**1. Introduction**

236 Gastrointestinal Endoscopy

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Ynfante Ferrús M, Aoufi S, Sánchez-Manjavacas Muñoz N, Ruiz Carrillo F. Efficacy of pediatric colonoscopy used as push enteroscopy in the management of capsule Endoscopic investigation has become more and more important for diagnosis, follow-up and management of Inflammatory Bowel Disease (IBD) affected patients in the last decades [1].

In fact it allows us to evaluate the grade and extension of bowel inflammation, thus the severity of disease, its prognosis, and the response to therapy as well as the possible indication to a surgical intervention [1]. An endoscopic treatment of several complications (i.e. stenosis) also represents a useful possibility being available.

Moreover, the advent of techniques such as capsule and both single and double-balloonassisted enteroscopy is revolutionizing small-bowel imaging and has major implications for diagnosis, classification, therapeutic decision making and outcomes in the management of IBD [2].

The last available Consensus document reached by a group of international experts in the fields of endoscopy and IBD at a meeting held in Brussels (organised jointly by the European Crohn's and Colitis Organisation ECCO and the Organisation Mondiale d'Endoscopie Digestive OMED) dates back to 12–13th December 2008 [2]. The statements included in this document with the relative levels of evidence and grades of recommendation will be reported as a referral along the chapter.

Endoscopy is able to differentiate Crohn's Disease (CD) and Ulcerative Colitis (UC) in 89% of cases. Essentially it is nowadays the most efficacious and diffused technique to evaluate CD localisation and activity at the level of terminal ileum and colon; its accuracy for results are therefore significantly superior with respect to bowel enema [1].

An immediate diagnosis with excellent accuracy is obtainable when endoscopy is associated to the histological examination of biopsy samples [3].

The endoscopic procedure for paediatric patients with IBD differs significantly from the modalities in use for adults, especially in regards of the use of sedation-analgesia, and the number and localisation of the mucosal biopsies effectuated and the regular inclusion of terminal ileum intubation within a complete investigation. [4-6].

In the paediatric age, assistance with anesthesia allows one to perform a complete endoscopic examination with visualisation of terminal ileum in 90% of cases [3].

Endoscopy in Paediatric Inflammatory Bowel Disease (IBD) 239

more rigid and diminishes the risk of loops formation; it requires, however, a peculiar attention of the operator for the risk of perforations, mainly for smaller children. Moreover its larger diameter can determine limitations in manoeuvrability in the more restricted

A colonscope with a diameter of 11.1-11.7 mm is therefore more indicated for the whole

Before any colonoscopy, it's good practice to perform a digital anal exploration and, subsequently, a rectal exploration in order to detect any possible lesion being localized at the lower segments; the retroversion of the colonoscope is also important for this purpose

An adequate lubrication allows an easier transit through into the rectum, which can also be

As for inflation, CO2 can represent an alternative to air since it is more rapidly absorbed thus produces minor discomfort, as well as a minor theoretical risk of perforation [4-5].

If during the procedure a difficulty in overcoming the splenyc flexure is observed, the patient can be replaced in the supine position as well as on the opposite side. An assistant located on the left of the operator exercises an abdominal pressure in order to check and prevent any loop formation at the sigma or traverse colon. A moderate air inflation is preferable in the Sigma to avoid that an excessive volume increases any risk of loop

When the operator needs to increase the penetration pressure of the instrument, a loop

The length of the colonoscope at the splenyc flexure in the absence of loops is of 40 cm for older children whereas it can decrease to 20-25 cm in children aged 3-4 years old. At the hepatic flexure, instead, it is of 60 cm in the absence of loops for the older children and 40 cm for 3-4 year old children. At the cecum, the length from the anus is about 80 cm for the older children and 40-60 cm for the younger ones. The ileum-cecal valve is localized at about 1-4 cm distally in respect to the appendix orifice and opens perpendicularly to the colon axis

In order to prevent any tension of the bowel wall, the aspiration of the air inside the cecum is suggested before ileum intubation. Ileum intubation allows its evaluation up to 40 cm. At this level, therapeutic dilations of the terminal ileum can be effectuated through a

Bioptic samples should be performed on each area, including segments of apparently



and large tortuous ones including areas of thickened mucosa within)

helped by the guide of the index finger of the operator [4-5].

The patient is usually placed in lateral security position [4-5].

lumen of the child.

pediatric age [7-8].

formation [4-5].

[4-5].

formation may have been produced [4-5].

perendoscopic balloon [4-5].

**4. Morphology of lesions** 



normal erythematous mucosa)

Typical endoscopic lesions in **CD** are [3-5] (Fig. 1-4):

normal mucosa [4-5].

[4-5].

Limitations of endoscopy are however the impossibility to completely evaluate the small bowel, just the first 2-3 loops of small-bowel and the last 20-30 cm of terminal ileum, as well as the necessity of profound sedation-analgesia in the paediatric age [3].

The endoscopic evaluation of mucosal healing is important to identify the efficacy of a specific therapeutic regimen: a significant correlation has been observed, for instance, among administration of new drugs such as anti TNF –α (infliximab, natalizumab and adalimumab), azathioprine and methotrexate, clinical improvement and disappearance of endoscopic lesions; mucosal healing has not been shown, but instead to be predictive for response to orally administered corticosteroids [1].

Determinant is the role of endoscopy for the prediction of a possible post-surgical relapse (endoscopic relapse is reported in 60- 70% of cases at 6- 12 months whereas a clinical relapse is observed in 50% of cases at 3 years follow-up for Crohn's disease); for those patients with an endoscopic remission, a significant reduction of hospitalization and surgical intervention has also been observed [1].
