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Journal of Pediatric Gastroenterology and Nutrition Volume 23, 107-110.
© 1996, Lippincott-Raven Publishers.


A Medical Position Statement of the North
American Society for Pediatric
Gastroenterology and Nutrition

Robert H. Squires, JR, MD, Children’s Medical Centre, University of Texas Southwestern Medical Centre at Dallas

Richard B. Colletti, MD, Department of Pediatrics, University of Vermont College of Medicine



Over the past 20 years, dramatic improvements in fiberoptic and video technology, conscious sedation, nursing support, and physicians’ experience have enhanced the execution of pediatric endoscopy. Diagnostic and therapeutic endoscopy procedures, including esophagogastroduodenoscopy, colonoscopy, dilation, variceal sclerotherapy or banding, polypectomy, and percutaneous endoscopic gastrostomy, are performed annually in thousands of infants, children, and adolescents. Pediatric endoscopy has become a valuable tool in the evaluation of gastrointestinal bleeding, dysphagia, severe pain disorders, inflammatory bowel disease, and radiographic abnormalities and for tissue diagnosis, removal of foreign bodies, and other clinical situations. 1-61

Endoscopy should be only one facet of a thoughtful and informed medical evaluation by a physician who is familiar with the patient and has demonstrated competence in pediatric gastroenterology. Like all tests, pediatric endoscopy is useful only when it will lead to an alteration in diagnosis, treatment, or prognosis that may result in an improved outcome of health care. The decision to perform endoscopy is also influenced by the availability of the test and necessary expertise as well as by its cost. Studies of diagnostic accuracy have shown that endoscopy is superior to radiography in the detection of peptic ulcers, polyps, and other mucosal abnormalities and that it offers the opportunity for tissue diagnosis or concomitant treatment not afforded by other diagnostic methods. Additional research that investigates cost, risk, and benefit in comparison with other diagnostic and treatment options will help determine the optimal usage of endoscopy in numerous clinical contents.

A document outlining the indications for endoscopy in adults has been published by the American Society for Gastrointestinal Endoscopy. The North American Society for Pediatric Gastroenterology and Nutrition (NASPGN) also recognizes the need to formulate a medical position statement on the indications for endoscopy in infants, children, and adolescents - to promote optimal patient care, to foster learning, to guide practitioners, as well as to facilitate peer and other review of clinical practices.

The following recommendations were prepared with the approval of the Patient Care Committee and the authorization of the Executive Council of NASPGN. In addition, they have been endorsed by the American Society for Gastrointestinal Endoscopy’s Standards of Care Committee and the American College of Gastroenterology’s Practice Parameters Committee. These recommendations are subject to change based on periodic review of subsequent research. Nonetheless, they are provided as a tool for improving the outcomes of care and to advance our understanding of them.


After acute volume resuscitation has been initiated for gastrointestinal bleeding, endoscopy may be considered for active, persistent, or recurrent bleeding, for hemodynamically significant hemorrhage, or to distinguish between variceal and non-variceal bleeding; for dysphagia, odynophagia, persistent refusal to eat, or persistent chest pain; for upper abdominal pain and/or discomfort with signs or symptoms suggesting serious organic disease (e.g., weight loss, anorexia, anemia), associated with significant morbidity (e.g., prolonged school absenteeism, hospitalization, limitation of usual activities), or from pain or discomfort which persists despite a course of therapy for vomiting of unknown cause, when sampling of esophageal, gastric, duodenal, or jejunal tissue/fluid is indicated, for clarification of imaging studies of the upper gastrointestinal tract, known or suspected ingestion of a caustic material, or unexplained iron deficiency anemia.


Diagnostic upper endoscopy is generally not indicated for uncomplicated gastroesophageal reflux, uncomplicated functional abdominal pain, or X-ray findings of uncomplicated gastroesophageal reflex, congenital hypertrophic pyloric stenosis, or isolated pylorospasm.


Diagnostic upper endoscopy is contraindicated for perforated viscus.


Sequential or periodic diagnostic upper endoscopy and biopsy is generally indicated for periodic surveillance for proven Barrett’s esophagus, follow-up of selected ulcers or mucosal abnormality if it is likely to alter clinical management, follow-up for adequacy of prior sclerotherapy or other variceal treatment (e.g., banding, shunting), surveillance for gastric or duodenal polyps in the polyposis syndromes, or surveillance for rejection or other complications following intestinal transplantation.


Sequential or periodic diagnostic upper endoscopy is generally not indicated for surveillance of healed benign disease.


Therapeutic upper endoscopy is generally indicated for removal of selected polypoid lesions, sclerotherapy or banding of esophageal varices during or following a bleeding episode; for dilation, placement of feeding tubes (percutaneous endoscopic gastrostomy, transpyloric), or treatment of persistent bleeding unresponsive to medical therapy; for removal of esophageal or sharp, foreign bodies, or objects retained in the stomach generally longer than two to four weeks or temporally related to symptoms (e.g., vomiting, pain); or for button batteries, either emergently, if the battery is lodged in the esophagus, or when the battery has not passed beyond the pylorus after an appropriate time.


Therapeutic upper GI endoscopy is generally not indicated for sclerotherapy or banding of esophageal varices prior to first documented variceal bleed.


Diagnostic colonoscopy and biopsy are generally indicated for unexplained iron deficiency anemia, evaluation of unexplained gastrointestinal bleeding such as melena of unknown origin or hematochezia; for clinical significant diarrhea of unexplained origin, evaluation of inflammation bowel disease, evaluation of an abnormality on radiographic imaging which is likely to be clinically significant (e.g., filling defect, stricture); for intraoperative identification of a lesion that it not apparent at surgery, evaluation of patients for sexually transmitted diseases or rectal trauma (sigmoidoscopy only), or to obtain ileal or colonic tissue for diagnosis.


Diagnostic colonoscopy is generally not indicated for acute self-limited diarrhea. GI bleeding with demonstrated upper GI source, chronic, stable irritable bowel syndrome or chronic nonspecific abdominal pain unassociated with significant morbidity; or for constipation and encopresis or inflammatory bowel disease responding to therapy.


Sequential or periodic diagnostic colonoscopy and biopsy are generally indicated for surveillance for dysplasia/malignancy, patients with increased risk of colonic malignancy (e.g., after ureterosigmoidostomy, polyposis syndromes), or surveillance for rejection or other complications following intestinal transplantation.


Diagnostic colonoscopy is contraindicated for fulminant colitis/toxic megacolon, suspected perforated viscus, or recent intestinal resection.


Therapeutic colonoscopy is generally indicated for polypectomy, dilation of stenotic lesions, treatment of bleeding vascular anomalies, ulcerations, or a polypectomy site, reduction of sigmoid volvulus, or removal of foreign body.


1. Ashorn M, Maki M, Ruuska T, et al. Upper gastrointestinal endoscopy in recurrent abdominal pain of childhood. J Pediatr Gastroenterol Nutr 1993;16:273-7

2. Benaroch LM, Rudolph CD. Introduction to pediatric esophagogastroduodenoscopy and enteroscopy. Gastrointest Endosc Clin North Am 1994;4:121-42

3. Benaroch LM, Rudolph CD. Pediatric endoscopy. Semin Gastrointest Dis 1994;5:32-46

4. Berenson GA, Wyllie R, Caulfield M, Steffen R. Intralesional steroids in the treatment of refractory esophageal strictures. J Pediatr Gastroenterol Nutr 1994;18:250-2

5. Biller JA, Winter HS, Grand RJ, Allred EN. Are endoscopic changes predictive of histologic esophagitis in children? J Pediatr 1983;103:215-8

6. Bond JH. Polyp guideline: diagnosis, treatment, and surveillance for patients with nonfamilial colorectal polyps. Ann Intern Med 1993;119:836-43

7. Burdelski M. Endoscopy in pediatric gastroenterology. Eur J Pediatr 1978;128:33-9

8. Cadranel S, Rodesch P. Peeters JP, Cremer OO. Fiberendoscopy of the gastrointestinal tract in children: a series of 100 examinations. Am J Dis Child 1977;131:41-5

9. Catto-Smith AG, Machida H, Butzner JD, Gall DG, Scott RB. The role of gastroesophageal reflux in pediatric dysphagia. J Pediatr Gastroenterol Nutr 1991;12:159-65

10. Caulfield M, Wyllie R, Sivak MV, Michener W, Steffen R. Upper gastrointestinal tract endoscopy in the pediatric patient. J Pediatr 1989;115:339-45

11. Countryman D, Norwood S, Andrassy RJ. Mallory-Weiss syndrome in children. South Med J 1982;75:1426-7

12. Cucchiara S. Guandalini S, Staiano A, et al. Sigmoidoscopy, colonoscopy, and radiology in the evaluation of children with rectal bleeding. J Pediatr Gastroenterol Nutr 1983;2:667-71

13. Cynamon HA,, Milov DE, Andres JM. Diagnosis and management of colonic polyps in children. J Pediatr 1989;114:593-6

14. Dahms BB, Rothstein FC. Mucosal biopsy of the esophagus in children. Perspect Pediatr Pathol 1987;11:97-123

15. Dahms BB, Rothstein FC. Barrett’s esophagus in children: a consequence of chronic gastroesophageal

reflux. Gastroenterol 1984;86:318-23

16. DiFebo G, Lauri A, Paganelli GM, et al. Endoscopic assessment of acute inflammation of the ileal reservoir after restorative ileo-anal anastomosis. Gastrointest Endosc 1990;36:6-9

17. Eraklis AJ, Folkman MJ. Adenocarcinoma at the site of ureterosigmoidostomies for exstrophy of the bladder. J Pediatr Surg 1978;13:730-4

18. Fleischer DE. Endoscopic control of upper gastrointestinal bleeding. J Clin Gastroenterol 1990;12:S41-7

19. Fox VL, Carr-Locke DL, Connors PJ. Leichtner AM. Endoscopic ligation of esophageal varices in children. J Pediatr Gastroenterol Nutr 1994;20:202-8

20. Gandhi RP, Niemirska M, Barlow B. Indications and techniques of upper gastrointestinal endoscopy in infants and children. J Pediatr Surg 1984;19:446-8

21. Gauderer MWL. Percutaneous endoscopic gastrostomy: a 10-year experience with 220 children. J Pediatr Surg 1991;26:288-94

22. Gaudreault P, Parent M, McGuigan MA, Chicoine L, Lovejoy FH. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatr 1983;71:767-70

23. Gleason WA, Goldstein PD, Shatz BA, Tedesco FJ. Colonoscopic removal of juvenile colonic polyps. J Pediatr Surg 1975;10:519-21

24. Goldthorn JF, Ball WS, Wilkinson LG, Seigel RS, Kosloske AM. Esophageal strictures in children: treatment by serial balloon catheter dilatation. Radiology 1984;153:655-8

25. Gregory PB. Prophylactic sclerotherapy for esophageal varices in men with alcoholic liver disease. N Engl J Med 1991;324:1779-84

26. Gyepes MT, Smith LE, Ament ME. Fiberoptic endoscopy and upper gastrointestinal series: comparative analysis in infants and children. Am J Roentgenol 1977;128:53-6

27. Habr-Gama A, Alves PRA, Gama-Rodrigues JJ, Teixiera MG, Barbieri D. Pediatric colonoscopy. Dis Colon Rectum 1979;22:530-5

28. Kawamitsu T, Nagashima K, Tsuchiya H, Sugiyama T, Ogasawara T, Cheng S. Pediatric total colonoscopy. J Pediatr Surg 1989;24:371-4

29. Hassal E. Barrett’s esophagus: new definitions and approaches in children. J Pediatr Gastroenterol Nutr 1993;16:345-64

30. Hassal E, Dimmick JE, Magee JF. Adenocarcinoma in childhood Barrett’s esophagus: case documentation and the need for surveillance in children. Am J Gastroenterol 1993;88:282-7

31. Hassall E, Barclay GN, Ament ME. Colonoscopy in childhood. Pediatr 1984;73:594-9

32. Hassall E, Berquist WE, Ament ME, Vargas J, Dorney S. Sclerotherapy for extrahepatic portal hypertension in childhood. J Pediatr 1989;115:69-74

33. Hassall E, Treem WR. To stab or strangle: how best to kill a varix? J Pediatr Gastroenterol Nutr 1995;20:121-4

34. Heymans HSA, Bartelsman JWFM, Herweijer TJ. Endoscopic balloon dilatation as treatment of gastric outlet obstruction in infancy and childhood. J Pediatr Surg 1988;23:139-40

35. Hoffer FA, Winter HS, Fellows KE, Folkman J. The treatment of postoperative and peptic esophageal strictures after esophageal atresia repair. Pediatr Radiol 1987;17:454-8

36. Holgersen LO, Mossberg SM, Miller RE. Colonoscopy for rectal bleeding in childhood. J Pediatr Surg 1978;13:83-5

37. Liebman WM. Fiberoptic endoscopy of the gastrointestinal tract in infants and children. I. Upper endoscopy in 53 children. Am J Gastroenterol 1977;68:362-6

38. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2,382 cases. Pediatr 1992;89:747-57

39. Litowitz TL. Battery ingestions: product accessibility and clinical course. Pediatr 1985;75:469-76

40. Marin OE, Glassman MS, Schoen BT, Caplan DB. Safety and efficacy of percutaneous endoscopic gastrostomy in children. Am J Gastroenterol 1994;89:357-61

41. Mee AS, Burke M, Vallon AG, Newman J, Cotton PB. Small bowel biopsy for malabsorption: comparison of the diagnostic adequacy of endoscopic forceps and capsule biopsy specimens. Br Med J 1985;291:769-72

42. Morrissey JF, Reichelderfer M. Gastrointestinal endoscopy (first of two parts). N Engl J Med 1991;325:1142-9

43. Morrissey JF, Reichelderfer M. Gastrointestinal endoscopy (second of two parts). N Engl J Med 1991;325:1214-22

44. Proujansky R, Orenstein SR, Kocoshis SA. Patient and procedure variables associated with complications following variceal sclerotherapy in children. J Pediatr Gastroenterol Nutr 1991;12:33-8

45. Sacks HS, Chalmers TB, Blum AL, Berrier J, Pagano D. Endoscopic hemostasis and effective therapy for bleeding peptic ulcers. JAMA 1990;264;492-9

46. Sarin SK, Misra SP, Singal AK, Thorat V, Broor SL. Endoscopic sclerotherapy for varices in children. J Pediatr Gastroenterol Nutr 1988;7:662-6

47. Schmidt-Sommerfeld E, Kirschner BS, Stephens JK. Endoscopic and histologic findings in the upper gastrointestinal tract of children with Crohn’s disease. J Pediatr Gastroenterol Nutr 1990;11:448-54

48. Schrock TR. Colonoscopic diagnosis and treatment of lower gastrointestinal bleeding. Surg Clin North Am 1989;69:1309-25

49. Shub MD, Ulshen MH, Hargrove CB, Siegal GP, Groben PA, Askin FB. Esophagitis: a frequent consequence of gastroesophageal reflux in infancy. J Pediatr 1985;107:881-4

50. Sorensen TIA. Prophylaxis of first hemorrhage from esophageal varices by sclerotherapy, propranolol or both in cirrhotic patients: a randomized multicenter trial. Hepatol 1991;14:1016-24

51. Steffen RM, Wyllie R, Sivak MV, Michener WM, Caulfield ME. Colonoscopy in the pediatric patient. J Pediatr 1989;115:507-13

52. Tam, PKH, Saing H. Pediatric upper gastrointestinal endoscopy: a 13-year experience. J Pediatr Surg 1989;24:443-7

53. Thapa BR, Singh K, Dilawari JB. Endoscopic removal of foreign bodies from gastrointestinal tract. Indian Pediatr 1993;30:1105-10

54. Thapa BR, Mehta S. Endoscopic sclerotherapy of esophageal varices in infants and children. J Pediatr Gastroenterol Nutr 1990;10:430-4

55. Treem WR, Etienne NL, Hyams JS. Percutaneous endoscopic placement of the "button" gastrostomy tube as the initial procedure infants and children. J Pediatr Gastroenterol Nutr 1993;17:382-6

56. Treem WR, Long WR, Friedman D, Watkins JB. Successful management of an acquired gastric outlet obstruction with endoscopy guided balloon dilatation. J Pediatr Gastroenterol Nutr 1987;6:992-6

57. Webb WA. Esophageal dilation: personal experience with current instruments and techniques. Am J Gastroenterol 1988;83:471-5

58. Williams CB, Laage NJ, Campbell CA, et al. Total colonoscopy in children. Arch Dis Child 1982;57:49-53

59. Wyllie R, Kay MH. Colonoscopy and therapeutic intervention in infants and children. Gastrointest Endosc Clin North Am 1994;4:143-60

60. Zahavi I, Arnon R, Ovadia B, Rosenbach Y, Hirsh A, Dinari G. Upper gastrointestinal endoscopy in the pediatric patient. Israel J Med Sci 1994;30:664-7

61. Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc 1991;37:165-9


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