The indications for performing colonoscopy in Iranian children – a cross-sectional study

Overview

Background: Colonoscopy is the gold standard dia­gnostic method for colon diseases providing an excellent view of the mucosal surface of the colon and terminal ileum. Colonoscopy in children is indicated for dia­gnosis and treatment of gastrointestinal diseases. In this study, we evaluated the reasons for performing colonoscopy in children. Methods: This was a descriptive cross-sectional study including all children referred for colonoscopy to the Gastroenterology clinic affiliated with the Shiraz University of Medical Sciences. The children were selected by a convenient sampling method. Statistical analysis was conducted in the SPSS 22 software. Results: From 389 children referred for colonoscopy, 203 were boys and 186 were girls. The mean age was 8.36 ±4.8 years. The most common reason for colonoscopy was rectal bleeding (63.5%) with the most prevalent dia­gnoses being juvenile polyp and inflammatory bowel disease, each accounting for 11.3% patients. Conclusions: The most common findings of colonoscopy were polyp, IBD and colon inflammation, and the most prevalent symptoms leading to colonoscopy were rectal bleeding, chronic diarrhea, IBD treatment follow-up, suspected IBD and abdominal pain. The high prevalence of pediatric patients presenting with these symptoms indicates the increasing importance of colonoscopy in these patients.

Keywords:

inflammatory bowel disease – colonoscopy – gastrointestinal bleeding – gastrointestinal diseases – colon polyps

Introduction

Introduction of flexible sigmoidoscopy (FS) and colonoscopy greatly developed the gastroenterology science by improving sensitivity and specificity for dia­gnosis of gastrointestinal disorders including colon cancer [1,2]. Since its introduction in 1970, colonoscopy has been utilized as a dia­gnostic modality for pediatric colon diseases [3,4]. Colonoscopy is the gold standard for dia­gnosis of colon disease providing high quality view of the entire colon and ileum [5–7]. It can assist gastroenterologists in the dia­gnosis of various diseases including colitis (ulcerative, pseudomembranous, acute bacterial, ameboid, collagenous and lymphocytic, enemas etc.) and Crohn’s disease. Colonoscopy can also be used for dia­gnosis of vascular lesions, hemangiomas, Kaposi sarcoma, colon lymphoma, colon constriction as well as for therapeutic purposes such as stopping colon bleedings, dilatation of colon strictures, decompressing, and polyp removal [8]. In order to perform colonoscopy, the patient’s colon need to be cleansed using specific preparation strategies by administrating oral agents such as polyethylene glycol (PEG) [9,10]. Colonoscopy complications have been noted in 0.4–1.4% of patients [11]. Bleeding after colonoscopy may happen following removal of polyps and due to colon rupture in 0.2–2.5% of cases [12]. Bacteremia may also be seen in 25% of patients under­going colono­scopy [13,14]. Colonoscopy in children is indicated for both dia­gnostic and therapeutic purposes in patients with inflammatory bowel disease (IBD), lower gastrointestinal bleeding, chronic diarrhea etc. [15,16]. On the other hand, colonoscopy is contraindicated in patients with a high risk of intestinal perforation, acute peritonitis, coagulopathies, thrombocytopenia, intestinal ischemia, recent surgeries etc. [17,18]. Therefore, colonoscopy imparts an essential role in both dia­gnosis and treatment of various gastrointestinal diseases in children. There is little information on the causes and indications of colonoscopy in Iranian children. In this study, we aim to describe various indications for performing colonoscopy in children referred to the gastroenterology clinic of the Shiraz University of Medical Sciences as the center most referred to in the south of Iran.

Methods

This was a descriptive retrospective study including children aged <18 years referred to the Gastroenterology clinic of the Nemazee Hospital affiliated with the Shiraz University of Medical Sciences during 2015 until 2017. Overall, 429 children were referred to the clinic during this time, out of which 30 were excluded because of incomplete data. Finally, 389 children were included. The data was collected using a researcher-made questionnaire addressing variables including age at colonoscopy, sex, colonoscopy indication, colonoscopy findings, complications, and final dia­gnosis. Statistical analyses were performed in IBM SPSS Statistics version 22. Normality of the data was checked by the Kolmo­gorov-Smirnov test. Independent samples Student’s t test was used for inferential statistics.

Results

Out of the 389 children who underwent colonoscopy, 203 were male and 186 were female. The mean age of the children was 4.8 ±8.36 years, ranging from 30 days to 18 years old. The most prevalent symptoms leading to colonoscopy were rectal bleeding (63.5%), chronic diarrhea (35%), IBD treatment follow-up (16%), suspected IBD (11.6%) and abdominal pain (2.6%) (Tab. 1). Out of the 389 children, the primary dia­gnosis was made by colonoscopy in 284. The most frequent endoscopic findings were colon ulcer (81%), polyp (53%), IBD (29%), and colon inflammation (28%) (Tab. 2). The distribution of histologically confirmed dia­gnoses is shown in Tab. 3. Juvenile polyp (11.3%), IBD (11.3%), lymphoid nodular hyperplasia (10.8%), and solitary rectal ulcer (10.5%) constituted the most frequent etiologies.

Discussion

In our study, rectal bleeding, suspected IBD, and chronic diarrhea were the most frequent indications for colonoscopy with 63.5%, 11.6%, and 9% prevalence, respectively. In addition, juvenile polyp and IBD constituted the most frequent final dia­gnoses based on clinical, colonoscopy and histological examinations. In a study on 72 Indian children, rectal bleeding was the most common indication for colonoscopy (83.3%), followed by prolonged colitis (14%), and colon obstruction (2.7%) [19]. Furthermore, juvenile polyp was the most frequent final dia­gnosis (69.4%) in the mentioned study [19]. In another report from Kuwait, IBD was the most common dia­gnosis in 151 children who underwent colonoscopy [20]. Furthermore, rectal bleeding (35%) and abdominal pain (27%) were the most frequent reasons for colonoscopy in children in Saudi Arabia (21). In a five-year-long survey on 7,792 colonoscopy procedures in 7,007 children, Thakkar et al reported the most common indications as lower GI bleeding (27.1%), abdominal pain (20.3%), diarrhea (14.2%), and IBD (8.5%) [22]. Similar results were reported by the American National Health Association on 13,115 children treated in 2000–2007 [23]. Likewise, a study on 123 Spanish children revealed that lower GI bleeding was the most common (71%) reason for colonoscopy in this population with rectal polyps and hemorrhagic colitis as the most frequently encountered dia­gnoses [24]. Consis­tently, rectal bleeding has been the leading cause for colonoscopy indication in children in other reports ranging from 48 to 97% [18,25–29]. Along with these common causes, other reasons for performing colonoscopy in children have been noted as weight loss, growth retardation, family history of polyps, nausea, abdominal distension, dia­gnosis of GVHD, and crissum abscess [29–31]. In an Australian report, from 652 colonoscopies performed within 2011–2015, following-up IBD was the most frequent reason (57.9%) for this procedure in children, followed by abdominal pain and rectal bleeding, each with 10.4% prevalence [32]. In previous studies in India [19], Saudi Arabia [21], the United States [22,23], Spain [24], South Korea [18,25], China [27], Taiwan [28], Kuwait [20], and Australia [32,33], IBD was reported as the most common indication for colonoscopy, while in our study IBD was the second rank indication. In other reports from the United States [29] and China [31], abdominal pain was described as the most indicated reason for colonoscopy. In our study, abdominal pain ranked as the 5^th indication. It seems that indications for colonoscopy in children around the world are similar; however, the frequencies of these may be different in various geographic locations. In most regions including Iran, gastrointestinal bleeding and IBD work up include the most frequent reasons. The commonest final dia­gnoses in our study, based on clinical, colonoscopy, and histological examinations, were juvenile polyp and IBD. On the other hand, studies in India [19], China [27,31], South Korea [18], Kuwait [20], Australia [32], and Saudi Arabia [21] reported colitis as the most common final dia­gnosis. In our study; however, colitis was the 5^th most frequent etiology. Overall, juvenile polyp, IBD, and colitis all comprised the most common dia­gnoses made after colonoscopy in children. Neither of the children assessed here were affected by colonoscopy complications such as bleeding, intestinal rupture, etc. Overall, colonoscopy-related complications may be seen in 1.1% of children undergoing this procedure [22]. Finally, colonoscopy provided a reliable dia­gnostic procedure for gastrointestinal disorders in children.

Conclusion

The most common findings of colonoscopy were colon ulcer, polyp, IBD, and colon inflammation and the most prevalent symptoms leading to colonoscopy were rectal bleeding, chronic diarrhea, IBD treatment follow-up, suspected IBD and abdominal pain. The high prevalence of pediatric patients presenting with these symptoms indicates the increasing importance of colonoscopy in these patients.

ORCID authors

S. M. Dehghani ORCID 0000-0001-5930-0110,

I. Shahramian ORCID 0000-0002-3760-7717,

H. Mirzaie ORCID 0000-0002-3271-1937,

F. Parooie ORCID 0000-0002-2367-3780,

M. Salarzaei ORCID 0000-0001-5508-8669,

M. Ataollahi ORCID 0000-0003-1876-5266.

Submitted/ Doručeno: 24. 8. 2020

Accepted/ Přijato: 9. 10. 2021

Prof. Iraj Shahramian, MD

Pediatric Gastroenterology and Hepatology

Research Center

Zabol University of Medical Sciences

Shahid Rajaei Street

9861615881 Zabol

Iran

ir_buper@yahoo.com