Tag Archives: ileal intubation

How Much Harder is a Colonoscopy in Children Less Than 6 Years of Age

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R Bolia et al. JPGN 2023; 77: 396-400. Characterization of Colonoscopies in Preschool Children

In this retrospective review, among 1671 colonoscopies (2014-2020), 13% (n=219) were in children less than 6 year of age (Median 3.9 yrs). Key findings:

  • Most common indications in preschoolers were rectal bleeding 35% (n = 78), inflammatory bowel disease 24% (n = 53), diarrhea 13% (n = 30), iron-deficiency anemia 11% (n = 25), and abdominal pain 7% (n = 16).
  • Ileal intubation rate (IIR) and cecal intubation rate (CIR) were lower in preschoolers (2 to <6 yrs) compared to older children, 81% vs 92% (P = 0.0001), and 93% vs 96.4% (P = 0.02), respectively, and even lower in those aged <2 years, 48.1% IIR (P = 0.0001) and 85.1% CIR. 
  • Diagnostic yield was highest for rectal bleeding at 41% (32/78) including juvenile polyps in 27. The diagnostic yield was 37% for those with diarrhea (12/30) and 36% (9/25) for those with iron deficiency anemia. Overall, diagnostic yield was 40% (87/219)
  • 10 patients (5% of total and 11.5% of those with abnormalities) had findings limited to right colon and/or ileum; thus, incomplete evaluation would have missed these findings.

The authors suggest modifying the PEnQuIN goal of IIR >/= 85% in young children. However, this is unnecessary as most endoscopists are not separating their cases by age.

My take: This study shows that colonoscopy is often more difficult to complete in younger children. Achieving high IIR improves the yield of colonoscopy. Overall, the findings in this report mirror our experience in which colonoscopy had a diagnostic yield of 42% (in non-folllowup colonoscopies) and findings isolated to ileum were noted in 6% (and additional 4% with grossly normal/abnormal histology).

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“Sub-10-minute High-quality Diagnostic Colonoscopy”

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Like the last two days, this post addresses “high quality” colonoscopy…

A recent report (M Thomson et al. JPGN 2019: 69: 6-12) describes quicker pediatric colonoscopy times than previously reported and with 100% rate of ileal intubation.

In this report, there were 181 colonoscopies.

Time of colonoscopy:

  • The authors emphasize the fact that their mean time to the terminal ileum was 9.8 minutes.  Their good technical skill is probably related in part to experience: all 6 endoscopists had more than 10 years of experience (mean 19 years) and more than a thousand prior colonoscopies each.

Ileal Intubation Rate:

  • The 100% ileal intubation rate similarly indicates good technical skill.  It may indicate that their patient population was healthier as ileal structuring (which can prevent ileal intubation) can be noted in patients with Crohn’s disease.

Low Diagnostic Yield:

  • In my view, the study reports a low diagnostic yield.  They report 33% had abnormal histology (when excluding patients with IBD followup examinations)
  • 38% of their patients had colonoscopy due to abdominal pain. They reported a yield in this group of only 11.6% though this includes 4 patients with “TI lymphoid hyperplasia.”   Is this an abnormal finding?

My take: This study shows that with good technical skill colonoscopy can be done quickly with ileal intubation times averaging 10 minutes and with ileal intubation rates close to 100%.  In my view, another quality metric is diagnostic yield and their yield is lower than has been reported in most pediatric studies.

Related references:

  • K Siau et al. JPGN 2019; 69: 18-23.  This study describes “Direct Observation of Procedural Skills” (DOPS). Among 29 trainees, 81% of DOPS were rate competent after 125-140 procedures.
  • MT Barakat et al. JPGN 2019; 69: 24-31. This study noted that the vast majority of pediatric GI centers (>90%) were performing less than 25 ERCPs annually and that >70% “believe their institution’s current arrangement for performing pediatric therapeutic endoscopy is inadequate.”

Quality Metrics in Pediatric Colonoscopy

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Continuing the theme from yesterday’s post…

Because of similar research in our group, I was interested in a recent study looking at pediatric colonoscopy quality indicators: CS Pasquarella et al.. JPGN 2019; 68: 648-54. (Editorial: CG Sauer, CM Walsh. JPGN 2019; 607-08.)

The authors analyzed 391 colonoscopies.

Key findings:

  • Ileal intubation rate of 91% (which is similar to our rate)
  • Ileal intubation rate was greater in their endoscopy suite where assistance was readily available.
  • Time for procedure: 34 minutes with staff alone compared to 42 minutes with a fellow trainee participant

To this point, we have not collected data on procedure duration at our institution –though 34 minutes seemed longer than I expected.

The authors also comment on cecal intubation.  I find this statistic to be less useful in pediatrics than adult medicine.  Reaching the cecum is important in cancer screening whereas reaching the ileum is important in identifying cases of inflammatory bowel disease.  The former is the main focus in adult gastroenterology and the latter is the main focus in pediatric gastroenterology.

My take: The editorial notes that “endoscopic providers and users can only know whether high-quality care is being delivered if it is being measured.”  I do think ileal intubation is important but other measures include good prep, low complication rate, appropriate patient selection (eg. good indication), and careful followup. Our work in this area will be presented at our upcoming NASPGHAN meeting–stay tuned.

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