Guideline

Pediatric gastrointestinal endoscopy: European

Society of Gastrointestinal Endoscopy (ESGE) and
European Society for Paediatric Gastroenterology
Hepatology and Nutrition (ESPGHAN) Guideline
Executive summary
Authors Andrea Tringali1, *, Mike Thomson2, *, Jean-Marc Dumonceau3, Marta Tavares4, Merit M. Tabbers5, Raoul Furlano6,
Manon Spaander7, Cesare Hassan8, Christos Tzvinikos9, Hanneke Ijsselstijn10, Jérôme Viala11, Luigi Dall’Oglio12,
Marc Benninga5, Rok Orel13, Yvan Vandenplas4, Radan Keil15, Claudio Romano16, Eva Brownstone17, Štěpán Hlava15,
Patrick Gerner18, Werner Dolak19, Rosario Landi1, Wolf Dietrich Huber19, Simon Everett20, Andreas Vecsei21,
Lars Aabakken22, Jorge Amil-Dias4, Alessandro Zambelli23

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Institutions Institutions are listed at end of article.

Bibliography This Executive summary of the Guideline on pe- management of corrosive ingestion and stricture/
DOI http://dx.doi.org/ diatric gastrointestinal endoscopy from the Euro- stenosis; upper and lower gastrointestinal bleed-
10.1055/s-0042-111002
pean Society of Gastrointestinal Endoscopy ing; endoscopic retrograde cholangiopancreato-
Published online: 2016
(ESGE) and the European Society for Paediatric graphy, and endoscopic ultrasonography. Percu-
Endoscopy
© Georg Thieme Verlag KG Gastroenterology Hepatology and Nutrition (ESP- taneous endoscopic gastrostomy and endoscopy
Stuttgart · New York GHAN) refers to infants, children, and adolescents specific to inflammatory bowel disease (IBD)
ISSN 0013-726X aged 0 – 18 years. The areas covered include: indi- have been dealt with in other Guidelines and are
cations for diagnostic and therapeutic esophago- therefore not mentioned in this Guideline. Train-
Corresponding author
Andrea Tringali, MD PhD
gastroduodenoscopy and ileocolonoscopy; ing and ongoing skill maintenance will be addres-
Digestive Endoscopy Unit endoscopy for foreign body ingestion; endoscopic sed in an imminent sister publication.
Catholic University
Largo A. Gemelli 8
00168 Rome Abbreviations Time definitions
Italy ! !
Fax: +39-6-30157220
AUGIB acute upper gastrointestinal bleeding Emergent/emergency < 2 hours
[email protected]
CT computed tomography Urgent/urgently < 12 hours or < 24 hours
EGD esophagogastroduodenoscopy and defined in text
ERCP endoscopic retrograde cholangio- Early < 48 hours but may be at clinician’s
This Executive summary and pancreatography discretion
the full Guideline are ESGE European Society of Gastrointestinal
published simultaneously in
Endoscopy
Endoscopy and the Journal of
Pediatric Gastroenterology
ESPGHAN European Society for Paediatric Introduction
Gastroenterology Hepatology and !
and Nutrition, respectively.
Copyright 2016 © Georg Nutrition Gastrointestinal (GI) endoscopy in the pediatric
Thieme Verlag KG and EBUS endobronchial ultrasound population has evolved during the last 30 years
© Wolters Kluwer. EUS endoscopic ultrasonography with an increasing number of diagnostic and
FCSEMS fully covered self-expandable metal therapeutic applications. Technological improve-
stent ments in endoscope design and endoscopic devi-
GI gastrointestinal ces have contributed to the evolution of pediatric
GRADE Grading of Recommendations Assess- endoscopy.
ment, Development and Evaluation Endoscopy in the pediatric population has gener-
GVHD graft-versus-host disease ally, to date, been performed by both non-pedia-
IBD inflammatory bowel disease tric endoscopists in conjunction with pediatri-
MMC mitomycin C cians and by pediatric endoscopists in specialized
NSAID non-steroidal anti-inflammatory drug centers.
RCT randomized controlled trial This document is the Executive summary of the
TAC triamcinolone acetonide Guideline on pediatric GI endoscopy [1] commis-
VCE video capsule endoscopy sioned by the European Society for Paediatric
Gastroenterology Hepatology and Nutrition (ESP-
GHAN) and the European Society of Gastrointesti-
nal Endoscopy (ESGE). The aims of the evidence-
* Co-First authors based and consensus-based Guideline are to pro-

Tringali Andrea et al. Guideline on pediatric endoscopy: Executive summary … Endoscopy

 Guideline

vide a comprehensive review of the clinical indications and tim- ESGE Governing Board, ESGE individual members and the ESP-
ing of diagnostic and therapeutic endoscopy in pediatric patients. GHAN Council.
It is not meant to be a comprehensive overview of a patient’s The manuscript was then submitted to the Journal of Pediatric
care, and investigation/therapy for each area will, of course, in- Gastroenterology and Nutrition for publication in full length and
volve the clinician’s discretion regarding the place of endoscopy to Endoscopy for publication of the Executive summary.
in overall management, encompassing, as it must, complemen- Both the Guideline and Executive summary were issued in 2016
tary non-endoscopic approaches. The role of endoscopy in the and will be considered for review and update in 2021 or sooner if
overall management will depend on a number of factors, includ- new and relevant evidence becomes available. Any updates to the
ing but not limited to the specific clinical features, the availabil- Guideline or Executive summary in the interim will be noted on
ity/appropriateness of non-endoscopic approaches, and the the ESGE and ESPGHAN websites: http://www.esge.com/esge-
available skills of the endoscopist. This Guideline tries to address guidelines.html and http://www.espghan.org/guidelines/
this issue of endoscopist skills, and certainly the upcoming ESP-
GHAN/ESGE Guideline on training in pediatric endoscopy will
help in this respect. How, where, and when endoscopy may be Recommendations
employed in pediatric management is particularly important in !

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the areas of GI bleeding and endoscopic retrograde cholangio- Esophagogastroduodenoscopy (EGD)
pancreatography/endoscopic ultrasound (ERCP/EUS). ESGE/ESPGHAN suggest diagnostic and therapeutic EGD for the
This undertaking is the first joint endoscopy review between pe- indications listed in ● ●
" Table 1 and " Table 2, respectively. (Weak

diatric and adult endoscopy representative groups in Europe. Our recommendation, low quality evidence.)
aspiration is that this Guideline may lead to a degree of standar- ESGE/ESPGHAN do not suggest EGD in the case of uncomplicated
dization in the utility and practice of endoscopic approaches for gastroesophageal reflux, functional gastrointestinal disorders, or
children, thereby contributing to excellence and appropriateness for diagnosing perforation. (Weak recommendation, low quality
of care. evidence.)
Percutaneous endoscopic gastrostomy and endoscopy specific to ESGE/ESPGHAN suggest routine tissue sampling even in the ab-
inflammatory bowel disease (IBD) have been dealt with in other sence of visible endoscopic abnormalities in all children under-
Guidelines [2 – 4], and are therefore not mentioned in the pedia- going EGD. (Weak recommendation, low quality evidence.)
tric GI endoscopy Guideline. Training and ongoing skill mainte-
nance will be addressed in an imminent sister publication.
Table 1 Typical diagnostic and therapeutic indications, non-indications,
and contraindications for esophagogastroduodenoscopy (EGD) in pediatric
Methods patients.
! Diagnostic indications Weight loss, failure to thrive
ESGE and ESPGHAN agreed to develop a joint guideline. Two Unexplained anemia
guideline leaders (A.T. for ESGE and M.T. for ESPGHAN) invited Abdominal pain with suspicion of
the listed authors to participate in the project. The key questions an organic disease
were prepared by the coordinating team (A.T., M.T., M.M.T., R.F., Dysphagia or odynophagia
Caustic ingestion
Y.V., J.-M.D.) and then approved by the other members. The coor-
Recurrent vomiting with unknown cause
dinating team established task force subgroups, each with its
Hematemesis
own leader, and assigned the following key topics among the
Hematochezia
task forces: esophagogastroduodenoscopy (EGD) and ileocolono-
Unexplained chronic diarrhea
scopy; foreign bodies; corrosive ingestion; corrosive ingestion Suspicion of graft versus host disease
and esophageal strictures/stenoses; GI bleeding; endoscopic Chronic GERD, to exclude other diseases,
retrograde cholangiopancreatography (ERCP); and endoscopic or surveillance of Barrett’s esophagus
ultrasonography (EUS). Each task force performed a systematic
literature search to prepare evidence-based and well-balanced Therapeutic indications Percutaneous endoscopic gastrostomy
statements on their assigned key questions. Searches were per- (re)placement
formed in PubMed and/or EMBASE and/or Cochrane (publication Duodenal tube placement
date from 2000 to May 2015, or before if strictly needed), includ- Foreign body removal
Food impaction
ing as a minimum the key words “pediatric” and “endoscopy.” All
Hemostasis
articles studying the application of diagnostic and therapeutic
Percutaneous jejunostomy placement
endoscopy in the pediatric age range were selected by title or ab-
Esophageal varices
stract. The results of the relevant publications were summarized Dilation of esophageal or upper GI stric-
in literature tables and graded by the level of evidence and tures
strength of recommendation according to the Grading of Recom- Perforation
mendations Assessment, Development and Evaluation (GRADE) Achalasia
system [5, 6]. Each task force proposed statements on their as- Polypectomy
signed key questions which were discussed and voted on during
the plenary meeting held in February 2015 in Munich. In Novem- Non-indications Uncomplicated GERD
ber 2015, a draft prepared by A.T., C.H. and M.T. was sent to all Functional GI disorders
group members. After agreement from all the authors on a final
Contraindications To diagnose perforation
version, the manuscript was reviewed by two members of the
GERD, gastroesophageal reflux disease; GI, gastrointestinal

Tringali Andrea et al. Guideline on pediatric endoscopy: Executive summary … Endoscopy

 Guideline

Table 2 Diagnostic indications for esophagogastroduodenoscopy (EGD) in Table 5 Typical diagnostic and therapeutic indications, non-indications,
pediatric patients: symptoms/signs according to suspected disease. and contraindications for ileocolonoscopy in pediatric patients.

Symptoms/signs Suspicion of: Diagnostic indications Unexplained anemia

Unexplained chronic diarrhea
Weight loss, failure to thrive, Celiac disease or IBD, giardiasis,
Perianal lesions (fistula, abscess)
chronic diarrhea, malabsorption, allergic enterocolitis, bleeding
Rectal blood loss
anemia, abdominal pain with lesions, graft versus host disease
Unexplained failure to thrive
suspicion of an organic disease
Suspicion of graft versus host disease
Dysphagia, odynophagia, chest Foreign body ingestion, food
Rejection or complications after intes-
pain, feeding difficulty impaction, caustic ingestion or
tinal transplantation
eosinophilic esophagitis
Radiological suspicion of ileocolonic
Hematemesis, hematochezia, Polyps, angiodysplasia, arterio-
stenosis/stricture
melena venous malformations, peptic ulcer
Polyposis syndromes
with or without Helicobacter pylori
infection, less common conditions
such as duplication cysts Therapeutic indications Polypectomy
Family history of polyposis Polyps (diagnostic and surveillance) Dilation of ileocolonic stenosis

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syndromes Treatment of hemorrhagic lesions
Foreign body removal
IBD, inflammatory bowel disease.
Reduction of sigmoidal volvulus

Table 3 Indication and site for tissue sampling during upper and lower Non-indications Functional GI disorders
endoscopy in pediatric patients. Constipation

Indication Tissue samples: sites and numbers Contraindications Toxic megacolon

Eosinophilic At least 3 biopsies should be taken, one from Recent colonic perforation
esophagitis proximal mid and distal esophagus, regardless of Recent intestinal resection (< 7 days)
the endoscopic appearance of the esophagus GI, gastrointestinal.
Helicobacter pylori 2 biopsies from both the antrum and the corpus (±
infection fundus)
Celiac disease At least 1 biopsy from the duodenal bulb and at least
4 biopsies from the second or third portion of the
duodenum ESGE/ESPGHAN suggest performing EGD in a child-friendly set-
IBD Multiple biopsies (2 or more per section) from ting with appropriate equipment and by an endoscopist trained
all sections of the visualized GI tract, even in the in pediatric gastroenterology. (Weak recommendation, low qual-
absence of macroscopic lesions ity evidence.)
IBD, inflammatory bowel disease; GI, gastrointestinal. ESGE/ESPGHAN suggest that when adult endoscopists perform
pediatric procedures, collaboration between adult gastroenterol-
ogists and pediatricians is always warranted. (Weak recommen-
ESGE/ESPGHAN suggest using ESPGHAN guidelines (on eosino- dation, low quality evidence.)
philic esophagitis, Helicobacter pylori, celiac disease, and inflam- ESGE/ESPGHAN suggest that the choice of gastroscope type
matory bowel disease [IBD]) for precise indications and preferred should depend on the child’s weight and age (● " Table 4). (Weak

sites for biopsy during EGD in children suspected of a specific dis- recommendation, low quality evidence.)
ease (●" Table 3). (Weak recommendation, low quality evidence.)

ESGE/ESPGHAN suggest performing EGD in children under gener- Ileocolonoscopy

al anesthesia or, only if general anesthesia is not available, under ESGE/ESPGHAN suggest ileocolonoscopy for the diagnostic and
deep sedation in a carefully monitored environment. (Weak re- therapeutic indications listed in ●
" Table 5. (Weak recommenda-

commendation, low quality evidence.) tion, low quality evidence.)

Table 4 Types of endoscopes used in pediatric patients according to body weight, age, and procedure.

EGD Colonoscopy ERCP EUS

Weight or age
< 10 kg or < 1 year ≤ 6 mm gastroscope preferred. ≤ 6 mm gastroscope, standard 7.5 mm duodenoscope Miniprobe or 7.4 mm
Consider standard adult adult gastroscope, or pediatric EBUS scope.
gastroscope if endotherapy colonoscope.
required.
≥ 10 kg or ≥ 1 year Standard adult gastroscope. Pediatric or adult colonoscope. Therapeutic duodenoscope Miniprobe or 7.4 mm
Therapeutic gastroscope if (4.2 mm operative channel) EBUS scope.
needed.
≥ 15 kg or ≥ 3 years – – – Adult radial/linear
echoendoscope
EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasonography; EBUS, endobronchial ultrasound.

Tringali Andrea et al. Guideline on pediatric endoscopy: Executive summary … Endoscopy

 Guideline

ESGE/ESPGHAN suggest against ileocolonoscopy in the case of ESGE/ESPGHAN suggest early EGD if the foreign body is in the
toxic megacolon, recent colonic perforation (< 28 days), recent esophagus. (Weak recommendation, low quality evidence.)
intestinal resection (< 7 days), or functional GI disorders. (Weak
recommendation, low quality evidence.) Blunt foreign bodies and coins
ESGE/ESPGHAN suggest performing ileocolonoscopy in children ESGE/ESPGHAN recommend removal of blunt foreign bodies and
under general anesthesia or, only if general anesthesia is not coins or impacted food from the esophagus urgently (< 24 hours),
available, under deep sedation in a carefully monitored environ- even in asymptomatic children. If the child is symptomatic an
ment. (Weak recommendation, low quality evidence.) emergent (< 2 hours) removal is indicated especially for button
ESGE/ESPGHAN suggest that ileocolonoscopy should be per- batteries. (Strong recommendation, moderate quality evidence.)
formed in a child-friendly setting with appropriate equipment ESGE/ESPGHAN suggest removal of blunt foreign bodies from the
and by an endoscopist trained in pediatric gastroenterology. stomach or duodenum if the child is symptomatic or if the object
(Weak recommendation, low quality evidence.) is wider than 2.5 cm in diameter or > 6 cm in length. Otherwise,
ESGE/ESPGHAN suggest that when non-pediatric endoscopists blunt foreign bodies in the stomach can be followed and retrieved
perform pediatric procedures in older children, collaboration only if they produce symptoms or do not pass spontaneously
with a pediatrician is always warranted. (Weak recommendation, after 4 weeks. (Weak recommendation, low quality evidence.)

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low quality evidence.)
ESGE/ESPGHAN suggest that the choice of colonoscope type Sharp-pointed objects
should depend on the child’s weight and age (● " Table 4). (Weak ESGE/ESPGHAN recommend emergent (< 2 hours) removal of
recommendation, low quality evidence.) sharp-pointed objects located in the esophagus (all cases).
(Strong recommendation, moderate quality evidence.)
Bowel preparation for ileocolonoscopy in children ESGE/ESPGHAN recommend emergent (< 2 hours) removal of
ESGE/ESPGHAN recommend low-volume preparation for bowel sharp-pointed objects in the stomach or proximal duodenum
cleansing in children, using either polyethylene glycol plus ascor- even in asymptomatic children. (Strong recommendation, mod-
bate or picosulphate plus magnesium citrate/Senokot. (Strong re- erate quality evidence.)
commendation, high quality evidence.)
ESGE/ESPGHAN recommend against the use of sodium phosphate Batteries
for bowel cleansing. (Strong recommendation, high quality evi- ESGE/ESPGHAN recommend to emergently (< 2 hours) remove
dence.) button batteries impacted in the esophagus. (Strong recommen-
dation, low quality evidence.)
Ileocolonoscopy in children: biopsy, carbon dioxide ESGE/ESPGHAN suggest to remove button batteries in the stom-
insufflation, ileal intubation, polypectomy technique ach emergently (< 2 hours) if the child is symptomatic and/or
ESGE/ESPGHAN suggest routine biopsy even in the absence of has a known or suspected anatomical pathology in the GI tract
visible endoscopic abnormalities in all children with suspected (e. g. Meckel’s diverticulum), and/or has simultaneously swal-
IBD undergoing ileocolonoscopy. (Weak recommendation, low lowed a magnet. (Weak recommendation, low quality evidence.)
quality evidence.) ESGE/ESPGHAN suggest that button batteries larger than > 20 mm
ESGE/ESPGHAN suggest using ESPGHAN guidelines relating to ul- present in the stomach should be checked by radiography and re-
cerative colitis and the revised Porto criteria for diagnosis of IBD moved if still in place after more than 48 hours. (Weak recom-
for precise indications and preferred sites to biopsy. (Weak re- mendation, low quality evidence.)
commendation, low quality evidence.) ESGE/ESPGHAN recommend an urgent endoscopic removal
ESGE/ESPGHAN did not find any evidence to recommend against (< 24 hours) for single cylindrical battery ingestion when impac-
or for the use of routine carbon dioxide insufflation during ileo- ted in the esophagus and as soon as possible elsewhere in the GI
colonoscopy in children. Pain seems to be rare and mild after tract when the child is symptomatic. (Strong recommendation,
ileocolonoscopy in children. (Weak recommendation, low quality moderate quality evidence.)
evidence.) ESGE/ESPGHAN suggest that a single cylindrical battery in the
ESGE/ESPGHAN suggest that ileal intubation should be attempted stomach can be observed and the child monitored as an out-
in symptomatic children with abdominal pain, intestinal bleed- patient and followed by X-ray 7 – 14 days after ingestion if the
ing, diarrhea, or with any suspicion of IBD. (Weak recommenda- battery is not passed in the stool. (Weak recommendation, low
tion, low quality evidence.) quality evidence.)
ESGE/ESPGHAN suggest removal of very small polyps (< 3 mm) by
cold biopsy forceps and 3 – 8 mm polyps by hot or cold snaring. Magnets
Cold snaring is advisable in the right colon where the perforation ESGE/ESPGHAN recommend urgent (< 24 hours) removal of all
risk is higher. For polyps > 8 mm, hot snaring is suggested. (Weak magnets within endoscopic reach. For those beyond endoscopic
recommendation, low quality evidence.) reach, close observation and surgical consultation for non-pro-
gression through the GI tract is advised. (Strong recommenda-
Foreign body ingestion tion, moderate quality evidence.)
ESGE/ESPGHAN recommend an early referral to the emergency
room and X-ray evaluation in all patients with suspected foreign Food bolus impaction
body ingestion even if asymptomatic. Biplane radiographs should ESGE/ESPGHAN recommend removal of impacted food from the
be obtained of the neck, chest, abdomen, and pelvis if indicated. esophagus as an emergency 2 hours from the time of presenta-
Computed tomography (CT) scan can be considered for radiolu- tion (and ideally from the time of ingestion) in case of symptoms
cent foreign bodies. (Strong recommendation, moderate quality (drooling, neck pain). If the child is asymptomatic an urgent
evidence.)

Tringali Andrea et al. Guideline on pediatric endoscopy: Executive summary … Endoscopy

 Guideline

(< 24 hours) removal is indicated. (Strong recommendation, mod- 4 weeks once the age-appropriate feeding diameter has been
erate quality evidence.) achieved (recurrent).” (Weak recommendation, very low level of
ESGE/ESPGHAN suggest investigation for underlying pathology of evidence.)
the esophagus in all cases of food impaction. (Weak recommen- ESGE/ESPGHAN suggest temporary stent placement or applica-
dation, low quality evidence.) tion of topical mitomycin C (MMC) following dilation for refrac-
tory esophageal stenosis in children. ESGE/ESPGHAN do not sug-
Drug packets gest the routine use of intralesional steroids for refractory esoph-
ESGE/ESPGHAN recommend against endoscopic removal of drug- ageal stenosis in children. (Weak recommendation, low quality
containing packets. (Strong recommendation, low quality evi- evidence.)
dence.) In patients operated for esophageal atresia, ESGE/ESPGHAN sug-
gest long-term endoscopic surveillance for Barrett’s esophagus
Equipment for removal of foreign bodies and cancer. Frequency would be dictated by the presence or not
ESGE/ESPGHAN suggest that flexible endoscopy is an effective of dysplasia and should follow standard guidelines already pub-
and safe procedure for removing foreign bodies from the GI tract, lished in the literature. (Weak recommendation, low quality evi-
with a high success rate using retrieval nets, polypectomy snares, dence.)

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and rat-tooth forceps. (Weak recommendation, very low quality
evidence.) Upper and lower GI bleeding
ESGE/ESPGHAN suggest that, having employed all necessary med-
Corrosive ingestion ical interventions as standard, EGD be performed very early
ESGE/ESPGHAN suggest that every child that has ingested a corro- (≤ 12 h) in acute upper GI bleeding (AUGIB) cases which require
sive substance should have a thorough follow-up, with endos- ongoing circulatory support or where a large hematemesis or
copy dictated only by symptoms, and dependent on the symp- melena occurs. (Weak recommendation, low quality evidence.)
toms the timing should be within 24 hours. (Strong recommen- ESGE/ESPGHAN recommend that, having employed all necessary
dation, high quality evidence.) medical interventions as standard, EGD be performed very early
ESGE/ESPGHAN recommend that every child with a suspected (< 12 h) in AUGIB in cases with known esophageal varices. (Strong
caustic ingestion and symptoms/signs (any oral lesions, vomiting, recommendation, moderate quality evidence.)
drooling, dysphagia, hematemesis, dyspnea, abdominal pain, etc) ESGE/ESPGHAN suggest that, having employed all necessary med-
should have an EGD in order to identify all consequent digestive ical interventions as standard, EGD be performed within 24 hours
tract lesions. (Strong recommendation, high quality evidence.) in AUGIB cases which require transfusion due to hemoglobin
ESGE/ESPGHAN suggest that in the case of suspected corrosive in- drop below 8 g/dL, where an acute drop of 2 g/dL is identified,
gestion EGD is withheld if the child is asymptomatic (no drooling and in those who are stable but whose bleeding score is above a
of saliva/other symptoms and no mouth lesions) and that ade- recognized threshold/validated score for probable endoscopic in-
quate follow-up is assured. (Weak recommendation, moderate tervention requirement. (Weak recommendation, moderate
quality evidence.) quality evidence.)
ESGE/ESPGHAN recommend to have the same grade of suspicion ESGE/ESPGHAN suggest that EGD be performed before hospital
for both acidic and alkali ingestion regarding potential mucosal discharge in children with AUGIB and pre-existing liver disease
injury. (Alkali ingestion, especially lye, is associated with more se- or portal hypertension. (Weak recommendation, low quality evi-
vere esophageal lesions and severe gastric lesions can occur in dence.)
acidic ingestion.) Stricture development has been associated ESGE/ESPGHAN do not suggest routine use of wireless capsule
with both acidic and alkali ingestion. (Strong recommendation, endoscopy/enteroscopy in AUGIB in children. (Weak recommen-
high quality evidence.) dation, moderate quality evidence.)
ESGE/ESPGHAN recommend high doses of intravenous dexame- ESGE/ESPGHAN suggest that urgent (24 hours) therapeutic ileo-
thasone (1 g/1.73 m2 per day) administration for a short period colonoscopy is not usually necessary in lower GI bleeding unless
(3 days) in IIb esophagitis after corrosive ingestion as a method severe enough to cause circulatory compromise but diagnostic
of preventing the development of esophageal stricture. There is ileocolonoscopy is needed as soon as is practical and safe. (Weak
no evidence of benefit for the use of corticosteroids in other recommendation, weak quality evidence.)
grades of esophagitis (I, IIa, III). (Strong recommendation, moder-
ate quality evidence.) Endoscopic hemostasis technique for GI bleeding
in children
Benign esophageal strictures ESGE/ESPGHAN recommend hemostasis of esophageal variceal
ESGE/ESPGHAN recommend esophageal dilation using balloon or bleeding in children, using band ligation, if feasible, or sclerother-
bougies for benign esophageal strictures only when symptoms apy as an alternative. (Strong recommendation, moderate quality
occur. (Strong recommendation, low quality evidence.) evidence.)
ESGE/ESPGHAN suggest the following definition of a benign re- ESGE/ESPGHAN suggest that the treatment of peptic ulcers and
fractory or recurrent stricture in children: “An anatomic restric- Dieulafoy’s lesion should not be carried out with epinephrine in-
tion because of cicatricial luminal compromise or fibrosis that re- jection alone but in combination with thermal or mechanical
sults in dysphagia in the absence of endoscopic evidence of in- techniques. (Weak recommendation, low quality evidence.)
flammation. This may occur as the result of either an inability to ESGE/ESPGHAN suggest adopting general anesthesia in children
successfully remediate the anatomic problem to obtain age-ap- undergoing endoscopy for GI bleeding. General anesthesia is re-
propriate feeding possibilities after a maximum of 5 dilation ses- commended in the case of variceal bleeding. Deep sedation may
sions (refractory) with maximal 4-week intervals, or as a result of be used in less severe bleeding in older children. (Weak recomen-
an inability to maintain a satisfactory luminal diameter for dation, low quality evidence.)

Tringali Andrea et al. Guideline on pediatric endoscopy: Executive summary … Endoscopy

 Guideline

ESGE/ESPGHAN suggest using video capsule endoscopy (VCE) in Prophylaxis of post-ERCP pancreatitis with non-steroidal anti-
children in the case of suspected small-intestinal bleeding and inflammatory drugs (NSAIDs) (diclofenac/indomethacin
in addition balloon enteroscopy for therapeutic purposes. (Weak suppository) is recommended in children older than 14 years.
recommendation, moderate quality evidence.) (Strong recommendation, high quality evidence.)
Protection of radiosensitive organs (thyroid gland, breasts, go-
Endoscopic retrograde cholangiopancreatography nads and eyes) is recommended together with adjustment of
(ERCP) collimation to the smaller size of children. (Strong recommenda-
ESGE/ESPGHAN suggest ERCP in pediatric patients (> 1-year-old) tion, high quality evidence.)
for therapeutic purposes following diagnostic information from ESGE/ESPGHAN recommend the pediatric 7.5-mm duodenoscope
non-invasive diagnostic modalities such as magnetic resonance for children weighing < 10 kg and that a therapeutic duodeno-
cholangiopancreatography (MRCP). Diagnostic ERCP can be con- scope can be used in those weighing ≥ 10 kg. (Strong recommen-
sidered in selected cases where advanced non-invasive imaging dation, low quality evidence.)
is inconclusive. (Weak recommendation, low quality evidence.)
ESGE/ESPGHAN recommend that therapeutic ERCP in pedia- Endoscopic ultrasonography (EUS)
tric patients (> 1-year-old) is considered for diseases listed in The endobronchial ultrasound (EBUS) endoscope can be adapted
●" Table 6 following diagnostic information from non-invasive

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for EUS in children with a weight below 15 kg. A standard linear
modalities such as MRCP. Results and complication rates of ERCP echoendoscope should only be employed in children under gen-
in children are similar to those reported in adults. (Weak recom- eral anesthesia, considering the stiff and potentially traumatic
mendation, low quality evidence.) distal part. (Weak recommendation, low quality evidence.)
ESGE/ESPGHAN suggest that diagnostic ERCP in neonates and in- ESGE/ESPGHAN suggest the use of EUS in children only in tertiary
fants (≤ 1-year-old) with cholestatic hepatobiliary disease is con- referral centers with experience in therapeutic endoscopy. Strict
sidered if non-invasive investigations are not conclusive in order collaboration between adult and pediatric gastroenterologists is
to allow timely referral to surgery for suspected biliary atresia or required in the case of EUS with standard echoendoscopes.
to avoid unnecessary surgery if biliary atresia is excluded. (Weak (Weak recommendation, low quality evidence.)
recommendation, low quality evidence.) ESGE/ESPGHAN suggest the use of radial EUS with mini-probes to
ESGE/ESPGHAN recommend that ERCP in children is performed diagnose congenital esophageal strictures (tracheobronchial
by an experienced endoscopist, in a high-volume tertiary care remnants vs. fibromuscular stenosis subtypes). (Weak recom-
center, and with pediatric involvement. (Strong recommenda- mendation, very low quality evidence.)
tion, moderate quality evidence.) ESGE/ESPGHAN suggest consideration of EUS for the diagnosis
ESGE/ESPGHAN suggest general anesthesia for ERCP in children. of pancreaticobiliary diseases in children where non-invasive
Deep/conscious sedation can be considered for teenagers (age imaging modalities (ultrasonography, MRCP) are inconclusive
12 – 17 years) although general anesthesia is the preferred choice. (●
" Table 7). (Weak recommendation, very low quality evidence.)

(Weak recommendation, low quality evidence.)

Table 6 Typical indications for ERCP in pediatric patients.

Biliary Pancreatic

Diagnostic Therapeutic Diagnostic Therapeutic

Cholestasis in neonates and infants Common bile duct stones Evaluation of anomalous Chronic pancreatitis
biliopancreatic junction
Choledochal cyst Bile leak Recurrent acute pancreatitis
(post-surgical/post-traumatic)
Primary sclerosing cholangitis Benign biliary strictures Pancreas divisum
(brush cytology)
Primary sclerosing cholangitis Pancreatic duct leak
(post-surgical/post-traumatic)
Malignant biliary strictures Pancreatic pseudocyst
Parasitosis
(ascariasis, fascioliasis)
ERCP, endoscopic retrograde cholangiopancreatography

Table 7 Typical indications for endoscopic ultrasonography in pediatric patients.

Esophagus Stomach Duodenum Biliopancreatic

Congenital esophageal stenosis Gastric duplication Duodenal duplication Bile duct stones
Eosinophilic esophagitis Gastric varices Pancreatic pseudocyst
(diagnosis and treatment)
Esophageal duplications Pancreatic diseases (± FNA)
FNA, fine-needle aspiration.

Tringali Andrea et al. Guideline on pediatric endoscopy: Executive summary … Endoscopy

 Guideline

ESGE/ESPGHAN suggest that EUS-guided drainage of pancreatic as a clinical investigator and/or advisory board member and/or
pseudocysts in children should be performed in large EUS centers consultant and/or speaker for any company.
with specific experience and expertise. (Weak recommendation, R.K. has not participated as a clinical investigator and/or advisory
low quality evidence.) board member and/or consultant and/or speaker for any compa-
ny.
C.R. has not participated as a clinical investigator and/or advisory
ESGE and ESPGHAN guidelines represent a consensus of best board member and/or consultant and/or speaker for any compa-
practice based on the available evidence at the time of prepara- ny.
tion. They may not apply in all situations and should be interpret- E.B. has not participated as a clinical investigator and/or advisory
ed in the light of specific clinical situations and resource availabil- board member and/or consultant and/or speaker for any compa-
ity. Further controlled clinical studies may be needed to clarify ny.
aspects of these statements, and revision may be necessary as S.H. has not participated as a clinical investigator and/or advisory
new data appear. Clinical considerations may justify a course of board member and/or consultant and/or speaker for any compa-
action at variance to these recommendations. ESGE and ny.
ESPGHAN guidelines are intended to be an educational device to W.D. has not participated as a clinical investigator and/or advi-

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
provide information that may assist endoscopists in providing sory board member and/or consultant and/or speaker for any
care to patients. They are not rules and should not be construed company.
as establishing a legal standard of care or as encouraging, advo- W-D.H. has not participated as a clinical investigator and/or advi-
cating, requiring, or discouraging any particular treatment. sory board member and/or consultant and/or speaker for any
company.
Competing interests: M.Th. has participated as a clinical investi- S.E. has participated as a clinical investigator and/or advisory
gator and/or advisory board member and/or consultant and/or board member and/or consultant and/or speaker for Olympus.
speaker and/or for Danone/Nutricia, Nestlé, Mead Johnson, A.V. has not participated as a clinical investigator and/or advisory
Movetis, Jannsen, Norgine, Reckitt-Benkeiser, Cook, Olympus_- board member and/or consultant and/or speaker for any compa-
KeyMed, Fujinon, Storz, Pentax and Boston-Scientific. ny.
A.T. has participated as a clinical investigator and/or advisory L.A. has not participated as a clinical investigator and/or advisory
board member and/or consultant and/or speaker for Boston Sci- board member and/or consultant and/or speaker for any compa-
entific. ny.
J-M. D. has not participated as a clinical investigator and/or advi- J. A-D. has participated as a clinical investigator and/or advisory
sory board member and/or consultant and/or speaker for any board member and/or consultant and/or speaker for Danone/Nu-
company. tricia, Astra Zeneca and Prospectos.
M. Tav. has not participated as a clinical investigator and/or advi- A.Z. has not participated as a clinical investigator and/or advisory
sory board member and/or consultant and/or speaker for any board member and/or consultant and/or speaker for any compa-
company. ny.
M. Tab. has not participated as a clinical investigator and/or advi-
sory board member and/or consultant and/or speaker for any
company. Institutions
1
R.F. has not participated as a clinical investigator and/or advisory Digestive Endoscopy Unit, Catholic University, Rome, Italy
2
International Academy for Paediatric Endoscopy Training, Sheffield Children’s
board member and/or consultant and/or speaker for any compa- Hospital, Weston Bank, Sheffield, UK
ny. 3
Gedyt Endoscopy Center, Buenos Aires, Argentina
4
M.S. has not participated as a clinical investigator and/or advisory Department of Pediatric Gastroenterology, Centro Hospitalar de São João,
Porto, Portugal
board member and/or consultant and/or speaker for any compa- 5
Department of Pediatric Gastroenterology, Emma Children’s Hospital,
ny. Academic Medical Center, Amsterdam, The Netherlands
6
C.H. has not participated as a clinical investigator and/or advisory Department of Pediatric Gastroenterology and Nutrition, University
Children’s Hospital Basel, Switzerland
board member and/or consultant and/or speaker for any compa- 7
Department of Gastroenterology, Erasmus MC Cancer Institute, Rotterdam,
ny. The Netherlands
8
C.T. has not participated as a clinical investigator and/or advisory Department of Gastroenterology, Nuovo Regina Margherita Hospital, Rome,
Italy
board member and/or consultant and/or speaker for any compa- 9
Department of Pediatric Gastroenterology, Alder Hey Children’s Hospital,
ny. Liverpool, UK
10
Department of Pediatric Surgery and Intensive Care, Erasmus MC, Sophia
H.I. has not participated as a clinical investigator and/or advisory
Children’s Hospital, Rotterdam, The Netherlands
board member and/or consultant and/or speaker for any compa- 11
Department of Pediatric Gastroenterology, Robert-Debré Hospital, Paris,
ny. France
12
Digestive Endoscopy and Surgery Unit, Bambino Gesù Children’s Hospital-
J.V. has not participated as a clinical investigator and/or advisory
IRCCS, Rome, Italy
board member and/or consultant and/or speaker for any compa- 13
Department of Gastroenterology, Hepatology and Nutrition, University
ny. Children’s Hospital Ljubljana, Slovenia
14
Pediatric Gastroenterology, UZ Brussel, Vrije Universiteit Brussel, Brussels,
L.D. has not participated as a clinical investigator and/or advisory
Belgium
board member and/or consultant and/or speaker for any compa- 15
Department of Gastroenterology, Motol University Hospital, Prague, Czech
ny. Republic
16
Department of Pediatrics, University of Messina, Italy
M.B. has participated as a clinical investigator and/or advisory 17
IV Medical Department, Rudofstiftung Hospital, Vienna, Austria
board member and/or consultant and/or speaker for Shire, Move- 18
Department of General Pediatrics, Children’s Hospital Freiburg University,
tis, Sucampo, Norgine, Astra Zeneca, Zeria, Novolac, Sensus, Da- Freiburg, Germany
19
Division of Gastroenterology and Hepatology, Department of Internal
none/Nutricia and Friesland Campina.R.O. has not participated

Tringali Andrea et al. Guideline on pediatric endoscopy: Executive summary … Endoscopy

 Guideline

Medicine III, Medical University of Vienna, Vienna, Austria References

20
Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust,
1 Thomson M, Tringali A, Dumonceau JM et al. Pediatric gastrointestinal
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GI Endoscopy Unit, OUS, Rikshospitalet University Hospital, Oslo, Norway nal Endoscopy (ESGE) Guidelines. J Pediatr Gastroenterol Nutr 2016:
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Gastroenterology and Digestive Endoscopy Unit, Ospedale Nuovo Robbiani
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rating quality of evidence and strength of recommendations. BMJ
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6 Dumonceau JM, Hassan C, Riphaus A et al. European Society of Gastro-
intestinal Endoscopy (ESGE) Guideline Development Policy. Endos-
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Tringali Andrea et al. Guideline on pediatric endoscopy: Executive summary … Endoscopy