**2. Upper gastrointestinal tract endoscopy: General aspects**

The presence of symptoms related to the upper gastrointestinal tract such as disphagia, odinophagia, nausea and/or vomit, oral ulcers, represents a typical indication to an uppertract endoscopy in the phases of diagnosis and staging of IBD [4-5].

It should also be noted that even in the absence of symptoms, the upper gastrointestinal tract involvement appears more and more frequently present at the endoscopic and histological evaluation of patients with CD. The importance of taking biopsies at this level has to be considered, even with an endoscopically normal mucosa [4-5].

'Small-bowel endoscopy' is defined as any endoluminal examination of the small bowel, including capsule endoscopy, push enteroscopy and balloon- or other device-assisted endoscopy [2].

A gastroscope with a diameter of 9 mm is used for children weighing more than 15 Kg and a probe with a diameter of 8 mm is used for body weights between 5 and 15 Kg. A diameter of 5-7 mm is used for newborns weighing 2.5-4 Kg whereas a probe with a diameter of 5-6 mm is used for newborn weighing less than 2.5 Kg [7-8].

The endoscopic lesions that are typically observed in oesophagus include erythema, ulcerations, strictures and mucosal bridges. The histological finding of non caseating granulomata in oesophagus is observed in 20-30% of patients [4-5].

At the gastric and duodenal levels, typical endoscopic lesions include ulcerations (which can be linear, curve-shaped, diffuse, superficial or aphtous), nodularities, cobble-stone mucosa, bowel wall rigidity and luminal strictures [4-5].

A focal antral gastritis, negative for Helicobacter Pylori, has been observed in 84% of CD affected patients.

UC was not traditionally associated to an extension involving more than colon and ileum.

However, inflammatory lesions at the level of the upper gastrointestinal tract have recently been frequently observed also in UC patients (up to 70%) [4-5].

### **3. Ileum – colonoscopy: General aspects**

A video – colonoscope with adulthood-dimensioned size can be used for patients aged from 3-4 years and/or with body weight of at least 12-15 Kg [4-5-8]. This colonoscope for adults is

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

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

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

The presence of symptoms related to the upper gastrointestinal tract such as disphagia, odinophagia, nausea and/or vomit, oral ulcers, represents a typical indication to an upper-

It should also be noted that even in the absence of symptoms, the upper gastrointestinal tract involvement appears more and more frequently present at the endoscopic and histological evaluation of patients with CD. The importance of taking biopsies at this level

'Small-bowel endoscopy' is defined as any endoluminal examination of the small bowel, including capsule endoscopy, push enteroscopy and balloon- or other device-assisted

A gastroscope with a diameter of 9 mm is used for children weighing more than 15 Kg and a probe with a diameter of 8 mm is used for body weights between 5 and 15 Kg. A diameter of 5-7 mm is used for newborns weighing 2.5-4 Kg whereas a probe with a diameter of 5-6 mm

The endoscopic lesions that are typically observed in oesophagus include erythema, ulcerations, strictures and mucosal bridges. The histological finding of non caseating

At the gastric and duodenal levels, typical endoscopic lesions include ulcerations (which can be linear, curve-shaped, diffuse, superficial or aphtous), nodularities, cobble-stone mucosa,

A focal antral gastritis, negative for Helicobacter Pylori, has been observed in 84% of CD

A video – colonoscope with adulthood-dimensioned size can be used for patients aged from 3-4 years and/or with body weight of at least 12-15 Kg [4-5-8]. This colonoscope for adults is

UC was not traditionally associated to an extension involving more than colon and ileum. However, inflammatory lesions at the level of the upper gastrointestinal tract have recently

as the necessity of profound sedation-analgesia in the paediatric age [3].

**2. Upper gastrointestinal tract endoscopy: General aspects** 

tract endoscopy in the phases of diagnosis and staging of IBD [4-5].

has to be considered, even with an endoscopically normal mucosa [4-5].

granulomata in oesophagus is observed in 20-30% of patients [4-5].

been frequently observed also in UC patients (up to 70%) [4-5].

response to orally administered corticosteroids [1].

is used for newborn weighing less than 2.5 Kg [7-8].

bowel wall rigidity and luminal strictures [4-5].

**3. Ileum – colonoscopy: General aspects** 

has also been observed [1].

endoscopy [2].

affected patients.

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 lumen of the child.

A colonscope with a diameter of 11.1-11.7 mm is therefore more indicated for the whole pediatric age [7-8].

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 [4-5].

An adequate lubrication allows an easier transit through into the rectum, which can also be helped by the guide of the index finger of the operator [4-5].

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].

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

When the operator needs to increase the penetration pressure of the instrument, a loop formation may have been produced [4-5].

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 [4-5].

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 perendoscopic balloon [4-5].

Bioptic samples should be performed on each area, including segments of apparently normal mucosa [4-5].
