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PEDIATRIC ENDOSCOPY

FRIDAY, MAY 21, 2021Pediatric EndoscopyLecture

ID: 3524236ENDOLUMINAL FUNCTIONAL LUMEN IMAGING PROBE(ENDOFLIP) IS SAFE IN CHILDREN UNDER 5 YEARS OLDBrett Hoskins*, Erik Almazan, Douglas Mogul, Kenneth NgBackground: Endoluminal functional lumen imaging probe (EndoFLIP) is a mini-mally-invasive, novel device that uses high-resolution impedance planimetry tomeasure important parameters of the GI lumen (i.e.: diameter, cross-sectional area,compliance, distensibility index, and pressure). EndoFLIP is FDA approved forchildren 5 years and older. We sought to evaluate the safety and luminal parametersin children 4 years and younger. Methods: A single-center retrospective review wasperformed to identify all pediatric patients who underwent an EGD with EndoFLIPfor evaluation of the lower esophageal sphincter between October 2017 andNovember 2020. Patient demographic, procedural, and pathologic data were ex-tracted from the medical record. Procedural data collected for group comparisonincluded esophageal diameter, compliance, cross-sectional area, distensibility index,and pressure readings at 30 and 40 mL balloon inflations. Categorical data wereevaluated by either the Chi-square test or the Fisher’s exact test. Independentcontinuous variables were compared using the Mann-Whitney U test. Results: Sixty-seven EGD with EndoFLIP cases from 56 patients were performed, including 13 thatwere in children <60 months and 54 in children �60 months. The median age in the<60 months group was 18 months (IQR, 11-52) and the youngest patient was 1month old. The median age in the �60 months group was 172 months (IQR, 95-193). The 2 groups did not differ in regards to gender, race, history of esophagealdisease, or history of abdominal surgery (all p>0.05). Patients �60 months weremore likely to have at least 1 prior endoscopy (pZ0.03). The most common chiefcomplaints in the <60 months group were dysphagia and vomiting (both 38% each),while dysphagia was the most common complaint in the �60 months group (67%).GERD was the most common past medical history in both groups (38% for <60months; 26% for �60 months). Median procedural times were similar (31.7 minutes[IQR, 23-48] for <60 months; 23 minutes [IQR, 20-33] for �60 months; pZ0.08).There were no complications or unplanned hospitalizations in either group. At 30mL inflation, the diameter, cross-sectional area, and pressure were statisticallydifferent between the 2 groups (pZ0.03, pZ0.03, pZ0.01, respectively), but therewas no difference in compliance or distensibility (both p>0.05). At 40 mL inflation,there was no significant difference in the diameter, compliance, cross-sectional area,distensibility index, or pressure between the 2 groups (all p>0.05). Conclusion:EndoFLIP is safe for use in children under 5 years of age. There was no statisticaldifference in procedure time between our 2 groups and there were no procedure-related complications. The diameter, cross-sectional area, and pressure parametersat 30 mL balloon inflation were different between the 2 groups, suggestive of age-dependent changes.


ID: 3526084INTERNATIONAL CONSENSUS ON PEDIATRICENDOSCOPY REPORTING ELEMENTS: A REPORT FROMTHE PEDIATRIC ENDOSCOPY QUALITY IMPROVEMENTNETWORK (PENQUIN)Jenifer R. Lightdale, Catharine M. Walsh*, David R. Mack,Elizabeth C. Utterson, Marta Tavares, Joel R. Rosh, Matthew R. Riley,Salvatore Oliva, Petar Mamula, Priya Narula, Quin Liu, Diana G. Lerner,Ian H. Leibowitz, Kevan Jacobson, Hien Q. Huynh, Matjaz Homan,Iva Hojsak, Peter M. Gillett, Raoul I. Furlano, Douglas S. Fishman,Nicholas M. Croft, Herbert Brill, Patrick Bontems, Jorge Amil,Robert Kramer, Lusine Ambartsumyan, Anthony R. Otley,Graham McCreath, Veronik Connan, Mike A. ThomsonIntroduction: High quality procedure reports are a cornerstone of high quality pedi-atric endoscopy as they ensure the clear communication of procedural events andoutcomes, guide patient care and facilitate continuous quality improvement. Theinternational Pediatric Endoscopy Quality Improvement Network (PEnQuIN) was

sponsored by the North American and European Societies of Pediatric Gastroen-terology Hepatology and Nutrition (NASPGHAN and ESPGHAN) to develop anddefine standard reporting elements for high quality pediatric endoscopy procedurereports. Methods: Delphi methodology was employed to identify key elements thatshould be included in all pediatric endoscopy reports. Potential reporting elementswere initially generated from a systematic literature review, a hand search of refer-ence lists of published endoscopy quality guidelines and a survey of PEnQuINmembers. Item reduction was then attained through iterative rounds of anonymizedonline voting using a 6-point scale. Responses were analyzed after each round anditems were excluded from subsequent rounds if � 50% of panelists rated them as 5(‘agree moderately’) or 6 (‘agree strongly’). Reporting elements that � 70% ofPEnQuIN members rated as ‘agree moderately’ or ‘agree strongly’ were consideredto have achieved consensus. Results: Twenty-six PEnQuIN working group membersfrom 25 centers in 8 countries across North America (nZ17, 65.4%) and Europe(nZ9, 34.6%) participated, representing various practice types (academic: 23(88.5%); community: 4 (15.4%)) and practice settings (pediatric-only endoscopyunit: 18 (69.2%); mixed adult-pediatric unit: 8 (30.8%)). Sixty-three potentialendoscopy reporting elements were identified for consideration during the Delphiprocess, with the flow of reporting elements throughout the process outlined inFigure 1. After three rounds of voting, 30 items reached consensus as key reportingelements for endoscopic procedures performed on pediatric patients (Table 1).Twenty-eight reporting elements met criteria for elimination, and 5 reporting ele-ments did not reach criteria for either elimination or consensus after three surveyrounds. Of the participating PEnQuIN members, all 26 (100%) completed all threerounds of voting. Across all 3 Delphi rounds, 0.48% of the items had missing ratings.Discussion: The PEnQuIN guideline development process establishes internationalagreement on key reporting elements essential for inclusion within a pediatricendoscopy report. It is recommended that the PEnQuIN standard reporting ele-ments for pediatric endoscopy be universally employed across all endoscopists,procedures and facilities as a foundational means of ensuring high quality endoscopyservices, while facilitating continuous quality improvement in endoscopic care forchildren.

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ID: 3520854ABBREVIATING FASTING BEFORE PEDIATRICENDOSCOPIES: A RANDOMIZED CLINICAL TRIAL ONTHE EFFECTS OF THE ADMINISTRATION OF DIFFERENTSOLUTIONS RICH IN CARBOHYDRATES ON GASTRICEMPTYING AND QUALITY OF GASTRIC VISIBILITYGustavo R. Lima, Pedro L. Lourenção, Giovana T. Comes, Rodrigo M. Lima,Lais Helena N. Lima, Debora R. Jozala, Laura C. Silva,Paulo Cezar H. de Amorim, Tatiane S. Diniz, Erika P. Ortolan*Introduction: The current guidelines recommend 2-hour fasting for children in thepre-anesthetic period, allowing for intake of clear liquids or drinks rich in carbohy-drates up to this time. However, direct quantitative and comparative analysis ofgastric residual volume (GRV) of different solutions rich in carbohydrates is non-existent in clinical settings, especially in pediatric patients undergoing uppergastrointestinal endoscopy (UGE). Objective: To compare the mucosa’s visibility andthe characteristics of the mucous lake in children who consumed one of three so-lutions rich in carbohydrates after abbreviated fasting of 2 hours (figure 1). We alsoaimed to evaluate the GRV after consuming different fluids and compare it withprolonged fasting. Methods: Prospective, randomized, double-blind clinical trial inpatients aged 3 to 15 years. Patients were randomized into three groups of carbo-hydrate-rich solutions (apple juice, maltodextrin, and an industrialized carbohydrate

beverage) or to the control group (prolonged fasting). After 2 hours of randomiza-tion, they underwent routine UGE, and the entire gastric chamber’s content wasaspirated under direct visualization. The quantity and quality of the aspirate werecompared between groups. The study was registered at the Brazilian Registry ofClinical Trials (RBR-8d9hxj). Results: One-hundred and one patients were included(figure 2). The main medical reason for the UGEs was dyspepsia (59.34%), followedby portal hypertension (15.38%). Other indications were dysphagia (5.5%), gastro-esophageal reflux disease (5.5%), H. Pylori eradication control (4.39%), chronicdiarrhea (3.3%), investigation of celiac disease (2.2%), low digestive bleeding (2.2%),Peutz-Jager syndrome (1.1%), and familial adenomatous polyposis (1.1%). Regardingage, weight, height, and BMI, there was no statistical difference between the groups.There was no statistical difference in patients’ fasting time at randomization (p Z0.52). There was no statistical difference in the analysis of the aspirated GRV of theapple juice 0.39 (0–1.49 ml/kg) and maltodextrin 0.4 (0.08–1, 32 ml/Kg) whencompared to the control group 0.47 (0–1.4 ml/Kg). However, in the industrializedcarbohydrate beverage (CB) group, the aspirated GRV was larger than the othergroups 1.89 (0-6.14 ml/kg; p<0.0001). The gastric mucosa was fully assessed infasting control groups, CB, maltodrextrin, and apple juice, at rates of 96.4%, 90.9%,95.6%, and 100%, respectively. The visibility was adequate in all cases. Conclusion:Although the gastric visibility quality was similar between the groups, the industri-alized CB solution presented a GRV higher than the other studied groups after 2-hours of ingestion.

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AB326 GASTROINTESTINAL ENDOSCOPY Volume 93, No. 6S : 2021 www.giejournal.org



ID: 3523595A RETROSPECTIVE ANALYSIS OF THE ROLE OF SERIALIMAGING AND LABS IN THE MANAGEMENT OFPEDIATRIC CHOLEDOCHOLITHIASISFrances C. Lee*, Amy Mehollin-Ray, Andrea T. Cruz, Sara C. Fallon,Robert J. Shulman, David M. Troendle, Douglas S. FishmanIntroduction: Pediatric patients with suspected choledocholithiasis may undergo se-rial imaging and labs to determine the next steps in management. Trans-abdominalultrasound (TUS) is commonly used but has poor sensitivity for identifying commonbile duct stones (CBD) and there is lack data on the changes in the bile ductdiameter in this population. This is the first study to evaluate the predictive value ofserial CBD measurements and laboratory values in planning for endoscopic retro-grade cholangiopancreatography (ERCP) and/or cholecystectomy. Methods: Aretrospective review of pediatric patients (0-18 yrs) presenting with suspectedcholedocholithiasis between 1/2016 and 6/2020 was conducted. Charts were re-viewed for demographics, laboratory values and imaging data, and clinical outcomes.Patients were grouped by whether they underwent ERCP, and whether CBD stonewas found at time of ERCP, and compared using Chi square test (Table 1). Changesin mean CBD size and laboratory values were compared between groups using in-dependent T-test. Results: 162 patients (7 months – 18 years) presented with sus-pected choledocholithiasis. 5 patients status post cholecystectomy were excludedfrom analysis. Two patients who underwent endoscopic ultrasound and intraoper-ative cholangiogram, respectively, were included. Of the remaining 157 patients, 95(60.5%) underwent ERCP, of which 71 (74.7%) had a CBD stone at time of ERCP.Patients with suspected choledocholithiasis without ERCP (No ERCP Group) hadhigher rates of pancreatitis on admission (p Z 0.004), MRCP (p Z 0.001), weremore likely to have been transferred from an outside facility (p Z 0.015), and wereless likely to have a CBD stone visualized on imaging (p < 0.001) (Table 1). Patientswithout ERCP had larger decreases in CBD size (p Z 0.041) on serial TUS and GGTon serial labs (p Z 0.015) (Table 2). Patients with a CBD stone at time of ERCP wereless likely to have sludge at time of ERCP (p Z 0.008), and less likely to have anadverse event associated with ERCP or anesthesia (pZ 0.002). Patients with stone attime of ERCP had higher mean conjugated bilirubin levels the day of ERCP, andsmaller changes in GGT on serial labs (p Z 0.013) (Table 2). Conclusion: Patientswho underwent ERCP had overall smaller variation of change in CBD size on serialTUS compared to those who did not undergo ERCP. The “No ERCP” and “No CBDStone at ERCP” Groups had larger decreases in GGT, suggesting a favorable role inidentifying patients with choledocholithiasis who require ERCP. These preliminarydata suggest the magnitude of the decrease in CBD on serial TUS may be beneficialin eliciting which patients could forego ERCP and related procedures. More researchis planned to evaluate whether monitoring changes in CBD size will the predictivevalue of CBD stone at time of ERCP.

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ID: 3526575EVOLUTION OF INTERNATIONAL PEDIATRICENDOSCOPIC PRACTICE CHANGES DURING THECOVID-19 PANDEMICWenly Ruan*, Douglas S. Fishman, Diana G. Lerner, Raoul I. Furlano,Mike Thomson, Catharine M. WalshBackground: The coronavirus disease 2019 (COVID-19) pandemic has drasticallyaltered endoscopic practice. In April 2020, we evaluated the initial impact of theCOVID-19 pandemic on pediatric endoscopic practice globally. This follow-up studyaims to assess changes in endoscopic practices 7 months following the initial surveyto delineate the patterns of practice change as the pandemic evolves. Methods:Pediatric gastroenterologists who responded to the initial survey (April 2020) werere-surveyed in November 2020 using REDCap. The survey recorded information onchanges in pediatric endoscopic practice patterns, including COVID-19 screeningprocesses and personal protective equipment (PPE) utilization. Results: Surveysrepresenting 75 unique institutions worldwide were completed out of the 145 initialresponses (51.7% response rate). Current characteristics of these institutions relatedto COVID-19 are detailed in Table 1. Overall, procedural volumes increased at mostinstitutions (nZ53, 70.7%). Previously, 80% of institutions were postponing allelective cases, whereas now, the majority are no longer postponing elective (nZ57,76%) and emergent/urgent procedures (nZ72, 96%). Most have started to performpreviously postponed cases (nZ69, 90.7%). Thirty-one institutions (41.3%) reportchanges to pre-endoscopy screening questionnaires, with inclusion of more symp-toms. 89.3% of institutions (nZ67) have a protocol in place to address patients whoscreen positive compared to 78% (nZ110) previously. Thirty-one institutions(41.3%) also report changes to pre-endoscopy SARS-CoV-2 testing, with most beingperformed to triage patients (nZ56, 74.7%), determine a PPE strategy for positivepatients (nZ31, 41.3%), and/or determine anesthesia risk (nZ20, 26.7%). Twenty-six institutions (34.7%) have performed procedures on COVID-19 positive patients.If patients test positive, most institutions (nZ66 for upper endoscopies, 88.0%;nZ64 for lower endoscopies, 85.3%) proceed with urgent/emergent procedures,while most institutions (nZ47 for upper endoscopies, 62.7%; nZ45 for lower en-doscopies, 60%) postpone elective procedures for a specific timeframe. Twenty-twoinstitutions (29.3%) have changed their PPE recommendations since April 2020.Most respondents’ personal PPE practices did not differ from their institutionalguidelines (nZ65, 86.7%). Given the initial concerns over PPE shortages, 38.5% ofhospitals had reported reusing surgical masks and 67.8% were reusing N95/N99masks. Currently, 26.7% of hospitals are reusing surgical masks and 54.7% are re-using N95/99 masks, with mask renewal based on the number of days of endoscopy.Conclusions: This is the first survey to highlight the evolution of pediatric endo-scopic practice related to the evolving COVID-19 pandemic, highlighting the needfor ongoing pandemic-related guidance for pediatric endoscopic practice.


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ID: 3521677CHARACTERISTICS AND FINDINGS IN PEDIATRICPATIENTS UNDERGOING ERCP WHEN LARGE DUCTOBSTRUCTION IS EVIDENT ON LIVER BIOPSYMelissa Martin*, Justin Lee, Andrew Ofosu, Roberto Gugig,Gregory Charville, Monique T. BarakatBackground: Liver biopsy performed after less invasive workup for evaluation ofabnormal liver function studies occasionally reveals large bile duct obstruction onhistology. Our data from the adult population indicate that over 80% of patients withhistologic evidence of large duct obstruction who undergo endoscopic retrogradecholangiopancreatography (ERCP) have biliary findings amenable to endoscopictherapy. The utility of ERCP in this setting has not been studied in pediatrics. In thepresent study, we address this important clinical issue. Methods: A retrospective reviewof our pediatric pathology and clinical records from 2010-2019 identified 123 pediatricpatients with large duct obstruction on liver biopsy. The absolute standardized differ-ence (ASD) was used to compare baseline covariates between patients who underwentERCP vs. all others. Covariates included age, gender, race, ethnicity, BMI, and labs (totalbilirubin, GGT, alkaline phosphatase, AST, ALT, platelets, and INR). The higher theASD, the larger the difference between the two groups. A value less than 0.2 denotes asmall effect size. Results: There were 85 unique patients who met our inclusion/exclusion criteria (Figure 1, Table 1). Of these patients, 15 (17.6%) underwent ERCP.The majority of patients who underwent ERCP (12/15, 80%) underwent therapeuticendoscopic biliary intervention with a favorable impact on clinical trajectory. The meanage of patients with large duct obstruction was 7 years old. Most patients were white(47%) followed by Asian (17%). Only 25% of patients identified as Hispanic. The meanlaboratory values were as follows: Total bilirubin 4.61 mg/dL, GGT 353 U/L, alkalinephosphatase 403 U/L, AST 343 U/L, ALT 251 U/L, platelets 289 K/uL, and INR 1.19.Absolute standardized differences comparing baseline covariates between the ERCPand non-ERCP groups are included in Table 1. The largest absolute standardized dif-ference between the two groups were for race (1.17), ethnicity (0.553) and GGT(0.463). Age, alkaline phosphatase, and INR were not significantly different betweenthe two groups (ASD <0.2 for both). Conclusions: In contrast to adult patients, inwhich we have found that 48.1% of patients with large duct obstruction on liver biopsyundergo ERCP, only 17.6% of pediatric patients with large duct obstruction on liverbiopsy undergo ERCP. This may reflect under-utilization of ERCP in this clinical contextin pediatrics, as 80% of these ERCP patients underwent endoscopic intervention thatfavorably impacted their clinical trajectory. Additional multi-center studies includingmore patients and focused on understanding the utility of ERCP and range of out-comes following the diagnosis of large duct obstruction in pediatrics would be infor-mative to guide pediatric hepatology and endoscopic practices.

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web4C=FPOFRIDAY, MAY 21, 2021Pediatric EndoscopyLecture

ID: 3524415GASTROINTESTINAL BLEEDING IN PEDIATRICPATIENTS WITH VENTRICULAR ASSIST DEVICES:RATES, ENDOSCOPIC INTERVENTIONS & CLINICALIMPACTMegan Foley*, Monique T. Barakat, Kathleen R. Ryan, Sukyung Chung,Jenna Murray, Roberto GugigBackground: Ventricular assist devices (VAD) are increasingly utilized for cardiovascu-lar support of critically ill children and adolescents. Hemostatic complications arecommon in patients with VAD due to converging pathophysiologic mechanismsleading to dysregulated hemostasis. When bleeding occurs in a VAD patient, identifi-cation of the source and severity of bleeding to achieve expeditious source control,implementation of adequate resuscitation to stabilize hemodynamics and decisionsregarding anti-coagulation management are key considerations. Limited adult studies


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report that gastrointestinal bleeding (GIB) occurs in up to 40% of VAD patients,however the frequency of GIB in pediatric VAD patients, management of GIB, andimpact of GIB event(s) on clinical outcomes are not well-characterized. Methods: Usingthe prospectively-maintained databases and the electronic medical record at our ter-tiary care pediatric institution, we identified patients who underwent VAD placementand were managed in the cardiovascular intensive care unit from November 2015-September 2020. Patient demographics, indications, VAD characteristics and duration,episodes of documented GIB, procedural intervention(s), anti-coagulation, modifica-tion of procedural interventions and findings, as well as available pathology results andclinical outcomes data were analyzed using descriptive statistics. Results: A total of 79patients underwent VAD placement during this time period (Table 1). 25 (32%) hadGIB episodes which ranged in severity from blood streaked stools to hemorrhagicshock. 8 (32%) of those patients had multiple bleeding episodes within the studyperiod. Of all total bleeding episodes, 19 (56%) were considered severe as defined byassociated hemodynamic instability, transfusion requirement, need for holding anti-coagulation and/or endoscopic/surgical intervention. Of these GIB episodes, only 3(9%) required endoscopic intervention and none (0%) required a hemostatic pro-cedure during endoscopy. 1 (3%) required an open surgical procedure. Hemostasisand ultimate survival from the bleeding episode was achieved in 32 (94%) of patients.Conclusions: Compared with the reported incidence of GIB after VAD placement inthe adult literature of 18-40%, our data indicate that GIB episodes occur with similarfrequently in pediatric patients. Among GIB episodes, very few required endoscopicintervention and most were due to lesions that were not amenable to endoscopictherapy. Nearly half, however, had an impact on anti-coagulation management. Limi-tations of this study include its single center nature and limited sample size. This studydemonstrates the importance of further investigation and developing pediatric-specificalgorithms for management of GIB in the expanding population of children and ado-lescents requiring VAD hemodynamic support.

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ID: 3519205LANDSCAPE OF PEDIATRIC ENDOSCOPICULTRASOUND: INCREASED UTILIZATION AND ANESCALATING PROPORTION OF THERAPEUTICPROCEDURES OVER TIMEMonique T. Barakat*, Yasemin Cagil, Roberto GugigBackground: Endoscopic ultrasound (EUS) has emerged as an integral diagnosticand therapeutic modality for gastrointestinal diseases and lesions in the vicinity ofgastrointestinal lumens in adults. EUS data in children are more limited, as there areconsiderations which limit utilization of EUS in children, including patient size, en-doscopist training and prevalence of pancreaticobiliary disorders in children. Herewe analyze pediatric EUS utilization patterns, the diagnostic yield and therapeuticrole of pediatric EUS and evolution in these parameters over the past 10 years at ourtertiary care, high volume pediatric endoscopy center. Methods: Using our pro-spectively-maintained endoscopy database, we identified patients 18 years andyounger who underwent EUS for all indications from July 2009 - July 2019. Demo-graphics, indications, procedural interventions and findings, as well as available pa-thology results and clinical outcomes data were analyzed using descriptive statisticalanalyses. Results: A total of 219 EUS procedures were performed for 201 pediatric

patients at our tertiary care medical institution (56% female, mean age of 15.2 � 3.8years, range 3–18). These included 205 (93.6%) upper EUS and 14 (6.4%) lower EUS.The majority of EUS procedure indications were related to evaluation and therapy ofthe pancreatobiliary region (155 procedures, 70.8%), followed by evaluation/sam-pling of subepithelial or regional lesions (39 patients, 17.8%). Most procedures (179,81.7%) were diagnostic; and 21.4% (40 procedures) were therapeutic (Figure 1). Astatistically significant increase in utilization of EUS and the proportion of thera-peutic EUS procedures over time (p<0.001) was noted. A subset of diagnostic EUSprocedures (16.7%) included fine needle biopsy/aspiration sampling, with a 96.7%diagnostic yield (Table 1). Therapeutic EUS procedures were predominately per-formed for pancreatic fluid collection drainage and walled off pancreatic necrosis.The vast majority of procedures (217/219, 99%) were technically successful. Therewere no associated adverse events, intraoperative or delayed complications notedfor these EUS procedures. Discussion: The diagnostic and therapeutic role for EUSin clinical practice is expanding, yet EUS indications and utilization remain some-what restricted in children relative to adult endoscopy practice. The present studyattests to the feasibility, safety and technical success of pediatric EUS, as well as therange of EUS indications in children at a tertiary care medical center. The clinicalimpact of EUS is substantial and this modality enables diagnosis and therapy in asingle anesthesia event, as well as minimization of radiation exposure. The signifi-cant increase in EUS utilization and the proportion of therapeutic procedures overtime supports the potential for escalation of therapeutic applications for EUS.

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ID: 3521190CHARACTERIZATION OF THE CURRENT TRAINING ANDPRACTICE ENVIRONMENT FOR PEDIATRIC ADVANCEDENDOSCOPISTS IN THE UNITED STATESPaul Tran*, Christopher Chu, Christopher Moreau, Jacob Mark,Travis L. Piester, Robert KramerBackground: Due to increased incidence of pancreaticobiliary disease in children,more pediatric gastroenterologists are performing Endoscopic Retrograde Cholan-giopancreatography (ERCP) and Endoscopic Ultrasound (EUS). Many of these pro-cedures are safely performed by appropriately trained pediatric advancedendoscopists (PAE) at pediatric facilities, but there is a lack of literature character-izing their training environment. The aim of this study is to describe practicing PAE’straining experiences in the United States. Methods: A 66-question survey was con-structed in REDCap and distributed via emails to 41 roster members of the 2018 and2020 ERCP Special Interest Group (ERCP SIG) of the North American Society ofPediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). Questionsincluded the number of procedures performed, supervision with an adult or pedi-atric preceptor, and overall comfort practicing independently at the conclusion oftraining. Respondents who do not perform ERCP or EUS independently wereexcluded from analysis. Results: Of 41 PAE’s surveyed, 38 (92.7%) responded and 28were included in analysis as they were independently practicing either procedure.Respondents practiced in 12 states, female gender was reported in 14% of respon-dents (nZ4), and 50% of respondents (nZ14) reported practicing EUS in additionto ERCP. Median years in practice was similar for ERCP (MZ5) and EUS (MZ4)practitioners. Almost all endosonographers (nZ13, 92.9%) reported trainingconcurrently with ERCP. Of respondents, 14 completed an advanced endoscopyfellowship, 2 of which were a dedicated pediatric fellowship. The majority of ERCP(nZ24, 85.7%) and EUS (nZ14, 100%) respondents reported an adult advancedendoscopist involved in their training with less than half (nZ13, 46.4%) training witha PAE. Respondents who perform ERCP completed a median 250 ERCPs duringtraining and a minority of these (mZ40%) were performed on pediatric patients.Endosonographers reported a median 240 EUS cases prior to independent practicewith even fewer (mZ14%) being performed in pediatric patients. Most respondentsfelt prepared to practice ERCP (mZ80%) and EUS (mZ79%) independently uponcompletion of training. Conclusions: Pediatric advanced endoscopists have variedtraining experiences which may be indicative of the relative lack of access to struc-tured training programs. Though training varies and most training cases were per-formed on adults, most PAEs feel prepared to practice independently on childrenupon completion of training. Additional studies are needed to fully describe thescope of ERCP and EUS training and practice in children.

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FRIDAY, MAY 21, 2021Pediatric EndoscopyPoster

ID: 3521268ENDOSCOPIC APPROACH TO ABNORMALPANCREATOBILIARY ANATOMY IN CHILDREN WITHTRISOMY 21Michelle M. Corrado*, Jacob Mark, Robert KramerIntroduction: Trisomy 21 is a genetic disorder that may be associated with congen-ital anomalies of the gastrointestinal (GI) system, including annular pancreas andduodenal atresia. Less well-described are other anatomical anomalies of the pan-creatobiliary system including abnormal location of the major papilla. There are nostudies in pediatrics that describe these specific anatomical variations in this patientpopulation along with their associated GI complications. Methods: We conducted aretrospective chart review of patients with trisomy 21 who underwent endoscopicretrograde cholangiopancreatography (ERCP) at Children’s Hospital Colorado from2006-2019 and were subsequently found to have pancreatobiliary anatomicalanomalies. Our primary aim was to describe symptomatic pancreatobiliary anatomicabnormalities in patients with trisomy 21 which may be associated with other GIcomplications. Results: Out of 427 patients undergoing ERCP during this period, 12patients had trisomy 21 (3%). Eight of the 12 patients had both trisomy 21 and anidentified pancreatobiliary anomaly (67%) and were included in our final analysis (3male, 5 female). In this cohort, 4 patients had a history of duodenal atresia (50%)and of those, the major papilla was located either just proximal to the duodenalanastomosis (nZ1), just distal to the anastomosis (nZ1), or along the wall of theclosed duodenal atresia (nZ1). Of the patients without duodenal atresia (nZ4), themajor papilla was located in the gastric antrum (nZ1) or the apex of the duodenalbulb (nZ1). The other two patients had expected location of the papilla, but onehad a long common channel. Cholelithiasis was present in 7 patients (88%) andcholedocholithiasis was present in 4 patients (50%). One patient (13%) underwent apancreatoduodenectomy for chronic pancreatitis. Indications for ERCP includedcholedocholithiasis (nZ4), concern for gallstone pancreatitis (nZ3), and right up-per quadrant pain with evidence of ductal obstruction (nZ1). Five patients requiredrepeat ERCP (63%). Conclusions: Our study describes pancreatobiliary abnormalitiesin children with trisomy 21 both with and without duodenal atresia. Endoscopistsshould be aware of the potential for abnormal anatomic anomalies that may makeidentification and cannulation of the papilla more challenging in these patients.Larger studies are needed to fully describe these abnormalities in patients with tri-somy 21.


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FRIDAY, MAY 21, 2021Pediatric EndoscopyPoster

ID: 3520631RISK FACTORS FOR STRICTURES IN CHILDREN ANDADOLESCENTS WITH EOSINOPHILIC ESOPHAGITISKumail Hussain, Vijayalakshmi Kory, Yi Li,Thirumazhisai S. Gunasekaran*Eosinophilic esophagitis (EoE) is an inflammatory disease of the esophagus,resultingin tissue remodeling and fibrosis and strictures may be an end result.Strictures aremore common in adults with EoE, but does occur in children and adolescents.Wesought out to find the risk factors associated with occurrence of strictures in EoEpediatric patients. Aim: Compare clinical features,EGD findings and histology todetermine risk factors associated with strictures in EoE pediatric patients. Methods:In this retrospective study,children with EoE seen between 2/1998 - 7/2020 wereseparated into two groups;Stricture Group (found at initial or follow-up visit) andstricture defined as;not able to pass a regular endoscope (OD 9mm) or when passedhad a mucosal tear, and Non-Stricture Group. Diagnosis of EoE was made as per theConsensus Statement. Patients were further stratified based on main presentingsymptom:dysphagia,abdominal pain without dysphagia,GE reflux/vomiting,failure tothrive and additional symptoms of food impaction, associated allergies,vomiting andGI bleeding were captured.Physical features,CBC,EGD findings and biopsy of thedistal and mid esophagus were captured.Treatments included topical steroids,diet-ary modification and PPIs. p-values were calculated to compare significance betweenstricture and non-stricture groups except Chi Square for gender. . Results: Within acohort of 221 patients,19 had strictures. Demographics,clinical features for strictureand non-stricture groups are outlined in Table 1 . EGD + biopsy findings are listedin Table 2. In stricture group the following were more prevalent and significant;dysphagia (stricture 100% vs. non-stricture 42%, p<0.0005) and food impaction(74%vs. 4%, p<0.0005); EGD findings;rings and exudate were strongly associated withstricture group ,42.1% vs. 25.74%, p< 0.17 & 47.6% vs. 4.5%, p< 0.0005 respectively.Abdominal pain was less in stricture group (5% vs. 31%, pZ0.016). Rest of thesymptoms, EGD findings & histology were not significant. Choice of treatment,captured in most of the patients, also did show any strong associations with eithergroups. Within the combined esophageal biopsies, peak and mean eosinophil countin stricture group were numerically higher but not significant. Same was observedwith the indivudual dital and mid esophageal biopsies within the groups.Conclusion: Risk factors for stricture occurrence in EoE pediatric patients include;patients presenting with dysphagia and food impaction and EGD findings ofesophageal rings and exudates on endoscopy. Abdominal pain was more commonand significant in non-stricture group,which raises the question if EoE patientspresenting with abdominal pain without dysphagia would be protected fromdeveloping strictures. Further prospective studies are needed to validate or chal-lenge these findings.

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SATURDAY, MAY 22, 2021Pediatric EndoscopyPoster

ID: 3526494INTERNATIONAL SURVEY OF PEDIATRICENTEROSCOPY PRACTICESWenly Ruan*, David M. Troendle, Steven H. Erdman,Mike Thomson, Victor L. Fox, Thomas M. Attard,Diana G. Lerner, Douglas S. FishmanBackground: Technical advancements have allowed for improved assessment of thesmall bowel, including balloon assisted enteroscopy. The usage of these techniqueshas been extensively evaluated in adults for diagnostic and therapeutic indications.However, pediatric data is mostly limited to retrospective single center data. This isthe first study to evaluate the current practices among pediatric gastroenterologistsinternationally. Methods: Pediatric gastroenterologists were surveyed using REDCapvia a listserv targeting pediatric gastroenterologists affiliated with the ESPGHAN andNASPGHAN. The survey recorded information regarding current pediatric entero-scopy practice patterns and training. Results: Ninety-one surveys were completed(16 countries, 32 US states). Fifty (54.9%) were from free-standing pediatric hospi-tals, 40 (44.0%) from pediatric endoscopy practices within an adult unit/hospital, and1 (1.1%) from a mixed endoscopy practice setting. Fifty-three (58.2%) perform pe-diatric enteroscopies. The majority were performed by either a pediatric advancedendoscopist (nZ26, 49.1%) or an adult gastroenterologist (37.7%). Push entero-scopy (71.7%), single balloon enteroscopy (66.0%), laparoscopic/surgery assistedenteroscopy (47.2%), and double balloon enteroscopy (39.6%) were the mostcommon types of enteroscopies performed. 15 (28.3%) report reaching the plannedoutcome 50-75% of the time, 28 (52.8%) reached the planned outcome 75-100% ofthe time, and 10 (18.9%) do not keep track of outcomes. Push enteroscopy is uti-lized most frequently for proximal lesions or small patient size. Other characteristicof enteroscopies performed at institutions are listed in Table 1. Regarding trainingexperience for pediatric enteroscopies, 15 (28.3%) received supervised training as afellow, 9 (17.0%) as a faculty member, 6 (11.3%) as a 4th year advanced endoscopyfellow, 8 (15.1%) had a combination of the three, and 11 (20.8%) did not requiretraining. Twenty-five (47.1%) participate in various forms of continuing education.Most performed up to 10 anterograde enteroscopies prior to independent practice(49.1%) and <5 retrograde enteroscopies prior to independent practice (43.4%).Twenty-five institutions (47.2%) allow trainees to be involved in pediatric enteros-copies with 15 (28.3%) actively training pediatric gastroenterologists or fellows.Conclusions: Pediatric gastroenterologists use enteroscopy to varying degreesworldwide. This survey highlights the need for better understanding of entero-scopy usage. Access to enteroscopy training for gastroenterologists and research toevaluate the diagnostic and therapeutic utility of pediatric enteroscopy is needed.


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SATURDAY, MAY 22, 2021Pediatric EndoscopyPoster

ID: 3526852TRANSPANCREATIC SPHINCTEROTOMY TECHNIQUEAND DOUBLE GUIDEWIRE PLACEMENT FOR DIFFICULTCANNULATION IN ENDOSCOPIC RETROGRADECHOLANGIOPANCREATOGRAPHY (ERCP). IS IT USEFULIN THE PEDIATRIC PATIENT?Ericka Montijo-Barrios*, Roberto Delano, Carlos Valenzuela-Salazar,Victor Antonio Sevilla Lizcano, Jose De Jesus Herrera EsquivelBackground: Selective bile duct cannulation is the prerequisite for all endoscopicbiliary therapeutic interventions, but this cannot always be achieved easily.Despite advances and new developments in endoscopic accessories, selective biliaryaccess fails in 5%-15% of cases, even in expert high-volume centers. Various tech-niques, such as double-guidewire induced cannulation, pre-cut papillotomy or transpancreatic sphincterotomy with or without placement of a pancreatic stent, havebeen used to improve cannulation success rates. Repeated and prolonged attemptsat cannulation increase the risk of pancreatitis. These techniques have been re-

ported in adults, but there are no data on their use in children. Aim: The objective ofthis work is to describe the results of performing the pancreatic sphincterotomy anddouble guidewire technique for difficult cannulation in ERCP in pediatric patients.Methods: We identified 5 patients over 2 years 2019-2020, who required ERCP, butfailed in guidewire selective biliary access, that were incidentally canulated in thepancreatic duct; in whom transpancreatic sphincterotomy and double-guide can-nulation was performed. Indications and clinical outcomes were reviewed. Results:Fifty percent of patients were female, median age was 8 years (range 30 months to12 years). The indication for the study was: 2 patients (40%) with choledocholi-thiasis, 2 patients (40%) with recurrent pancreatitis due to sphincter of Oddi dys-tonia, 1 patient (20%) with pancreas divisum. In 4 (80%) of the patients, selectiveand deep cannulation of the bile duct was achieved using this technique. Chole-docholithiasis was resolved in both patients, and post-procedure pancreatitis has notoccurred in cases of sphincter of Oddi dystonia. In none of the cases were adverseevents. Imagen 1 and imagen 2.

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SUNDAY, MAY 23, 2021Pediatric EndoscopyPoster

ID: 3521556WHITE SPOTS IN THE DUODENAL MUCOSA INPEDIATRIC ENDOSCOPIES: IS THERE A PATHOLOGICALMEANING?Debora R. Jozala, Pedro L. Lourenção, Simone A. Terra, Giovana T. Comes,Gustavo R. Lima, Rodrigo Corsato Scomparin, Erika P. Ortolan*Introduction: Although there is a routine of performing biopsies in pediatric diges-tive endoscopies, children’s duodenal pathologies have received little attention fromliterature studies. The presence of white spots on the duodenal mucosa is a com-mon finding in pediatric endoscopies. Studies with adults suggested the relation ofwhite spots with physiologic modifications and with some pathologies, like giardi-asis, lymphangioma, Whipple disease, lymphangiectasia, and duodenitis. However,no study in literature addressed the meaning of these white spots in children.Objective: Investigate agreement between white spots in the duodenum with clinicalinformation and histopathological findings. Methodology: an observational, retro-spective case-control study, based on the analysis of upper endoscopies reports andreview of duodenal biopsies of patients from 0 to 18 years old, at a referral publichospital from January 2012 to May 2019. Patients with endoscopic reports of whitespots in the duodenum were selected, and possible concordances were analyzedrelated to the histopathological findings and clinical indications of upper endos-copies, paired with patients without the presence of white spots. Results: reports of137 patients with white spots in the duodenum and 132 patients with normalmacroscopic appearance in endoscopies were included in the study (figure1). Therewas a minimal agreement between the presence of white spots and histopatholog-ical alterations (kappa Z 0.055). The diagnosis capacity of histologic findings in thepresence of white spots in duodenum, showed low values of sensibility (53.73%) andspecificity (51.85%), with low diagnostic accuracy (52.79%). There was no influenceof the clinical indication of endoscopic exams on the finding of white spots andhistopathological changes. The most common histological alterations in patientswith white spots were lymphoid accumulations, chronic duodenitis with eosino-phils, and intraepithelial lymphocytosis, but none of them influenced the concor-dance between white spots and histologic alterations (pZ 0.302). Almost half of thepatients (49.8%) of both groups had histopathological changes, and 46.3% hadnormal macroscopy (figure 2). Conclusion: there was no agreement between thepresence of endoscopic white spots in the duodenum and endoscopy clinical indi-cation or specific histopathological findings.

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ID: 3526749ENDOSCOPIC RETROGRADECHOLANGIOPANCREATOGRAPHY (ERCP) IN MEXICANCHILDRENEricka Montijo-Barrios*, Roberto Delano, Carlos Valenzuela-Salazar,Victor Antonio Sevilla Lizcano, Jose De Jesus Herrera EsquivelBackground: ERCP is a diagnostic and therapeutic procedure used to study a widevariety of pancreatic-biliary pathologies. It is important to remember that accord-ing to the age group the indications vary, being adolescents those who will haveindications similar to adults (choledocholithiasis) and in neonates the indicationswill be: pathologies such as bile duct atresia or anatomical alterations in thepancreatic-biliary junction , choledochal cyst among others. Although the perfor-mance of ERCP in children has increased in recent years, there are still many doubtsabout the indications, efficacy and safety of the procedure. Aim: The objective of thisreport is to show the results achieved by our group in endoscopic treatment duringERCP in pediatric patients with biliopancreatic system disorders. Methods: Anobservational, descriptive and cross-sectional study was carried out of the records of20 endoscopic retrograde cholangiopancreatographies (ERCP) performed in 19pediatric patients with suspected biliopancreatic disorders during a period of 2 years2019-2020. Results: Of the total number of patients, 12 (63.1%) were female, themean age was 8 years (range 30 months to 18 years) The primary indication was bileduct pathology in 14 (73.6%) and pancreatic pathology in 5 (26.3%). The biliaryindications were choledocholthiasis in 10 patients, choledochal cyst in 1. Thepancreatic indications were recurrent acute pancreatitis due to sphincter of Oddidysfunction in 7 and pancreatic malformation (pancreas divisum) in one. 2 (10.5%)were diagnostic and 17 (89.5%) therapeutic, performing sphincterotomy in 14(73.6%), in 5 (26.3%) transpancreatic sphincterotomy technique and doubleguidewire placement because of a difficult cannulation. Complications were post-ERCP pancreatitis in 1 (5.2%). There were no procedure related deaths, andcomplication improved under supportive care. All cases were performed undergeneral anesthesia and intubation, with continuous monitoring. Fluid load at


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20ml/kg/dose and rectal anti-inflammatory was indicated prior to the procedure as apreventive measure for post-procedure pancreatitis. Conclusion: this work demon-strates the great diagnostic utility and therapeutic success of ERCP in pediatric pa-tients, with minimal complications in a series of cases of Mexican children. Studieswith a larger number of cases are required.

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ID: 3524181A SURVEY ON THE STATUS OF ENDOSCOPICDIAGNOSIS AND TREATMENT OF PEDIATRICCOLORECTAL POLYPS IN CHINAYing Fang*, Hongbin Yang, Hua Wang, Lina Sun, Huanyu LiuObjective: This study aims to investigate the current endoscopic diagnosis andtreatment of colorectal polyps, and promote the proper use of colonoscopy inChina. Methods: An online questionnaire designed to assess the basic information ofprofessionals, facilities, endoscopic diagnosis and treatment of colorectal polyps wassent to 57 hospitals qualified to do the endoscopy. Results: Valid questionnaireswere received from 54 hospitals (94.74%). A total of 54 (100.00%) and 52 (96.30%)hospitals were able to diagnose and treat colorectal polyps by colonoscopy,respectively. The number of patients underwent the colonoscopy, diagnosed withcolorectal polyps and treated by the colonoscopy in 2019 accounted for 32.62%(18035/55295), 36.40% (4083/11217)，69.77% (3877/5557) among recent threeyears (2017-2019), respectively. Most hospitals (96.30%，52/54) had the digestiveendoscopy centers, and some hospitals had ultrasound endoscopy (35.19%, 19/54),electronic staining endoscopy (74.07%, 40/54) and electrotome (96.30%, 52/52).However, problems including uneven operation level, poor facilities and a lack ofexperience when conducting colonoscopy existed in all hospitals. There is also a lackof pediatric digestive endoscopy standards and guidelines in China. A total of 54hospitals indicated that guidelines or consensus on management of pediatric colo-rectal polyps should be developed. Conclusions: With the steady development ofendoscopic diagnosis and treatment of pediatric colorectal polyp in China, there isno standard for reference. The guidelines or consensus for management of pediatriccolorectal polyp by endoscopic are urgently needed.


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