The aim of our study is to determine the demographic data, indications, performance, and security of gastroscopy in children in Ivory Coast. Patients and Methods: This is a retrospective analytical study based on reports of upper digestive endoscopy per-formed in children (from 1 day to 15 years included) in 2 university hospitals in Abid-jan from March 2009 to March 2016. Results: 276 upper gastrointestinal endoscopies (UGIE) were performed in children during the study period. UGIE was performed with a diagnostic purpose in most cases (99%). The indications of UGIE were abdominal pains (38.95%), ingestion of caustic substances (29.82%), upper gastrointestinal bleeding (10.87%) and vomiting (10.17%). UGIE was normal in 39.49% of cases for all ages. The main anomalies observed in upper gastrointestinal (GI) endoscopy for all ages were gastropathies (29%); caustic lesions (13.02%) and bile reflux (10.45%). Ul-cers were rarely found (2.54%). Histological examination of biopsies revealed chronic H. pylori gastritis in 67% of gastric samples examined. All endoscopic examinations were performed without incident. Conclusion: Gastroscopy is a harmless examination with a great diagnostic and therapeutic utility in digestive pathology of children in Ivory Coast.
Upper gastrointestinal endoscopy (UGIE) or gastroscopy is a test that allows visual exploration of the inner walls (mucosa) of the esophagus, the stomach and the duodenum to detect anomalies, and sample tissues (biopsies) for histological study.
Since its introduction in children in the 1970s, gastrointestinal endoscopy has rapidly developed to become one of the most commonly used explorations in pediatric gastroenterology   . The development of flexible endoscopes with small caliber and the experience of the operators have made possible gastroscopy at any age including the newborn.
Upper gastrointestinal diseases are common in children worldwide and digestive endoscopy despite its invasive nature plays an important role in their explorations  .
Several African  -  and European    studies were interested in gastrointestinal endoscopy in children. We notice a large variability of indications, of the practice or not of sedation and/or biopsies, of lesions observed during these studies.
In this manuscript, the authors have studied the demographic data, indications, performance, and security of gastroscopy in children in Ivory Coast.
2. Patients and Methods
This is a retrospective analytical study based on reports of upper gastrointestinal endoscopy performed in 2 university hospitals in Abidjan over a period of 7 years from March 2009 to March 2016. Both University Hospitals have digestive endoscopy units for adults receiving both adults and children. These endoscopy units have video-endo- scopy Fujinon brand column with gastroscopes for adults with medium caliber 9mm and pediatric with small caliber 5 mm and 7.8 mm. These endoscopy centers receive both inpatients and outpatients. The exams are usually performed by skillful gastroenterologists assisted by a nurse specialist in digestive endoscopy. All of the pediatric patients (aged from1day to 15 years included) in which upper GI endoscopy was performed during the study period were included in the study. The patients aged over 15 years in which upper GI endoscopy was performed during the study period were excluded from the study.
For each child’s record included in the study, we provided the information as follows:
-Demographic data: age, gender.
-Indications of UGIE.
-Results of upper gastrointestinal endoscopy.
-Practice of sedation or not (substance used for sedation)
-Performance or not of biopsies (site of biopsies and their indication).
-Presence or absence of a reported incident during the exam.
The children included in the study were distributed in 4 groups according to age: Newborn (from 0 to 28 days), Infant (from 29 days to 23 months), Small children (from 2 to 6 years), Child (from 6 to 12 years) and adolescents (from 12 to 15 years).
We have grouped under the term of abdominal pains, any kind of abdominal pains that motivated the performance of gastroscopy (epigastric pain, ulcer syndrome, dyspeptic syndrome, retrosternal pains, abdominal pains poorly systematized).
All data were collected using a survey form.
The authors showed that 276 upper gastrointestinal endoscopies (UGIE) were performed in children during the study period.
These 276 UGIE accounted for 3.30% of all upper gastrointestinal endoscopies (8314) performed in the 02 university hospitals during the study period. The age of our children ranged from 21 days to 15 years with a mean age of 7.97 years and a median of 09 years. More over it was noted a female predominance with a sex ratio male/female of 0. 92.
Teenagers were the most represented age group with a frequency of 36.73%.
UGIE was performed with a diagnostic purpose in most cases 99% and with therapeutic purpose in only 03 cases (foreign body extraction). The indications of UGIE were dominated by abdominal pains (38.95%), ingestion of caustic substances (29.82%), upper gastrointestinal hemorrhage (10.87%) and vomiting (10.17%) (Table 1 and Table 2). However the indications vary depending on the age of the children. Abdominal pains represent the leading indication in adolescents (over 68% of cases) and children (in over 55% of cases).
Table 1. Sociodemographic and clinical characteristics of children.
Table 2.Indications of UGIE and their variations depending on the age of children.
For small children and infants UGIE was performed for accidental ingestion of caustic substances in over 65% of cases, in small children and 60% in infants (Table 2).
Sedation was done during UGIE with either midazolam or by intravenous diazepam. The dose administered depended on the age of children. It was carried out in 123 children among the 276 (44.57%) and it improved the tolerance of the examination (Figure 1).
UGIE was normal in 39.49% of cases for all ages and lesions were found in nearly 60% of cases. The most common site of lesions was gastric (45.36%) followed by esophagus (20.28%). Cardial (3.26%) and duodenum (7.2%) were rarer. The main anomalies observed in upper GI endoscopy for all ages were gastropathy (29%); caustic lesions (13.02%) and bile reflux in (10.45%).
Ulcers were rarely found with a frequency of 2.54% for bulbar ulcer and 0.72% for gastric ulcer. These ulcers were found in children and adolescents and were revealed by abdominal pains in most cases.
Apart from these lesions, it was observed a case of malignant squamous cell carcinoma of the esophagus 0.36% in an adolescent revealed by dysphagia, 14 cases of esophageal varices 5.07% and 5 cases of peptic esophagitis 1.81% (Table 3).
Biopsies were performed in only 49 children out of the 276 (17.75%). The most common site of biopsies was gastric (97.96%) against only 02 esophageal biopsies. Histological examination of biopsies revealed chronic H. pylori gastritis in 67% of examined samples and squamous cell carcinoma of the esophagus. Tolerance of gastroscopy was generally good in most cases (over 63% of cases). It was improved with age and sedation.
All endoscopic examinations were performed without incident.
Figure 1. Distribution tolerance depending on the age and sedation.
Table 3. Upper gastrointestinal endoscopy finding in children.
Despite its key role in the exploration of the digestive pathology of children the child's UGIE accounted for only 3.3% of all upper gastrointestinal endoscopies performed during the study period. This low rate is common to African studies with frequencies from 1.2% to 6.5%     .
The frequent failure of the technical facilities and the lack of pediatric gastroenterology department in these countries explain the fact that UGIE there is not commonly performed in children. Unlike European series teenagers are the age groups most represented in our study and in several African studies    due to the lack of pediatrician gastroenterologist. The presence of these specialists would better refine the indications for upper gastrointestinal endoscopies in small children and infants in our country.
Although indications for upper gastrointestinal endoscopy are well codified in children according to the consensus of the SFED (French Digestive endoscopy Society) and GFHGNP(French Hepatology, Gastroenterology and Pediatric Nutrition Group)  , there is a variability of indications based on studies.
In the literature of most developing countries, recurrent abdominal pains were reported as the most frequent indications for upper gastrointestinal endoscopy in children. Several studies demonstrate it with frequencies ranging from 22% to 90%       . These abdominal pains are the primary reason for the performance of gastroscopy in our study with a frequency of 38.45% for all ages. They are especially common in children after 6 years (child and adolescent) in whom they alone represent over 70% of indications. Our data are consistent with data from the literature of these developing countries.
However in similar studies of Jantchou in France  , Mouzan in Saudi Arabia  and Toufouki in Morocco  , the malabsorption syndrome was the major indication of performance of upper gastrointestinal endoscopy with frequencies of 27% - 40%. This syndrome has not been found as an indication in our study. The malabsorption syndrome helps suspect celiac disease whose jejunal biopsy remains the gold standard diagnosis  .
Celiac disease is a rare disease in our area, however the importance of upper gastrointestinal endoscopy in children affected by chronic diarrhea should be raised among pediatricians in our context.
The ingestion of caustic substance remains a frequent accident in children, even if the prognosis is usually benign   . Severe digestive lesions can be observed developing into sequelar strictures responsible for significant mortality. It was found in 85 cases in our study that is (29.80%) of indications of UGIE in children. It predominates in the infants and small children (over 60% of indications) as pointed out by other authors     .
Upper gastrointestinal bleeding is an extremely common medical and surgical emergency in children and is a sign of alarm. It represents an extreme indication for the performance of upper gastrointestinal endoscopy between the 6th and 24th hour in a clinically stable child with no sign of active bleeding. Aoulou  and Boudabbous  reported it as the most common reason for performing upper gastrointestinal endoscopy in their series in 37% and 43% of cases. However it has represented only 11% of indications in our children, 10.44% for Lawson  , and 9.73% for Toufiki  . These results show that upper GI bleeding remains common in children and the observed differences are probably due to sampling fluctuations. Upper gastrointestinal endoscopy is the key to lesion diagnosis of upper gastrointestinal bleeding with a high profitability of over 70%  .
Despite the low rate of gastroscopy in children the diagnostic profitability was good (nearly 60%). In this study, the most commonly observed lesions in upper gastrointestinal endoscopy were gastropathies as in many developing countries studies where abdominal pains were the main indication for upper gastrointestinal endoscopy      .
The high frequency of gastropathies in these studies is correlated to the high prevalence of H. pylori infection in developing countries (60% - 80%)  . In Ivory Coast it various from 53% to 91%    .
In the industrialized countries, particularly in France where the prevalence of this infection is relatively low 5% - 10%  , the study of Anicicleroy in Lille  found 8.64% of gastropathies and that of Poissy hospital 13%  . These results show that H.pylori is the first etiological factor of chronic gastritis as Diomandé  Attia  and Bougouma reported  .
Ulcers are rare in our study, 2.52% (7 cases) for duodenal ulcers and 0.72% (2 cases) for gastric ulcer. These ulcers were more common after 6 years and were revealed by abdominal pains in most cases. The rarity of ulcers was observed by other authors   .
Esophageal varices are relatively rare in children, 0.49% in the series of Lawson  , 2% in that of Christina  and 5.07% in ours. They are encountered at all ages and most often diagnosed during the upper gastrointestinal bleeding. Unlike the study of Lawson  where no biopsy was performed, we notice the performance of biopsies in 49 children (17.75%). Almost all (45/49) of these biopsies were sampled from the stomach (03 antral, 02 fundic, 01 angular) to search for chronic Helicobacter pylori (H.pylori) gastritis. These biopsies were performed mainly in children and adolescents seen in endoscopy for abdominal pains.
The histological examination allowed to objectify a case of squamous cell carcinoma of the esophagus in a 15-year-old child and 30 cases of H. pylori infection (67%). These results confirm the rarity of malignant tumor diseases in children on the one hand and on the other hand the high prevalence of H. pylori infection in Ivory Coast. Given these findings gastric biopsy (looking for H.pylori) must be systematic in children seen in endoscopy for abdominal pains.
The lack of technical facilities and financial resources explain the low rate of interventional endoscopy (1.05%) performed in children in our context (03 foreign body extractions).
UGIE was performed without incident for all our children. The complication rate of this examination in children is only 2.3%  . The majority of the complications is related to anesthesia. Sedation was performed in 44% and mainly restricted to teenagers. It improved the tolerance of the examination.
The authors conclude that gastroscopy is a harmless examination with a great diagnostic and therapeutic utility in digestive pathology of children in Ivory Coast. However, it is not of commonly practice in children at an early age. The etablishment of a pediatric gastroenterology departement is necessary for a best practice of digestive endoscopy in children in our country.