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T H E J O U R N A L O FP E D I A T R I C S

S E P T E M B E R 1 9 8 9 Volume 115 Number 3

MEDICAL PROGRESSU p p e r g a s t r o i n t e s t i n a l t r a c t e n d o s c o p yin t h e p e d i a t r ic p a t i e n tMaureen Caulfield, MD, Robert Wyllie, MD, Michael V. Sivak, Jr., MD,William Michener, MD, and Rita Steffen, MDFrom the Section of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, andthe Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio

S i n c e t h e i n t r o d u c t i o n o f f l e x i b l e f i b e r o p t i c e n d o s c o p y i n t h ee a r l y 1 9 70 s, e s o p h a g o g a s t r o d u o d e n o s c o p y h a s b e c o m e a ne s t a b l i s h e d p r o c e d u r e f o r t h e d i a g n o s i s , e v a l u a t i o n , a n dt r e a t m e n t o f g a s t r o in t e s t i n a l t ra c t d i s e a s e in p e d i a t r i c p a -t i en t s . T h e s e p r o c e d u r e s h a v e i n c r e a s e d d r a m a t i c a l l y d u r -i n g t h e p a s t t w o d e c a d e s , a n d t h e u s e a n d i m p o r t a n c e o fg a s t r o i n t e s ti n a l t ra c t e n d o s c o p y h a v e c o n t i n u e d t o i n c r e a s ea s i n s t r u m e n t s s p e c i f i c a l l y d e s i g n e d f o r p e d i a t r i c p a t i e n t sh a v e c o m e i n t o r o u t i n e u s e . P r o g r e s s i n t h e r a p e u t i c e n d o s -c o p y i s e x p e c t e d t o f u r t h e r e n h a n c e t h e u s e f u l n e s s o f u p p e re s o p h a g o g a s t r o d u o d e n o s c o p y . T h e t e c h n i q u es o f t h i s p r o -c e d u r e , i t s c o m p l i c a t i o n s , a n d i n d i c a t i o n s f o r i t s u s e a r e r e -v i e w e d .F A C I L I T I E S

R o u t i n e u p p e r g a s t r o i n t e s t i n a l t ra c t e n d o s c o p y i n i n f a n tsa n d c h i l d r e n i s a n o u t p a t i e n t p r o c e d u r e u s i n g p a r e n t e r a ls e d a t i o n p e r f o r m e d w i t h a f l e x i b l e p e d i a t r i c e n d o s c o p e i n aw e l l - eq u i p p e d en d o s c o p y s u it e . T h e a t m o s p h e r e a n d f u r -n i s h in g s o f t h e s u i t e h a v e a n i m p o r t a n t b e a r i n g o n t h ec h i l d ' s r e a c t i o n t o t h e p r o c e d u r e. P r e p r o c e d u r e a n x i e t y i sd i m i n i s h e d b y p r o v i d i n g a n e n d o s c o p y a s s i s t a n t w h o g r e e t st h e p a t i e n t , e s c o r t s t h e c h i l d t o t h e r o o m , a n d h o l d s a n d r e -a s s u r e s t h e c h i l d t h r o u g h o u t t h e p r o c e d u r e . T h e c h i l d i sRep rint requests: Robert W yllie, MD , Cleveland Clinic Found a-tion, 9500 Euclid Ave., Cleveland, OH 44106.9 /18/12923

t h e n t r a n s p o r t e d t o a r e c o v e r y a r e a a n d i s a l lo w e d t o s l e e pu n d e r t h e o b s e r v a t io n o f p a r e n t s a n d a n u r s e .S E D A T I O N

P a r e n t e r a l p r e m e d i c a t i o n i s u se d t o s e d a t e m o s t p e d i a t -r i c p a ti e n t s n o t o n l y t o m i n i m i z e d i s c o m f o r t b u t a l s o t o p r o -v i d e a m n e s i a f o r a n d c o o p e r a t i o n d u r i n g t h e e v e n t . I n t h ep a s t 1 0 y e a r s , m o s t p e d i a t r i c g a s t r o e n t e r o l o g i s t s h a v er e p l a c e d g e n e r a l a n e s t h e s i a w i t h i n t r a v e n o u s s e d a t i o n f o ru p p e r a n d l o w e r g a s t r o i n t e s t i n a l t r a c t e n d o s c o p y . F e ws t u d i es a r e a v a i l a b l e c o m p a r i n g v a r i o u s p r e p r o c e d u r e m e d -i c a t i o n s i n c h i l d r e n . I n o n e s t u d y , 5 8 c h i l d r e n w e r e r a n -d o m l y a s s ig n e d t o r e c e i v e o n e o f t h r e e r e g i m e n s : i n t r a m u s -c u l a r a d m i n i s t r a t i o n o f m e p e r i d i n e a l o n e , i n t r a m u s c u l a ra d m i n i s t r a t i o n n o f a t r o p i n e w i t h i n t r a v e n o u s a d m i n i s t r a -t i o n o f d i a z e p a m , o r i n t r a m u s c u l a r a d m i n i s t r a t i o n o f m e -p e r id i n e , p r o m e t h a z i n e , a n d c h l o r p r o m a z i n e . 1 N o r e g i m e nw a s s h o w n t o b e s u p e r i o r , a l t h o u g h t h e c h i l d r e n w h or e c ei v e d t h e t h r e e d r u g s w e r e m o r e s e d a t e d b u t r e q u i r e d a na v e r a g e o f 2 28 m i n u t e s t o r e c o v er a d e q u a t e l y f o r d i s c h a r g e ,i n c o m p a r i s o n w i t h 5 6 a n d 8 8 m i n u t e s f o r t h e p a t i e n t s s e -d a t e d w i t h o n e a n d t w o d r u g s , r e s p e c t i v e l y . I n a d d i t i o n , t h em a j o r i t y o f t h e p a t i e n t s i n e a c h g r o u p r e q u i r e d a d d i t i o n a ls e d a t io n w i t h i n t r a v en o u s a d m i n i s t r a t i o n o f e i t h e r m e p e r i -d i n e o r d i a z e p a m . M i d a z o l a m , a n i m i d a z o l e b e n z o d i a z e p i n eu s e d a s a s e d a t i v e f o r e n d o s c o p y i n a d u l t s , 2 d e c r e a s e si n d u c t i o n t i m e , i n c r e a s e s a m n e s i a f o r t h e p r o c e d u r e , a n dp r o d u c e s f e w e r i n s t a n c e s o f t h r o m b o p h l e b i t i s , c o m p a r e d

3 3 9

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3 4 0 Caulfie ld el al. The Journal of PediatricsSeptember 1989

with diazepam. The combination of midazolam and mepe-ridine is gaining popularity among pediatric gastro-enterologists.3 We have performed over 500 procedureswith a combination of 1 to 2 mg/k g of intravenouslyadminist ered meper idine for 1 to 2 minute s followed by 0.01mg/kg of midazolam, which is then titrated to the desiredlevel of sedation, General anes thesia is necessary in only anoccasional patient, one who is uncooperative despite int ra-venous sedation, one who will require a lengthy or compli-cated procedure, or one who has ext enuating medical prob-lems.I N S T R U M E N T A T I O N

The first crude fiberscope for gastroscopy was devised byHirschowitz in 1957. Subsequently, the instrument hasbeen highly refined with respect to optical clarity an d ma-neuverability. The major limitation has been the inability oprovide a permanent record of the examination. Videoen-doscopy, which uses a video camera with a charge-coupledevice, is now available. This system permits storage andretrieval of data but is limited in that adequate images can-not be generat ed in the smaller-diameter endoscopes. How-ever, the majori ty of older children and adolescents can beexamined with the larger 9.5 mm diameter instrument.Eventu ally, as the technique improves, videoendoscopy willbe available and widely used in pediatric as well as adultpatients.

The esophagus in the term infant measures 10 cm inlength and 4 to 6 mm in diameter. Although the smallestpediatric gastrointestinal endoscope measures 7.6 mm indiameter, it passes easily and no trauma is sustained by theesophagus in these small patients. Fo r the exam inati on ofpremature infants , a fiberoptic bronchoscope with a diam-eter of 3.55 m m may be used. The standard 9.0 to 9.8 mmdiameter endoscopes are employed in older children andadolescents. Portable light sources are available, so endo-scopic procedures can be performed at the bedside if nec-essary. In addition, prototype side-viewing endoscopes havebeen used for the occasional infan t or child who needs en-doscopic retrograde cholangiopancreatography.C O M P L I C A T I O N S

Upper gastrointestinal tract endoscopy is considered asafe procedure, although reported complications includehypoxemia, apnea, aspiration, cardiac arrhythmia, bacter-emia, perforation, and bleeding.49 In one series, 1~ 35 com-plications followed 2045 pediatri c upper endoscopies; tran-sient respiratory arrest from oversedation, bronchospasmrelated to general anesthe.~ia, and phlebitis were the threemost common.

Vagal stimulation or airway compression, resulting inbradycardia or stridor, may occur in young infants.6, 11

These symptoms resolve with removal of the endoscope.Studies in adults have shown that hypoxemia occurs duringendoscopy. 12 Some studies have shown increased desatura-tion after intravenous administration of diazepam, whereasothers have found no addit iona l effect. 13 The degree ofoxygen desatu ration correlated with inexperience of the en-doscopist but not with intravenous administ ration of diaz-epam or midazolam. 14 Mucosal tears can occur in patientswho are not well sedated or who have a paradoxic excite-ment reaction to benzodiazepines.15 Uncommonly, per fo-ration or aspiration occurs, although neither has been stud-ied prospectively. Bacteremia with the group A streptococ-cus was reported in 1 of 50 children undergoing upperendoscopy and biopsy. 16 The patient had no clinical signs ofinfection and was not treated with antibiotics. Until therisks are defined, the use of prophy lactic antibiotics is rec-ommended only for patients with prosthetic heart valves,surgically constructed systemic-pulmonary shunts, and aprevious history of endocarditis. 17 The exact incidence ofminor complications such as phlebitis, dental injury, drugreactions, and prolonged obtundat ion has not been reportedin children; it is approximately 1% in adults58

The use of cardiac mon itors and pulse oximeters to mon-itor the child closely during the sedation and the procedureis now standard practice in a well-equipped endoscopy suite.These measures have served to further decrease the risksand compl ications of the procedure.I N D I C A T I O N S F O R U P P E RG A S T R O I N T E S T I N A L T R A C T E N D O S C O P Y

Upper gastroint estinal tract endoscopy is effective in thedetection of mucosal abnormalit ies in the esophagus, stom-ach, and duodenum. Esophageal lesions include esophagitis(reflux, fungal, viral, caustic), stricture, hiatus hernia, andesophageal varices. Gastri c abnormalit ies such as gastritis(drug or toxin induced, eosinophilic), ulceration, postoper-ative deformities, gastric varices, and hypertrophic gas-tropathies are easily detected, as well are duodenal lesionssuch as ulcerations, duodenitis, and webs. Biopsies are eas-ily performed and may be necessary to diagnose Barrettesophagus, lymphoma, Crohn disease, eosinophilic gastro-enteritis, Campylobacter gastritis, and small-bowel dis-eases such as celiac sprue and giardiasis. Endoscopic can-nulation of the ampulla of Vater, followed by retrogradecholangiopancreatography, can now be done to aid in thediagnosis of some biliary tract disorders in pediatric pa-tients.

Because symptoms of upper gastrointestinal tract diseasein children are var iable and endoscopy is superior to uppergastrointestinal tract radiography in the diagnosis of mostof the lesions, whether endoscopy should be recommendedas the initial diagnostic test for the evaluation of children

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Volume 115 Upper GI tract endoscopy 3 4 1Number 3

T a b l e I . Source of upper gastrointest inal t ract bleeding in infants and childrenN o . o f D u o d e n a l G a s t r ic G a s t r icA g e p a t i e n t s u l c e r D u o d e n i t is u lc e r e ro s i o n s E s o p h a g i t is V a r i c e s

0-12 mo 30 7 2 3 7 41-6 yr 33 4 2 11 3 3 47-18 yr 58 18 1 7 8 6 7Modified from WyliieR. Esophagogastroduodenoscopy n the pediatric patient. In: Sivak MV ed. Gastroenterologicendoscopy.Philadelphia:WB Saunders,1987:314.

with abdominal symptoms such as nausea, vomiting, andabdominal pain remains tinanswered. Potential problemsinclude the costs in terms of time, labor, and other expenses.a higher (albei t low) compli cation rate. and the po tentia l foroveruse. Opinion even among pediatric gastroenterologistsis divided. For the primary health care provider, additionalconsideratiOnS should include the available resources andthe expertise of the local endoscopists.

Therapeutic uses of upper gastrointestinal tract endos-copy include dilation of esophageal strictures, sclerosis ofesophageal vances, removal of esophageal or gastric foreignbodies, coagulat ion of bleeding lesions in the stomach andduodenum, ablation of antral or duoden~d webs, and poly-pectomy. Other uses include percutaneous placement ofgastrostomy feeding tubes and manipulat ion of the biliarytract (sphincterotomy, stent placement).

R ecu rren t a b d o m in a l p a in a n d V o m it in g . Upper gas-trointe stinal tract endoscopy should be considered for chil-dren with recurrent abdominal pain who have associatedsymptoms of weight loss, nausea, vomiting, or hema teme-sis: who awaken at night with pain: who have gross or oc-cult blood in the stool; or who have persistence of the s amedegree of severity or increasing severity of the pain. Radio-graph ic studies are, in genera l, less sensitive and specificthan endoscopy for identify ing upper tr act lesions. Uppergastroin testinal ract endoscopy can be recommended as theinitial diagnostic test where experienced pediatric endo-scopists are available.

Persistent vomiting may be the presenting symptom of avariety of upper tract diseases. In most infants less than 6months of age who are growing normally, no diagnosticstudy is needed. In older infants and children who persis-tently vomit, metabolic and anatomic abnormalities can beidentified with labo ratory .tests and an upper gast rointesti-nal tract radiographic series and small-bowel follow-throughradiography. Endoscopy should eventually be done in theface of persistent vomiting associated bleeding or weightloss to exclude the variety of mucosal lesions that could bemissed with the barium study.G a stro in tes t in a l t ra c t h em o rrh a g e . Most gastroenterolo-gists and surgeons agree that endoscopy should be per-formed in patients with bleeding from the upper gastrointes-

tinal tract In most cases, endoscopy will provide an accu-rate diagnosis, will establish the site of bleeding, willindicate how active the bleeding is. and may help to predictthe chance of rebleeding.

In the preendoscopy era. the cause of upper gastrointes-tinal tract hemorrhage was not identified m approximatelyhalf of all pediatric patients. 19 Current ly, the site of bleed-mg can be identified in 75% to 95% of children and infants.2~

The cause of upper gastrointestinal tract hemorrhagevaries with age. 4-6- 11.21.22 Esophagit is, gastric and duode-nal ulcers, and gastric erosions account for the majo rity Ofbleeding in children less tha n 1 year of age. In patients aged1 to 6 years, gastric ulcers and inflamm ation of the duode-num or esophagus are seen. Duodenal ulcer is the mostcommon cause of bleeding in patients aged 7 to 18 years,followed by gastric erosions, varices, and esophagitis (Ta-ble I).

Endoscopic treatment of upper gastrointestinal tractbleeding may be performed once the source of bleeding isfound. The risk of rebleeding has been well studied in adultsand appears to be re lated to the age of the patient, coexist-ent disease in othei" systems, and the natu re of the lesion thathas bled. 23 Superf icial lesions sucl~ as those caused byesophagitis, gastritis, or duodenal erosions rarely rebleed.On the other hand, esophageal and gastric varices almostalways rebleed eventually. Hemor rhage from peptic ulcersrecurs approximately 25% of the time. The identification ofulcers with a high risk Of rebleeding is imperative so thatendoscopic therapy can be completed. Rebleeding is corre-lated with the presence of stigmata of recent hemorrhage.These stigmata include fresh bleed ing from the lesion, freshor altered blood clot or black slough adherent to the lesion.and a vessel protruding from the base or margin of theulcer. 24 If identified, ablation of the Ulcer base and visiblevessel may be attempted. Data for pediatric patients arelimited, however, regarding therma l and electrocoagula-tion. caustic injection, and laser photocoagulation.

Variceal bleeding may occur at any age. Extrahepaticportal hypertension is more common in children thancirrhosis and may be associated with a history of umbilicalvein manipulation, omphatitis, or congenital anomalies.Those patients with extrahepatic portal hypertension have

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3 4 2 Caulf ield et al. The Journal of PediatricsSeptember 1989

T a b l e I I . C o m p l i c a t io n s a f t e r s c l e r o t h e r a p y o fe s o p h a g e a l v a r i c e s i n c h i l d r e n

C o m p l i c a t i o n

S e r i e sS t a m a t a k i s V a n e D o n o v a n S a ri n

e t a l. , 2 s e t a l . , 2 6 e t a l . , 2 8 e t a J ., 2 71 9 8 5 1 9 8 5 1 9 8 6 4 9 8 8

( n = 2 1 ) ( n = 1 3 ) ( n = 1 6 ) ( n = 3 1 )Rebleeding 5 1 4* 5Str ic ture 2 0 1 4Performation 0 0 0 0Chest pain NR NR 8 12Ulceration 5 1 1 5Es0Phagit is NR 9 NR NROb literatio n of 18 8 11 31varicesNR, Not reported.*All pa tients bled from g as tr ic var ices .tN in e episodes o f bleeding in five patients.

n o r m a l l i v e r f u n c t i o n a n d a f a v o r a b l e p r o g n o s i s b e c a u s e o ft h e s p o n t a n e o u s p o r t a s y s t e m i c sh u n t s . T h e p a t i e n t s o f t enh a v e v a r i c e a l b l e e d i n g a s t h e i n i t i a l e v e n t l e a d i n g t o t h e d i -a g n o s i s . C h i l d r e n w i t h v a r i c e a l b l e e d i n g b e c a u s e o f i n t r a -h e p a t i c o r e x t r a h e p a t i c p o r t a l h y p e r t e n s io n h a v e b e e n s u c -c e s s f u l l y t r e a t e d w i t h e n d o s c o p i c s c l e r o t h e r a p y .25-27 In as e r i e s o f 1 6 c h i l d r e n w i t h b l e e d i n g v a r i c e s , t h e i n c i d e n c e o fr e b l e e d i n g a n d t r a n s f u s i o n r e q u i r e m e n t s w e r e s i g n i f i c a n t l yr e d u c e d d u r i n g a 3 - y e a r f o l l o w - u p .2a N o s t u d i e s h a v e b e e nd o n e c o m p a r i n g s c l e r o t h e r a p y w i th t h e u s e o f p o r t a c a v a ls h u n t s i n c h i ld r e n . I n a d u l t s , i t i s u n c l e a r w h e t h e r s o - c a l l e dp r o p h y l a c t i c s c l e r o t h e r a p y b e f o r e t h e f i rs t v a r i c e a l b l e e d i n ge p i s o d e i m p r o v e s m o r b i d i t y o r m o r t a l i t y r a t es . A l t h o u g h n od a t a e x i s t f o r c h i l d r e n , i t s e e m s r e a s o n a b l e t o i n j e t i d e n t i -f i ed v a r i c e s , e s p e c i a l l y i n t h o s e p a t i e n t s w i t h e x t r a h e p a t i cp o r t a l h y p e r t e n s i o n , i n a n e f f o r t t o p r e v e n t t h e f i r s t v a r i c e a lh e m o r r h a g e .

E n d o s c o p i c s c l e r o si s o f t h e e s o p h a g e a l v a r i x c a n b e d o n ei n m a n y d i f fe r e n t w a y s d e p e n d in g o n t h e p r e f e r e n c e o f t h ee n d o s c o p i s t r e g a r d i n g t h e t y p e o f s c l e r o s in g a g e n t , i n j e c t i o nv o l u m e , p a t t e r n o f i n j e c t io n s , a n d i n t r a v a r i c e a l v e rs u sp a r a v a r i c e a l i n j e c t i o n s . C o m p l i c a t i o n s o f e n d o s c o p i c s c l e -r o t h e r a p y f o r e s o p h a g e a l v a r i c e s i n c l u d e b l e e d i n g , s t r i c t u r e ,u l c e r a t i o n , p e r f o r a t i o n , a n d i n f e c t i o n . T h e c o m p l i c a t i o nr a t e i n a d u l t s r a n g e s f r o m 2 % t o 1 5 % . 29 T h e c o m p l i c a t i o n sd e s c r i b e d i n f o u r s e r i e s re p o r t i n g t h e u s e o f p e d i a t r i c e n d o -s c o p ic s c l e r o t h e r a p y2s-28 a r e l i s ted in Ta ble I I .

Foreign bod y ingestion . M o s t f o r e i g n b o d i e s t r a v e r s e t h eg a s t r o i n t e s t i n a l t r a c t w i t h o u t d i f f ic u l t y . T h e m o s t c o m m o ns i t e o f i m p a c t i o n i s t h e e s o p h a g u s j u s t b e l o w t h e c r i c o -p h a r y n g e a l s p h i n c t e r a t t h e t h o r a c i c i n l e t . C o m m o n p r e -s e n t in g s y m p t o m s i n i n f a n t s a n d s m a l l c h i l d re n i n c l u d ec h o k i n g , e x c e s s i v e d r o o l i n g , p o o r f e e d i n g , o r a d r a s t i cc h a n g e i n e a t i n g h a b i t s . O l d e r c h i l d r e n m a y c o m p l a i n o f

s u b s t e rn a l p a i n a n d d y s p h a g i a . L o d g e d r a d i o p a q u e o b j e c t sa r e e a s i l y id e n t i f i e d b y l a t e r a l r a d i o g r a p h s o f t h e n e c k a n dc h e s t . F l a t o b j e c t s t e n d t o l i e i n t h e c o r o n a l p l a n e i n t h ee s o p h a g u s a n d i n t h e s a g i t t a l p l a n e i n t h e t r a c h e a .P a t i e n t s w i t h f o r e i g n b o d i e s l o d g e d i n t h e e s o p h a g u ss h o u ld u n d e r g o f i b e ro p t i c e n d o s c o p y t o s n a r e a n d r e m o v et h e o b j e c t u n d e r d i r e c t v i s u a l i z a t i o n . S h a r p o b j e c t s , s u c h a sr a z o r b l a d e s a n d o p e n s a f e t y p i n s , a n d t h o s e u n l i k e l y t o p a s st h r o u g h t h e p y l o r u s m a y a l so b e r e m o v e d e n d o s c o p i c al l y .S o m e c h i l d r e n m a y r e q u i r e g e n e r a l a n e s t h e s i a i f t h e o b j e c tc a n n o t b e g r a s p e d a n d w i t h d r a w n n q u i c k l y . A n o v e r t u b e ,w h i c h s l i d e s o v e r t h e o b j e c t , m a y b e u s e d t o p r o t e c t t h ee s o p h a g u s d u r i n g e x t r a c ti o n .

O n c e i n t h e s t o m a c h , 9 5 % o f a l l i n g e s t e d O b j ec t s p a s s u n -e v e n t f u ll y th r o u g h t h e r e m a i n d e r o f t h e g a s t r o i n t e s ti n a lt r a c t . 3 ~ C o n s e r v a t iv e m a n a g e m e n t i s i n d i c a t e d i n a l m o s t a l li n s t a n c e s i n w h i c h t h e f o r e i g n b o d y h a s e n t e r e d t h e s t o m -a c h . S i t e s o f p o s s i b l e i m p a c t i o n i n c l u d e t h e p y l o r u s , t h e i l -e o c e c a l v a lv e , t h e C - s h a p e d l o o p o f t h e d u o d e n u m , a s u r g i -c a l a n a s t o m o t i c s i t e, o r a c o n g e n i t a l m a l f o r m a t i o n s u c h a sa w e b , d i a p h r a g m , o r d i v e r t i c u l u m . M o s t o b j e c t s w i l l p a s si n 4 t o 6 d a y s , a l t h o u g h s o m e m a y n o t p a s s f o r 3 to 4 w e e k s .

M a n a g e m e n t a f t e r b a t t e r y i n g e st i o n re m a i n s c o n t r o v er -S ia l. T w o f a t a l i t i e s h a v e b e e n r e p o r t e d a f t e r b a t t e r y i m p a c -t ion in the esoph agu s , 31, 32 and a l l b a t te r ie s lo dged in thee s o p h a g u s sh o u l d b e r e m o v e d i m m e d i a t e l y . M a n a g e m e n t o fa b a t t e r y i n t h e s t o m a c h i s l e s s c e r t a i n . I t s e e m s p r u d e n t t oo b s e r v e t h e p a t i e n t f o r 2 4 h o u r s , b u t i f s y m p t o m s d e v e l o po r t h e b a t t e r y h a s n o t l e f t t h e s t o m a c h a t t h e e n d o f t h e o b -s e r v a t i o n p e r i o d , i t s h o u l d b e r e m o v e d e n d o s c o p i c a l l y . L e a di s r a p i d l y l e a c h e d b y g a s t r i c a c i d a n d t h u s a l l l e a d -c o n t a i n i n g o b j e c t s sh o u l d p r o b a b l y b e r e m o v e d e n d o s c op i -c a l l y i f t h e y f a i l t o r e a c h t h e s m a l l b o w e l w i t h i n 1 w e e k o fi n g e s t i o n .

C o m p l i c a t i o n s o f f o r e i g n b o d y i n g e s t i o n a r e i n f r e q u e n t .P e r f o r a t i o n o f t h e i n t e s t i n a l l u m e n b y a f o re i g n b o d y w i t hg e n e r a l i z e d p e r i t o n i t i s i s u n u s u a l . M o s t o b j e c t s t h a t p u n c -t u r e t h e b o w e l w a l l a r e s l o w l y e x t r u d e d i n t o t h e p e r i t o n e a lc a v i t y . T h e a r e a i s u s u a l l y i s o l a t e d b y a d j a c e n t b o w e l lo o p sa n d o m e n t u m , a n d a n i n f l a m m a t o r y m a s s f o rm s . M e c h a n -i c a l o b s t r u c t i o n o c c u rs f r o m t r a p p i n g o f a n o b j e c t o r s h a r pa n g u l a t i o n o f t h e i n v o l v e d b o w e l l o o p. T h e m o s t c o m m o ns i t e o f p e r f o r a t i o n i s t h e i l e o c e e a l v a l v e a r e a , i n c l u d i n g t h ea p p e n d i x . 33 D u o d e n a l p e r f o r a t i o n o c c a s i o n a l l y o c c u r s w h e no b j e c t s g r e a t e r t h a n 5 o r 6 c m i n t h e l a r g e s t d i m e n s i o n f a i lt o p a s s t h r o u g h t h e d u o d e n u m . E n d o s c o p i c o r s u rg i c a l in -t e r v e n t i o n i s i n d i c a t e d i f a f o r e i g n b o d y r e m a i n s w i t h i n t h ed u o d e n u m m o ~ e t h a n 5 d a y s.

Ingestion of caustic substances . T h e r o le o f e a r l y e n d o s-c o p y i n t h e m a n a g e m e n t o f i n g e st i o n o f c a u s ti c s u b s t an c e si s t o d e f i n e t h e e x t e n t a n d s e v e r i t y o f t i s s u e i n j u r y a n d d i s -c r i m i n a t e b e t w e e n t h o s e p a t i e n t s w h o c a n b e m a n a g e d b yo b s e r v a t i o n a l o n e a n d t h o s e w h o w i l l r e q u i r e a g r e s s i v e

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Volume 115 Up per GI t rac t endosco py 3 4 3Number 3

t h e r a p y . 34-36 S i g n i f i c a n t e s o p h a g e a l i n j u r y m a y e x i s t i n t h ea b s e n c e o f o r a l l e s i o n s , a n d t h u s a n o r m a l p h y s i c a l e x a m -i n a t i o n a f t e r t h e i n g e s t i o n c a n n o t a i d i n t h e d e c i s i o n a s t ow h e t h e r t o in v e s t i g a t e t h e p a t i e n t e n d o s c o p i c a l l y .35, 36 F o rt h i s re a s o n , e n d o s c o p y i s a n e s s e n t i a l p a r t o f t h e c a r e o f a l lc h i l d r e n w h o h a v e i n g e s t e d c a u s t i c s u b s t a n c e s a n d i sp e r f o r m e d w i t h i n t h e f ir s t 2 4 h o u r s a f t e r i n g e s t i o n . U n c o m -p l i c a t e d m u c o s a l i n f l a m m a t i o n i s c h a r a c t e r i z e d b y t h ep r e s en c e o f e r y t h e m a , e d e m a , a n d f o c a l h e m o r r h a g e . T h e s ep a t i e n t s d o n o t r e q u i r e s p e c i f ic t h e r a p y , a n d t h e i r p r o g n o s i si s f a v o r a b l e . M o r e s e v e r e t i s s u e i n j u r y i s i d e n t i fi e d b y h e m -o r r h a g e , u l c e r a t i o n , a n d f o c a l n e cr o s i s. T h e d e p t h o f i n j u r ym a y b e d i f fi c u l t t o d e t e r m i n e i f t h e i n v o l v e d a r e a i s c o v e r e dw i t h a n e x u d a t e . W h e n c i r c u m f e r e n t i a l a re a s o f i n j u r y a r en o t e d , p a t i e n t s s h o u l d b e w a t c h e d c l o s e l y f o r s t r i c t u r e f o r -m a t i o n . P a t i e n t s w i t h e v i d e n c e o f s e v e r e t i s s u e i n j u r y m a yr e q u i r e a g g r es s iv e t h e r a p y s u c h a s t o t a l p a r e n t e r a ln u t r i t i o n , 37 a n t i b i o t i c s , c o r t i c o s t e r o i d s ,3 8 o r e s o p h a g e a ls t e n t p l a c e m e n t . 39

S t r i c t u r e f o r m a t i o n i s a l a t e c o m p l i c a t i o n t h a t m a y o c c u r2 1 t o 2 8 d a y s a f t e r i n g e s t i o n in 2 % t o 2 5 % o f p a t i e n t s a n dm a y i n v o l v e t h e e s o p h a g u s o r g a s t r i c a n t r u m . T h e s e l e s i o n sm a y b e i d e n t i fi e d e n d o s c o p i c a l ly a n d d i l a t e d w i t h M a l o n e y( l e a d w e i g h t e d ) o r S a v a r y ( p l a c e d o v e r a g u i d e w i r e ) d i l a -t o r s . I n o n e r e t r o s p e c t i v e s e ri e s o f 1 7 6 p a t i e n t s , 5 0 % o f t h o s ew i t h s t r i c t u r e f o r m a t i o n r e q u i r e d c o l o n i c i n t e r p o s i t i o n b e -c a u s e o f r e f r a c t o r y e s o p h a g e a l s t r i c t u r e s . 35 C a r c i n o m a o ft h e e s o p h a g u s i s e s t i m a t e d t o o c c u r 1 0 00 t i m e s m o r e t h a nt h e e x p e c t e d i n c i d e n c e 1 0 t o 7 0 y e a r s a f t e r i n j u r y . 4 ~ T h em e a n a g e o f p a t i e n t s w i th l y e c o r r o s io n c a r c i n o m a i s l o w e rt h a n t h a t o f p a t i e n ts w i t h o r d i n a r y e s o p h a g e a l c a r c i n o m a . 41T h e s e p a t i e n t s s h o u l d b e e x a m i n e d i m m e d i a t e l y w i t he n d o s c o p y i f d y s p h a g i a d e v e l o p s. P r o p h y l a c t i c s c r e e n i n gw i t h u p p e r g a s t r o i n t e st i n a l t r a c t e n d o s c o p y t o i d e n t i f y d y s -p l a s ia b e f o r e t h e d e v e l o p m e n t o f c a r c i n o m a i s c o n t ro v e r s i a lw i t h r e g a r d t o t i m i n g a n d f r e q u e n c y .

P e p t i c u l c e r d i s e a s e . F i b e ro p t i c e n d o s co p y h a s m o d i f i e do u r c o n c e p t s o f p e p t i c u l c e r d i s e a s e i n c h i l d r e n w i t h r e s p e c tt o p r e v a l en c e a n d a c c u r a c y o f d ia g n o s i s. M a n y s t u d i e s h a v ed e m o n s t r a t e d l ow s e n s i ti v i ty a n d s p e c i fi c it y o f b a r i u m c o n -t r a s t r a d i o g r a p h y in c o m p a r i s o n w i t h u p p e r e n d o s c o p y .F a l s e n e g a t i v e r a t e s r a n g e f r o m 4 5 % t o 7 5 % . 15, 42 C o n v e r s e -l e y , i n 6 3 % o f c h i l d r e n t h o u g h t t o h a v e p e p t i c u l c e r d i s e a s eo n t h e b a s is o f r a d i o g r a p h y , u p p e r e n d o s c o p ic e x a m i n a t i o nshow s no r m al f ind ings . 4~

P e p t i c u l c e rs i n c h i l d r e n c a n b e d i v i d e d i n t o p r i m a r y a n ds e c o n d a r y t y p e s.44 P r i m a r y u l c e r s o c c u r i n o t h e r w i s e h e a l t h yc h i l d r e n a n d a c c o u n t f o r 7 0 % o f t h e u l c e r s i n o l d e r c h i l d r e na n d a d o l e s c e n t s . S e c o n d a r y u l c e r s o c c u r i n a s s o c i a i o n w i t ho t h e r d i s e a s e s a n d a r e s e e n i n a p p r o x i m a t e l y 8 0 % o f i n f a n t sw i th u l c e rs . S y m p t o m s t h a t a c c o m p a n y p r i m a r y u l c e r s a r ea g e d e p e n d e n t . N e o n a t e s u s u a l l y h a v e p e r f o r a t i o n , b l e e d -i n g , o r b o t h . O l d e r i n f a n t s m a y f e e d p o o r l y , v o m i t , a n d f a i l

t o g a i n w e i g h t . I n c h i l d r e n y o u n g e r t h a n 6 y e a r s o f a g e w i t hp e p t i c u lc e rs , v o m i t i n g is c o m m o n a n d a b d o m i n a l p a i n i si n f re q u e n t . A p p r o x i m a t e l y 3 0% o f t h es e p a t i e n t s h a v eb l e e d i n g a s t h e f i rs t s y m p t o m . I n o l d e r c h i ld r e n , a b d o m i n a lp a i n i s t h e m o s t c o m m o n c o m p l a i n t , b u t i t i s o f t e n a t y p i c a li n l o c a ti o n a n d v a r i a b l y r e l a t e d t o m e a l s . A d o l e s c e n tp a t i e n t s o f t e n h a v e t y p i c a l u l c e r p a i n , s i m i l a r t o t h a t o fa d u l t p a t i e n t s w h i c h i s e p i g a s t r ic o r p e r i u m b i l i c a l a n dr e l i e v e d w i t h f o o d o r a n t a c i d s .

T h e r o l e o f C a m p y l o b a c te r p y l o r i i n t h e p a t h o g e n e s i s o fg a s t r i t i s a n d u l c e r d i s e a s e r e m a i n s c o n t r o v e r s i a l . A m o n g 6 7c h i l d r e n u n d e r g o i n g u p p e r e n d o s c o p y fo r t h e p r e s e n c e o f C .p y l o r i a n d w i t h h i s t o l o g i c e v i d e n c e o f g a s t r i t i s ,45 7 of th e 10c h i l d re n w i t h p r i m a r y g a s t r i t is ( t h o s e w i t h n o u n d e r l y i n gc a u s e f o r g a s t r i t i s ) h a d C. py lor i i d e n t i f i e d i n t h e b i o p s y9 s p e ci m e n s . N o n e o f t h e c h i l d r e n w i t h s e c o n d a r y g a s t r it i s o rn o r m a l f i n d i n g s o n e x a m i n a t i o n h a d t h e o r g a n i s m i d e n t i -f ie d . I n a d d i t i o n , a l l f iv e p a t i e n t s w i t h d u o d e n a l u l c e r s h a dC. py lor i i s o l a t ed f ro m t h e a n t r a l t i ss u e . T h e s e d a t a a r ec o m p e l l i n g in t e r m s o f c a u s e a n d e f f e c t. H o w e v e r , o t h e rs t u d ie s i n a d u l t s h a e i d e n t if i e d t h e o r g a n i s m i n a s y m p t o m -a t i c v o l u n t e e r s w i t h o u t h i s t o l o g i c e v id e n c e o f g a s t r it i s . T h eo r g a n i s m c a n u s u a l l y b e e r a d i c a t e d w i t h a n t i b i o t i c t h e r a p ya l t h o u g h o f t e n t w o o r m o r e d ru g s a r e r e q u i r e d . M o r e d a t aa r e n e e d e d b e f o r e t h e s e i s s u e s w i l l b e c l ar i f ie d .

E s o p h a g i t i s . E s o p h a g i t i s m a y b e d u e tO g a s tr o e s o p h a g e a lr e fl u x , i n f e c t io n s , o r c h e m i c a l a g e n t s . G a s t r o e s o p h a g e a l r e -f l u x a c c o u n t s f o r t h e m a j o r i t y o f e s o p h a g i t i s i n t h e p e d i a t -r i c a g e g r o u p . I t i s m o s t c o m m o n b u t r a r e l y s ig n i f i c a n t d u r -i n g t h e f i r s t 6 m o n t h s o f l i f e , w h e n t h e l o w e r e s o p h a g e a ls p h i n c t e r i s u n d e r g o i n g f u n c t i o n a l m a t u r a t i o n . C h i l d r e nw i t h e s o p h a g i t is m a y c o m p l a i n o f n o n d e s c r i p t p ai n , v o m i tf r e q u e n t l y , o r f e e d p o o r l y . C o m p a r a t i v e a n a l y s i s o f t h em e t h o d s f o r i d e n t i f i c a t i o n o f r e l u x i n c h i l d r e n s u g g e s t s t h a tt h e b e s t s i n g l e t e s t i s p r o l o n g e d e s o p h a g e a l p H m o n i -t o r i n g . 46 H o w e v e r , p H s t u d i e s d o n o t i d e n t i f y i n f l a m m a t o r ym u c o s a l c h a n g e s o r c o n d i t i o n s t h a t m a y r e q u i r e c a r e f u lf o l l o w - u p , s u c h a s B a r r e t t e s o p h a g u s , a m e t a p l a s t i c r e -s p o n se o f t h e e s o p h a g e a l s q u a m o u s e p i t h e l iu m t h a t m a y b ea s s o c i a t e d w i t h a d e n o c a r c i n o m a . 47-49

O r g a n i s m s r e s p o n s i b l e f o r i n fe c t i o u s c a u s e s o f e s o p h a g i -t i s i n c l u d e Candida a lb i cans , h e r p e s s i m p l e x a n d h e r p e szos te r , g r oup A ~3- hemoly t ic s t r ep tococc i , and L a c t o b a c i l -l u s ac idoph i lus . T h e s e i n f e c t i o n s g e n e r a l l y o c c u r i n h o s p i -t a l i z e d a n d s e v e r e ly im m u n o s u p p r e s s e d p a t i e n t s a n d a r ee a s i l y d i f f e r e n t i a t e d b y e n d o s c o p i c a l l y o b t a i n e d c u l t u r e s .E N D O S C O P I C R E T R O G R A D EC H O L A N G I O P A N C R E A T O G R A P H YE n d o s c o p i c r e t r o g r a d e c h o l a n g i o p a n c r e a t o g r a p h y i s as o p h i s t i c a te d t e c h n i q u e t h a t i s b o th e n d o s c o p i c a n d r a d i o -l o g i c . T h e e n d o s c o p e i s g u i d e d t o t h e d u o d e n u m a n d t h ea m p u l l a o f V a t e r i s c a n n u l a t e d w i t h a s m a l l T e f lo n c a t h e -

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3 4 4 Ca ulf i e ld et aL The Journal of PediatricsSeptember 1989

ter. Contrast material is then injected through the catheterand radiographs a re taken of the biliary or pancreat ic ducts,or both.

Diseases of the pancreas and biliary tree are r are i n chil-dren, but this technique may be useful in the evaluati on ofidiopathic, nonresolving, or r ecurren t pancreatitis; preop-erative pseudocysts; and cert ain cases of obstructive jaun-dice. T he use of this technique in children older than 6 yearsof age was first described in 19785o and again i n 1982. s~ Inattempts to differentiate biliary atresia from neonatalhepatit is, 52 the procedure was successful in 85% of the pa-tients and an accurate disgnosis was made in all those inwhom the procedure was successful a sensitivity and spee-ificity of 100%. Morbidit y occurred in 15%. secondary tooversedation or tracheal compression. Recurrent pancre-atitis has been the most frequent indication for the study inchildren and has been successful in 92% of 39 patients. 53 Anabnormali ty of the panc reaticobili ary system was identifiedin half of the patients. These defects included pancreas di-vlsum, sclerosing cholangitis, choledochal cyst, chronicpancreatitis, choledochocele, pancreatic pseudocyst, andcommon duct stone. Mild pancreatitis occurred in 11% ofthese patients after the procedure.P E R C U T A N E O U S E N D O S C O P I CG A S T R O S T O M Y T U B E P L A C E M E N T

Placement of feeding tubes has usually been performedthrough an abdominal incision with the patient under gen-eral anesthesia. However, and endoscopic placement inchildren can be done with int ravenous sedation without theneed for surgery. 54 This technique has been successful in atleast 51 pediat ric patients. 55 The complications after per-cutaneous endoscopic gastrostomy placement do not appeartobe any different from those seen after conventionalplacement. In neurologically mpaired children, gstrostomytube placement done without an antireflux procedure maylead to the development of significant gastroesophageal re-flux despite a thorough negative preoperative evaluation forthe presence of ref lux) 6 Thus the procedure should be donewith this caveat in mind. Contraindicat ions include esoph-ageal obstruction or atresia, varices, ascites, active pepticulcer disease, gastroesophageal reflux, and morbid obesity.F U T U R E D I R E C T I O N S

Pediatric gastroenterology has come of age with the ex-pansion of the diagnosti c and therapeutic spectra providedby gastrointestinal tract endoscopy, a procedure t hat is safeand provides a means for accurate diagnosis. The uncha rtedterritory of the small bowel may soon be routinely examinedwith a special endoscope. This procedure is current ly avail-able in only a few centers for adult patients. Therapeuticcapabilities have lagged behind the diagnost ic precision of

upper gastrointestinal tract but they will certainly expandas pediatric gastroenterologists acquire more experience, inaddition, technical advancement will soon allow the effi-cient l~eeording, storage, and ret rieval of data, thereby pro-viding less biased documentation.

13.

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17.

REFERENCES1. Figueroa-Col0nR, Grunow JE. Randomized study of premed-ication for esophagogastr0duodenoseopy n children and ado-lescents. J Pediatr Gastroenterol Nutr 1988;7i359=66.2. C0ie SG, BrozinskyS, Isenberg JI. Midazolam, a new, morepotent benzodiazepine, compared with diazepam: a r~tndom-ized, double-blind study of preendoscopy sedatives. Gas-trointest Endosc 1983;29:21%22.3. Ament ME, Berquist WE, Vargas J , Perisie V~ Fiberoptic up-per intestinal endoscopy in infants and children. Pediatr ClinNorth Am 1988;35:141-55.4. Gleason WA Jr , Tedeseo FJ, Keating JP, G01dstein PD.Fiberoptic gastrointestinal endoscopy in infants and children.J PEDIATR 1974;85:810-3.5. Liebman WM, Thaler MM, Bujanover Y. Endoscopic evalu-ation of upper gastrointestina bleeding in the newborn. Am JGastroenterol 1978;69:607-&6. Graham DY, Klish WJ, Ferry GD, Sabel JS, Value offiberoptic gastrointestinal endoscopy of infants and children.South Med J 1978;71:558-60.7. Akasaka Y, Misaka F, Miyaoka T, Nakajima M, Kawai K.Endoscopy in pediatric patients with upper gastrointestinalbleeding. Gastrointest Endosc 1977;23:199-200.8. K0hli Y, Fuse Y, Kodawa T, et al. Upper gastrointestinal fi-bergptic endoscopy in pediatric patients, Gastrointest Endosc1981;23:1294-30L9. Prolta JC, Diehl AS, Benvenutti GA, Loguercio SV, Maga!-haes DS, Silveira TR. Upper gastrointestinal fiberopticendos-copy in pediatric patients. Gastrointest Endosc 1983;29:279-81.10. Ament ME. Prospectivestudy of risks of complication n 6,424procedures in pediatric gastroenterology[Abstraet]. PediatrRes 1981; 15:524.11. Hargrove CB, Ulshen MR, Shub MD. Upper gastrointestinalendoscopy in infants: diagnostic usefulnessand safetY. Pediat-rics 1984;74:828-31.12. Lieberman DA, Wuerker CK, Katon RM. Cardiopulmonary

risk of esophagogastroduodenoseopy. Gastroenterology I 985;85:468-72.Whorwell P J, Smith CL, Foster KJ. Arterial bloodgas tensionsduring upper gastrointestinal endoscopy. Gut 1976;17:797-800.Lavies NG, Creasey T, Harris K, Hanning CD. Arterial sat-uration during upper gastrointestifial endoscopy: influence ofsedation and operator experience. Am J Gastroenterol i988;83:618:22.Ament ME, Christie DL. Upper gastrointestinal fiberoptieen-doscopy in pediatric patients. Gastroenterology i977;72:1244-8.Byrne WJ, Euler AR, Campbell M, Eisenaeh KD. Bacteremiain children following upper gastrointestinal endoscopy orcolonoseopy. J Pediatr Gastr0enterol Nutr 1982;1:551-3.Statements and guidelines developed by the Standards of theTraining and Practice Committee of the Afi~ericanSociety forGastrointestinal Endoscopy.Gastro~ntestEndosc 1988;34:39S.

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Volume 11 5 Upper GI tract endoscopy 3 4 5Number 3

1 8 . M a n d e l s t a m P , S u g a w a C , S i l vi s S E , N e b e l O T , R o g e r s B H .C o m p l i c a t i o n s a s s o c i a t e d w i t h e s o p h a g o g a s t r o d u o d e n o s c o p ya n d w i t h e s o p h a g e a l d i l a t io n . G a s t r o i n t e s t E n d o s c 1 9 76 ;2 3 :16-9.

1 9 . C o l l i n s R E C . S o m e p r o b l e m s o f g a s t r o i n t e s t in a l b l e e d in g i nch i ld ren . Arch Dis Chi ld 1971 ;46 :110-2 .

2 0. H y a m s J S , L e i c h t n e r A M , S c h w a r t z A N . R e c e n t a d v an c e s i nd i a g n o s i s a n d t r e a t m e n t o f g a s t r o i n t e s t in a l h e m o r r h a g e i n i n -fan ts an d child ren. J PEDIATR 1985;106:1-9.

2 1 . C o x K , A m e n t M E . U p p e r g a s t r o i n t e s ti n a l b l e e d i n g i n c h i l d r e nand ado lescen ts . Ped ia t r i c s 1979 ;63 :408-13 .

2 2 . G r y b o s k i J D . T h e v a l u e o f u p p e r g a s t r o i n t e s t i n a l e n d o sc o p y i nchildren. Dig Dis Sci 1981;26:17s-21s.

2 3 . S i l v e r s t e in F E , G i l b e r t D A , T e d e s c o F J , B u e n g e r N K , P e r s i n gJ . T h e N a t i o n a l A S G E s u r v e y o n u p p e r g a s t r o i n t e s t i n a lb l e e d i n g . II . C l i n ic a l , p r o g n o s t i c f a c to r s . G a s t r o i n t e s t E n d o s c1981 ;27 :80-93 .

2 4 . S t o r e y D W , B o w e n S G , S w a i n C P , S a l m o n P R , K i r k h a m J S ,N o r t h f i e l d T C . E n d o s c o p i c p r e d i c t io n o f r e c u r r e n t b l e e d i n g i npep t ic u lce r s . N E ngl J M ed 1981 ;305 :915-6 .

2 5. S t a m a t a k i s J D , H o w a r d E R , P s a c h a ro p o u l o s H T , M o w a t A P .I n j e c t i o n s c l e r o t h e r a p y f o r o e s o p h a g e a l v a r i c e s i n c h i l d r e n . B rMed J 1985;69:74-5.

2 6 . V a n e D W , B o le s E T , C l a t w o r t h y H W . E s o p h a g e a l s c l e ro t h e r -a p y : a n e f f e c t iv e m o d a l i t y i n c h i ld r e n . J P e d i a t r S u r g 1 9 85 ;20 :703-7 .

2 7 . S a r i n S K , M i s r a S P , S i n g a l A K , T h a r a t V , B r o o r S L . E n d o -s c o p i c s c l e ro t h e r a p y f o r v a r i c e s i n c h il d r e n . J P e d i a t r G a s t r o -en te ro l Nut r 1988 :7 :662-6 .

2 8 . D o n o v a n T J , W a r d M , S h e p h e r d R W . E v a l u a t i o n o f e n d o -scop ic sc le ro the rap y o f e sophag ea l va r ices in ch i ld ren . J Ped i -a t r Gas t roen te ro l N ut r 1986 ;5 :696-700 .

2 9 . S i v a k M V . E s o p h a g e a l v a r i c es . I n : S i v a k M V , e d. G a s t r o e n -te ro log ic endoscopy . Ph i lade lp h ia : W B Saunde rs , 1987 :342-72 .

3 0 . S t e v e n s o n E O , H a s t i n g s N . F o r e i g n b o d i es in t h e g a s t ro i n t e s -t i n a l t r a c t o f in f a n t s a n d c h i l d r e n . A m S u r g 1 9 6 8 ; 3 4: 1 5 1 -8 .

3 1 . B l a t n i k D S , T o o h i l l R J , L e h m a n R H . F a t a l c o m p l i c a t i o n sf r o m a n a l k a l i n e b a t t e r y f o r e i g n b o d y i n t h e e s o p h a g u s . A n nOtol 1977;86:611-5.

3 2 . S h a b i n o C L , F e i n b e r g A N . E s o p h a g e a l p e r f o ra t i o n s e c o n d a r yto a lka l ine ba t t e ry inges t ion . JACEP 1979 ;8 :360-3 .

3 3 . P e l l e r i n D , F o r t i e r - B e a u l i e u M , Q u e q u a n J . T h e f a t e o f s w a l -lowed fo re ign bod ies : exper ien ce o f 1250 ins tances o f subd ia -p h r a g m a t i c f o r e i g n b o d i e s i n c h i l d r e n . P r o g P e d i a t r R a d i o l1969;2:286-302.

3 4. G a u d r e a u l t P , P a r e n t M , M c G u i g a n M A , C h i c o in e L, L o v e-j o y F H . P r e d i c t a b i l i t y o f e s o p h a g e a l i n j u r y f r o m s i g n s a n ds y m p t o m s : a s t u d y o f c a u s t i c i n g e s t i o n i n 3 7 8 c h i l d r e n . P e d i -atr ics 1983;71:767-70.

3 5 . S y m b a s P N , V l a s is S e , H a t c h e r C R . E s o p h a g i t i s s e c o n d a r y t oi n g e s t i o n o f c a u s t ic m a t e r i a l . A n n T h o r a c S u r g 1 9 8 3 ; 3 6: 7 3 -7 .

3 6 . C r a i n E F , G e r s h e l J C , M e z e y A P . C a u s t i c i n g es t io n s : s y m p -t o m s a s p r e d i c t o r s o f e so p h a g e a l i n ju r y . A m J D i s C h i l d 1 9 84 ;138:863-5.

3 7 . D i C o s t a n z o J , N o i r c l e r c M , J o u g l a r d J , e t a t . N e w t h e r a p e u -t i c a p p r o a c h t o c o r r o s i v e b u r n s o f t h e u p p e r g a s t r o i n t e s t i n a ltract . Gut 1980;21:370-5.

3 8 . O a k e s D D , S h e r c k J P , M a r k J B D . L y e i n g e s t io n : c l i n ic a l p a t -t e r n s a n d t h e r a p e u t i c i m p l i c a t io n s . J T h o r a c C a r d i o v a s c S u r g1982;83:194-204.

3 9 . C o l n D , C h a n g J H T . E x p e r i e n c e w i t h e s o p h a g e a l s t e n t i n g f o rcaus t i c burns in ch i ld ren . J Ped ia t r Surg 1986 ;721 :588-91 .

4 0 . K i v i r a n t a U K . C o r r o s i o n c a r c i n o m a o f t h e e s o p h a g u s : 3 8 1c a u s e s o f c o r ro s i o n a n d n i n e c a s u e s o f c a r c i n o m a . A c t a O t o -la ryngo l 1952 ;42 :89-95 .

4 1 . A p p e l q v i s t P , S a l m o M . L y e c o r r o s i o n c a r c i n o m a o f t h eesophagus : a r ev iew of 63 cases . Cancer 1980 ;45 :2655-8 .

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4 5 . D r u m m B , S h e r m a n P , C u t z E , e t a l. A s s o c i a ti o n o f Campy-lobacter pylori o n t h e g a s t r i c m u c o s a w i t h a n t r a l g a s t r i t i s i nc h i l d r e n . N E n g l J M e d 1 9 8 7 ; 3 16 : 1 5 5 7 -6 1 .

4 6 . A r a s u T , W y l l i e R , F i t z g e r a l d J F , e t a l. G a s t r o e s o p h a g e a l r e -f lu x i n i n f a n t s a n d c h i l d r e n : c o m p a r a t i v e a c c u r a c y o f d i a g n o s -t ic m ethod s. J PEDIATR 1980;96:798-803.

4 7 . B i l l er J A , W i n t e r H S , G r a n d R J , A l t r e d E N . A r e e n d o s c o p i cchan ges p red ic t ive o f h i s to log ic esophag i t i s in ch i ld ren ? J PE-DIATR 1983;1 03:2t 5-8.

4 8 . B a r r e t t - D a h m s B , R o t h s t e i n F C . B a r r e t t ' s e s o p h a g u s i n ch i l -d r e n : a c o n s e q u e n c e o f c h r o n i c g a s t r o e s o p h a g e a l r e f l ux . G a s -t roen te ro logy 1984 ;86 :318-23 .

4 9 . H a s s a l l E , W e i n s t e i n W M , A m e n t M E . B a r r e t t ' s e s o p h a g u s i nch i ldhood . Gas t roen te ro logy 1985 ;89 :1331-7 .

5 0 . R e i m a n n J F , K o c h H . E n d o s c o p y o f t h e b i l i a ry t r a c t a n d p a n -c reas in ch i ld ren . Endoscopy 1978 ;10 :166-72 .

5 1 . C o t t o n P B , L a n g e N G . E n d o s c o p i c r e t r o g r a d e c h o l a n g i o p a n -e rea tography in ch i ld ren . Arch Dis Chi ld 1982 ;131 :6 .

5 2 . G u e l r u d M , J a e n D , T o r r e s P , e t a l . E n d o s c o p i c c h o l a n g i o p a n -c r e a t o g r a p h y i n t h e i n f a n t : e v a l u a t i o n o f a n e w p r o t o t y p e p e -d ia t r i c duodenoscope . Gas t ro in tes t Endosc 1987 ;33 :4 -8 .

5 3 . A l l e n d o r p h M , W e r l i n S L , G r e e n e n J E , e t a l . E n d o s c o p ic r e t-r o g r a d e c h o l a n g i o p a n e r e a t o g r a p h y i n c h i l d r e n , J P E D I A T R1987;110:206-11.5 4. G a u d e r e r M W L , P o n s k y J L , I z a n t R J . G a s t r o s t om y w i t h o u tl a p a r o t o m y : a p e r c u t a n e o u s e n d o s c o p i c t e c h n i q u e . J P e d i a t rSurg 1980;15:872-5.

5 5 . M a g o H , C h e n C L , W e s s o n D E , F i l l e r R M , I n c i s io n l e s s g a s -t r o s t o m y f o r n u t r i t i o n a l s u p p o r t . J P e d i a t r G a s t r o e n t e r o l N u t r1986;5:66-9.

5 6 . M o l l i t t D L , G o l l i d a y E S , S i e b e r t J J . S y m p t o m a t i c g a s t r o -esophagea l r e f lux fo l lowing gas t ros tomy in neuro log ica l ly im-pa i red pa t i en t s . Ped ia t r i c s 1985 ;75 :1124-6 .