Until recently, performing an upper GI endoscopy with biopsies for a child who has eosinophilic esophagitis (EoE) required deep sedation or general anesthesia and a four-hour stay at the hospital. To best monitor and treat this condition, that child may need this procedure every six to eight weeks.
This was the case for 12-year-old Haylie Nielsen, whose chronic stomach pain had her doctors at Children’s Hospital Colorado — Joel Friedlander, DO, and David Fleischer, MD, — suspecting she had EoE and food allergies.
Besides the inconvenience that a traditional endoscopy brought for Haylie and her family — following intense NPO guidelines, staying in a hotel the night before, a full day’s recovery — there was another problem: Haylie was allergic to certain types of anesthesia.
Doctors at another hospital first discovered this allergy when Haylie woke up from an unrelated surgery with a severe allergic reaction — an event that caused her great pain, and her mother, Michelle, great anxiety about future procedures.
To evaluate and treat Haylie’s condition after her first therapy, her caregivers needed to perform a follow-up endoscopy. Though anesthesia experts from Children’s Colorado ensured she wouldn’t have an allergic reaction, it didn’t keep her mother from worrying. Michelle couldn’t imagine enduring that anxiety through more endoscopies until Haylie was better.
A new way to monitor treatment in EoE
At about that time, Dr. Friedlander consulted with his colleagues Jeremy D. Prager, MD, pediatric otolaryngologist, and Emily DeBoer, MD, pediatric pulmonologist, in Children’s Colorado’s Aerodigestive Program, who were pioneering a new way to monitor treatment in EoE: pediatric transnasal esophagoscopy/endoscopy with biopsies (TNE).
Hour average time from admit to discharge compared to 4 hours with sedated endoscopy
The cost of sedated endoscopy
Hours without eating instead of 10 hours with general anesthesia
While used at times in adults to monitor Barrett’s esophagus, no one had yet studied it for EoE or in young children. Furthermore, the endoscope used for unsedated transnasal endoscopy in adults was 4.9 millimeters in diameter — too big for most children.
But Dr. Friedlander knew that the Aerodigestive Program had been using similar endoscopes between 2.8 and 4 millimeters in diameter to perform pediatric bronchoscopy or flexible laryngoscopy. Could that tube work for pediatric TNE with biopsies?
Dr. Friedlander and his colleagues invited 22 children to participate in a study to see if it would work, including Haylie. Though the procedure was momentarily uncomfortable for Haylie, it was faster, safer and more convenient, and it put her mother at ease.
The new procedure, which takes place in an outpatient exam room, uses a numbing agent on the nose and throat and then threads the endoscope through the nasal passage into the esophagus and stomach. Dr. Friedlander then takes tiny pieces of tissue through the endoscopy for evaluation. The procedure takes seven to eight minutes, and the patient is at the hospital for a total of 45 minutes, maybe an hour.
Haylie has since had three TNE endoscopies. “It has worked out amazingly,” Michelle says. “It obviously saves us from the worry of going under. It’s so fast.”
How the new procedure helped Haylie
Through these new transnasal endoscopies, Drs. Friedlander and Fleischer discovered that besides having EoE, Haylie was also allergic to wheat. Now armed with the appropriate medication and diet, Haylie’s stomach pain has subsided and her EoE appears to be under control.
For the other 20 children who ended up participating in the study, Dr. Friedlander and his colleagues found the procedure to be an overwhelming success.
“We've been searching for many years for ways to monitor this disease without anesthesia,” Dr. Friedlander says. “This technique really opens up the possibility to monitor and treat this disease much more aggressively without repetitively putting children asleep. It does this at approximately one-third of the cost and allows children and parents to return to their normal activities immediately after leaving the hospital.