5,557

Ola galal Ali Behairy1, Bahaa Eldeen Hassanin1, Rasha Mahmoud Abdrabo2, Eman Elsayed Abdekader3

Ola galal Ali Behairy1, Bahaa Eldeen Hassanin1, Rasha Mahmoud Abdrabo2, Eman Elsayed Abdekader3

1 Pediatrics department, Faculty of Medicine, Benha University, Egypt;
2 pathology department, Faculty of Medicine, Benha University, Egypt;
3 M.B.B.Ch., Faculty of Medicine, Benha University, Egypt.

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Ola galal Ali Behairy, faculty of medicine - Benha university -Benha -Qualiopia -Egypt.
Email: olaped99@yahoo.com
Telephone: +01011655885

Received: June 23, 2021
Revised: July 12, 2021
Accepted: July 15, 2021
Published online: August 21, 2021

ABSTRACT

BACKGROUND: In the pediatric population, recurrent abdominal pain (RAP) is one of the most frequent indications of upper gastrointestinal endoscopy. AIM: To evaluate the diagnostic role of upper gastrointestinal endoscopy (UGIE) in children with recurrent abdominal pain.

MATERIALS AND METHODS: A three year prospective study was conducted on 100 consecutive children with recurrent abdominal pain who had UGIE. Baseline sociodemographic data, dyspepsia and any alarm symptoms were recorded. Other investigations such as stool analysis for ova, parasites, occult blood and fecal antigen for Helicobacter pylori as well as an abdominal ultrasound were also registered.

RESULTS: Our children were 47 (47%) males and 53 (53%) females with mean ±SD age of 10.9 ±4.2. Red flag symptoms were seen in 39(39%) of the subjects, and dyspepsia was seen in 52(52%). Endoscopy was diagnostic in 75 patients with the following endoscopic findings were: Esophagitis & hiatus hernia in 7%, gastritis in 39% of cases, nodularity in 25% of cases, 6% had gastric erosion, gastric ulcer was present in 5 %, 14% had hyperemia& erythemic membrane in the duodenum, and duodenal ulcer was seen in 2%. Significantly greater diagnostic yield of UGIE was determined in patients with alarm symptoms (66.6%) compared to those without (OR = 6.7, 95% CI: 2.5-23.3, p = 0.03).

CONCLUSION: Upper gastrointestinal endoscopy is a helpful tool for determining the reason of recurrent abdominal pain in children because it provides an accurate assessment of gastrointestinal etiology.

Key words: Children; Recurrent abdominal pain; Upper gastrointestinal endoscopy

© 2021 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Ola G. Behairy, Bahaa Eldeen M. Hassanin, Rasha M. Abdrabo, Eman E. Abdekader. Role of Upper Gastrointestinal Endoscopy in Diagnosis of Recurrent Abdominal Pain in Children. Journal of Gastroenterology and Hepatology Research 2021; 10(4): 3554-3560 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/3193

INTROUDUCTION

In children, abdominal pain is a common gastrointestinal symptom. Recurrent abdominal pain (RAP) affects 34% of the world’s population, with RAP prevalence ranging from 10 to 20% in school children[1]. RAP has long been considered as functional and psychological problem in children, as well as a public health issue [2].

According to the Rome IV Criteria, RAP is described as abdominal pain that lasts for ≥ 2 months and has at least one episode of pain/week that is severe enough to interfere with children’s daily activities[3]. RAP is a common cause for child’s referral to the paediatric gastroenterology unit and when treating any child with this condition, the attending physician must be able to rule out any organic causes[4].

With the emergence of new technologies and technical advances, organic causes of RAP are increasingly being discovered, especially with diagnostic gastrointestinal endoscopy[5].

Abdominal pains are the most common indications of upper gastrointestinal endoscopy (UGIE) in children in African countries, according to several studies[6-8] with rates varying from 22% to 90%. The definition of the alarm features or “red flags” has been developed in order to recognize organic causes of RAP in children, and it is suspected that endoscopy is more commonly associated with abnormal findings in patients who have alarm features than in those who do not. Weight loss, poor growth, GI bleeding, significant vomiting, abdominal tenderness, abdominal mass, and other alarm features are examples of such warning signs[9].

Upper gastrointestinal endoscopy (UGIE) or gastroscopy is a procedure that allows for visual inspection of the inner walls (mucosa) of the esophagus, stomach and duodenum as well as the collection of tissues (biopsies) for histological analysis[6]. This crucial diagnostic tool aids us in distinguishing organic causes, which account for 10% to 50% of RAPs from functional abdominal pain in children[10].

Therefore, the aim of this study was to evaluate the diagnostic role of upper gastrointestinal endoscopy (UGIE) in children with recurrent abdominal pain.

Material and methods

This was a three year prospective study on 100 consecutive children with recurrent abdominal pain who went to pediatric gastroenterology and hepatology clinic and had UGIE from December 2017 to December 2020, ranging in age from 4 to 17 years. The parents of the enrolled children signed a written informed consent. The study was approved by Benha University’s ethical committee. The inclusion criteria were: children and adolescents younger than 18 years old with recurrent abdominal pain that motive the performance of UGIE with no prior gastrointestinal endoscopy procedures. Exclusion criteria were: children with previous identified organic diseases (such as inflammatory bowel disease, peptic ulcer, or celiac disease), or who had previously undergone gastrointestinal endoscopy, use of proton pomp inhibitors (PPIs) during the previous two weeks, critically ill children and patients with medical comorbidities or any other major chronic diseases.

Methods

All enrolled children were subjected to:

A: Full history was taken and detailed clinical examination that focused on the following: 1-abdominal pain, described as (abdominal pain for ≥ 2 months with at least one episode of pain/week extreme enough to interfere with children’s daily activities). 2-dyspepsia is characterized by the following symptoms: Peptic-like dyspepsia is diagnosed by the presence of two or more of the following symptoms: periodic pain, pain relieved by food, pain relieved by antacid, pain before meal or when hungry, nausea and/or vomiting, and night pain. Dysmotility-like dyspepsia is diagnosed by the presence of two or more of the following: abdominal bloating or distention, pain exacerbated by food or milk, and pain relieved by belching. Reflux-like dyspepsia is diagnosed if the child had heartburn, chest pain or acid regurgitation[11]. 3-Alarm symptoms (red flags) including: anemia, high ESR, gastrointestinal bleeding, faltering of growth (failure to thrive), significant vomiting (defined as prolonged or protracted vomiting; bilious vomiting or a pattern of vomiting that was concerning to the referring clinician), chronic diarrhea, unexplained fever, persistent pain in the right upper quadrant or right lower quadrant, presence of abdominal mass, hepatomegaly, splenomegaly, perianal anomalies were also documented [12].

B: Laboratory investigations: Abdominal ultrasonography, complete blood count (by SysmexKX-21N; Sysmex Corporation, America, Inc., Mundelein, IL, USA), urine analysis and culture, erythrocyte sedimentation rate (ESR), stool analysis and culture for ova, parasites, occult blood and antigen for helicobacter pylori ( by bioNexia® H. pylori Ag test) which is a rapid immunochromatographic test (monoclonal antibodies specific to H. pylori antigen) for the qualitative detection of H. pylori antigen in human stool. During testing, the stool sample interacts with anti-H. pylori monoclonal antibody coated red latex particles. The particle-antigen-antibody complexes migrate by capillary along the membrane that is pre-coated with anti-H.pylori monoclonal antibody in the test line region in the case of a positive sample. The complex particle antibody-antigen reacts with these specific antibodies, resulting in a red line in the test-line region. The green control line shows that test migration was completed successfully.

C: Upper GIT endoscopy and histopathology of gastric and duodenal biopsies. Prior to endoscopy, patients were asked to fast overnight. Single dose of intravenous midazolam 0.1mg/kg and intravenous ketamine 1-2 mg/kg was administered with proper monitoring of the vital signs. The pulse oximeter was also used to check oxygen saturation. Flexible fibreoptic pediatric gastroscopy (Olympus XQ20) was used to perform upper GIT endoscopy. After each application, the endoscope and biopsy forceps were disinfected with 2% glutaraldheyde. Biopsies were taken from the stomach (3 antral, 2 fundal, 1angular) and second portion of the duodenum and sent for histopathological analysis. The specimens were embedded in paraffin wax, sectioned, and stained with haematoxylin and eosin after being fixed in 10% buffered formalin. H. pylori infection was confirmed by presence of H. pylori at antral biopsy stained with Giemsa staining and positive rapid urease test. H. pylori, chronic inflammation, activity, atrophy, and intestinal metaplasia were all identified and graded using the updated Sydney system[13]. Two pathologists were blinded to the patients’ health condition and endoscopic results while evaluating biopsy specimens.

Statistical analysis

SPSS software program, version16 (Spss Inc., Chicago, IL, U.S.A.) was used to analyze the data. The mean ± standard deviation (SD) was used to present descriptive statistics. In two-group comparisons, student’s t test was used for normally distributed variables and the Mann-Whitney U test for non-normally distributed variables. Number (percent) was used to classify qualitative data and the chi-square (χ2) test was used to compare them. To quantify the strength of the study, odds ratio (OR) and 95% confidence interval (CI) were calculated. Significance was set at p < 0.05.

RESULTS

A total 100 children with recurrent abdominal pain were enrolled in this study and had an upper gastrointestinal endoscopy. The mean ± SD age was 10.9 ± 4.2, 47 (47%) males and 53 (53%) females. The mean duration of recurrent abdominal pain was 19 ± 22 months, the main complaint was 94% of patients had epigastric pain, the pain was relieved by antacid in 33% of patients, the pain occurred before meals in 40% of cases, there was vomiting in 28% of patients and 17% of patients had attacks of night pain. 52% of the children had dyspepsia in form of dysmotility like dyspepsia symptoms (34% of patients had abdominal distension, 52% of patients the pain was aggravated by food, and in 17% of patients the pain was relieved by bleaching).

Reflux like dyspepsia and bowel habits symptoms was (38% of patients had heart burn, 35% of patients had chest pain, 19% of patients had acid regurgitation, 21% of patients had constipation, and 5% of patients had diarrhea).

Red flag symptoms were present in 39% as 20% of patients had anemia, and 11% of patients had GI bleeding which occurred secondary to the ingestion of NSAIDs, vomiting in 28% and 13% had weight loss.

Fifty two (52.0%) of the children were H.pylori positive (Table 1).

Table 1 General characteristics of the studied patients.
VariablesStudy group (n=100)N (%)
Duration of recurrent abdominal pain (month) Mean ± SD 19 ± 2233.00%
Range3-7267.00%
Dysmotility like dyspepsia
Epigastric painNo66.00%
Yes9494.00%
Pain relieved by antacidNo6767%
Yes3333%
Pain before mealNo6060.00%
Yes4040.00%
Night painNo8383.00%
Yes1717.00%
Abdominal distensionNo6666.00%
Yes3434.00%
Pain aggravated by foodNo4848.00%
Yes5252..0%
Pain relieved by bleachingNo8383.00%
Yes1717.00%
Reflux like dyspepsia and bowel habits
Heart burnNo6262.00%
Yes3838.00%
Chest painNo65650%
Yes3535.00%
Acid regurgitationNo8181.00%
Yes1919.00%
ConstipationNo7979
Yes2121
DiarrheaNo9494
Yes55
Red flag symptoms
AnemiaNo8080.00%
Yes2020.00%
GI bleedingNo8989.00%
Yes1111.00%
vomitingNo7272.00%
Yes2828.00%
weight lossNo8787.00%
Yes1313.00%
High ESRNo100100.00%
Yes00.00%
Presence of Helicobacter pylori
H pylori stool antigenPositive5252.00%
Negative4848.00%

Endoscopic findings in the study participants with RAP

The diagnostic yield of UGIE in children’s abdominal pain was 75% which were diagnosed to have an organic etiology for their RAP while the examination was normal in 25% of cases which had a non-organic cause. Regarding esophagus examination; 93% of cases had normal esophagus examination, 7% of cases had Esophagitis & hiatus hernia. Regarding stomach examination; 25% of cases had normal stomach examination, 39% of patients had hyperemia & erythemic membrane, 25% of cases had nodularity, 6% had erosion, and 5% had ulcer. Regarding the duodenum examination; 84% of cases had normal duodenum examination, 14% had hyperemia& erythemic membrane, and 2% had ulcer (Table 2).

Table 2 Upper GI endoscopy findings in the studied group.
  Study group (n=100)%
Endoscopic finding in esophagusNormal9393
Esophagitis & hiatus hernia77
Endoscopic finding in stomachNormal2525
Hyperemia & erythemic membrane3939
Nodularity2525
Erosion66
Ulcer55
Endoscopic finding in duodenumNormal8484
Hyperemia & erythemic membrane1414
Ulcer22

Histopathology findings

The histopathology of gastric and duodenal biopsies finding among the studied group; 52% of patients had normal histopathologic examination, 28% of patients had non-atrophic H.pylori associated gastritis and duodenitis with mild activity and mild H. pylori density, 14 % of patients had non-atrophic H.pylori associated gastritis and duodenitis with moderate activity and moderate to marked H.pylori density, and 6 % of patients had non-atrophic H.pylori associated gastritis and duodenitis with sever activity and marked H.pylori density, with superficial ulceration in gastric and duodenal mucosa.

Red flag symptoms and endoscopic findings

39 children (39%) of the studied children had red flag symptoms and 26 of these children with red flag signs had significantly greater diagnostic yield of UGIE was determined in patients with alarm symptoms (66.6%) compared to those without (OR = 6.7, 95% CI: 2.5-23.3, p = 0.03) as (11 children had Upper GI bleeding (Hematemesis and Melena) had significant endoscopic findings inform of gastritis and gastric erosions, 28 participants (28%) had significant vomiting and only 4 of them had hiatus hernia. Anemia was seen in 20 children, only 11 of them had endoscopic findings inform of (hyperemia and gastritis associated with positive H.pylori. Weight loss was also present in 13 participants however the endoscopy was normal in this instance.

Dyspepsia and endoscopic findings

Fifty two (52%) children presented with dyspepsia and 36 (69.2%) of these participants had significant endoscopic findings. Thirty three of the dyspeptic children had gastritis (Hyperemia & erythemic membrane) the remaining 3 participants had hiatus hernia and esophagitis.

Comparison between patients with and without upper GI diagnostic yield regarding clinical data (dysmotility like dyspepsia and reflex like dyspepsia, red flag symptoms and H. pylori stool test)

There was a statistical significant difference between both groups and the diagnostic yield of UGIE which was greater in children with epigastric pain (p = 0.031, OR = 4.9, 95% CI: 3.7-9.8), the duration of abdominal pain (p = 0.049, OR = 2.9, 95% CI: 1.12-6.71), history of pain relieved by antacid (p = 0.029, OR = 1.5, 95% CI: 1.12-1.92), night pain (p = 0.028, OR = 2.9, 95% CI: 0.9-13.4), pain aggravated by food (p = 0.055, OR = 1.9, 95% CI: 0.76-4.5), heart burn (p = 0.04, OR = 3.1, 95% CI: 1.1-9.2), and chest pain(p = 0.039, OR = 3.7, 95% CI: 1.2-10.3), anemia (p = 0.03, OR = 2.1, 95% CI: 0.5-8.1), history of vomiting (p = 0.033, OR = 2.49, 95% CI: 0.77-8), GI bleeding (p = 0.04, OR = 1.6, 95% CI: 0.32-7.78) and red flag (p = 0.03, OR = 6.7, 95% CI: 2.5-23.3). While there was no significant difference between groups regarding pain before meal, pain relieved by bleaching, the abdominal distension, weight loss, acid regurgitation, constipation, diarrhea, weight loss or H. pylori test (Table 3).

Table 3 Comparison between patients with and without upper GI diagnostic yield regarding clinical data (Dysmotility like dyspepsia and reflex like dyspepsia, red flag symptoms and H. pylori stool test).
  Upper GI endoscopyTestP valueOR(95% CI)
with diagnostic yieldWithout diagnostic yield
N=75%N=25%
Duration of abdominal pain (month)Mean±SD29.24±20.6421.08±24.5t=1.5660.049 2.9 (1.12-6.71)
Range3-723-72
Dysmotility like dyspepsia
Epigastric painNo00.00%624.00%X2=40.320.031 4.9(3.7-9.8)
Yes75100.00%1976.00%
Pain relieved by antacidNo5066.70%728.00%X2=3.220.029 1.5 (1.12-1.92)
Yes2533.30%1872.00%
Pain before mealNo4458.70%1664.00%X2=0.2220.637-
Yes3141.30%936.00%
Night painNo6080.00%2392.00%X2=3.150.028 2.9 (0.9-13.4)
Yes1520.00%28.00%
Pain aggravated by foodNo3344.00%1560.00%X2=1.8550.055 1.9 (0.76-4.5)
Yes4256.00%1040.00%
Pain relieved by bleachingNo6384.00%2080.00%X2=0.2310.642 
Yes1216.00%520.00%
Abdominal distensionNo4864%1872%X2=0.5350.432 -
Yes2736%728%
reflex like dyspepsia
Heart burnNo4256.00%2080.00%X2=5.5030.04 3.1 (1.1-9.2)
Yes3344.00%520.00%
Chest painNo4458.70%2184.00%X2=4.4170.039 3.7 (1.2-10.3)
Yes3141.30%416.00%
Acid regurgitationNo6181.30%2080.00%X2=0.020.883-
Yes1418.70%520.00%
ConstipationNo5776.00%2257X2=1.640.202-
Yes1824.00%318
DiarrheaNo6993.20%2569X2=1.780.182-
Yes56.80%05
red flag symptoms and H. plyori stool test
AnemiaNo5877.30%2288.00%X2=3.5710.03 2.1 (0.5-8.1)
Yes1722.70%312.00%
GI bleedingNo6688.00%2392.00%X2=2.920.04 1.6 (0.32-7.78)
Yes912.00%28.00%
VomitingNo5168%2184%X2=2.390.033 2.49 (0.77-8)
Yes2432%416%
Weight lossNo6586.70%2288.00%X2= 0.860.423 -
Yes1013.30%312.00%
High ESRNo75100.00%25100.00%-- -
Yes00.00%00.00%
H. pyloriPositive3952.00%1352.00%X2=01 
Negative3648.00%1248.00%
X2: Chi-square test, t: student t-test.

Comparison between patients with and without red flag symptoms regarding clinical data(dysmotility like dyspepsia and reflex like dyspepsia, patient with diagnostic yield and H. pylori stool test).

There was a statistical significant difference between groups regarding duration of recurrent abdominal pain, recurrent abdominal pain, pain relieved by antacid, pain before meal, night pain, and vomiting and patient with diagnostic yield, while there was no statistical difference between groups regarding or history of pain relieve by bleaching, history of abdominal distension, heart burn, chest pain, acid regurgitation, constipation, diarrhea H. pylori stool antigen (p = 0.571) (Table 4).

Table 4 Comparison between patients with and without red flag symptoms regarding presenting symptoms (Dysmotility like dyspepsia and reflex like dyspepsia, patient with diagnostic yield and H. pylori stool test).
  Red flag symptoms 
YesNo
N=39%N=61%
Duration of abdominal pain (month) Mean ± SD 28.4 ± 21.8 19.5 ± 21.5t=2.2620.044
Range3-723-72
Epigastric painNo00.00%69.80%X2=5.140.024
Yes39100.00%5590.20%
Pain relieved by antacidNo1435.90%5386.90%X2=6.05<0.001
Yes2564.10%813.10%
Pain before mealNo1641.10%4472.10%X2=8.180.004
Yes2358.90%1727.90%
Night painNo2461.50%5996.70%X2=9.1<0.001
Yes1538.50%23.30%
VomitingNo1538.50%5793.40%X2=11.9<0.001
Yes2461.50%47.60%
Pain relieved by bleachingNo3487.20%4980.30%X2=0.1780.78
Yes512.80%1219.70%
Abdominal distensionNo2974.40%3760.60%X2=1.830.116
Yes1025.60%2439.40%
Heart burnNo2564.10%3760.60%X2=0.1720.768
Yes1435.90%2439.40%
Chest painNo2564.40%4065.50%X2=0.060.844
Yes1435.90%2134.40%
Acid regurgitationNo3262.10%4980.30%X2=0.6160.442
Yes717.90%1219.70%
ConstipationNo3076.90%4980.30%X2=0.450.67
Yes923.10%1219.70%
DiarrheaNo3487.20%61100.00%X2=6.460.025*
Yes512.80%00.00%
Patients with diagnostic yield No1333.30%3961.80%X2=2.270.031
Yes 2666.60%2236.10%
H pylori stool antigen Positive1948.70%3354.10%X2=0.3170.571
Negative2051.30%2845.90%
X2: Chi-square test, t: student t-test.

DISCUSSION

Recurrent abdominal pain is still a significant public health problem, despite the fact that most cases were previously classified as functional. However, since the introduction of GI endoscopy, the number of organic causes of RAP in children has increased[4,9,14]. In the present study, 100 upper GI endoscopies were performed on children and adolescents with RAP in order to elucidate potential underlying gastrointestinal causes. Epigastric pains were the most common reason for gastroscopy in our study as it was 94%. These findings are consistent with these results[2,15,16] which found that epigastric pain was present in 88% of cases.

We found in the present study that 75% of RAP cases had endoscopic abnormalities and the most common endoscopic findings in this current study were gastropathies, particularly gastritis. These findings were in accordance with studies in Northern Thailand by Ukarapol[5] and Aanpreung[17] perform a similar study as they were able to demonstrate organic causes of RAP in44.7% and 51.6% of children respectively. Joshi[16] conduct another study at Kathmandu medical college teaching hospital and found that out of 26 cases of RAP, 8 cases (30%) had positive finding in endoscopy. Also Akbulut et al., [18] found that EGD had a high diagnostic yield in children with CAP with a prevalence of 209 patients out 372 (56.2%; 95% CI: 30.35-40.05%), and the most common diagnosis was Helicobacter pylori (+) gastritis (35.2%), followed by reflux esophagitis (8.6%). Thakkar et al[19] found that EGD has a diagnostic yield of 38% in children with CAP. Also endoscopic abnormality was found in 28.9% of children with CAP who underwent endoscopy and histopathological abnormality was found in 35.2%[20]. Organic endoscopic abnormalities were found in 76 (87.4%) and 84% of children with RAP according to Adeniyi et al[4] and Motamed et al[21]. However, in the above studies gastroscopy was only conducted on children with alarm symptoms or red flag signs, which may account for the high number. Children with RAP are seldom referred to our center for gastroscopy because other investigations have not shown an underlying cause and the prescribing doctor still suspect an underlying organic pathology. This may explain why our research found such a high prevalence of endoscopic abnormalities. Nevertheless, studies from Ivory Coast by Banguorou et al[2] and Nepal by Upadhyay et al[1] found endoscopic abnormalities in up to 70% and 71% of the children respectively, when gastroscopies were performed for all patients who presented with RAP.

The most common endoscopic findings in this current study were gastropathies, particularly gastritis. These correspond to the results of [1,2,4,16,21,22]. The high prevalence of H.pylori infection in our study may be attributed to the high incidence of gastritis, as 48% of the participants were H.pylori positive. However, only small number of participants had gastric or duodenal ulcers in our study, which may be secondary to the ingestion of non-steroidal anti-inflammatory drugs. This result is constant with studies from Nigeria where gastric ulcers were reported to be (2.3%) and duodenal ulcers were reported to be (1.1%)[4]. In Ivory Coast, ulcers were 2.70% for bulbar ulcer and 0.90% for gastric ulcer in [2], while in Uganda ulcer were (14.8%)[32], and in Kathamandu ulcer were (13%)[16].

In the present study 39 % of the patients reported alarm symptoms and there was a statistically significant difference in alarm symptoms between patients with and without upper GI diagnostic yield. These findings are consistent with Thakkar et al[19] who found gastrointestinal system pathologies by UGIE in children having chronic abdominal pain (CAP) with alarm symptoms at a high rate (39%). In addition, Akbulut et al[18] found that UGIE has a higher diagnostic yield in children with CAP who have alarm symptom(s) than in those who do not. Also Adeniyi et al[4] found that eleven (12.6%) of the study participants had red flag symptoms with 6 of these children having endoscopic findings, yielding 54.5% overall yield.

In comparison to our findings, several studies have shown that children with RAP and alarm symptoms are more likely to have the functional form of chronic abdominal pain (CAP)[23-24], as alarm symptoms were seen in 59% of children with functional chronic abdominal pain according to Gijsbers et al[23]. Furthermore, they claimed that while alarm symptoms may aid in the diagnosis of serious diseases like crohn’s disease, they are useless in the diagnosis of functional diseases. Also Akbulut et al[18] stated that there was no significant difference in EGD diagnostic yield when patient with alarm symptoms.

However, according to the ESPGHAN and ESGE guidelines, EGD is recommended in pediatric patients who have alarm symptoms such as weight loss, persistent vomiting, retardation of growth, unexplained anemia, chronic diarrhea, dysphagia or gastrointestinal bleeding[25]. Endoscopy is now recommended for children with red flags or alarm symptoms and it can be a practical way to evaluate them[26].

In the current research, UGIE was used to diagnose H. pylori gastritis in 48% in children with RAP. These results come in accordance with Akbulut et al[18] who discovered that H. pylori (+) gastritis were the most common pathology in children with CAP (35.2%). Thakkar et al[19] used EGD to diagnose H. pylori gastritis in 8 (2.8%) of 290 children with CAP. Low socioeconomic status, poor living and hygiene conditions, crowded conditions and intra-familial interaction are the most significant risk factors for the spread of H. pylori infection. The infection transmitted from one person to another through fecal-oral or oral-oral transmission[27]. The association between H. pylori infection and CAP in children is still a point of contention. Apart from the development of peptic ulcer, no evidence of relation between CAP and H. pylori infection has been found[28-31]. Furthermore, some studies have found no change in abdominal pain or gastric inflammation in children after H. pylori eradication[32].

Majority of children with dyspepsia (52%) in the present study had significant endoscopic abnormalities 36 (69.2%). Other scholars have made similar reports[16,22] although other researchers have reported contradictory reports[1,2,17]. Nevertheless, in the paediatric age group with dyspepsia, endoscopy continues to be useful in the diagnosis of dyspepsia.

Our study was limited due to our sample only reflect small percentage of children with RAP.

Conclusion

Upper GI endoscopy plays an important role in determining the cause of RAP in children, particularly when alarm features are present. The upper gastrointestinal endoscopy is now being used to examine children of all ages and has proven to be an important diagnostic tool that allow for direct visualization of the GI tract and when combined with histopathologic assessment, allows for accurate diagnosis.

Acknowledgements

Authors would like to thank all children and their parents who participated in this study.

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