Demographic and clinical data
A total of 380 children underwent 410 GI endoscopic procedures. Seventy-three of the cases were excluded due to missing data, and 23 were excluded because the procedure was performed in an acute setting. Thirty procedures were multiple endoscopies, leaving a total of 284 procedures that were performed on 284 children for final analysis. Of these children, 117 (41.2%) were males and 167 (58.8%) were females, with a median age of 10.7 years and range of 1.5-18 years [interquartile range (IQR) of 6.7-14.8 years]. An upper GI endoscopy was performed in 210 cases (73.9%), lower GI endoscopy in 16 (5.6%), and both upper and lower GI endoscopies in 58 (20.4%). Therapeutic procedures (mainly polypectomy) were performed in six cases (2.4%).
The main indications for the GI endoscopy were abdominal pain (n = 117, 41.2%), suspected celiac disease (n = 100, 35.2%), investigation of diarrhea (n = 30, 10.6%) and polyposis surveillance (n = 21, 7.4%). Other indications for endoscopy were rectal bleeding, vomiting, failure to thrive, iron deficiency and dysphagia.
The main histological findings were celiac disease (n = 82, 28.9%), gastritis (n = 78, 27.5%), inflammatory bowel disease (n = 25, 8.8%) and normal (n = 88, 31%).
Sedation included propofol in all children in addition to gas induction in 34 (12%) and midazolam in 51 (18%). The median (IQR) procedure duration was 9 (6-32) minutes and the median (IQR) recovery duration was 2.1 (1.8-2.7) hours (Table 1).
Table 1 - Demographic and clinical data by post procedure pain score
P
|
Severe Pain 6+
N=35
|
Moderate Pain 3-5
N=50
|
No to mild Pain 0-2
N=199
|
Total
N=284
|
|
<0.001
|
14.4 (10.5-16)
|
12.4 (8.7-14.9)
|
9.5 (5.6-14)
|
10.7 (6.7-14.8)
|
Age years, median (IQR)
|
0.485
|
19 (54.3%)
16 (45.7%)
|
33 (66%)
17 (34%)
|
115 (57.8%)
84 (42.2%)
|
167 (58.8%)
117 (41.2%)
|
Gender:
Female
Male
|
<0.001
|
16 (45.7%)
3 (8.6%)
16 (45.7%)
|
30 (60%)
3 (6%)
17 (34%)
|
164 (82.4%)
10 (5%)
25 (12.6%)
|
210 (73.9%)
16 (5.6%)
58 (20.4%)
|
Procedure:
Gastroscopy
Colonoscopy
Both
|
<0.001
|
20 (57.1%)
6 (17.1%)
9 (25.7%)
|
43 (86.0%)
5 (10.0%)
2 (4.0%)
|
174 (87.4%)
11 (5.5%)
14 (7.0%)
|
237 (83.4%)
22 (7.7%)
25 (8.8%)
|
Pre-procedural pain:
0-2
3-5
6+
|
<0.001
|
35 (7.5-58.2)
|
13 (6-46.5)
|
7 (6-14)
|
9 (6-32)
|
Procedure duration (min)
|
<0.001
|
5 (3-8)
|
3 (2-5.2)
|
3 (2-3)
|
3 (2-4)
|
Number of biopsies
|
<0.001
|
28 (77.7%)
1 (2.7%)
4 (11.1%)
3 (8.3%)
|
28 (63.6%)
3 (6.8%)
12 (27.2%)
1 (2.2%)
|
10 (29.4%)
22 (64.7%)
2 (5.8%)
0 (0%)
|
66 (57.9%)
26 (22.8%)
18 (15.8%)
4 (3.5%)
|
Location of pain:
Abdomen
Hand
Head
Throat
|
0.018
|
2.6 (1.9-3.3)
|
2.2 (1.7-2.7)
|
2.1 (1.8-2.5)
|
2.1 (1.8-2.7)
|
Recovery duration (h)
|
Post-procedure pain
A total of 170 children (59.8%) had no post-procedural pain, 29 children (10.2%) had mild pain (a score of 1-2), 50 children (17%) had moderate pain (a score of 3-5) and 35 children (12.3%) had severe pain (a score of 6 and above) (Table 1). Of 114 patients (40.1%) with post-procedure pain, in 66 (57.9%) the pain originated in the abdomen and in 26 (22.8%) in the intravenous line, while 18 (15.8%) complained of headache, and 4 (3.5%) of throat pain.
Risk factors for high post-procedure pain scores
Children with higher post-procedure pain scores were significantly older (significant results for severe and moderate pain compared to mild, P = 0.005), had higher pre-procedure pain scores (significant results for severe pain compared to moderate and mild, P = 0.003 and P < 0.001, respectively), longer procedure durations, higher numbers of biopsies and longer recovery durations (Table 1). While in 188 (66.2%) children the level of pre and post-procedure pain was similar, in 27 (9.5%) children the pre-procedure pain was more severe compared to the post-procedure pain, and in 69 (24.3%) children the pain was escalated after the procedure (Table 1).
There was no relation between pain score and gender, vital signs, the experience of the gastroenterologist or anesthesiologist, endoscopic findings, dose of propofol and the use of other sedation agents (midazolam or inhaled gas) in addition to propofol.
In a multivariate analysis adjusted for age, gender and type of procedure, older age and higher pain score before the procedure were associated with higher post-procedure pain scores (Table 2).
Table 2 - Multivariate analysis* for higher post-procedure pain scores
|
|
adjusted OR
|
95% CI
|
P
|
All endoscopies
(N=284)
|
Age
|
1.016
|
1.007-1.025
|
<0.001
|
Pain score before the procedure
|
12.42
|
3.67-42
|
<0.001
|
Upper GI endoscopies
(N=210)
|
Age
|
1.015
|
1.004-1.026
|
0.008
|
Pain score before the procedure
|
8.097
|
1.990-32.939
|
0.003
|
Post-procedure abdominal pain
|
5.2
|
1.34-20.4
|
0.017
|
*Every variable was adjusted for age, gender and type of procedure.
The variables that were included in the multivariate analysis were pre-procedure pain scores, procedure duration, number of biopsies, endoscopic findings, dose of propofol/midazolam.
Risk factors in children underwent upper GI endoscopy
A total of 210 children underwent upper GI endoscopy. Their median (IQR) age was 9.86 (6.09-13.28) years, and 130 (61.9%) were males. A multivariate analysis of these cases revealed that older age, higher pain score before the procedure, and post-procedure abdominal pain were associated with higher post-procedure pain scores (Table 2).
Risk factors for high post-procedure abdominal pain scores
One-hundred and fourteen patients (40.1%) had post-procedure pain, and 66 of them (57.9%) originating in the abdomen. When compared to 218 patients who had no post-procedural pain, or pain in other locations, or pain in no specified location, those with abdominal pain were older [13.6 (9.5-15.2) years compared to 9.9 (5.8-14.2), P < 0.001)], had frequent diarrhea as a symptom (22.7% compared to 6.9%, P < 0.001), had a longer procedure [32 (10-55.7) minutes compared to 7 (6-14) minutes, P < 0.001)], and had a higher number of biopsies [4 (3-8) compared to 3 (2-3), P < 0.001)]. The children with post-procedure abdominal pain had higher post-procedure pain scores [42.4% compared to 0 with 6+ pain score, P < 0.001,) and higher pre-procedure pain scores (19.4% compared to 6.3% with 6+ pain score, P < 0.001) compared to children with pain in other locations.
Recovery time
A longer procedure (P = 0.002) and a higher post-procedure pain score (P = 0.021) were associated with a prolonged recovery time. A multivariate analysis adjusted for age and gender revealed that the patients with a higher pre-procedure pain score had a prolonged recovery time (OR 5.28, 95% CI 1.93-14.49, P = 0.001).