When Standard Scopes Are Not Enough: Advanced Endoscopy in Pediatric GI Care

For children with gastrointestinal (GI) bleeding, small bowel pathology, pancreaticobiliary disease or complex strictures, standard upper endoscopy and colonoscopy may not provide sufficient diagnostic reach. Advanced endoscopy can help fill that gap as well as enable specialized techniques for minimally invasive treatment.

At Cleveland Clinic Children’s, these procedures are available for young patients through a care model that pairs pediatric and adult expertise in advanced endoscopy.

Going beyond standard endoscopy

“At its core, advanced endoscopy is anything outside of the typical colonoscopy and upper endoscopy,” says Jessica Barry, MD, a gastroenterologist at Cleveland Clinic Children’s. “A lot of times, it is both diagnostic and therapeutic. We are not just identifying a problem. We are treating it, often with specialized tools passed through the endoscope.”

Advanced endoscopy procedures include:

• Small bowel balloon enteroscopy to evaluate and treat bleeding, vascular malformations, polyps, masses and small bowel Crohn’s disease as well as care for children after small bowel transplant
• Endoscopic retrograde cholangiopancreatography (ERCP) to remove stones, dilate strictures, place stents and address other abnormalities in the biliary tract or pancreas
• Techniques to control GI bleeding, such as injection therapy, banding, clipping and coagulation
• Dilation of GI strictures
• Placement of stents or other devices to relieve GI obstruction

“With advanced endoscopy, we can reach problems that standard scopes can’t,” Dr. Barry explains. “Standard upper endoscopy and colonoscopy can evaluate the digestive tract from above and below, but much of the small bowel remains out of reach. Single balloon enteroscopy, using a longer-than-typical endoscope and an overtube balloon that helps the scope pass through the intestine, allows us to go farther into the bowel, past the duodenum.”

A rare capability in pediatric care

While advanced endoscopy is well established in adult gastroenterology, it remains less common in pediatrics. The techniques typically are not part of pediatric gastroenterology fellowship training, and subspecialty training opportunities are rare.

As a result, many children who need advanced endoscopic procedures receive them from adult gastroenterologists, often in adult hospitals. Cleveland Clinic Children’s offers a different model: procedures performed in a pediatric setting by a pediatric gastroenterologist who has pursued training and collaboration with adult advanced endoscopy colleagues.

“The techniques aren’t different for pediatric patients,” Dr. Barry says. “I was trained and mentored by adult advanced endoscopists to perform the same techniques. What is unique is being able to offer that care within a children’s hospital.”

Children undergoing these procedures at Cleveland Clinic remain in a pediatric environment, supported by pediatric anesthesiologists, pediatric nurses, child life specialists and pediatric recovery teams.

“We are still in a children’s hospital, so patients have all of those pediatric supports around them during the procedure and recovery,” Dr. Barry says. “That is quite rare and very important.”

At the same time, the pediatric program is backed by adult gastroenterologists with extensive experience in advanced endoscopy, creating an added layer of expertise and collaboration for especially complex cases.

“If there is something that requires additional support or a technique we do less frequently, I am supported by adult gastroenterologists who have extensive training in advanced endoscopy and perform a multitude of techniques,” Dr. Barry says.

A minimally invasive option for complex cases

One of the major advantages of advanced endoscopy is that, for selected patients, it may offer a less invasive alternative to surgery and another monitoring option for those recovering from transplant, living with inflammatory bowel disease or managing other medically complex conditions.

Rather than requiring an open abdominal operation, some problems can be managed through the GI tract using a scope. For example, some extra-intestinal pathology, such as an abscess or mass, may be treated or removed endoscopically via the bowel without external incisions. That can mean a shorter recovery.

“By combining pediatric-focused procedures with support from adult advanced endoscopists, Cleveland Clinic Children’s provides an uncommon level of care for children with complex GI, pancreatic and biliary disorders,” Dr. Barry concludes.