VCE was approved to be used in pediatrics over two years of age by the US FDA in 2009 [3]. The most frequent indications for VCE in children is inflammatory bowel disease (IBD), obscure gastrointestinal bleeding (OGIB), malabsorption, protein-losing enteropathies, abdominal pain, small bowel polyps and tumors [4]. We have widely applied VCE in the diagnosis and evaluation of Crohn’s disease, abdominal pain, small intestinal bleeding, small intestinal polyps and chronic diarrhea in our hospital. And the application of VCE is rare except retention observed in our experience.
Diagnosis of HSP usually does not need endoscopy examination. However, patients with the following indications need perform endoscopy. 1). Abdominal pain without typical purpura, and could not be explained by other acute abdominal diseases; 2). HSP with massive intestinal bleeding; 3). HSP with recurrent intestinal symptoms or steroid- dependent; 4). Chronic abdominal pain needs to be differentiated from other gastrointestinal diseases, especially Crohn’s disease. Under these circumstances, it is crucial to perform an endoscopy to confirm the diagnosis and understand the extent of the disease. Furthermore, perform endoscopy is also beneficial to determine the proper medical treatment and duration of treatment. It is dependent on the clinical manifestation to perform the EGD, colonoscopy, or VCE.
To our best knowledge, there is no study focused on the VCE examination of pediatric HSP patients. This study is the largest cohort of pediatric HSP patients who have a VCE examination so far. The typical finding of VCE in the small intestinal is similar to the discovery by EGD in other reports from the adult cohort [5], presenting with mucosal edema, congestion, erosion, sporadic purpura or diffuse purpura, and usually with multiple irregular superficial ulcers. In our cohort, the most frequently involved part of the GI tract was jejunum. Almost all the patients had jejunum involved except one did not pass through pylorus. It was different from the reported literature by Eon Jeong Nam et al. [2]. In their report with a series of adult HSP patients, the second part and the terminal ileum were the most frequently involved parts of HSP patients, and colon was frequently involved as well. However, the VCE or small intestinal endoscopy was not performed in this study; thus, the jejunum was not assessed. On the contrary, in our cohort, none of the patients had colon involved. The difference between the studies could partially be explained by the age of patients in the study. The mean age of patients was 96.7 months in our cohort while they were adults in the study of Eon Jeong Nam et al.. And also, the location and extent of disease depends on the time of performing endoscopy and the severity of disease. The media time of our patients had VCE was around three weeks.
It is accessible to diagnosis HSP with typical symptom and skin purpura according to the diagnostic criteria [6]. HSP is reported to share similar clinical manifestation and sometimes has a colonoscopy appearance that resembles ulcerative colitis[7]. Application of VCE in these patients could help to make the diagnosis, thus avoid unnecessary prolong use of steroids and also the side effects of steroids. Although HSP is self-limited, we observed that the inflammation of small intestinal is rather long in our study. The most prolonged patients observed inflammation in the small bowel more than eight months.
MRE and CT were also performed in 14 patients, and 71.4% of them detected thickening of the small intestinal wall. Compared with VCE, the MRE and CT finding of these patients are not typical, and could not identify superficial ulcers of mucosa or evaluate the condition of bleeding.
This study has some limitations. First, this was a retrospective study with a small cohort of patients. The study only included patients diagnosed by VCE as HSP, not all the HSP patients with GI symptoms were evaluated. Second, all of the patients had EGD and VCE in this study. But not all patients had a colonoscopy examination. Thus, the lesions in the colon may be omitted in some patients.