I
nte
rna
t
io
na
l J
o
urna
l o
f
P
u
bli
c
H
ea
lt
h Science
(
I
J
P
H
S)
Vo
l.
1
3
,
No
.
4
,
Dec
em
b
er
20
24
,
p
p
.
1
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~
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I
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J
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:
h
ttp
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//
ijp
h
s
.
ia
esco
r
e.
co
m
Indica
tions
a
nd f
i
nding
s o
f
upp
er g
ut
endo
sco
py
in
p
edia
tric
pa
tient
s
Anni
s
a
’
H
a
s
a
na
h
1
,
T
a
ra
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a
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iricha
2
1
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e
p
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t
me
n
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o
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c
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n
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a
mm
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p
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o
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a
Art
icle
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nfo
AB
S
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RAC
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ticle
his
to
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y:
R
ec
eiv
ed
Dec
1
2
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2
0
2
3
R
ev
is
ed
Feb
2
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2
0
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ted
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r
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Ch
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u
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g
m
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g
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in
tes
ti
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l
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p
ies
wit
h
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t
th
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ry
in
d
ica
ti
o
n
s
ris
k
se
rio
u
s
a
d
v
e
rse
e
ffe
c
ts.
Th
e
re
fo
re
,
u
p
p
e
r
G
I
(U
G
I)
e
n
d
o
sc
o
p
y
e
x
a
m
in
a
ti
o
n
re
q
u
ires
se
lec
ti
v
e
in
d
ica
ti
o
n
s
to
m
in
imiz
e
th
e
risk
o
f
u
n
n
e
c
e
ss
a
ry
u
se
o
f
UG
I
e
n
d
o
s
c
o
p
y
.
T
h
is
st
u
d
y
a
ime
d
t
o
a
n
a
ly
z
e
th
e
in
d
ica
ti
o
n
s
fo
r
e
n
d
o
sc
o
p
y
b
a
se
d
o
n
t
h
e
m
a
in
UG
I
c
o
m
p
lain
ts
in
p
e
d
iatric
p
a
ti
e
n
ts
a
t
Dr.
S
a
ifu
l
A
n
wa
r
G
e
n
e
r
a
l
Ho
sp
it
a
l
M
a
lan
g
.
A
r
e
tro
sp
e
c
ti
v
e
a
n
a
ly
sis o
f
th
e
first
d
iag
n
o
stic e
n
d
o
sc
o
p
y
in
c
h
il
d
re
n
wa
s c
o
n
d
u
c
te
d
b
e
twe
e
n
J
u
ly
2
0
2
2
to
J
u
ly
2
0
2
3
a
t
Dr
.
S
a
if
u
l
A
n
wa
r
G
e
n
e
ra
l
Ho
sp
it
a
l
M
a
lan
g
.
Am
o
n
g
6
0
p
a
ti
e
n
ts
we
re
i
n
c
lu
d
e
d
with
a
n
a
g
e
o
f
0
-
1
5
y
e
a
rs
o
ld
;
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1
.
7
%
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re
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o
y
s
a
n
d
4
8
.
3
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g
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s
.
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e
re
su
lt
s
sh
o
we
d
re
c
u
rre
n
t
a
b
d
o
m
in
a
l
p
a
in
(RAP)
a
s
th
e
p
rima
ry
c
a
u
se
o
f
UG
I
e
n
d
o
sc
o
p
ic
in
d
ica
ti
o
n
s
(3
8
.
3
%
),
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ll
o
we
d
b
y
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l
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o
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v
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m
it
in
g
(3
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%
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te
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b
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m
in
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l
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(2
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%
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d
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ro
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n
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v
o
m
it
in
g
(
6
.
6
6
%
).
In
c
o
n
c
l
u
sio
n
,
re
c
u
rre
n
t
a
b
d
o
m
in
a
l
p
a
i
n
in
c
h
il
d
re
n
is
th
e
m
o
st
t
y
p
ica
l
re
a
so
n
fo
r
u
p
p
e
r
g
a
stro
i
n
tes
ti
n
a
l
e
n
d
o
s
c
o
p
y
,
a
n
d
p
e
rsiste
n
t
g
a
strit
is
is t
h
e
m
o
st t
y
p
i
c
a
l
u
n
d
e
rl
y
in
g
c
o
n
d
i
ti
o
n
.
K
ey
w
o
r
d
s
:
C
h
ild
r
en
E
n
d
o
s
co
p
y
Gastritis
Ped
iatr
ic
R
ec
u
r
r
en
t a
b
d
o
m
in
al
p
ain
Up
p
er
GI
co
m
p
lain
ts
T
h
is i
s
a
n
o
p
e
n
a
c
c
e
ss
a
rticle
u
n
d
e
r th
e
CC B
Y
-
SA
li
c
e
n
se
.
C
o
r
r
e
s
p
o
nd
ing
A
uth
o
r
:
An
n
is
a’
Hasan
ah
Dep
ar
tm
en
t o
f
Ped
iatr
ic,
Facu
lty
o
f
Me
d
icin
e,
Un
iv
er
s
ity
o
f
Mu
h
am
m
ad
iy
a
h
Ma
lan
g
E
ast J
av
a,
I
n
d
o
n
esia
E
m
ail: a
n
is
ac
t@
u
m
m
.
ac
.
id
1.
I
NT
RO
D
UCT
I
O
N
Fu
n
ctio
n
al
g
astro
in
test
in
al
d
is
o
r
d
er
s
(
FGI
D)
ar
e
wid
esp
r
ea
d
is
s
u
es
am
o
n
g
ch
ild
r
en
an
d
ar
e
ch
ar
ac
ter
ized
b
y
c
h
r
o
n
ic
GI
s
y
m
p
to
m
s
(
e
g
,
a
b
d
o
m
i
n
al
p
ain
,
d
y
s
p
h
a
g
ia,
d
y
s
p
ep
s
ia,
d
iar
r
h
e
a,
co
n
s
tip
atio
n
,
an
d
b
lo
atin
g
)
with
o
u
t
o
v
er
t
p
ath
o
l
o
g
y
o
n
c
o
n
v
e
n
tio
n
al
test
s
[
1
]
,
[
2
]
.
T
h
e
f
r
e
q
u
en
c
y
o
f
FGI
D
is
2
1
.
8
%
f
o
r
p
eo
p
le
ag
ed
4
to
1
8
a
n
d
2
2
.
2
%
f
o
r
ch
ild
r
en
u
n
d
er
th
e
ag
e
o
f
4
.
Fu
n
ctio
n
al
co
n
s
tip
atio
n
an
d
v
o
m
itin
g
wer
e
m
o
s
t
p
r
ev
alen
t
in
c
h
ild
r
en
1
3
t
o
4
8
m
o
n
th
s
o
f
a
g
e,
wh
ile
f
u
n
ctio
n
al
d
y
s
p
e
p
s
ia
an
d
co
n
s
tip
atio
n
wer
e
m
o
s
t
p
r
ev
alen
t
i
n
ch
ild
r
en
o
v
er
f
o
u
r
y
ea
r
s
[
3
]
.
Gastro
in
test
in
al
en
d
o
s
co
p
y
as
a
d
iag
n
o
s
tic
an
d
th
er
a
p
eu
tic
in
th
e
p
ed
iatr
ic
p
o
p
u
latio
n
h
as
b
ee
n
wid
ely
ca
r
r
ie
d
o
u
t
at
Dr
.
Saif
u
l
An
war
Ho
s
p
ital.
I
t
is
cr
u
cial
to
p
er
f
o
r
m
an
en
d
o
s
co
p
ic
ex
am
i
n
atio
n
as
a
p
r
elim
in
ar
y
s
cr
ee
n
in
g
f
o
r
d
y
s
p
ep
s
ia
co
m
p
lain
ts
in
ch
ild
r
en
,
as
in
d
icate
d
clea
r
ly
.
Ma
k
in
g
s
u
r
e
t
h
at
ch
ild
r
e
n
wh
o
s
atis
f
y
s
p
ec
if
ic
r
eq
u
ir
e
m
en
ts
lik
e
s
y
m
p
to
m
in
ten
s
ity
,
d
u
r
at
io
n
,
o
r
n
o
n
r
esp
o
n
s
e
to
co
n
v
e
n
tio
n
al
tr
ea
tm
en
ts
ar
e
th
e
o
n
ly
o
n
es
wh
o
u
n
d
er
g
o
s
cr
ee
n
in
g
en
d
o
s
co
p
y
c
an
b
e
en
s
u
r
e
d
b
y
estab
lis
h
in
g
p
r
ec
is
e
cr
iter
ia.
H
o
wev
er
p
ed
iatr
ic
en
d
o
s
co
p
y
a
s
s
o
ciate
d
with
ad
v
er
s
e
e
v
en
ts
in
clu
d
in
g
b
leed
in
g
,
p
er
f
o
r
atio
n
,
in
f
ec
tio
n
,
a
n
d
ca
r
d
iac
co
m
p
r
o
m
is
e.
T
h
e
to
tal
r
ate
o
f
co
m
p
licatio
n
s
d
u
r
in
g
p
ed
iatr
ic
en
d
o
s
co
p
y
,
ac
co
r
d
in
g
to
d
ata
p
u
b
lis
h
ed
b
y
th
e
p
e
d
iatr
ic
clin
ical
o
u
tc
o
m
es
r
esear
ch
in
itiativ
e
(
PE
DS
-
C
O
R
I
)
,
is
2
.
3
%.
T
h
is
r
ate
in
clu
d
es
a
s
p
ec
if
ic
r
is
k
o
f
h
y
p
o
x
ia
(
1
.
5
%)
an
d
b
leed
in
g
(
0
.
3
%)
[
4
]
.
T
h
er
ef
o
r
e,
u
p
p
er
GI
en
d
o
s
co
p
y
ex
am
in
atio
n
r
e
q
u
ir
es selectiv
e
in
d
icatio
n
s
to
m
in
im
ize
t
h
e
r
i
s
k
o
f
u
n
n
ec
ess
ar
y
u
s
e
o
f
UGI
en
d
o
s
co
p
y
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
3
,
No
.
4
,
Dec
em
b
er
20
24
:
1
8
0
3
-
1
8
0
8
1804
T
h
er
e
a
r
en
'
t
m
an
y
s
tu
d
ies
th
at
ad
d
r
ess
wh
eth
er
p
ed
iatr
ic
p
at
ien
ts
s
h
o
u
ld
r
ec
eiv
e
UGI
en
d
o
s
co
p
y
in
th
e
g
u
id
elin
es
o
r
m
ed
ical
liter
atu
r
e
wo
r
ld
wid
e
.
Du
e
to
its
in
cr
ea
s
ed
ea
s
e
o
f
u
s
e,
clin
ician
s
ar
e
m
o
r
e
lik
el
y
to
r
ec
o
m
m
en
d
UGI
en
d
o
s
co
p
y
f
o
r
ch
ild
r
e
n
ex
h
ib
itin
g
v
ag
u
e
s
y
m
p
to
m
s
,
wh
ich
h
as
r
esu
lted
in
an
o
v
er
ab
u
n
d
a
n
ce
o
f
th
ese
p
r
o
c
ed
u
r
es.
T
h
is
m
ak
es
it
ch
allen
g
in
g
t
o
p
er
f
o
r
m
an
a
p
p
r
o
p
r
iaten
ess
ass
e
s
s
m
en
t
b
ased
o
n
h
i
g
h
-
q
u
ality
ev
id
en
ce
,
wh
ich
is
wh
y
it
v
i
o
lates
a
f
u
n
d
am
e
n
tal
ev
alu
atio
n
p
r
in
cip
le.
A
m
u
ltid
is
cip
lin
ar
y
ex
p
e
r
t
p
an
e
l
s
y
s
tem
ca
lled
th
e
R
AND/
u
n
iv
er
s
ity
o
f
C
alif
o
r
n
ia
at
L
o
s
An
g
eles
(
UC
L
A)
m
eth
o
d
an
d
m
o
d
if
ied
Delp
h
i
p
r
o
ce
s
s
h
ad
b
ee
n
in
u
s
e
f
o
r
a
wh
ile
to
ev
al
u
ate
th
e
s
u
itab
ilit
y
o
f
p
r
o
ce
d
u
r
es
in
a
v
ar
iety
o
f
m
ed
ical
an
d
s
u
r
g
ical
s
itu
atio
n
s
,
wh
er
e
th
er
e
is
s
o
m
e
u
n
ce
r
tain
ty
ab
o
u
t
t
h
e
m
o
s
t
ef
f
ec
tiv
e
th
er
ap
eu
tic
an
d
d
iag
n
o
s
tic
ap
p
r
o
ac
h
to
u
s
e
an
d
litt
le
p
u
b
lis
h
ed
ev
id
en
ce
s
u
p
p
o
r
tin
g
it
[
5
]
–
[
7
]
.
Ho
wev
er
,
it
h
as a
lr
ea
d
y
b
ee
n
u
s
ed
o
n
ad
u
lt p
atien
ts
u
n
d
er
g
o
in
g
UGI
en
d
o
s
co
p
y
.
T
h
e
aim
o
f
th
is
s
tu
d
y
is
to
ev
alu
ate
th
e
in
d
icatio
n
s
an
d
o
u
tco
m
es o
f
en
d
o
s
co
p
y
f
o
r
ch
ild
r
en
b
ased
o
n
u
p
p
er
GI
p
r
o
b
lem
s
at
Dr
.
Saif
u
l A
n
war
Gen
er
al
Ho
s
p
ital b
et
wee
n
J
u
ly
2
0
2
2
to
J
u
ly
2
0
2
3
.
Ad
d
itio
n
ally
,
it c
an
r
ev
ea
l
th
e
an
ato
m
ical
an
d
p
h
y
s
io
lo
g
ical
r
o
o
ts
o
f
p
e
d
iatr
ic
GI
d
is
o
r
d
er
s
.
T
h
e
g
en
er
al
p
u
b
li
c,
in
p
ar
ticu
lar
th
e
p
atien
t'
s
p
ar
en
ts
,
also
lear
n
s
ab
o
u
t
th
e
ea
r
ly
s
ig
n
s
o
f
p
e
d
iatr
ic
GI
d
is
ea
s
e
th
at
ca
n
b
e
d
etec
ted
d
u
r
in
g
en
d
o
s
co
p
y
.
T
h
u
s
,
it
is
im
p
o
r
tan
t
to
k
n
o
w
th
e
in
d
icatio
n
s
f
o
r
u
p
p
er
GI
en
d
o
s
co
p
y
b
ased
o
n
UGI
s
y
m
p
to
m
s
in
p
ed
iatr
ic
p
atien
ts
,
th
er
ef
o
r
e
d
iag
n
o
s
is
an
d
tr
ea
tm
en
t a
r
e
o
n
t
ar
g
et.
2.
M
E
T
H
O
D
T
h
is
d
escr
ip
tiv
e
s
tu
d
y
was
c
o
n
d
u
cte
d
f
r
o
m
J
u
ly
2
0
2
2
to
J
u
ly
2
0
2
3
at
th
e
E
n
d
o
s
co
p
y
Un
it
o
f
Dr
.
Saif
u
l
An
war
Gen
e
r
al
Ho
s
p
i
tal,
E
ast
J
av
a,
I
n
d
o
n
esia.
A
to
tal
o
f
s
ix
ty
c
h
ild
r
en
h
ad
UGI
en
d
o
s
co
p
ies
p
er
f
o
r
m
ed
f
r
o
m
J
u
ly
2
0
2
2
to
J
u
ly
2
0
2
3
.
T
h
e
s
u
b
jects
wer
e
all
p
ed
iatr
ic
p
atien
ts
y
o
u
n
g
e
r
th
an
1
5
y
ea
r
s
with
UGI
s
y
m
p
to
m
s
wh
o
u
n
d
er
we
n
t
en
d
o
s
co
p
y
a
n
d
wer
e
r
ec
o
r
d
ed
in
t
h
e
m
ed
ical
r
ec
o
r
d
s
at
Dr
.
Saif
u
l
An
war
Ma
lan
g
.
Patien
ts
wh
o
f
u
lf
illed
th
e
c
r
iter
ia
an
d
wer
e
elig
ib
le
f
o
r
t
h
e
s
tu
d
y
wer
e
o
f
f
er
ed
an
d
in
f
o
r
m
ed
ab
o
u
t
it.
T
h
e
en
d
o
s
co
p
ic
r
o
o
m
m
an
ag
er
ac
co
m
p
a
n
ied
th
e
r
ese
ar
ch
er
to
d
is
cu
s
s
th
e
in
ten
d
ed
co
u
r
s
e
o
f
th
e
in
v
esti
g
atio
n
.
T
h
e
p
atien
t
was
ask
ed
to
s
ig
n
a
n
in
f
o
r
m
ed
c
o
n
s
en
t
f
o
r
m
a
f
ter
d
ec
i
d
in
g
to
p
r
o
ce
ed
.
Descr
ip
tiv
e
s
tatis
t
ics
wer
e
u
s
ed
to
s
o
r
t
th
e
d
ata
af
ter
it
wa
s
m
an
u
ally
co
llected
.
T
h
e
eth
ical
ap
p
r
o
v
al
(
No
.
E
.
5
.
a/2
3
9
/KE
PKUMM
/VI
I
I
/2
0
2
3
)
was
o
b
tain
ed
f
r
o
m
th
e
E
th
ics
C
o
m
m
ittee
o
f
Me
d
ical
Facu
lty
o
f
Un
iv
er
s
ity
o
f
Mu
h
am
m
ad
iy
a
h
Ma
lan
g
,
E
ast J
av
a,
I
n
d
o
n
esia.
E
v
er
y
in
d
iv
id
u
al
i
n
v
o
lv
ed
in
t
h
is
s
tu
d
y
p
r
o
v
id
ed
th
eir
o
r
al
in
f
o
r
m
e
d
p
er
m
is
s
io
n
.
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
T
h
e
s
am
p
les
wer
e
d
r
awn
f
r
o
m
th
e
p
atien
ts
in
th
e
p
ed
iatr
i
c
p
o
ly
clin
ic
at
Dr
.
Saif
u
l
An
war
Gen
er
al
Ho
s
p
ital
Ma
lan
g
.
Of
th
e
6
0
p
atien
ts
,
3
1
(
5
1
.
7
%)
wer
e
b
o
y
s
an
d
2
9
(
4
8
.
3
%)
wer
e
g
ir
ls
.
T
h
e
lar
g
est
ag
e
g
r
o
u
p
was 1
1
-
1
5
y
ea
r
s
2
6
(
5
1
.
6
%)
T
ab
le
1
.
Ho
wev
er
,
s
im
ilar
s
tu
d
i
es h
av
e
f
o
u
n
d
th
at
g
ir
ls
ar
e
m
o
r
e
lik
ely
th
an
b
o
y
s
to
ex
p
er
ien
ce
FGI
D
an
d
th
at
th
eir
s
y
m
p
to
m
s
ar
e
m
o
r
e
s
ev
er
e
[
8
]
.
T
h
is
is
b
ec
au
s
e
co
n
s
tip
atio
n
,
b
lo
atin
g
,
an
d
d
iar
r
h
ea
f
r
e
q
u
en
tly
af
f
ec
t
g
ir
l
s
d
u
e
to
co
n
co
m
itan
t
an
x
iety
o
r
s
ad
n
ess
.
Ad
d
itio
n
ally
,
s
to
m
ac
h
em
p
ty
in
g
an
d
s
lu
g
g
is
h
co
lo
n
ic
tr
an
s
it
ar
e
c
o
m
m
o
n
in
g
ir
ls
.
Ad
d
itio
n
al
s
t
u
d
y
i
n
d
icate
s
th
at
en
d
o
s
co
p
ic
ev
id
en
ce
o
f
p
ep
tic
illn
ess
is
m
o
s
t
p
r
ev
alen
t
in
y
o
u
n
g
s
ter
s
o
f
th
e
f
em
i
n
in
e
g
en
d
er
.
C
h
ild
r
en
ty
p
ically
h
a
v
e
a
b
d
o
m
in
al
d
is
co
m
f
o
r
t
th
at
last
s
a
lo
n
g
tim
e,
is
s
ev
er
e,
in
ter
f
er
es
with
d
aily
ac
tiv
ities
,
an
d
is
ac
co
m
p
an
ied
b
y
n
a
u
s
ea
an
d
v
o
m
itin
g
.
C
h
ild
r
en
ty
p
ically
e
x
p
er
ien
c
e
ab
d
o
m
i
n
al
d
is
co
m
f
o
r
t
at
th
e
b
o
tto
m
o
r
in
th
e
m
eso
g
astriu
m
,
wh
er
ea
s
ad
o
lescen
ts
ex
p
er
ien
ce
p
ain
m
o
r
e
ac
cu
r
ately
in
th
e
e
p
ig
astriu
m
[
9
]
.
T
ab
le
2
p
r
esen
ts
r
ec
u
r
r
en
t
ab
d
o
m
in
al
p
ain
(
R
AP)
as
th
e
p
r
im
a
r
y
ca
u
s
e
o
f
UGI
en
d
o
s
co
p
ic
in
d
icatio
n
s
(
3
8
.
3
%),
th
e
m
o
s
t
co
m
m
o
n
s
y
m
p
t
o
m
o
f
u
p
p
e
r
GI
as
th
e
m
ain
co
m
p
lain
t
o
f
ch
ild
r
en
with
a
d
iag
n
o
s
is
o
f
ch
r
o
n
ic
g
astritis
at
th
e
p
ed
iatr
ic
p
o
ly
clin
ic
at
D
r
.
Saif
u
l
An
war
Gen
er
al
Ho
s
p
ital
Ma
lan
g
.
T
h
is
i
s
co
n
s
is
ten
t
with
th
e
s
tu
d
y
b
y
Ad
en
iy
i
et
a
l.
[
1
0
]
,
wh
ic
h
f
o
u
n
d
th
at
R
AP
is
a
f
r
e
q
u
en
t
ca
u
s
e
o
f
r
ef
er
r
al
an
d
a
ju
s
tific
atio
n
f
o
r
u
p
p
er
G
I
en
d
o
s
co
p
y
to
f
ac
ilit
ate
a
p
r
ec
is
e
d
iag
n
o
s
is
o
f
th
e
etio
lo
g
y
.
T
ab
le
1
.
C
h
ar
ac
ter
is
tics
o
f
p
at
ien
ts
(
n
=6
0
)
C
h
a
r
a
c
t
e
r
i
s
t
i
c
n
%
A
g
e
(
y
e
a
r
)
0
-
5
15
25
6
-
10
19
3
1
.
7
11
-
15
26
4
3
.
3
G
e
n
d
e
r
B
o
y
s
31
5
1
.
7
G
i
r
l
s
29
4
8
.
3
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
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lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
I
n
d
ica
tio
n
s
a
n
d
fin
d
in
g
s
o
f
u
p
p
er g
u
t
en
d
o
s
co
p
y
in
p
ed
ia
tr
ic
p
a
tien
ts
…
(
A
n
n
is
a
’
Ha
s
a
n
a
h
)
1805
T
ab
le
2
.
Up
p
er
GI
e
n
d
o
s
co
p
y
in
d
icatio
n
I
n
d
i
c
a
t
i
o
n
n
%
P
e
r
si
st
e
n
t
v
o
mi
t
i
n
g
4
6
.
6
6
R
e
c
u
r
r
e
n
t
a
b
d
o
m
i
n
a
l
p
a
i
n
23
3
8
.
3
B
l
o
o
d
v
o
mi
t
i
n
g
(
h
e
ma
t
e
m
e
si
s)
20
3
3
.
3
A
c
u
t
e
a
b
d
o
mi
n
a
l
p
a
i
n
13
2
1
.
6
R
AP
h
as
b
ee
n
m
o
d
if
ied
with
th
e
estab
lis
h
m
en
t
o
f
R
o
m
e
I
to
I
I
I
cr
iter
ia
(
cu
r
r
en
tly
k
n
o
wn
as
R
o
m
e
I
V)
,
wh
ich
id
en
tify
g
u
t
-
b
r
ain
in
ter
ac
tio
n
d
is
o
r
d
er
s
(
DGBIs
)
an
d
was
r
elea
s
ed
b
y
T
h
e
R
o
m
e
Fo
u
n
d
atio
n
in
2
0
1
6
[
1
1
]
.
T
h
e
R
o
m
e
I
V
d
e
f
i
n
es
R
AP
as
ab
d
o
m
i
n
al
d
is
co
m
f
o
r
t
last
in
g
m
o
r
e
th
a
n
two
m
o
n
th
s
with
at
least
o
n
e
ep
is
o
d
e
o
f
p
ain
ev
e
r
y
w
ee
k
th
at
is
s
ev
er
e
en
o
u
g
h
to
p
r
ev
en
t
t
h
e
ch
ild
r
e
n
f
r
o
m
e
n
g
ag
in
g
in
ty
p
ical
ac
tiv
ities
[
1
2
]
–
[
1
4
]
.
Or
g
a
n
ic
c
au
s
es
o
f
R
AP
ca
n
b
e
f
o
u
n
d
,
n
o
n
eth
eless
,
as
a
r
esu
lt
o
f
t
h
e
d
ev
elo
p
m
en
t
o
f
n
ew
tech
n
o
lo
g
y
f
r
o
m
d
ia
g
n
o
s
tic
GI
en
d
o
s
co
p
y
.
Acc
o
r
d
in
g
to
T
a
b
le
3
,
UGI
en
d
o
s
co
p
ic
f
in
d
in
g
s
s
h
o
wed
th
at
as
m
an
y
as
7
5
%
o
f
p
atien
ts
with
co
m
p
lain
ts
o
f
p
er
s
is
ten
t
v
o
m
i
tin
g
h
ad
g
astro
eso
p
h
a
g
ea
l
r
ef
l
u
x
an
d
o
n
ly
2
5
%
wer
e
f
o
u
n
d
to
b
e
an
ato
m
ically
n
o
r
m
al.
W
h
er
ea
s
p
atien
ts
wit
h
p
er
s
is
ten
t
v
o
m
itin
g
d
id
n
o
t
h
av
e
a
h
iatal
h
er
n
ia
(
0
%).
Ped
iatr
ic
p
atien
ts
with
R
AP
ex
p
er
ien
ce
d
th
e
m
o
s
t
ch
r
o
n
ic
g
astritis
(
3
0
.
4
%)
f
o
llo
wed
b
y
er
o
s
iv
e
g
astritis
(
2
1
.
7
%)
an
d
d
u
o
d
en
itis
(
2
1
.
7
%).
I
n
a
d
d
itio
n
,
t
h
e
lo
w
est
n
u
m
b
er
o
f
R
AP
with
eso
p
h
ag
itis
(
4
.
3
%),
g
astric
u
lcer
(
4
.
3
%),
a
n
d
n
o
r
m
al
en
d
o
s
co
p
ic
f
in
d
in
g
s
with
o
u
t
an
ato
m
ic
ab
n
o
r
m
alities
(
4
.
3
%).
T
h
e
m
o
s
t
co
m
m
o
n
ca
u
s
e
o
f
v
o
m
itin
g
b
lo
o
d
(
h
ae
m
atem
esis
)
is
eso
p
h
ag
ea
l
v
ar
ices
(
4
0
%),
f
o
llo
wed
b
y
er
o
s
iv
e
g
astritis
(
2
5
%)
an
d
g
astric
u
lcer
(
2
0
%).
Fu
r
th
er
m
o
r
e
,
th
e
m
o
s
t
co
m
m
o
n
p
ed
iatr
ic
p
atien
ts
with
ac
u
te
ab
d
o
m
in
al
p
ain
ex
p
e
r
i
en
ce
d
ac
u
te
g
astritis
(
7
6
.
9
%),
wh
ile
th
e
r
est h
ad
n
o
r
m
al
g
astro
in
test
in
al
an
ato
m
y
(
2
3
%).
T
ab
le
3
.
Up
p
er
g
astro
i
n
test
in
al
en
d
o
s
co
p
y
f
in
d
i
n
g
s
b
ased
o
n
in
d
icatio
n
s
En
d
o
s
c
o
p
y
r
e
s
u
l
t
s
n
%
P
e
r
si
st
e
n
t
v
o
mi
t
i
n
g
(
n
=
4
)
G
a
st
r
o
e
so
p
h
a
g
e
a
l
r
e
f
l
u
x
3
75
H
i
a
t
a
l
h
e
r
n
i
a
0
0
N
o
r
mal
1
25
R
e
c
u
r
r
e
n
t
a
b
d
o
m
i
n
a
l
p
a
i
n
(
n
=
2
3
)
Eso
p
h
a
g
i
t
i
s
1
4
.
3
H
y
p
e
r
e
mi
c
g
a
s
t
r
i
t
i
s
3
13
G
a
st
r
i
c
u
l
c
e
r
1
4
.
3
D
u
o
d
e
n
i
t
i
s
5
2
1
.
7
Er
o
si
v
e
g
a
st
r
i
t
i
s
5
2
1
.
7
C
h
r
o
n
i
c
g
a
st
r
i
t
i
s
7
3
0
.
4
N
o
r
mal
1
4
.
3
B
l
o
o
d
v
o
mi
t
i
n
g
(
H
a
e
mat
e
me
si
s)
(
n
=
2
0
)
Eso
p
h
a
g
i
t
i
s
0
0
Er
o
si
v
e
g
a
st
r
i
t
i
s
5
25
V
a
r
i
c
e
s
e
s
o
p
h
a
g
e
a
l
8
40
D
u
o
d
e
n
u
m
t
u
m
o
r
0
0
D
u
o
d
e
n
u
m
u
l
c
e
r
1
5
G
a
st
r
i
c
u
l
c
e
r
4
20
P
o
r
t
a
l
h
y
p
e
r
t
e
n
si
o
n
2
10
A
c
u
t
e
a
b
d
o
mi
n
a
l
p
a
i
n
(
n
=
1
3
)
A
c
u
t
e
g
a
s
t
r
i
t
i
s
10
7
6
.
9
A
c
u
t
e
d
u
o
d
e
n
i
t
i
s
0
0
N
o
r
mal
3
23
I
n
th
e
c
u
r
r
e
n
t
s
tu
d
y
,
th
e
r
esp
o
n
d
en
ts
wh
o
wer
e
r
ea
d
y
to
u
n
d
er
g
o
en
d
o
s
co
p
y
wer
e
a
g
ed
0
-
1
5
y
ea
r
s
.
Am
o
n
g
th
e
m
o
s
t
f
r
eq
u
e
n
t
co
m
p
lain
ts
b
ef
o
r
e
u
n
d
er
g
o
i
n
g
a
n
en
d
o
s
co
p
y
is
ex
p
er
ien
cin
g
R
AP.
T
h
is
co
u
ld
b
e
r
elate
d
to
th
e
H.
p
yl
o
r
i
in
f
ec
tio
n
,
wh
ich
f
r
eq
u
en
tly
af
f
ec
ts
ch
ild
r
en
.
T
h
e
an
tr
u
m
an
d
b
o
d
y
o
f
th
e
s
to
m
ac
h
ar
e
h
ea
v
ily
co
lo
n
ized
with
H.
p
yl
o
r
i
,
ca
u
s
in
g
s
ev
er
e
m
u
co
s
al
in
f
lam
m
atio
n
[
1
5
]
.
C
h
ild
r
en
w
h
o
h
ad
s
y
m
p
t
o
m
s
o
f
r
ec
u
r
r
en
t
a
b
d
o
m
in
al
p
ain
a
n
d
wer
e
d
iag
n
o
s
ed
with
g
astri
tis
wen
t
th
r
o
u
g
h
a
n
en
d
o
s
co
p
ic
p
r
o
ce
d
u
r
e
[
1
0
]
.
E
n
d
o
s
co
p
y
f
r
eq
u
en
tly
lin
k
s
d
u
o
d
en
al
eo
s
in
o
p
h
ilia
to
d
y
s
p
e
p
s
ia
in
ch
ild
r
en
.
Fu
n
ctio
n
al
d
y
s
p
ep
s
ia
(
FD)
h
a
s
b
ee
n
ass
o
ciate
d
with
in
cr
ea
s
e
d
d
u
o
d
e
n
al
eo
s
in
o
p
h
ilia
wo
r
l
d
wid
e
[
1
6
]
–
[
2
0
]
.
I
t
h
as
b
ee
n
h
y
p
o
th
esized
th
at
in
p
eo
p
le
wh
o
h
a
v
e
a
g
en
etic
p
r
e
d
is
p
o
s
itio
n
to
in
n
ate
im
m
u
n
e
ac
tiv
atio
n
,
an
aller
g
en
in
cl
u
d
i
n
g
wh
ea
t
p
r
o
tein
o
r
in
f
ec
tio
n
m
ay
ca
u
s
e
an
tig
en
p
r
esen
tatio
n
,
ep
ith
elial
b
a
r
r
ier
d
is
r
u
p
tio
n
,
an
d
a
n
in
n
ate
im
m
u
n
e
ty
p
e
2
h
elp
er
T
-
ce
ll
r
esp
o
n
s
e,
in
wh
ich
e
x
ce
s
s
iv
e
eo
s
in
o
p
h
ils
m
ay
d
e
g
r
an
u
late
to
ca
u
s
e
in
f
lam
m
a
tio
n
an
d
n
e
u
r
o
n
al
s
en
s
itiv
ity
[
1
2
]
,
[
2
1
]
–
[
2
3
]
.
T
h
is
m
ig
h
t
lead
to
c
y
to
k
in
e
r
e
lease
an
d
cir
cu
latin
g
h
o
m
in
g
T
-
ce
lls
to
r
esu
lt
in
alter
ed
g
astro
d
u
o
d
en
al
f
u
n
ctio
n
,
wh
ich
co
u
ld
ac
co
u
n
t
f
o
r
wh
y
s
y
m
p
to
m
s
ar
e
tied
to
m
ea
l
s
[
1
2
]
,
[
2
1
]
,
[
2
4
]
.
A
s
im
ilar
p
ath
o
p
h
y
s
io
lo
g
y
m
e
d
iated
b
y
cy
t
o
k
in
es
h
as
b
ee
n
p
r
o
p
o
s
ed
f
o
r
g
astro
eso
p
h
ag
ea
l
r
ef
lu
x
d
is
ea
s
e
(
GE
R
D
)
[
2
5
]
,
[
2
6
]
.
I
n
th
o
s
e
with
f
u
n
ctio
n
al
d
y
s
p
ep
s
ia
an
d
p
o
s
t
-
p
r
an
d
ial
d
is
tr
ess
s
y
n
d
r
o
m
e
at
b
aselin
e,
d
u
o
d
e
n
al
eo
s
in
o
p
h
ilia
is
lin
k
ed
to
an
elev
ated
r
is
k
o
f
GE
R
D
at
1
0
-
y
ea
r
f
o
llo
w
-
u
p
.
T
h
e
co
n
n
ec
tio
n
b
etwe
en
Evaluation Warning : The document was created with Spire.PDF for Python.
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b
lic
Hea
lth
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,
Vo
l.
1
3
,
No
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4
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Dec
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b
er
20
24
:
1
8
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8
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1806
f
u
n
ctio
n
al
d
y
s
p
ep
s
ia
an
d
GE
R
D
m
ay
b
e
ex
p
lain
ed
b
y
d
u
o
d
e
n
al
eo
s
in
o
p
h
ilia,
s
u
g
g
esti
n
g
th
at
s
o
m
e
s
u
b
g
r
o
u
p
s
o
f
b
o
t
h
d
is
o
r
d
e
r
s
m
ay
b
el
o
n
g
t
o
th
e
s
am
e
d
is
ea
s
e
s
p
ec
tr
u
m
[
2
7
]
.
T
h
e
m
o
s
t
f
r
eq
u
en
t
ca
u
s
e
o
f
ab
d
o
m
in
al
p
ain
is
s
tr
ess
,
wh
ich
also
p
la
y
s
a
s
ig
n
if
ican
t
r
o
le
in
th
e
p
ath
o
p
h
y
s
io
lo
g
ical
alter
atio
n
s
th
at
m
ig
h
t
o
cc
u
r
in
th
e
d
i
g
e
s
tiv
e
s
y
s
tem
[
2
8
]
.
T
h
e
s
tu
d
y
’
s
f
in
d
in
g
s
r
ev
ea
led
th
at
th
e
r
eq
u
ir
e
m
en
t
f
o
r
an
en
d
o
s
co
p
y
is
in
d
icate
d
wh
en
a
ch
ild
'
s
d
y
s
p
ep
tic
s
y
m
p
to
m
s
in
ter
f
er
e
with
ev
er
y
d
a
y
ac
tiv
ities
,
th
e
p
atie
n
t
is
o
ld
er
th
an
1
0
y
ea
r
s
o
ld
,
th
e
d
u
r
atio
n
is
lo
n
g
er
th
a
n
s
ix
m
o
n
th
s
,
a
n
d
th
e
s
y
m
p
to
m
s
ar
e
g
ettin
g
wo
r
s
e
[
2
9
]
.
W
h
er
ea
s
f
o
r
ass
ess
m
en
t,
an
en
d
o
s
co
p
y
s
h
o
u
ld
tak
e
al
ar
m
s
y
m
p
to
m
s
lik
e
s
ig
n
if
ican
t
v
o
m
itin
g
,
ch
r
o
n
ic
d
iar
r
h
ea
,
GI
b
lo
o
d
l
o
s
s
,
o
n
g
o
in
g
ab
d
o
m
in
al
p
ain
in
th
e
u
p
p
er
o
r
r
ig
h
t
lo
wer
q
u
ad
r
a
n
ts
,
an
d
a
f
am
ily
h
is
to
r
y
o
f
in
f
lam
m
ato
r
y
b
o
wel
d
is
e
ase
to
war
d
ass
es
s
m
en
t
[
3
0
]
.
Par
ticip
an
ts
with
th
e
m
o
s
t
f
ea
tu
r
es
id
e
n
tifie
d
b
y
e
n
d
o
s
co
p
y
wer
e
b
o
y
s
b
etwe
en
t
h
e
ag
es
o
f
1
1
a
n
d
1
5
.
I
n
co
n
t
r
ast,
an
o
th
er
s
tu
d
y
f
o
u
n
d
th
at
th
e
h
i
g
h
est
p
r
ev
ale
n
ce
o
f
clin
ical
in
d
icatio
n
s
an
d
en
d
o
s
co
p
ic
i
n
f
o
r
m
atio
n
r
elat
ed
to
p
ep
tic
d
is
ea
s
e
was
in
g
ir
ls
[
9
]
.
E
v
en
th
e
p
atter
n
o
f
ab
d
o
m
in
al
p
ain
in
y
o
u
n
g
c
h
ild
r
en
is
s
ev
er
e,
las
ts
a
lo
n
g
tim
e,
a
n
d
in
ter
f
er
es
with
r
e
g
u
lar
a
ctiv
ities
wh
ile
also
ca
u
s
in
g
n
au
s
ea
a
n
d
v
o
m
itin
g
.
C
h
ild
r
en
'
s
ab
d
o
m
in
al
p
ain
ty
p
ically
o
cc
u
r
s
at
th
e
b
o
tto
m
o
r
in
th
e
m
eso
g
astriu
m
,
wh
er
ea
s
ad
o
lescen
ts
'
ab
d
o
m
in
al
p
ain
is
m
o
r
e
lik
ely
to
o
cc
u
r
in
th
e
ep
ig
astriu
m
.
W
h
ile
en
d
o
s
co
p
y
o
f
th
e
u
p
p
e
r
g
astro
in
test
in
al
tr
ac
t
is
f
r
eq
u
en
tly
b
en
ef
icial
in
ch
ild
r
e
n
as
well
a
s
ad
u
lts
,
th
er
e
is
litt
le
d
ir
ec
t
in
f
o
r
m
atio
n
r
eg
a
r
d
in
g
h
o
w
e
n
d
o
s
co
p
y
af
f
ec
ts
th
e
p
r
o
g
n
o
s
is
o
f
p
ed
iatr
ic
d
y
s
p
e
p
s
ia
p
atien
ts
[
3
1
]
.
T
h
er
e
is
o
n
l
y
o
n
e
r
etr
o
s
p
ec
tiv
e
s
tu
d
y
th
at
ex
am
in
es
th
e
a
p
p
r
o
p
r
iaten
ess
o
f
UGI
e
n
d
o
s
co
p
y
i
n
p
ed
iatr
ic
p
atien
ts
.
I
t
r
ev
iewe
d
2
9
3
en
d
o
s
co
p
ies
d
o
n
e
o
n
2
5
1
p
atien
ts
f
o
r
a
v
ar
iety
o
f
in
d
icatio
n
s
(
s
u
ch
as
d
y
s
p
h
ag
ia,
r
ec
u
r
r
en
t
ab
d
o
m
in
al
p
ain
,
v
o
m
itin
g
,
b
lee
d
in
g
,
d
i
ar
r
h
ea
,
an
d
f
ailu
r
e
to
th
r
iv
e)
.
I
t
also
ev
alu
ated
th
e
ef
f
ec
t
o
f
th
e
p
r
o
ce
d
u
r
e
o
n
t
h
e
p
atien
t'
s
tr
ea
tm
en
t
ac
co
r
d
in
g
to
t
h
e
g
u
id
elin
es
p
r
o
v
id
ed
b
y
th
e
Gr
o
u
p
e
Fra
n
co
p
h
o
n
e
d
'
Hep
ato
lo
g
ie,
Gastro
en
ter
o
lo
g
ie
et
Nu
tr
itio
n
Ped
iatr
iq
u
es
[
3
2
]
.
T
h
e
cu
r
r
en
t
s
tu
d
y
'
s
r
esu
lts
h
ig
h
lig
h
t
th
e
n
ec
ess
ity
f
o
r
e
n
d
o
s
co
p
is
ts
to
p
o
s
s
ess
r
ec
o
m
m
en
d
atio
n
s
f
o
r
th
e
ap
p
r
o
p
r
iaten
ess
o
f
u
p
p
er
g
astro
in
test
in
al
en
d
o
s
co
p
y
in
p
ed
iatr
ic
p
atien
ts
to
p
r
ev
en
t
o
v
er
u
s
e
o
f
th
e
o
p
er
atio
n
an
d
th
e
co
n
s
eq
u
e
n
t
u
n
war
r
an
te
d
ex
p
o
s
u
r
e
o
f
p
atie
n
ts
to
its
p
o
s
s
ib
le
s
id
e
ef
f
ec
ts
.
Acc
o
r
d
in
g
to
o
u
r
r
esear
c
h
,
ce
r
tain
ch
ild
r
en
with
d
y
s
p
ep
tic
s
y
m
p
to
m
s
m
ay
b
en
ef
it
f
r
o
m
UGI
en
d
o
s
co
p
y
,
b
u
t
n
o
t
all
o
f
th
e
m
.
Ho
wev
er
,
th
er
e
a
r
e
p
atien
t
an
d
p
r
o
ce
d
u
r
e
asp
ec
ts
th
at
n
e
ed
to
b
e
u
n
d
er
s
to
o
d
as
th
ey
r
aise
th
e
p
o
s
s
ib
ilit
y
o
f
ad
v
er
s
e
e
v
en
ts
(
AE
s
)
o
cc
u
r
r
in
g
d
u
r
in
g
o
r
a
f
ter
th
e
s
u
r
g
er
y
.
E
n
d
o
s
co
p
ic
AE
s
ca
n
b
e
r
o
u
g
h
ly
class
if
ied
as b
leed
in
g
,
p
er
f
o
r
atio
n
,
in
f
ec
tio
n
,
an
d
s
ed
atio
n
-
r
elate
d
p
h
y
s
io
lo
g
ical
ab
n
o
r
m
alities
.
Av
o
id
in
g
ex
ce
s
s
iv
e
u
s
e
o
f
U
GI
en
d
o
s
co
p
y
is
ad
v
is
ed
:
W
h
en
u
s
ed
o
n
p
e
d
iatr
ic
p
atien
t
s
,
th
e
p
r
o
ce
d
u
r
e
is
s
im
p
le
to
p
e
r
f
o
r
m
b
u
t
s
till
r
e
q
u
ir
es
s
p
ec
ial
atten
tio
n
;
it
s
h
o
u
ld
o
n
ly
b
e
u
s
ed
o
n
th
e
p
at
ien
ts
wh
o
h
av
e
th
e
h
ig
h
est
ch
an
ce
o
f
b
e
n
ef
itin
g
f
r
o
m
it.
Ad
d
itio
n
ally
,
en
d
o
s
co
p
is
ts
m
ay
n
ee
d
to
ass
ess
th
e
ap
p
licab
ilit
y
o
f
o
u
r
s
tu
d
y
r
esu
lts
to
c
o
n
ce
n
t
r
ate
th
eir
ef
f
o
r
ts
o
n
in
d
iv
i
d
u
als
m
o
s
t
lik
ely
to
b
en
e
f
it,
s
o
p
r
ev
e
n
tin
g
b
o
th
t
h
e
u
n
d
er
-
an
d
o
v
er
u
s
e
o
f
u
p
p
er
en
d
o
s
co
p
y
as
well
as
th
e
u
n
n
ec
ess
ar
y
ex
p
o
s
u
r
e
o
f
p
atien
ts
t
o
n
o
n
-
n
e
g
lig
ib
le
en
d
o
s
co
p
ic
s
id
e
ef
f
ec
ts
.
T
h
e
u
s
e
o
f
u
p
p
er
en
d
o
s
co
p
y
in
p
e
d
iatr
ics
will
lik
ely
b
e
s
ig
n
if
ican
tly
i
m
p
ac
ted
b
y
f
u
tu
r
e
ad
v
an
ce
m
e
n
ts
in
s
ed
atio
n
an
d
an
esth
esia.
T
h
is
r
esear
ch
h
as
th
e
c
o
n
s
tr
ain
t
o
f
b
ei
n
g
r
estricte
d
t
o
a
s
in
g
le
h
o
s
p
ital,
n
ec
ess
itatin
g
th
e
co
n
s
id
er
atio
n
o
f
co
n
tex
t
u
al
co
n
s
id
er
atio
n
s
wh
en
ex
tr
ap
o
latin
g
f
in
d
i
n
g
s
to
o
th
er
c
o
n
d
itio
n
s
.
Nev
er
th
eless
,
th
e
E
ast
J
av
a
r
eg
io
n
is
d
ep
icted
b
ec
au
s
e
Dr
.
Saif
u
l
An
war
Ge
n
er
al
Ho
s
p
ital
Ma
lan
g
is
a
ty
p
e
A
r
ef
er
e
n
ce
th
at
r
ec
eiv
es
p
atien
ts
f
r
o
m
m
an
y
ar
ea
s
.
Su
g
g
esti
o
n
s
f
o
r
ad
d
itio
n
al
s
tu
d
y
ar
e
to
b
e
co
n
d
u
cte
d
at
m
u
ltip
le
ce
n
te
r
s
ar
o
u
n
d
I
n
d
o
n
esia.
4.
CO
NCLU
SI
O
N
I
n
c
o
n
clu
s
io
n
,
u
p
p
er
GI
e
n
d
o
s
co
p
y
is
cr
u
cial
in
d
eter
m
in
in
g
t
h
e
o
r
ig
in
o
f
R
AP
in
ch
ild
r
en
,
esp
ec
ially
wh
en
alar
m
in
g
s
ig
n
s
ar
e
p
r
esen
t.
As
a
r
esu
lt
o
f
th
e
p
r
o
ce
d
u
r
e'
s
s
u
cc
ess
as
a
d
ia
g
n
o
s
tic
to
o
l,
k
i
d
s
o
f
all
ag
es
ar
e
n
o
w
s
u
b
jecte
d
to
th
e
p
r
o
ce
d
u
r
e
f
o
r
ev
alu
ati
o
n
.
W
h
en
p
air
ed
with
h
is
to
p
ath
o
lo
g
ic
an
aly
s
is
,
en
d
o
s
co
p
y
allo
ws
f
o
r
d
ir
ec
t
v
i
s
u
aliza
tio
n
o
f
th
e
G
I
tr
ac
t,
p
r
e
cise
d
iag
n
o
s
is
,
an
d
th
e
p
o
s
s
ib
ilit
y
o
f
th
er
ap
e
u
tic
m
ea
s
u
r
es.
I
n
o
r
d
er
to
p
r
o
p
e
r
ly
ca
r
r
y
o
u
t
th
is
in
v
esti
g
ati
o
n
a
n
d
d
eter
m
in
e
a
d
iag
n
o
s
is
,
ca
r
ef
u
l
clin
ical
ev
alu
atio
n
,
an
ad
eq
u
ate
h
is
to
r
y
,
an
d
a
p
h
y
s
ical
ex
am
i
n
atio
n
ar
e
n
ec
ess
ar
y
.
E
n
d
o
s
co
p
y
is
n
o
t
a
r
eq
u
ir
ed
test
f
o
r
t
h
e
d
ia
g
n
o
s
is
o
f
f
u
n
ctio
n
al
d
y
s
p
ep
s
ia
a
n
d
m
u
s
t
also
b
e
b
ased
o
n
R
o
m
e
cr
iter
ia
c
o
n
ce
r
n
in
g
to
alar
m
s
y
m
p
to
m
s
.
RE
F
E
R
E
NC
E
S
[
1
]
A
.
F
i
k
r
e
e
a
n
d
P
.
B
y
r
n
e
,
“
M
a
n
a
g
e
m
e
n
t
o
f
f
u
n
c
t
i
o
n
a
l
g
a
st
r
o
i
n
t
e
st
i
n
a
l
d
i
s
o
r
d
e
r
s,”
C
l
i
n
i
c
a
l
Me
d
i
c
i
n
e
,
v
o
l
.
2
1
,
n
o
.
1
,
p
p
.
4
4
–
5
2
,
Ja
n
.
2
0
2
1
,
d
o
i
:
1
0
.
7
8
6
1
/
c
l
i
n
me
d
.
2
0
2
0
-
0
9
8
0
.
[
2
]
A
.
S
p
e
r
b
e
r
e
t
a
l
.
,
“
W
o
r
l
d
w
i
d
e
p
r
e
v
a
l
e
n
c
e
a
n
d
b
u
r
d
e
n
o
f
f
u
n
c
t
i
o
n
a
l
g
a
s
t
r
o
i
n
t
e
s
t
i
n
a
l
d
i
s
o
r
d
e
r
s,
r
e
s
u
l
t
s
o
f
r
o
me
f
o
u
n
d
a
t
i
o
n
g
l
o
b
a
l
st
u
d
y
,
”
G
a
s
t
ro
e
n
t
e
r
o
l
o
g
y
,
v
o
l
.
1
6
0
,
n
o
.
1
,
p
p
.
9
9
–
1
1
4
,
2
0
2
1
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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t J Pu
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Hea
lth
Sci
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N:
2252
-
8
8
0
6
I
n
d
ica
tio
n
s
a
n
d
fin
d
in
g
s
o
f
u
p
p
er g
u
t
en
d
o
s
co
p
y
in
p
ed
ia
tr
ic
p
a
tien
ts
…
(
A
n
n
is
a
’
Ha
s
a
n
a
h
)
1807
[
3
]
A
.
V
e
r
n
o
n
-
R
o
b
e
r
t
s,
I
.
A
l
e
x
a
n
d
e
r
,
a
n
d
A
.
S
.
D
a
y
,
“
S
y
st
e
ma
t
i
c
r
e
v
i
e
w
o
f
p
e
d
i
a
t
r
i
c
f
u
n
c
t
i
o
n
a
l
g
a
st
r
o
i
n
t
e
st
i
n
a
l
d
i
so
r
d
e
r
s
(
R
o
m
e
i
v
c
r
i
t
e
r
i
a
)
,
”
J
o
u
r
n
a
l
o
f
C
l
i
n
i
c
a
l
M
e
d
i
c
i
n
e
,
v
o
l
.
1
0
,
n
o
.
2
1
,
2
0
2
1
,
d
o
i
:
1
0
.
3
3
9
0
/
j
c
m1
0
2
1
5
0
8
7
.
[
4
]
J.
R
.
Li
g
h
t
d
a
l
e
,
M
.
Th
o
ms
o
n
,
a
n
d
D
.
S
.
F
i
s
h
ma
n
,
“
H
i
g
h
‐
r
i
s
k
p
e
d
i
a
t
r
i
c
e
n
d
o
sc
o
p
y
,
”
i
n
Pra
c
t
i
c
a
l
P
e
d
i
a
t
ri
c
G
a
s
t
ro
i
n
t
e
s
t
i
n
a
l
En
d
o
s
c
o
p
y
,
W
i
l
e
y
,
2
0
2
1
,
p
p
.
1
7
5
–
1
8
2
,
d
o
i
:
1
0
.
1
0
0
2
/
9
7
8
1
1
1
9
4
2
3
4
9
2
.
c
h
1
9
.
[
5
]
R
.
H
.
C
o
r
r
e
i
a
,
H
.
Y
.
-
H
.
S
i
u
,
M
.
V
a
n
s
t
o
n
e
,
A
.
J
o
n
e
s,
A
.
G
o
p
a
u
l
,
a
n
d
A
.
P
.
C
o
st
a
,
“
D
e
v
e
l
o
p
me
n
t
o
f
p
r
a
c
t
i
c
e
-
b
a
s
e
d
q
u
a
l
i
t
y
i
n
d
i
c
a
t
o
r
s
f
o
r
t
h
e
p
r
i
mar
y
c
a
r
e
o
f
o
l
d
e
r
a
d
u
l
t
s:
A
R
A
N
D
/
U
C
LA
A
p
p
r
o
p
r
i
a
t
e
n
e
ss
M
e
t
h
o
d
s
t
u
d
y
p
r
o
t
o
c
o
l
,
”
BM
J
O
p
e
n
,
v
o
l
.
1
3
,
n
o
.
9
,
S
e
p
.
2
0
2
3
,
d
o
i
:
1
0
.
1
1
3
6
/
b
mj
o
p
e
n
-
2
0
2
3
-
0
7
2
2
3
2
.
[
6
]
S
.
S
.
A
c
e
v
e
s
e
t
a
l
.
,
“
En
d
o
sc
o
p
i
c
a
p
p
r
o
a
c
h
t
o
e
o
si
n
o
p
h
i
l
i
c
e
so
p
h
a
g
i
t
i
s
:
A
S
G
E
c
o
n
se
n
su
s
c
o
n
f
e
r
e
n
c
e
m
e
m
b
e
r
o
f
i
n
i
t
i
a
l
c
o
r
e
g
r
o
u
p
o
f
e
x
p
e
r
t
s
,
”
G
a
st
r
o
i
n
t
e
s
t
i
n
a
l
En
d
o
sc
o
p
y
,
n
o
.
1
1
,
2
0
2
2
.
[
7
]
J.
D
.
F
e
u
e
r
st
e
i
n
e
t
a
l
.
,
“
Tr
i
a
g
e
o
f
g
e
n
e
r
a
l
g
a
s
t
r
o
i
n
t
e
s
t
i
n
a
l
e
n
d
o
s
c
o
p
i
c
p
r
o
c
e
d
u
r
e
s
d
u
r
i
n
g
t
h
e
C
O
V
I
D
-
1
9
p
a
n
d
e
m
i
c
:
R
e
s
u
l
t
s
f
r
o
m
a
n
a
t
i
o
n
a
l
d
e
l
p
h
i
c
o
n
s
e
n
su
s
p
a
n
e
l
,
”
T
e
c
h
n
i
q
u
e
s
a
n
d
I
n
n
o
v
a
t
i
o
n
s
i
n
G
a
st
r
o
i
n
t
e
st
i
n
a
l
E
n
d
o
sc
o
p
y
,
v
o
l
.
2
3
,
n
o
.
2
,
p
p
.
1
1
3
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