Therapeutic Endoscopy Rarely Beneficial in Infants with Gastrointestinal Bleeding

P Bose et al. JPGN 2022; 75: 514-520. Endoscopy in Infants With Gastrointestinal Bleeding Has Limited Diagnostic or Therapeutic Benefit

I read this article shortly after convincing a surgical colleague to explore a well-appearing 6 month old with gastrointestinal bleeding for a Meckel’s diverticulum rather than undergo endoscopy.

In this retrospective cohort study of hospitalized infants (n=56, =/< 12 months) with gastrointestinal bleeding, the authors reviewed endoscopic procedures (EGD, Colonoscopy, Flexible Sigmoidoscopy) with respect to identifying diagnosis and in terms of outcomes.

Key points:

  • Seven endoscopies identified sources of GIB: gastric ulcers, a duodenal ulcer, gastric angiodysplasia, esophageal varices, and an anastomotic ulcer.
  • Intervention for bleeding control occurred in just 3 cases (5.4%); two of these had liver disease.
  • Most (55%) had no abnormalities on endoscopy
  • The authors detail two fatal cases in which GIB started in the first week of life. Both had complications occurring within 3 hours of endoscopy, one with a gastric perforation and one with necrotizing enterocolitis.

My take: Endoscopy in infants with GIB is rarely beneficial. Supportive care and surgical interventions should be considered, especially in those without underlying liver disease.

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Is Reflux Really a Disease in Premature Infants?

From Atlanta Botanical Garden

Z Sultana et al. Gastro Hep Advances 2022; 1: 869-881: Open Access! Symptom Scores and pH-Impedance: Secondary Analysis of a Randomized Controlled Trial in Infants Treated for Gastroesophageal Reflux

In the introduction, the authors note: “Gastroesophageal reflux (GER) is a physiological process defined as the passage of gastric contents into the esophagus with or without regurgitation and vomiting, while GER disease (GERD) is pathophysiologic and occurs when GER is associated with troublesome symptoms and/or complications.”

“This distinction between GER and GERD remains enigmatic among survivors in the neonatal intensive care unit (NICU). Reflux-type symptoms (arching, irritability, acute life-threatening events, coughing, failure to thrive, and swallowing difficulties) in this high-risk infant population can be troublesome to the parent and provider, and empiric management using pharmacological and dietary changes are common albeit with consequences.”

Methods: “Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) and 24-hour pH-impedance data were analyzed from 94 infants…[and] Longitudinal data from 40 infants that received randomized GER therapy (proton pump inhibitor [PPI] with or without feeding modifications) for 4 weeks followed by 1-week washout were analyzed. Relationships between I-GERQ-R and pH-impedance metrics (acid reflux index, acid and bolus GER events, distal baseline impedance, and symptoms) were examined and effects of treatments compared.”

Key findings:

  • Acid-suppressive therapy with feeding modifications had no effect on symptom scores or pH-impedance metrics. Clearance of refluxate worsened despite PPI therapy.
  • Correlations between I-GERQ-R and pH-impedance metrics were weak or non-existent, indicating that physicians cannot depend only on the questionnaire to diagnose and treat GERD in premature infants.

My take: This study shows that reflux symptoms are unreliable in establishing a diagnosis of reflux disease in infants. In addition, medical treatments were not beneficial in infants with abnormal pH-impedance metrics. Perhaps, it is time to acknowledge that we cannot even agree what reflux “disease” is in (premature) infants.

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