There were a total of 61 endoscopies performed on 27 patients (15 male) during the study period. shows baseline characteristics and reasons for initial endoscopy in the cohort.
Characteristics of 27 children with IF and indications for GI endoscopy (n = 61)
There were 61 total endoscopies: 34 esophagogastroduodenoscopies (EGD), 17 colonoscopies, 7 flexible sigmoidoscopies, and 3 ileoscopies. Seventy percent (n = 43) of the endoscopies revealed a gross, histopathologic, or microbiologic abnormality. These results, shown in , included those of normal (30%), infectious (20%), anatomical (18%), peptic (15%), allergic (15%), and other (2%) findings.
Distribution of findings on 61 GI endoscopies in 27 patients with IF.
Twelve patients were found to have infectious findings, and all but 2 of these patients had bacteria grown from duodenal aspirates, confirming a diagnosis of bacterial overgrowth [11
]. For these 2 patients who did not have duodenal aspirates performed, histopathology revealed severe villous blunting consistent with bacterial overgrowth. In total, there were 15 duodenal aspirates obtained from 34 EGDs, and 11 (73%) grew a spectrum of 17 different bacterial species ().
Spectrum of bacterial species found on duodenal aspirates
Fifty-three percent of the bacteria were gram-negative organisms, and 47% were gram-positive organisms. The most common gram-negative organisms found were Klebsiella
(35%) and Escherichia coli
(20%), whereas the most common gram-positive organisms were Streptococcus viridans
(27%) and Enterococcus
(27%). Six duodenal cultures (55%) grew both gram-positive and gram-negative organisms, whereas 4 cultures (36%) grew strictly gram negatives, and 1 culture (9%) only grew gram-positive organisms. Nine of the 11 positive aspirates were associated with additional findings of erythema, villous atrophy, copious duodenal fluid, or gross mucosal ulcerations. One of the patients with severe bacterial overgrowth and lactic D-acidosis underwent a serial transverse enteroplasty after her endoscopic findings [13
Among the 11 anatomical findings of ulcerations, strictures, and varices, one patient underwent a small bowel resection and stricturoplasty. This patient had GI bleeding and was found to have gross evidence of perianastomotic ulcers that were initially managed with sulfasalazine. She had continued GI bleeding, and when repeat lower endoscopy revealed persistent anastomotic ulcers, she underwent surgical resection of these lesions.
Seven patients were found to have evidence of peptic disease, either gastritis or esophagitis. Six of these patients were subsequently started on a proton pump inhibitor (PPI) or had their PPI dose increased [14
Previously undiagnosed allergic disease was identified in 5 patients, based on their initial endoscopic findings. All diagnoses were made by correlating gross endoscopic appearance with histopathologic findings [7
]. As a result of these diagnoses, all 5 patients were transitioned to a hypoallergenic formula or diet [16
], and 1 patient was started on sulfasalazine [16
Overall, 24 (89%) of 27 patients were found to have at least one abnormality on endoscopy, and 8 patients (30%) were found to have multiple abnormalities. Changes in clinical management were defined as surgical intervention or a change in medical or nutritional therapy. We noted a change in clinical management in 20 patients (83% of the 24 patients with abnormal endoscopic findings and 74% of the 27 total patients) after their initial endoscopies ().
Results of initial endoscopy in 27 patients (44 total endoscopies)
Four patients had follow-up endoscopies (15%) to follow progression of the initially diagnosed disease (eg, allergic colitis, varices). Three patients had additional endoscopies at a later date, but most had developed new indications. One patient has required multiple endoscopies because of persistent GI bleeding.