Publications by authors named "Salvatore Oliva"

100 Publications

Reversal of fibrosis in eosinophilic esophagitis: Another feather in the PPI cap?

Dig Liver Dis 2021 Sep 13. Epub 2021 Sep 13.

Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1016/j.dld.2021.08.012DOI Listing
September 2021

A Quantitative Assessment of Mucosal Eosinophils in the Gastrointestinal Tract of Children Without Detectable Organic Disease.

Pediatr Dev Pathol 2021 Sep 7:10935266211039474. Epub 2021 Sep 7.

Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Background: Accurate measurements of mucosal eosinophil concentrations in gastrointestinal tracts of healthy children are necessary to differentiate health and disease states in general, and better define eosinophilic gastrointestinal diseases.

Study: We retrospectively reviewed gastrointestinal biopsies from children with macroscopically normal endoscopies, who, after a minimal follow-up of one year, were not diagnosed with any organic disease. Peak eosinophil concentrations and distributions were assessed from each segment of the gastrointestinal tract.

Results: Three centers (Italy, United Kingdom, and Israel) contributed 202 patients (median age 13 years IQR 9.5-15.5, range 1-18 years). Median (IQR, range) eosinophil concentrations (eos/mm) were: esophagus 0 (0-0, 0-84), stomach 0 (0-4, 0-84), duodenal bulb 20 (13-30, 7-67), second part of duodenum 20 (13-29, 0-105), terminal ileum 29 (14-51, 0-247), cecum 53 (37-89, 10-232), ascending colon 55 (25-84, 0-236), transverse colon 38 (21-67, 4-181), descending colon 29 (17-59, 0-114), sigmoid colon 25 (13-40, 0-215) and rectum 13 (4-28, 0-152). Significant geographical variance was present, however, no differences in eosinophil concentrations were identified between children with resolving symptoms vs. those with functional diagnoses, nor across age groups.

Conclusions: Standardized eosinophil concentrations from the gastrointestinal tracts of children without organic disease will serve to better define both health and disease states. No differences were found between resolved symptoms vs. functional diagnoses nor between age groups in this pediatric cohort.
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http://dx.doi.org/10.1177/10935266211039474DOI Listing
September 2021

Capsule Endoscopy in Children.

Front Pediatr 2021 13;9:664722. Epub 2021 Aug 13.

Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, University Hospital Umberto I, Sapienza - University of Rome, Rome, Italy.

Since its clearance for use throughout the world, capsule endoscopy (CE) has become an important diagnostic tool, helping us to understand and document both normal and abnormal findings in the small intestine, especially in children, since CE usually can be employed without sedation or radiation. The indications in children and adults are similar, though their relative frequencies are different, with evaluation of potential and known inflammatory bowel disease the most common in the pediatric population, with CE also yielding increased diagnostic certainty compared to radiographic studies and surrogate biomarkers. Newer capsules now create opportunities to expand that understanding and our practices so that we can learn when and how to employ CE and pan-enteric CE to better monitor and guide therapy. It will take further studies to determine the best uses for CE and how to select the appropriate candidates, especially with ongoing concern about capsule ingestion vs. placement, the potential for capsule retention (particularly in known Crohn's disease), still elusive optimal methods for bowel cleansing, and the most meaningful scoring for research and clinical use.
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http://dx.doi.org/10.3389/fped.2021.664722DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8414564PMC
August 2021

Pediatric Endoscopy Quality Improvement Network (PEnQuIN) Pediatric Endoscopy Reporting Elements: A Joint NASPGHAN/ESPGHAN Guideline.

J Pediatr Gastroenterol Nutr 2021 Aug 16. Epub 2021 Aug 16.

Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada Division of Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA Pediatric Gastroenterology & Nutrition, Department of Pediatrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield University, Sheffield, South Yorkshire, United Kingdom Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, University J.J. Strossmayer Medical School, Osijek, Croatia Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Umberto I - University Hospital, Sapienza - University of Rome, Rome, Italy Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Department of Pediatric Gastroenterology, Providence St. Vincent's Medical Center, Portland, OR, USA Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada Division of Pediatric Gastroenterology, Department of Pediatrics, Goryeb Children's Hospital, Icahn School of Medicine at Mount Sinai, Morristown, NJ, USA Division of Gastroenterology, Hepatology and Nutrition, British Columbia's Children's Hospital and British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada Division of Pediatrics, Pediatric Gastroenterology Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington D.C., USA Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA Blizard Institute, Barts and the London School of Medicine, Royal London Children's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, United Kingdom Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Department of Paediatrics, William Osler Health System, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada Division of Gastroenterology and Hepatology, Medicine and Pediatrics, Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA Division of Pediatrics, Department of Pediatric Gastroenterology, Queen Fabiola Children's University Hospital, ICBAS - Université Libre de Bruxelles, Brussels, Belgium Division of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Children's of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA Pediatric Gastroenterology, Department of Pediatrics, Centro Hospitalar Universitário S. João, Porto, Portugal Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, Colorado, USA Gastroenterology & Nutrition, Department of Pediatrics, IWK Health, Dalhousie University, Halifax, Nova Scotia, Canada Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, WA, United States of America Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.

Introduction: High quality procedure reports are a cornerstone of high quality pediatric endoscopy as they ensure the clear communication of procedural events and outcomes, guide patient care and facilitate continuous quality improvement. The aim of this document is to outline standardized reporting elements that achieved international consensus as requirements for high quality pediatric endoscopy procedure reports.

Methods: With support from the North American and European Societies of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used Delphi methodology to identify key elements that should be found in all pediatric endoscopy reports. Item reduction was attained through iterative rounds of anonymized online voting using a 6-point scale. Responses were analyzed after each round and items were excluded from subsequent rounds if ≤50% of panelists rated them as 5 ('agree moderately') or 6 ('agree strongly'). Reporting elements that ≥70% of panelists rated as 'agree moderately' or 'agree strongly' were considered to have achieved consensus.

Results: Twenty-six PEnQuIN group members from 25 centers internationally rated 63 potential reporting elements that were generated from a systematic literature review and the Delphi panelists. The response rates were 100% for all three survey rounds. Thirty reporting elements reached consensus as essential for inclusion within a pediatric endoscopy report.

Discussion: It is recommended that the PEnQuIN Reporting Elements for pediatric endoscopy be universally employed across all endoscopists, procedures and facilities as a foundational means of ensuring high quality endoscopy services, while facilitating quality improvement activities in pediatric endoscopy.
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http://dx.doi.org/10.1097/MPG.0000000000003266DOI Listing
August 2021

Pediatric Endoscopy Quality Improvement Network (PEnQuIN) Quality Standards and Indicators for Pediatric Endoscopists and Endoscopists in Training: A Joint NASPGHAN/ESPGHAN Guideline.

J Pediatr Gastroenterol Nutr 2021 Aug 16. Epub 2021 Aug 16.

Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada Division of Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington D.C., USA Division of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Children's of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA Division of Gastroenterology and Hepatology, Medicine and Pediatrics, Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, South Yorkshire, United Kingdom Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Umberto I - University Hospital, Sapienza - University of Rome, Rome, Italy Department of Pediatric Gastroenterology, Providence St. Vincent's Medical Center, Portland, OR, USA Division of Pediatric Gastroenterology, Department of Pediatrics, Goryeb Children's Hospital, Icahn School of Medicine at Mount Sinai, Morristown, NJ, USA Division of Pediatrics, Pediatric Gastroenterology Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA Pediatric Gastroenterology, Department of Pediatrics, Centro Hospitalar Universitário S. João, Porto, Portugal Division of Pediatrics, Department of Pediatric Gastroenterology, Queen Fabiola Children's University Hospital, ICBAS - Université Libre de Bruxelles, Brussels, Belgium Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Department of Paediatrics, William Osler Health System, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada Blizard Institute, Barts and the London School of Medicine, Royal London Children's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, United Kingdom Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA Pediatric Gastroenterology & Nutrition, Department of Pediatrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, University J.J. Strossmayer Medical School, Osijek, Croatia Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada Division of Gastroenterology, Hepatology and Nutrition, British Columbia's Children's Hospital and British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, WA, United States of America Gastroenterology & Nutrition, Department of Pediatrics, IWK Health, Dalhousie University, Halifax, Nova Scotia, Canada Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, Colorado, USA Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield University, Sheffield, South Yorkshire, United Kingdom.

Introduction: High quality pediatric endoscopy requires reliable performance of procedures by competent individual providers who consistently uphold all standards determined to assure optimal patient outcomes. Establishing consensus expectations for ongoing monitoring and assessment of individual pediatric endoscopists is a method for confirming the highest possible quality of care for such procedures worldwide. We aim to provide guidance to define and measure quality of endoscopic care for children.

Methods: With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopists. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

Results: The PEnQuIN working group achieved consensus on 6 standards that all providers who perform pediatric endoscopy should uphold and 2 standards for pediatric endoscopists in training, with a corresponding 7 indicators that can be used to identify high quality endoscopists. Additionally, these can inform continuous quality improvement at the provider level. Minimum targets for defining high quality pediatric ileocolonoscopy were set for 2 key indicators: cecal intubation rate (≥90%) and terminal ileal intubation rate (≥85%).

Discussion: It is recommended that all individual providers performing or training to perform pediatric endoscopy initiate and engage with these international endoscopist-related standards and indicators developed by PEnQuIN.
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http://dx.doi.org/10.1097/MPG.0000000000003265DOI Listing
August 2021

Pediatric Endoscopy Quality Improvement Network (PEnQuIN) Quality Standards and Indicators for Pediatric Endoscopic Procedures: A Joint NASPGHAN/ESPGHAN Guideline.

J Pediatr Gastroenterol Nutr 2021 Aug 16. Epub 2021 Aug 16.

Division of Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Umberto I - University Hospital, Sapienza - University of Rome, Rome, Italy Division of Gastroenterology, Hepatology and Nutrition, British Columbia's Children's Hospital and British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, University J.J. Strossmayer Medical School, Osijek, Croatia Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom Pediatric Gastroenterology & Nutrition, Department of Pediatrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA Blizard Institute, Barts and the London School of Medicine, Royal London Children's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, United Kingdom Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Department of Paediatrics, William Osler Health System, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada Division of Pediatrics, Department of Pediatric Gastroenterology, Queen Fabiola Children's University Hospital, ICBAS - Université Libre de Bruxelles, Brussels, Belgium Pediatric Gastroenterology, Department of Pediatrics, Centro Hospitalar Universitário S. João, Porto, Portugal Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA Division of Pediatrics, Pediatric Gastroenterology Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal Division of Pediatric Gastroenterology, Department of Pediatrics, Goryeb Children's Hospital, Icahn School of Medicine at Mount Sinai, Morristown, NJ, USA Department of Pediatric Gastroenterology, Providence St. Vincent's Medical Center, Portland, OR, USA Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield University, Sheffield, South Yorkshire, United Kingdom Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada Division of Gastroenterology and Hepatology, Medicine and Pediatrics, Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA Division of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Children's of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington D.C., USA Gastroenterology & Nutrition, Department of Pediatrics, IWK Health, Dalhousie University, Halifax, Nova Scotia, Canada Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, Colorado, USA Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, WA, United States of America Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.

Introduction: High quality pediatric gastrointestinal procedures are performed when clinically indicated and defined by their successful performance by skilled providers in a safe, comfortable, child-oriented and expeditious manner. The process of pediatric endoscopy begins when a plan to perform the procedure is first made and ends when all appropriate patient follow-up has occurred. Procedure-related standards and indicators developed to date for endoscopy in adults emphasize cancer screening and are thus unsuitable for pediatric medicine.

Methods: With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopic procedures. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

Results: The PEnQuIN working group achieved consensus on 14 standards for pediatric endoscopic procedures, as well as 30 indicators that can be used to identify high quality procedures. These were subcategorized into 3 subdomains: Preprocedural (3 standards, 7 indicators), Intraprocedural (8 standards, 18 indicators) and Postprocedural (3 standards, 5 indicators). A minimum target for the key indicator, 'rate of adequate bowel preparation,' was set at ≥80%.

Discussion: It is recommended that all facilities and individual providers performing pediatric endoscopy worldwide initiate and engage with the procedure-related standards and indicators developed by PEnQuIN to identify gaps in quality and drive improvement.
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August 2021

Pediatric Endoscopy Quality Improvement Network (PEnQuIN) Quality Standards and Indicators for Pediatric Endoscopy Facilities: A Joint NASPGHAN/ESPGHAN Guideline.

J Pediatr Gastroenterol Nutr 2021 Aug 16. Epub 2021 Aug 16.

Division of Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, South Yorkshire, United Kingdom Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA Division of Pediatrics, Pediatric Gastroenterology Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal Division of Pediatric Gastroenterology, Department of Pediatrics, Goryeb Children's Hospital, Icahn School of Medicine at Mount Sinai, Morristown, NJ, USA Department of Pediatric Gastroenterology, Providence St. Vincent's Medical Center, Portland, OR, USA Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Umberto I - University Hospital, Sapienza - University of Rome, Rome, Italy Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada Division of Gastroenterology and Hepatology, Medicine and Pediatrics, Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA Division of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Children's of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington D.C., USA Division of Gastroenterology, Hepatology and Nutrition, British Columbia's Children's Hospital and British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, University J.J. Strossmayer Medical School, Osijek, Croatia Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom Pediatric Gastroenterology & Nutrition, Department of Pediatrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA Blizard Institute, Barts and the London School of Medicine, Royal London Children's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, United Kingdom Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Department of Paediatrics, William Osler Health System, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada Division of Pediatrics, Department of Pediatric Gastroenterology, Queen Fabiola Children's University Hospital, ICBAS - Université Libre de Bruxelles, Brussels, Belgium Pediatric Gastroenterology, Department of Pediatrics, Centro Hospitalar Universitário S. João, Porto, Portugal Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, Colorado, USA Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, WA, United States of America Gastroenterology & Nutrition, Department of Pediatrics, IWK Health, Dalhousie University, Halifax, Nova Scotia, Canada Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield University, Sheffield, South Yorkshire, United Kingdom.

Introduction: There is increasing international recognition of the impact of variability in endoscopy facilities on procedural quality and outcomes. There is also growing precedent for assessing the quality of endoscopy facilities at regional and national levels by using standardized rating scales to identify opportunities for improvement.

Methods: With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of facilities where endoscopic care is provided to children. Consensus was reached via an iterative online Delphi process and subsequent in-person meeting. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) approach.

Results: The PEnQuIN working group achieved consensus on 27 standards for facilities supporting pediatric endoscopy, as well 10 indicators that can be used to identify high quality endoscopic care in children. These standards were subcategorized into 3 subdomains: Quality of Clinical Operations (15 standards, 5 indicators); Patient and Caregiver Experience (9 standards, 5 indicators); and Workforce (3 standards).

Discussion: The rigorous PEnQuIN process successfully yielded standards and indicators that can be used to universally guide and measure high quality facilities for procedures around the world where endoscopy is performed in children. It also underscores the current paucity of evidence for pediatric endoscopic care processes, and the need for research into this clinical area.
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August 2021

Overview of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) Quality Standards and Indicators for Pediatric Endoscopy: A Joint NASPGHAN/ESPGHAN Guideline.

J Pediatr Gastroenterol Nutr 2021 Aug 16. Epub 2021 Aug 16.

Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada Division of Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada Pediatric Gastroenterology, Department of Pediatrics, Centro Hospitalar Universitário S. João, Porto, Portugal Division of Pediatrics, Department of Pediatric Gastroenterology, Queen Fabiola Children's University Hospital, ICBAS - Université Libre de Bruxelles, Brussels, Belgium Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Department of Paediatrics, William Osler Health System, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada Blizard Institute, Barts and the London School of Medicine, Royal London Children's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, United Kingdom Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA Pediatric Gastroenterology & Nutrition, Department of Pediatrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, University J.J. Strossmayer Medical School, Osijek, Croatia Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada Division of Gastroenterology, Hepatology and Nutrition, British Columbia's Children's Hospital and British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington D.C., USA Division of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Children's of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA Division of Gastroenterology and Hepatology, Medicine and Pediatrics, Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, South Yorkshire, United Kingdom Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Umberto I - University Hospital, Sapienza - University of Rome, Rome, Italy Department of Pediatric Gastroenterology, Providence St. Vincent's Medical Center, Portland, OR, USA Division of Pediatric Gastroenterology, Department of Pediatrics, Goryeb Children's Hospital, Icahn School of Medicine at Mount Sinai, Morristown, NJ, USA Division of Pediatrics, Pediatric Gastroenterology Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, WA, United States of America Gastroenterology & Nutrition, Department of Pediatrics, IWK Health, Dalhousie University, Halifax, Nova Scotia, Canada Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, Colorado, USA Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.

Introduction: Pediatric-specific quality standards for endoscopy are needed to define best practices, while measurement of associated indicators is critical to guide quality improvement. The international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) working group was assembled to develop and define quality standards and indicators for pediatric gastrointestinal endoscopic procedures through a rigorous guideline consensus process.

Methods: The Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument guided PEnQuIN members, recruited from 31 centers of various practice types representing 11 countries, in generating and refining proposed quality standards and indicators. Consensus was sought via an iterative online Delphi process, and finalized at an in-person conference. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

Results: Forty-nine quality standards and 47 indicators reached consensus, encompassing pediatric endoscopy facilities, procedures, endoscopists and the patient experience. The evidence base for PEnQuIN standards and indicators was largely adult-based and observational, and downgraded for indirectness, imprecision and study limitations to 'very low' quality, resulting in 'conditional' recommendations for most standards (45/49).

Conclusions: The PEnQuIN guideline development process establishes international agreement on clinically meaningful metrics that can be used to promote safety and quality in endoscopic care for children. Through PEnQuIN, pediatric endoscopists and endoscopy services now have a framework for auditing, providing feedback and, ultimately, benchmarking performance. Expansion of evidence and prospective validation of PEnQuIN standards and indicators as predictors of clinically relevant outcomes and high quality pediatric endoscopic care is now a research priority.
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http://dx.doi.org/10.1097/MPG.0000000000003262DOI Listing
August 2021

Significant variations across European centres in implementing recommended guidelines for the paediatric gastroenterology endoscopy suite during the COVID-19 pandemic.

JPGN Rep 2021 Aug 27;2(3):e061. Epub 2021 May 27.

University Children's Hospital, Basel, Switzerland.

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published recommendations regarding protection for the paediatric endoscopist during the coronavirus 2019 (COVID-19) pandemic.The aim of this survey was to investigate whether European paediatric gastroenterology centres applied the recommendations and how this extraordinary situation was handled by the different centres.

Results: Twelve paediatric European gastroenterology centres participated. Nine centres (75%) screened their patients for possible COVID-19 infection before the procedure, the same amount of hospitals changed their practice based on the ESPGHAN recommendations. Six-seven percentage of the centres reduced the staff in the endoscopy suite, 83% of the units used FFP2/3 masks and protective goggles during the procedure and 75% wore waterproof gowns.

Conclusion: Uniform guidelines could not be applied by all European hospitals at a certain time point of the viral spread, as different regions of Europe were not only affected differently by COVID-19, but also had different access to personal protective equipment.
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http://dx.doi.org/10.1097/PG9.0000000000000061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162040PMC
August 2021

Risks and Protective Factors Associated With Mental Health Symptoms During COVID-19 Home Confinement in Italian Children and Adolescents: The #Understandingkids Study.

Front Pediatr 2021 11;9:664702. Epub 2021 Jun 11.

Department of Human Neuroscience, Sapienza - University of Rome, Rome, Italy.

To identify risk and protective factors for mental health symptoms associated with lifestyle changes caused by home confinement in pediatric subjects and in children and adolescents with a neuropsychiatric disorder. This was a prospective, cross-sectional study conducted from May 10 to May 31, 2020. Two online anonymous surveys were developed: population-based and clinical-based (children with neuropsychiatric disorders). Outcomes included emotional and behavioral symptoms, as assessed by psychometric scales (BPSC, PPSC, PSC, CES-DC and SCARED, respectively), and lifestyle changes during home confinement (i.e., physical activity, screen time, home schooling, reading). The sample included 9,688 pediatric subjects, and 289 children and adolescents with a neuropsychiatric disorder. The presence of siblings was a protective factor in all ages. In pre- and school children: male sex, a diagnosis of autism, residency in highly affected areas, high parental educational level or job loss, and screen time (>2 h/day) were risk factors. Physical activity, home-schooling, reading, talking with other people were protective factors. Residency in highly affected areas, a diagnosis of mood disorder, parental job loss, and screen time, were associated with a worsening of the depressive symptoms, whereas physical activity, talking with other people, playing with parents were protective activities. Screen time was also a risk factor for anxiety symptoms, while physical activity, reading and talking with other people were protective factors. This study identified risk and protective factors for mental health symptoms associated with lifestyle changes caused by COVID-19 home confinement to promote mental well-being in pediatrics during pandemic times.
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http://dx.doi.org/10.3389/fped.2021.664702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8225997PMC
June 2021

Percutaneous Endoscopic Gastrostomy in Children: An Update to the ESPGHAN Position Paper.

J Pediatr Gastroenterol Nutr 2021 Sep;73(3):415-426

Centro Hospitalar S. João, Porto, Portugal.

Background: The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position paper from 2015 on percutaneous endoscopic gastrostomy (PEG) required updating in the light of recent clinical knowledge and data published in medical journals since 2014.

Methods: A systematic review of medical literature from 2014 to 2020 was carried out. Consensus on the content of the manuscript, including recommendations, was achieved by the authors through electronic and virtual means. The expert opinion of the authors is also expressed in the manuscript when there was a lack of good scientific evidence regarding PEGs in children in the literature.

Results: The authors recommend that the indication for a PEG be individualized, and that the decision for PEG insertion is arrived at by a multidisciplinary team (MDT) having considered all appropriate circumstances. Well timed enteral nutrition is optimal to treat faltering growth to avoid complications of malnutrition and body composition. Timing, device choice and method of insertion is dependent on the local expertise and after due consideration with the MDT and family. Major complications such as inadvertent bowel perforation should be avoided by attention to good technique and by ensuring the appropriate experience of the operating team. Feeding can be initiated as early as 3 hours after tube placement in a stable child with iso-osmolar feeds of standard polymeric formula. Low-profile devices can be inserted initially using the single-stage procedure or after 2-3 months by replacing a standard PEG tube, in those requiring longer-term feeding. Having had a period of non-use and reliance upon oral intake for growth and weight gain-typically 8-12 weeks-a PEG may then safely be removed after due consultation. In the event of non-closure of the fistula the most successful method for closing it, to date, has been a surgical procedure, but the Over-The-Scope-Clip (OTSC) has recently been used with considerable success in this scenario.

Conclusions: A multidisciplinary approach is mandatory for the best possible treatment of children with PEGs. Morbidity and mortality are minimized through team decisions on indications for insertion, adequate planning and preparation before the procedure, subsequent monitoring of patients, timing of the change to low-profile devices, management of any complications, and optimal timing of removal of the PEG.
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http://dx.doi.org/10.1097/MPG.0000000000003207DOI Listing
September 2021

COVID-19 and celiac disease: A pathogenetic hypothesis for a celiac outbreak.

Int J Clin Pract 2021 Sep 17;75(9):e14452. Epub 2021 Jun 17.

Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, Rome, Italy.

Background: A growing body of evidence supports the intestinal trophism of SARS-CoV-2, with ciliated cells and intestinal enterocytes being target cells because of the high expression of ACE2 and TMPRSS2. Indeed, COVID-19 promotes a "cytokine storm" in the intestinal mucosa: the resulting epithelial damage leads to increased barrier permeability, allowing the passage of gliadin in the intestinal lamina.

Methods: Based on current literature, we hypothesize the role of COVID-19 as a potential trigger factor for celiac disease in predisposed patients.

Conclusions: Genetically predisposed patients could be more likely to develop celiac disease following SARS-CoV-2 infection, making COVID-19 a candidate culprit for a potential outbreak of celiac disease in the forthcoming future.
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http://dx.doi.org/10.1111/ijcp.14452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420168PMC
September 2021

Monitoring established Crohn's disease with pan-intestinal video capsule endoscopy in Europe: clinician consultation using the nominal group technique.

Curr Med Res Opin 2021 Sep 30;37(9):1547-1554. Epub 2021 Jun 30.

Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy.

Objective: Monitoring established Crohn's disease (CD) through a "treat-to-target" strategy aims to reduce and prevent long-term bowel damage and disability. Despite the availability of different monitoring techniques, there is a current lack of integrated evidence to guide optimal monitoring in terms of appropriate tools and timing. Pan-intestinal video capsule endoscopy (PCE) enables non-invasive and direct visualization of the entire intestinal tract with proven safety and efficacy. This study aims to generate insights on the value of PCE for monitoring established CD from the physician's perspective.

Methods: The Nominal Group Technique (NGT) was used to create discussion around pre-defined research questions aimed at identifying target patient populations for PCE, benefits of PCE in terms of improving disease management, comparative benefits of PCE over standard of care, research priorities to ratify the use of PCE, and hurdles to PCE utilization. A NGT panel was held in Brussels, Belgium in October 2018 with 9 gastroenterology experts. Data were collected from multiple rankings of statements to the research questions and analyzed descriptively.

Results: Consensus indicated that PCE is differentiated from other diagnostic tools, allowing for non-invasive and direct visualization of the luminal intestinal tract in one single procedure. Participants agreed that PCE is beneficial for mapping and grading established CD in all patients, enabling individual and tailored treatment decision-making. Time required to read PCE results was identified as the main utilization hurdle by participants. Well-designed studies are needed to confirm improved outcomes amongst patients with CD managed through a PCE-guided approach.

Conclusions: This study, using the NGT, generated expert opinion on the value of PCE for monitoring established CD in terms of target patient populations and benefits compared to other diagnostic modalities. Participants perceived PCE to facilitate a "treat-to-target" strategy for CD management. Further research is needed to support this value perception.
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http://dx.doi.org/10.1080/03007995.2021.1940910DOI Listing
September 2021

Nasopharyngeal tubes in pediatric anesthesia: Is the flow-dependent pressure drop across the tube suitable for calculating oropharyngeal pressure?

Paediatr Anaesth 2021 07 6;31(7):809-819. Epub 2021 May 6.

Medical Engineering Laboratory, Department of Civil Engineering and Computer Science Engineering, University of Rome "Tor Vergata", Rome, Italy.

Background: Nasopharyngeal tubes are useful in pediatric anesthesia for insufflating oxygen and anesthetics. During nasopharyngeal tube-anesthesia, gas insufflation provides some positive oropharyngeal pressure that differs from the proximal airway pressure owing to the flow-dependent pressure drop across the nasopharyngeal tube (ΔP ).

Aims: This study aimed to investigate whether ΔP could be used for calculating oropharyngeal pressure during nasopharyngeal tube-assisted anesthesia.

Methods: In a physical model of nasopharyngeal tube-anesthesia, using Rohrer's equation, we calculated ΔP for three nasopharyngeal tubes (3.5, 4.0, and 5.0 mm inner diameter) under oxygen and several sevoflurane in oxygen combinations in two ventilatory scenarios (continuous positive airway pressure and intermittent positive pressure ventilation). We then calculated oropharyngeal pressure as proximal airway pressure minus ΔP . Calculated and measured oropharyngeal pressure couples of values were compared with the root mean square deviation to assess accuracy. We also investigated whether oropharyngeal pressure accuracy depends on the nasopharyngeal tube diameter, flow rate, gas composition, and leak size. Using ΔP charts, we tested whether ΔP calculation was feasible in clinical practice.

Results: When we tested small-diameter nasopharyngeal tubes at high-flow or high-peak inspiratory pressure, proximal airway pressure measurements markedly overestimated oropharyngeal pressure. Comparing measured and calculated maximum and minimum oropharyngeal pressure couples yielded root mean square deviations less than 0.5 cmH O regardless of ventilatory modality, nasopharyngeal tube diameter, flow rate, gas composition, and leak size.

Conclusion: During nasopharyngeal tube-assisted anesthesia, proximal airway pressure readings on the anesthetic monitoring machine overestimate oropharyngeal pressure especially for smaller-diameter nasopharyngeal tubes and higher flow, and to a lesser extent for large leaks. Given the importance of calculating oropharyngeal pressure in guiding nasopharyngeal tube ventilation in clinical practice, we propose an accurate calculation using Rohrer's equation method, or approximating oropharyngeal pressure from flow and pressure readings on the anesthetic machine using the ΔP charts.
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http://dx.doi.org/10.1111/pan.14194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252547PMC
July 2021

Diagnostic Value of Persistently Low Positive TGA-IgA Titers in Symptomatic Children With Suspected Celiac Disease.

J Pediatr Gastroenterol Nutr 2021 05;72(5):712-717

Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department.

Objectives: While the algorithm to diagnose celiac disease (CD) in children with elevated anti-transglutaminase IgA (TGA-IgA) titers (>10 times upper limit of normal, ULN) is well defined, the management of children with low TGA-IgA values represents a clinical challenge. We aimed to identify the diagnostic value of persistently low positive TGA-IgA titers in predicting CD in children.

Methods: We retrospectively analyzed children with symptoms or signs of CD, not eligible for a no-biopsy approach. We included children with at least 2 TGA-IgA measurements, endomysial antibody (EMA) assessment and esophagogastroduodenoscopy with biopsies. TGA-IgA values were provided as multiples of ULN. Patients were classified in groups according to median TGA-IgA values: A (TGA-IgA>1 ≤ 5 × ULN; defined as "low-positive"), B (TGA-IgA > 5 < 10 × ULN; "moderate-positive"), and C (controls).

Results: Data of 281 children were analyzed. Of 162 children in group A, CD was diagnosed in 142 (87.7%), whereas normal duodenal mucosa was found in 20. In group B, all 62 children (100%) received a CD diagnosis. Group C included 57 controls. EMA were undetectable in 31 (15%) of mucosal atrophy cases. On the receiver-operating characteristic curve (area under the curve = 0.910), a mean value of 1.7 ULN showed a sensitivity of 81.4% and specificity of 81.8% to predict mucosal damage.

Conclusions: Repeated low or moderate TGA-IgA values (<5 ULN or <10 ULN) are good predictors of a CD diagnosis. Symptomatic children with persistently low positive TGA-IgA titers should undergo esophagogastroduodenoscopy regardless of their EMA status.
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http://dx.doi.org/10.1097/MPG.0000000000003047DOI Listing
May 2021

Scoring Endoscopy in Pediatric Inflammatory Bowel Disease: A Way to Improve Quality.

J Pediatr Gastroenterol Nutr 2021 07;73(1):48-53

Pediatric Gastroenterology and Liver Unit, Maternal and Child Heath Department, Sapienza - University of Rome, Italy.

Objectives And Study: There is a large interobserver variability in evaluating mucosal lesions of inflammatory bowel disease (IBD), especially in pediatric patients. This multicenter prospective observational study aims to evaluate interobserver agreement (IOA) among pediatric endoscopists in assigning validated IBD endoscopic scores in children.

Methods: Fifteen videos of follow-up ileocolonoscopies in children with IBD were recorded and selected as cases. Eleven pediatric endoscopists from different centers blindly evaluated all videos and calculated scores: either Ulcerative Colitis Endoscopic Index of Severity (UCEIS) or Simple Endoscopic Score for Crohn Disease (SES-CD). Scores from all reviewers were compared in order to calculate IOA for general videos and specific sections. Scores from an expert adult reader were used to calculate possible reviewer's characteristics affecting scores' reliability.

Results: Intraclass correlation was 0.298 (95% confidence interval [CI]: 0.13-0.55) for ulcerative colitis (UC) and 0.266 (0.11-0.52) for Crohn disease (CD). When a disease activity categorization was adopted (remission, mild, moderate, severe activity) Fleiss kappa coefficient was 0.408 (0.29-0.53) for UC and 0.552 (0.43-0.73) for CD. When stratified by item, vascular pattern of UC was the most reliable item IC: 0.624 (0.321-0.854). In multivariable analysis, none of the reviewer's characteristics affected the readers' errors.

Conclusions: This multicenter study shows low agreement among pediatric endoscopists in evaluating endoscopic scores in children with IBD. By using disease activity categorization, agreement slightly increased, mostly for CD. All readers showed a low-grade concordance with the expert adult gastroenterologist's evaluations. Future-specific training programs should be considered to increase IOA in using IBD endoscopic activity scores.
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http://dx.doi.org/10.1097/MPG.0000000000003090DOI Listing
July 2021

Gastrointestinal endoscopy in children and adults: How do they differ?

Dig Liver Dis 2021 Jun 7;53(6):697-705. Epub 2021 Mar 7.

Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Rome, Italy. Electronic address:

Gastrointestinal endoscopy has grown dramatically over the past century, and with subsequent improvements in technology and anaesthesia, it has become a safe and useful tool for evaluation of GI pathology in children. There are substantial differences between paediatric and adult endoscopy beyond size, including: age-related patho-physiology and the different spectrum of diseases in children. Literature on endoscopic procedures in children is sparse but significant. The present review aims at describing the current knowledges on paediatric endoscopy practice and highlights the main areas of differences between paediatric and adult practice.
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http://dx.doi.org/10.1016/j.dld.2021.02.016DOI Listing
June 2021

Changes to Pediatric Gastroenterology Practice During the COVID-19 Pandemic and Lessons Learned: An International Survey of Division and Group Heads.

Gastroenterology 2021 Sep 4;161(3):1052-1055. Epub 2021 Mar 4.

Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada. Electronic address:

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http://dx.doi.org/10.1053/j.gastro.2021.02.064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093127PMC
September 2021

Quality performance measures for small capsule endoscopy: Are the ESGE quality standards met?

Endosc Int Open 2021 Feb 25;9(2):E122-E129. Epub 2021 Jan 25.

Divisione di Gastroenterologia U, Azienda Ospedaliero-Universitaria, Città della Salute e della Scienza, Torino, Italy.

 The European Society of Gastrointestinal Endoscopy (ESGE) recently issued a quality performance measures document for small bowel capsule endoscopy (SBCE). The aim of this nationwide survey was to explore SBCE practice with ESGE quality measures as a benchmark.  A dedicated per-center semi-quantitative questionnaire based on ESGE performance measures for SBCE was created by a group of SBCE experts. One-hundred-eighty-one centers were invited to participate and were asked to calculate performance measures for SBCE performed in 2018. Data were compared with 10 ESGE quality standards for both key and minor performance measures.  Ninety-one centers (50.3 %) participated in the data collection. Overall in the last 5 years (2014-2018), 26,615 SBCEs were performed, 5917 of which were done in 2018. Eighty percent or more of the participating centers reached the minimum standard established by the ESGE Small Bowel Working Group (ESBWG) for four performance measures (indications for SBCE, complete small bowel evaluation, diagnostic yield and retention rate). Conversely, compliance with six minimum standards established by ESBWG concerning adequate bowel preparation, patient selection, timing of SBCE in overt bleeding, appropriate reporting, reading protocols and referral to device-assisted enteroscopy was met by only 15.5 %, 10.9 %, 31.1 %, 67.7 %, 53.4 %, and 32.2 % of centers, respectively. The present survey shows significant variability across SBCE centers; only four (4/10: 40 %) SBCE procedural minimum standards were met by a relevant proportion of the centers ( ≥ 80 %). Our data should help in identifying target areas for quality improvement programs in SBCE.
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http://dx.doi.org/10.1055/a-1319-0742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834698PMC
February 2021

Association between Elevated TGA-IgA Titers and Older Age at Diagnosis with Absence of HBV Seroconversion in Celiac Children.

Vaccines (Basel) 2021 Jan 28;9(2). Epub 2021 Jan 28.

Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, 00161 Rome, Italy.

Patients with celiac disease can have a low rate of protective hepatitis B (HBV) antibody titers after vaccination. We aimed to evaluate the HBV seroconversion in celiac disease (CD) children at the time of diagnosis as well as to identify the presence of possible predictive factors. Celiac disease children were prospectively enrolled and tested for antibodies against the S protein of HBV (HBsAg) at time of diagnosis between January 2009 and February 2020. Based on the serologic response to the vaccine, "responders" and "non-responders" were identified. Statistical analysis has been performed through R statistical software (3.5.1 version, R core Team) Of 96 CD children evaluated, 41.7% (n = 40) showed non-protective or absent antibody titers against HBV. Elevated IgA-antibodies against transglutaminase 2 (TGA-IgA) values and older age at diagnosis were associated with an absent seroconversion to HBV vaccine, while presenting symptoms were not significant. An elevated prevalence of absent seroconversion to HBV vaccine exists in this cohort of CD patients at the time of disease diagnosis. Elevated TGA-IgA titers and older age at diagnosis seem to negatively predict seroconversion. Further studies are needed to identify the real profile of "non-responders", aiming to organize surveillance and eventual revaccination strategy.
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http://dx.doi.org/10.3390/vaccines9020101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7912643PMC
January 2021

Fecal and mucosal microbiota profiling in pediatric inflammatory bowel diseases.

Eur J Gastroenterol Hepatol 2021 Jan 18. Epub 2021 Jan 18.

Scientific Institute Pediatric Hospital "Bambino Gesù" Department of Women's and Children's Health, Sapienza University of Rome Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy.

Background: An altered gut microbiota profile has been widely documented in inflammatory bowel diseases (IBD). The intestinal microbial community has been more frequently investigated in the stools than at the level of the mucosa, while most of the studies have been performed in adults. We aimed to define the gut microbiota profile either by assessing fecal and colonic mucosa samples (inflamed or not) from pediatric IBD patients.

Patients And Methods: Fecal and colonic samples from pediatric IBD (Crohn's disease or ulcerative colitis) and controls were analyzed. The relative abundance of bacteria at phylum and genus/species levels and bacterial diversity were determined through 16S rRNA sequence-based of fecal and mucosal microbiota analysis.

Results: A total of 59 children with IBD (26 Crohn's disease, 33 ulcerative colitis) and 39 controls were analyzed. A clear separation between IBD and controls in the overall composition of fecal and mucosal microbiota was found, as well as a reduced bacterial richness in the fecal microbiota of IBD. At the phylum level, abundance of Proteobacteria and Actinobacteria occurred in fecal microbiota of IBD, while species with anti-inflammatory properties (i.e., Ruminococcus) were reduced. Fusobacterium prevailed in inflamed IBD areas in comparison to noninflamed and controls samples.

Conclusion: Significant alterations in gut microbiota profile were shown in our IBD pediatric patients, in whom an abundance of species with a proinflammatory mucosal activity was clearly detected. An analysis of gut microbiota could be incorporated in designing personalized IBD treatment scenarios in future.
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http://dx.doi.org/10.1097/MEG.0000000000002050DOI Listing
January 2021

Systemic steroids have a role in treating esophageal strictures in pediatric eosinophilic esophagitis.

Dig Liver Dis 2021 03 15;53(3):324-328. Epub 2020 Dec 15.

Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Background: The role of systemic steroids in the treatment of esophageal strictures in children with Eosinophilic Esophagitis (EoE) is poorly defined.

Aims: To describe a cohort of children with EoE-associated esophageal strictures responding to systemic steroids.

Methods: Retrospective review of medical records of children with EoE and moderate (<9 mm) to severe (<6 mm) strictures, who responded clinically and endoscopically to systemic steroids.

Results: Twenty children (median age 10.6 ± 4.2 years; 17 males) from nine centers in six countries were included in the analysis; 16 had moderate and four, severe strictures; 18 had dysphagia or bolus impaction; median diagnostic delay was 8 months (IQR 3.5-35). Eighteen patients received oral systemic steroids (mean dose 1.4 mg/kg/day) for a median of 4 weeks, while two initially received IV steroids. All patients showed clinical improvement and 15/20 became asymptomatic. Stricture resolution at endoscopy was found in 19/20, while histological resolution of EoE (<15 eos/hpf) in 13/20. Only minor side effects were reported: hyperphagia (10/20); weight gain (5/20); hyperactivity (2/20) and acne (1/20). Esophageal dilation was required in 3/20 patients during a median follow-up of 48.5 months (IQR 26.7-73.2).

Conclusion: Children with EoE and esophageal strictures, may benefit from the use of a short course of systemic steroids, avoiding mechanical dilation.
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http://dx.doi.org/10.1016/j.dld.2020.11.025DOI Listing
March 2021

The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update.

J Crohns Colitis 2020 Oct 7. Epub 2020 Oct 7.

Assistance Publique- Hôpitaux de Paris, Hôpital Necker Enfants Malades, Pediatric Gastroenterology, Paris, France.

Objective: We aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn's disease [CD].

Methods: We formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained.

Results: We established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone.

Conclusions: We present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.
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http://dx.doi.org/10.1093/ecco-jcc/jjaa161DOI Listing
October 2020

ESPGHAN 'biopsy-sparing' guidelines for celiac disease in children with low antitransglutaminase during COVID-19.

Eur J Gastroenterol Hepatol 2020 12;32(12):1523-1526

Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy.

Objectives: Recent guidelines for celiac disease have allowed a biopsy-free approach in endomysial antibodies (EMAs) positive children with high antitransglutaminase (TGA-IgA) titer [>10 time upper limit of normal (ULN)]. Esophagogastroduodenoscopy is still necessary for diagnosis in children with lower title. Because elective pediatric endoscopy has been substantially shouted down during coronavirus disease (COVID-19) pandemic, many children remained undiagnosed - and therefore untreated - for a long time. We aimed to analyze the feasibility and accuracy of a biopsy-free approach in suspected celiac disease children with TGA-IgA values <10 ULN to facilitate the diagnostic process by avoiding endoscopy.

Methods: In this study cohort, we retrospectively analyzed all biopsy-confirmed diagnosis of celiac disease in our center (between 2014 and 2019). The positive predictive value (PPV) of TGA-IgA titers between 5 and 10 ULN and positive EMA in diagnosing celiac disease were determined. Mucosal atrophy and resolution of symptoms after gluten-free diet (GFD) were considered to confirm initial diagnosis.

Results: Of 430 celiac disease patients (F: 274; mean age 7.54 years) diagnosed by endoscopy, 84 (F: 46; mean age 8 years) with TGA-IgA between 5 and 10 ULN and positive EMA were identified. The PPV of TGA-IgA between 5 and 10 ULN and positive EMA was 0.93 (95% confidence interval 0.90-0.96). All these children had a symptom resolution and antibodies normalization after GFD.

Conclusion: During the COVID-19 outbreak, a temporarily reduction of the TGA-IgA threshold for biopsy-sparing approach seems feasible in EMA positive children with TGA-IgA between 5 and 10 ULN.
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http://dx.doi.org/10.1097/MEG.0000000000001924DOI Listing
December 2020

Distribution of eosinophils in the gastrointestinal tract of children with no organic disease.

Ann Gastroenterol 2020 Sep-Oct;33(5):508-515. Epub 2020 Jun 22.

Division of Gastroenterology and Hepatology, First Department of Pediatrics, University of Athens, Agia Sofia Children's Hospital, Athens, Greece (Eleni Koutri, Maria Noni, Alexandra Papadopoulou).

Background: This study aimed to assess the eosinophil (eos) density of the mucosa of the gastrointestinal (GI) tract in children undergoing endoscopic procedures following an extensive workup, without diagnosis of an organic disease.

Methods: Biopsies from GI endoscopies performed at 3 major children's hospitals (Athens, Madrid and Rome), between January 2012 and June 2018, were evaluated by a single pathologist in each center. Peak eos counts were expressed /high power field and /mm. Other histological abnormalities were also reported.

Results: A total of 111 children (median age 11 years; 48 boys) underwent upper endoscopy (333 biopsies), while 44 (median age 12; 25 boys) underwent ileocolonoscopy (262 biopsies). The median (interquartile range) eos/mm were as follows: esophagus 0 (0-0); stomach 0 (0-3); duodenum 22 (13-29); ileum 29 (19-46); cecum 39 (25-71); ascending colon 24 (20-41); transverse colon 27 (21-57); descending colon 21 (13-27); sigmoid colon 22 (13-30); and rectum 10 (6-22). Geographical variations in GI tissue eos counts were found amongst the participating centers, but the causative factors need further evaluation. Functional GI disorders according to the Rome IV criteria were diagnosed in 73 children (37 boys, median age 13 years). No differences were found between children with or without functional GI disorder diagnosis, with regard to eos density in the GI tract.

Conclusion: The reported peak counts of GI tissue eos in children with no organic diseases provide normative values that may be useful in the evaluation of children with GI symptoms suggestive of eosinophilic GI disorders.
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http://dx.doi.org/10.20524/aog.2020.0518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406818PMC
June 2020

Foreign body and caustic ingestions in children: A clinical practice guideline.

Dig Liver Dis 2020 11 8;52(11):1266-1281. Epub 2020 Aug 8.

Pediatric Hepatology Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy.

Foreign body and caustic ingestions in children are usually the most common clinical challenges for emergency physicians, general pediatricians and pediatric gastroenterologists. Management of these conditions often requires different levels of expertise and competence. Endoscopy is often necessary but there is a high risk of misusing this tool with incorrect timing and indications. The imprecise clinical history frequently leaves clinicians uncertain about timing and nature of the ingestion. Few clinical guidelines regarding management of these ingestions in children have been published, none of which from the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP). An expert panel of Italian endoscopists was convened by the SIGENP Endoscopy Working Group to produce the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body and caustic ingestions. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) has also endorsed the project since many adult endoscopists usually manage children with these conditions. Differently from the other published guidelines, the proposed one focuses on the role of the endoscopists (regardless of whether they are adult or pediatric gastroenterologists) in the diagnostic process of children with foreign body and caustic ingestions.
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http://dx.doi.org/10.1016/j.dld.2020.07.016DOI Listing
November 2020

Children and Fecal SARS-CoV-2 shedding: Just the tip of the Iceberg of Italian COVID-19 outbreak?

Dig Liver Dis 2020 11 7;52(11):1219-1221. Epub 2020 Jul 7.

Maternal and Child Health Department, Sapienza University of Rome, Department of Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy.

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http://dx.doi.org/10.1016/j.dld.2020.06.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340015PMC
November 2020

Long-term effects on growth of an energy-enhanced parenteral nutrition in preterm newborn: A quasi-experimental study.

PLoS One 2020 6;15(7):e0235540. Epub 2020 Jul 6.

Department of Maternal and Child Health Policlinico Umberto I, University La Sapienza, Rome, Italy.

Aim: To assess the best energy intake in Parenteral Nutrition (PN) for preterm newborns, considering both possible benefits for growth and risk of complications.

Methods: Quasi-experimental study comparing two cohorts of newborns, receiving Energy-Enhanced vs. Standard PN (Cohort A, from 1st January 2015 to 31 January 2016 and Cohort B from 1st February 2016 to 31 March 2017; respectively) after implementation of a change in the PN protocol. The primary outcome measure was growth at 24 months of life. The PN associated complications were also measured.

Results: We enrolled 132 newborns in two Cohorts, similar for prenatal and postnatal clinical characteristics. Although, body weight and length at 24 months of life were significantly higher (p<0.05) in the Cohort A (11.1, 95% CI 10.6 to 11.6 Kg; 85.0 95% CI 83.8 to 86.2 cm) compared with Cohort B (10.4, 95% CI 9.9 to 10.9 Kg; 81.3 95% CI 79.7 to 82.8 cm), body weight and length Z-Score in the first 24 months of life were similar between the two Cohorts. The rate of PN associated complications was very high in both study Cohorts (up to 98% of enrolments). Multivariate analysis showed that length at 24 months was significantly associated with receiving standard PN (cohort A) in the first week of life and on the energy intake in the first week of life. We also found a marginally insignificant association between Cohort A assignment and body weight at 24 months of life (p = 0.060).

Conclusions: Energy-enhanced PN in early life has not significant effects on long-term growth in preterm newborns. The high prevalence of PN associated complications, poses concerns about the utility of high energy intake recommended by current guidelines for PN.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235540PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337335PMC
September 2020

Eosinophilic Esophagitis: Update on Diagnosis and Treatment in Pediatric Patients.

Paediatr Drugs 2020 Aug;22(4):343-356

Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy.

Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disorder characterized by symptomatic esophageal dysfunction and an eosinophil-predominant inflammation of the esophagus. EoE arises from interaction between genetic and environmental factors. In pediatric patients, clinical manifestations vary depending on age, from a gastroesophageal reflux disease (GERD)-like condition to severe dysphagic symptoms. Upper endoscopy is considered the gold standard for diagnosis and monitoring of EoE; however, significant efforts are underway to identify noninvasive diagnostic tools and biomarkers to avoid repetitive invasive procedures. Therapeutic first-line options currently available for EoE are elimination diets, proton pump inhibitors (PPIs), and steroids. The aim of treatment is to improve clinical symptoms while obtaining mucosal healing and avoiding long-term complications. Dietary treatment options comprise different empiric diets or an exclusively amino acid formula. Despite the efficacy of diets, compliance is often challenging. PPIs and topical steroids represent the main pharmacological options for EoE, and both can induce and maintain remission. Topical steroids have been reported as more effective, but data on long-term safety remain insufficient for both these and PPIs. Endoscopic dilations are currently reserved for severe untreated fibrostenotic disease unresponsive to medical therapies. Several biologic agents are available but not yet approved for EoE.
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http://dx.doi.org/10.1007/s40272-020-00398-zDOI Listing
August 2020

Panenteric capsule endoscopy versus ileocolonoscopy plus magnetic resonance enterography in Crohn's disease: a multicentre, prospective study.

BMJ Open Gastroenterol 2020 06;7(1)

Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: Crohn's disease diagnosis and monitoring remains a great clinical challenge and often requires multiple testing modalities. Assessing Crohn's disease activity in the entire gastrointestinal (GI) tract using a panenteric capsule endoscopy (CE) system could be used as an alternative to colonoscopy and cross-sectional imaging. This study assessed the accuracy and safety of panenteric CE in Crohn's disease as compared with ileocolonoscopy (IC) and/or magnetic resonance enterography (MRE).

Methods: A prospective, multicentre study was performed in subjects with established Crohn's disease. Individuals with proven small bowel patency underwent a standardised bowel preparation, followed by CE ingestion and IC either the same or following day. MRE, IC, and CE interpretations were performed by blinded central readers using validated scoring systems. The primary endpoint was the overall sensitivity of CE vs MRE and/or IC in Crohn's disease subjects.

Results: Study enrolment included 158 subjects from 21 sites in the USA, Austria, and Israel. Of those, 99 were included in the analysis. Imaging modality scores indicated none to mild inflammation in the proximal small bowel and colon, but discrepant levels of inflammation in the terminal ileum. Overall sensitivity for active enteric inflammation (CE vs MRE and/or IC) was 94% vs 100% (p=0.125) and specificity was 74% vs 22% (p=0.001). Sensitivity of CE was superior to MRE for enteric inflammation in the proximal small bowel (97% vs 71%, p=0.021), and similar to MRE and/or IC in the terminal ileum and colon (p=0.500-0.625). There were seven serious adverse advents of which three were related to the CE device.

Conclusion: Panenteric CE is a reliable tool for assessing Crohn's disease mucosal activity and extent compared with more invasive methods. This study demonstrates high performance of the panenteric CE as compared to MRE and/or IC without the need for multiple tests in non-stricturing Crohn's disease.

Trial Registration Number: ClinicalTrials.gov NCT03241368.
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http://dx.doi.org/10.1136/bmjgast-2019-000365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282309PMC
June 2020
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