreatic lesions which are often difficult to diagnose by other biopsy methods including CT-guide biopsy. EUS FNA provides a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 84.3%, 97%, 99%, 64%, and 84%, respectively, for solid pancreatic masses which could not be diagnosed by other methods.[32]

The role of EUS in the evaluation and management of complications of portal hypertension, especially gastroesophageal varices are evolving. It can help assess the risk of variceal development, bleeding, efficacy of eradication therapy, and rebleeding risk.[33],[34],[35] EUS has higher sensitivity for detection of gastroesophageal varices compared to esophagogastroduodenoscopy.[36] EUS can predict the risk of variceal bleeding by assessing its cross-sectional area.[33] The diameter of left gastric vein corresponds with variceal size.[37] A rapid hepatofugal flow velocity ≥ 12 cm/s in the left gastric vein detected by color Doppler EUS examination suggests a high risk of an early recurrence of esophageal varices treated with either esophageal band ligation or sclerotherapy.[38] The recently described EUS-guided cyanoacrylate injection with or without coil embolization of varices is highly effective, requires fewer endoscopic sessions, and results in fewer adverse events.[39],[40],[41] Although it has been described in adults, it can be safely applied to children as well. However, it needs further studies involving pediatric patients.

  Intestinal Indications Top

Congenital esophageal stenosis (CES) is an extremely rare malformation consisting of 3 types: fibromuscular thickening (54%), tracheobronchial remnants (TBR, 30%), and membranous web (16%).[42],[43],[44] Standard diagnostic criteria and treatment have not yet been established. Endoscopic dilatation and surgery are treatment options where surgery is reserved for ineffective dilatation. However, the efficacy and risk of these procedures are controversial. Dilatation for TBR type of CES has low-success rate and high rate of perforation. EUS helps differentiate different types of CES with TBR showing multiple echogenic regions in the muscle layer that represent aberrant cartilaginous remnants. EUS findings of TBR correlate well with surgical pathology.[45] Overall success rate of dilatation and rate of perforation for CES with or without case selection using EUS are 90% and 29% and 7% and 24%, respectively.[46] Hence, EUS-guided repetitive dilatation with gradual step up can be a safe approach to minimize the risk of perforation.

EUS can detect various congenital anomalies of GI tract and guide their management. EUS is the modality of choice to evaluate and diagnose duplication cysts as it can distinguish between solid and cystic lesions.[47] EUS can also delineate cyst location relative to surrounding tissues effectively guiding surgical or endoscopic therapies.[48],[49] Duodenal duplication cysts are adherent to the duodenum, are noncommunicating, and may occasionally include the distal part of the pancreaticobiliary duct or a vessel within its common wall. EUS guided minimally invasive endoscopic therapy or intracavitary surgery allowing resection of the common wall is currently the preferred treatment in children with biliary involvement.[50] Ectopic pancreatic rests, often seen in stomach, duodenum or jejunum can sometimes be mistaken with a tumor owing to its endoscopic appearance or associated symptoms. EUS can identify these benign embryologic structures as anechoic, isoechoic, or hypoechoic structures contained within the submucosa.[51] EUS assessment of depth of submucosal infiltration by heterotopic gastric mucosa in rectum can help in deciding the appropriate treatment modality.[52]

High-resolution EUS demonstrates increased thickness of esophageal wall as well as its individual wall layers including the combined mucosa and submucosa, and muscularis propria in children with eosinophilic esophagitis compared with healthy controls. Treatment with steroids results in decrease in wall thickness.[53],[54] EUS can help define the etiology and treatment strategy in children with esophageal stenosis.[55] Disruption of submucosal and muscular layers seen on EUS suggests gastroesophageal reflux resulting in esophageal stenosis. It can delineate the depth of injury in patients with caustic injury, thereby determining the need for endoscopic/surgical therapy. EUS can determine the extent of disease and efficacy of endoscopic or surgical therapy in patients with achalasia, a rare disorder in children.[56]

EUS can help differentiate patients with inflammatory bowel disease into active ulcerative colitis (UC) and Crohn's disease (CD) and quantify the level of colonic inflammation.[57] Estimation of mucosal-submucosal and total wall thickness with locoregional lymph node assessment by EUS has 92% sensitivity in discriminating UC and CD. EUS can predict remission and relapses in patients with inflammatory bowel disease based on changes in wall thickness.[58],[59],[60] EUS has been demonstrated to be superior to fistulography, CT, and equal to or superior to MRI in evaluation of perirectal and perianal complications of CD.[59] It better delineates the length and extent of ileocolonic strictures in CD, thus allowing optimal medical/surgical treatment in these patients.

  Future Perspectives Top

With progressively increasing number of EUS indications in children, it is likely to gain more acceptances for pediatric population. EUS miniprobes or endoscopic bronchial probes (provides option of FNA also) can be used in smaller children. More data are required on therapeutic applications of EUS in children.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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