Gastric lavage in the diagnosis of pulmonary tuberculosis in children: a systematic review
Colecta de lavado gástrico para diagnóstico de tuberculosis pulmonar infantil: revisión sistemática
Ethel Leonor Noia MacielI, II, III; Léia Damasceno de Aguiar BrottoI; Carolina Maia Martins SalesI; Eliana ZandonadeII; Clemax Couto Sant'AnnaIV
IDepartamento de Enfermagem. Centro de Ciências da Saúde (CCS). Universidade Federal do Espírito Santo (UFES). Vitória, ES, Brasil
IIPrograma de Pós-graduação em Saúde Coletiva. CCS-UFES. Vitória, ES, Brasil
IIINúcleo de Doenças Infecciosas. Centro de Ciências da Saúde. CCS-UFES. Vitória, ES, Brasil
IVInstituto de Puericultura e Pediatria Martagão Gesteira. Faculdade de Medicina. Universidade Federal do Rio de Janeiro. Rio de Janeiro, RJ, Brasil
Correspondência | Correspondence
OBJECTIVE: To analyze standardization of gastric lavage protocols in the diagnosis of pulmonary tuberculosis in children.
METHODS: A systematic review was conducted for the period between 1968 and 2008 in the following databases: LILACS, SCIELO and MEDLINE. The search strategy included the following terms: "gastric lavage and tuberculosis" or "gastric washing and tuberculosis" with the restriction of "children aged up to 15 years;" "gastric lavage and tuberculosis and childhood" or "gastric washing and tuberculosis and childhood." There were retrieved 80 articles and their analysis was based on information on the gastric lavage protocol for the diagnosis of pulmonary tuberculosis in children: preparation of children and fasting; time of gastric aspiration; aspiration of gastric residues; total volume of aspirate; solution used for aspiration of gastric contents; decontaminant solution; buffer solution; and time for forwarding samples to the laboratory. After a thorough analysis, 14 articles were selected.
RESULTS: No article detailed the whole procedure. Some articles had missing information on: amount of gastric aspirate; aspiration before or after solution injection; solution used for gastric aspiration; buffer solution used; and waiting time between specimen collection and laboratory processing. These results showed inconsistencies of gastric lavage protocols.
CONCLUSIONS: Although gastric lavage is a secondary diagnostic approach used only in special cases that did not reach the diagnostic scoring as recommended by the Brazilian Ministry of Health, there is a need to standardize gastric lavage protocols for the diagnosis of pulmonary tuberculosis in children.
Descriptors: Gastric Lavage, methods. Tuberculosis, diagnosis. Diagnostic Techniques, Respiratory System. Systematic review.
OBJETIVO: Analizar la estandarización de la colecta del lavado gástrico para diagnóstico de tuberculosis en niños.
MÉTODOS: Estudio de revisión sistemático referente a los años de 1968 a 2008. El levantamiento de artículos científicos fue hecho en las bases de datos Lilacs, SciELO y Medline, utilizándose la estrategia de búsqueda ("gastric lavage and tuberculosis" o "gastric washing and tuberculosis", con el límite "niños con edad hasta 15 años"; y "gastric lavage and tuberculosis and childhood" o "gastric washing and tuberculosis and childhood"). El análisis de los 80 artículos recuperados se basó en las informaciones sobre el protocolo de colecta de lavado gástrico para diagnóstico de la tuberculosis en niños: preparo del niño y horas de ayuno, horario de la colecta, aspiración del residuo gástrico, volumen total aspirado, solución usada para aspiración del contenido gástrico, solución descontaminante, solución tampón, y tiempo de envío de las muestras al laboratorio Posterior al análisis con los criterios, de estos, fueron seleccionados 14 artículos.
RESULTADOS: Ningún artículo explicaba detalladamente todo el procedimiento. En algunos artículos no constaban: cantidad de aspirado gástrico, aspiración antes o después de insuflar una solución, solución usada en la aspiración gástrica, solución tampón utilizada, tiempo de espera entre colecta y procesamiento del material. Estos resultados muestran inconsistencias entre los protocolos de colecta de lavado gástrico.
CONCLUSIONES: A pesar de que este sea un método secundario en Brasil, reservado a casos que no alcanzaron puntuación diagnóstica por el sistema recomendado por el Ministerio de la Salud, es necesario estandarizar la colecta de lavado gástrico para diagnóstico de tuberculosis pulmonar en la infancia.
Descriptores: Lavado Gástrico, métodos. Tuberculosis, diagnóstico. Técnicas de Diagnóstico del Sistema Respiratorio. Revisión sistematica.
It is estimated there are around 1.3 million cases of tuberculosis (TB) in children under 15 years living in developing countries, with approximately 450,000 deaths annually.30,31 In Brazil, 15% of reported TB cases occur in those under 15 years old.13,14,21
TB in children should be considered a sentinel event from a public health perspective as it indicates recent infection due to exposure to an infectious person.2 Children play a major role in the chain of TB transmission being reservoirs of Mycobacterium tuberculosis and may later develop active disease.28
TB in children has broad clinical presentations, from asymptomatic to severe disseminated forms, usually accompanied by severe cachexia, which often leads to death.9 It is difficult to make an accurate bacteriological diagnosis of TB in children because those under ten usually have paucibacillary forms. Those over ten can present pulmonary TB with open (bacillary) lesions. In those cases of extrapulmonary TB, biopsy or lesion puncture can sometimes be performed.20,25
TB diagnosis in children is based on the following criteria: radiographic or clinical manifestations consistent with TB; positive tuberculin skin test; and evidence of recent exposure to a known case of infectious TB.16,ª Even when all these criteria are met, it is commonly difficult to have bacteriological confirmation of TB.16
There have been studied other tests for bacteriological confirmation of pulmonary TB in children such as gastric lavage,27 induced sputum,33 and bronchoalveolar lavage (BAL)29 with proven validity and efficacy. However, gastric lavage has been the test of choice for diagnostic confirmation of TB in children because they are usually not able to produce sputum and have few bacilli in the lesions,21 in addition to its relative low cost.
In Brazil the diagnosis of TB in children is currently made based on a scoring system developed by the Brazilian Ministry of Health (2002). Gastric lavage is used only when the diagnostic score is lower than 30.5,23
Gastric lavage is typically performed in hospitals,4 which increases diagnosis costs since they have to stay in hospital for an average of three days.
Gastric lavage is intended to collect a sample of respiratory secretions that were swallowed during the night. It is performed early in the morning after an overnight fasting. A nurse inserts a nasogastric tube into the child's stomach and then aspirates its contents.11,18,32 The administration of an infusion, time, solution and amount used vary according to different protocols. It can be either an inpatient or outpatient procedure15 and should be performed in three consecutive days.
Gastric lavage samples are then digested and decontaminated with sodium hydroxide and N-acetyl L-cysteine. After buffering, they are centrifuged at high rotation per minute for a specified time and sediments are then stained by Ziehl-Neelsen technique for the detection of acid-fast bacilli.15,27 Its accuracy ranges from 20% to 52%.21
However, the lack of standardization of gastric lavage protocols has resulted in inconsistent results and the need for three samples per patient has been questioned. Thus, the objective of the present study was to analyze standardization and sensitivity of gastric lavage in the diagnosis of pulmonary TB in children.
A systematic review was conducted from September to December 2008 in LILACS, SCIELO and MEDLINE databases for the period between 1968 and 2008.
The search strategy included the following terms: "gastric lavage and tuberculosis" or "gastric washing and tuberculosis" with the restriction of "children aged up to 15 years;" "gastric lavage and tuberculosis and childhood" or "gastric washing and tuberculosis and childhood."
Inclusion criteria included articles that made reference to gastric lavage and were published in English, Portuguese, and Spanish.
The criteria for analysis of the articles were: use of gastric lavage in the bacteriological diagnosis of TB; comparison between gastric lavage and BAL in the bacteriological diagnosis of TB; comparison between gastric lavage and induced sputum in the bacteriological diagnosis of TB; and comparison of the accuracy of gastric lavage in TB diagnosis made inhospital and outpatient settings.
There were retrieved 80 articles in the initial literature review. The selection process of the 14 articles that were included in the analysis is shown in Figure.
For assessing the methodological quality of studies, each article selected was scored according to criteria proposed by Downs & Black.6 The original checklist was modified by the authors and criteria exclusively related to intervention studies were excluded. Nineteen items were assessed to a maximum score of 20. Table 1 shows the items assessed.
The articles were independently reviewed by two researchers (LDAB and CMMS). The agreement of scores reported by the reviewers was assessed using intraclass correlation coefficient (ICC) and was classified in an agreement scale as proposed by Shrout26 as follows: virtually none (<0.1), slight (0.11 to 0.40), fair (0.41 to 0.60), moderate (0.61 to 0.80), and substantial agreement (0.81 to 1.0). Discordant cases were reviewed by a third investigator (ELM). The comparison of scores assigned to studies by different reviewers (ICC = 0.95, 95% CI: 0.84;0.98) indicated high level of agreement (substantial agreement).
Statistical analyses were performed in SPSS 15.0.
The completeness of gastric lavage technique was evaluated based on the description of three or more of the following steps: child preparation and fasting time; time of gastric aspiration; aspiration of gastric residues; total volume of aspirate; solution used for aspiration of gastric contents; decontaminant solution; buffer solution; and time for forwarding samples to the laboratory.
The articles were grouped according to similar methods and steps of gastric lavage.
Most articles were published from 2000 to 2005, and the countries that published most were South Africa and India. Most studies were prospective (Table 2).
The most common diagnostic methods used in the selected studies were physical examination, radiological studies, medical history, tuberculin skin test and gastric lavage. The study samples ranged from 13 to 1,732 children.
Table 3 shows that positive results for pulmonary TB in the gastric lavage ranged from 0 to 182. Most selected studies did not describe the complete technique of gastric lavage, only 14 articles met at least three completeness criteria.
The mean score of methodological quality was 11.53, ranging between seven and 15.
Table 4 summarizes the most relevant results. The sensitivity of the technique ranged from 0 to 92.3%.
The studies that described the technique of gastric lavage were inconsistent regarding major aspects such as: child preparation and fasting time; time of gastric aspiration; aspiration of gastric residues; administration of buffer solution; type of buffer; and total volume of aspirate.
The production of articles with adequately detailed description of the technique of gastric lavage is scarce. Only two studies examined the scientific evidence that the procedure has the same sensitivity regardless of performance setting, time of gastric aspiration and number of gastric lavage samples collected.11,15 The lack of standardization and low sensitivity found in these studies indicate generally difficult technical support in health settings.
In 2002, the Brazilian Ministry of Health proposed a scoring system for identification of children with TB, which showed more than 80% sensitivity in studies.14,21,22 In addition to improved accuracy (around 85%) compared to gastric lavage (20% to 52%21), this scoring system can ensure early treatment for children reaching the diagnostic score without the need for further investigation of those with suspected TB and eliminating admission or outpatient attendance of children for three consecutive days to perform gastric lavage. Moreover, this scoring system, unlike other diagnostic approaches,5 showed similar sensitivity in children coinfected with HIV.19
Pulmonary TB in children has two major forms. The first one is primary TB due to primary infection by M. tuberculosis, which is more common in patients under ten and has particular clinical and radiological manifestations: most cases are non-bacillary (negative in the bacteriological examination) and radiographic studies show closed lesions (hilar lymphadenopathy, infiltrates and consolidation).
In children with suspected TB, gastric lavage is used only when their score is lower than 30 based on the Brazilian Ministry of Health scoring system.5 They have negative bacteriological tests as a result of the actual pathogenesis of TB and usually are not able to expectorate due to young age. In addition to gastric lavage, other diagnostic methods can be used such as bronchoscopy, serological tests, and biopsies among others.
In children older than ten, TB has a similar presentation to that found in adults: TB reinfection characterized by respiratory symptoms such as cough, expectoration, hemoptysis and sometimes extensive or open radiological lesions (infiltrates in the upper third of the lungs and cavitations).24 These patients are able to expectorate and the diagnosis can be made in most of the cases by sputum examination.24
A recent review of the Guidelines for Tuberculosis of the Brazilian Society of Tuberculosis and Lung Diseases5 clearly defines gastric lavage as a complementary diagnostic approach when the scoring system does not provide information for the treatment of children with suspected TB. In addition, gastric lavage should only be performed when culture for M. tuberculosis is available since direct smear microscopy is subject to false positives by the finding of other mycobacteria in the gastric content.ª
Due to its importance as a complementary diagnostic approach, there is a need for standardization of the technique of gastric lavage as well as advances in other more widely used and less costly and invasive technologies for the diagnosis of pulmonary TB in children.
1. Abadco DL, Steiner P. Gastric lavage is better than bronchoalveolar lavage for isolation of Mycobacterium tuberculosis in childhood pulmonary tuberculosis. Pediatric Infect Dis J. 1992;11(9):735-8.
2. Alves R, Sant'Anna CC, Cunha AJLA. Epidemiologia da tuberculose infantil na cidade do Rio de Janeiro, RJ. Rev Saude Publica. 2000;34(4):409-10. DOI:10.1590/S0034-89102000000400015.
3. Bhandari B, Singh SV, Sharma VK. Bacteriological diagnosis of pulmonary tuberculosis. A comparative study of gastric wash, laryngeal swab and lung puncture. Indian J Pediatric. 1971;38(284):349-53.
4. Castelo Filho A, Kritski AL, Barreto AW, Lemos ACM, Netto AR, Guimarães CA, et al. II Consenso Brasileiro de Tuberculose - Diretrizes Brasileiras para 2004. J Bras Pneumol. 2004;30(Supl 1):57-86. DOI:10.1590/S1806-37132004000700002
5. Conde MB, Melo FAF, Marques AMC, Cardoso NC, Pinheiro VGF, Dalcin PTR, et al. III Diretrizes para Tuberculose da Sociedade Brasileira de Pneumologia e Tisiologia. J Bras Pneumol. 2009;35(10):1018-48. DOI:10.1590/S1806-37132009001000011
6. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84. DOI:10.1136/jech.52.6.377.
7. Giammona ST, Zelkowitz PS. Superheated nebulized saline and gastric lavage to obtain bacterial cultures in primary pulmonary tuberculosis in children. Am J Dis Child. 1969;117(2):198-200.
8. Hatherill M, Hawkridge T, Whitelaw A, Tameris M, Mahomed H, Moyo S, et al. Isolation of non-tuberculous mycobacteria in children investigation for pulmonary tuberculosis. PLoS One. 2006;1:e21. DOI:10.1371/journal.pone.0000021
9. Houwert KA, Borggreven PA, Schaaf HS, Nel E, Donald PR, Stolk J. Prospective evaluation of World Health Organization criteria to assist diagnosis of tuberculosis in children. Eur Respir J. 1998;11(5):1116-20. DOI:10.1183/09031936.98.11051116
10. Jeena PM, Pillay P, Pillay T, Coovadia HM. Impacto of HIV-1 co-infection on presentation and hospital-related mortality in children with culture proven pulmonary tuberculosis in Durban, South Africa. Int J Tuberc Lung Dis. 2002;6(8):672-8.
11. Lobato MN, Loeffler AM, Furst K, Cole B, Hopewell PC. Detection of mycobacterium tuberculosis in gastric aspirates collected from children: hospitalization is not necessary. Pediatrics. 1998;102(4):E40. DOI:10.1542/peds.102.4.e40.
12. Lloyd AV. Bacteriological diagnosis of tuberculosis in children: a comparative study of gastric lavage and laryngeal swab methods. East Afr Med J. 1968 Mar; 45(3):140-3.
13. Maciel ELN, Marinato CA, Bandeira CFR, Tonini MS, Dietze R, Ramos MC. O perfil epidemiológico da tuberculose em crianças e adolescentes menores de 15 anos na Grande Vitória, Brasil, no período de 1990 a 2001. Cad Saude Colet (Rio J). 2006;14(1):81-94.
14. Maciel ELN, Dietze R, Silva RECF, Hadad DJ, Struchiner CJ. Avaliação do sistema de pontuação para o diagnóstico da tuberculose na infância preconizado pelo Ministério da Saúde, Brasil. Cad Saude Publica. 2008;24(2):402-8. DOI:10.1590/S0102-311X2008000200019.
15. Maciel ELN, Dietze R, Lyrio RP, Vinhas SA, Palaci M, Rodrigues RR, et al. Acurácia do lavado gástrico realizado em ambiente hospitalar e ambulatorial no diagnóstico da tuberculose pulmonar em crianças. J Bras Pneumol. 2008;34(6):404-11. DOI:10.1590/S1806-37132008000600011.
16. Marais BJ, Gie RP, Hesseling AC, Schaaf HS, Lombard C, Enarson DA, et al. A refined sympton-based approach to diagnose pulmonary tuberculosis in children. Pediatrics. 2006;118(5):e1350-9. DOI:10.1542/peds.2006-0519
17. Migliori GB, Borghesi A, Rossanigo P, Adriko C, Néri M, Santini S, et al. Proposal of an improved score method for the diagnosis of pulmonary tuberculosis in childhood in developing countries. Tuber Lung Dis. 1992;73(3):145-9. DOI:10.1016/0962-8479(92)90148-D
18. Okutan O, Kartaloglu Z, Kilic E, Bozkanat E, Ilvan A. Diagnostic contribution of gastric and bronchial lavage examinations in cases suggestive of pulmonary tuberculosis. Yonsei Med J. 2003;44(2):242-8.
19. Pedrozo C, Sant'Anna CC, March MF, Lucena S. Clinical scoring system for paediatric tuberculosis in HIV-infected and non-infected children in Rio de Janeiro. Intern J Tuberc Lung Dis. 2009;13(3):413-5.
20. Sant'Anna CC. Tuberculose na infância e na adolescência. São Paulo: Atheneu; 2002.
21. Sant'Anna CC, Mourgues LV, Ferrero F, Batanzat AM. Diagnóstico e terapêutica da tuberculose infantil: uma visão atualizada de um antigo problema. J Pediatr (Rio J). 2002;78(Supl 2):205-14. DOI:10.1590/S0021-75572002000800011
22. Sant'Anna CC, Orfalias CTS, March MFBP. A retrospective evaluation of a score system adopted by the Ministry of Health, Brazil, in the diagnosis of pulmonary tuberculosis in childhood: a case control study. Rev Inst Med Trop São Paulo. 2003;45(2):103-5. DOI:10.1590/S0036-46652003000200010
23. Sant'Anna CC, Santos MA, Franco R. Diagnosis of pulmonary tuberculosis by score system in children and adolescents: a trial in a reference center in Bahia, Brazil. Braz J Infect Dis. 2004;8(4):305-10.
24. Sant´Anna C, March MF, Barreto M, Pereira S, Schmidt C. Pulmonary tuberculosis in adolescents: radiographic features. Intern J Tuberc Lung Dis. 2009;13(12):1566-8.
25. Sequeira MD, Imaz MS, Barrera L, Poggio GH, Latini AO. Diagnostico de la tuberculosis infantil em provincias de la Argentina. Medicina (Buenos Aires). 2000;60(2):170-8.
26 Shrout PE. Measurement reability and agreement in psychiatry. Stat Methods Med Res. 1998;7(3):301-17. DOI:10.1191/096228098672090967
27. Singh M, Moosa NV, Kumar L, Sharma M. Role of gastric lavage and broncho-alveolar lavage in the bacteriological diagnosis of childhood pulmonary tuberculosis. Indian Pediatr. 2000;37(9):947-51.
28. Singh M, Mynak ML, Kumar L, Mathew JL, Jindal SK. Prevalence and risk factors for transmission of infection among children in household contact with adults having pulmonary tuberculosis. Arch Dis Child. 2005;90(6):624-8. DOI:10.1136/adc.2003.044255
29. Somu N, Swaminathan S, Paramasivan CN, Vijayaserkaran D, Chandrabhooshanam A, Vijayan VK, et al. Value of bronchoalveolar lavage and gastric lavage in the diagnosis of pulmonary tuberculosis in children. Tuber Lung Dis.1995;76(4):295-9. DOI:10.1016/S0962-8479(05)80027-9
30. Starke JR, Jacobs RF, Jereb J. Resurgence of tuberculosis in children. J Pediatr. 1992;120(6):839-55. DOI:10.1016/S0022-3476(05)81949-3
31. Starke JR. Childhood tuberculosis. A diagnotic dilemma. Chest. 1993;104(2):329-30. DOI:10.1378/chest.104.2.329
32. Zar HJ, Tannenbaum E, Apolles P, Roux P, Hanslo D, Hussey G. Sputum induction for the diagnosis of pulmonary tuberculosis in infants and young children in an urban setting in South África. Arch Dis Child. 2000;82(4):305-8. DOI:10.1136/adc.82.4.305
33. Zar HJ, Hanslo D, Apolles P, Swingler G, Hussey G. Induced sputum versus gastric lavage for microbiological confirmation of pulmonary tuberculosis in infants and young children: a prospective study. Lancet. 2005;365(9454):130-4. DOI:10.1016/S0140-6736(05)17702-2
Correspondência | Correspondence:
Ethel Leonor Noia Maciel
Núcleo de Doenças Infecciosas
Universidade Federal do Espírito Santo
Av. Marechal Campos, 1468 - Maruípe
29040-091 Vitória, ES, Brasil
This study was funded by the Ministério da Ciência e Tecnologia/Conselho Nacional de Desenvolvimento Científico e Tecnológico/Ministério da Saúde-Decit (MS-SCTIE-DECIT - Process: 410497/2006-1) and by the International Clinical, Operational and Health Services Research and Training Award (ICOHRTA - Process: U2R TW006883-02).
The authors declare that there are no conflicts of interest
a World Health Organization. Guidance for national tuberculosis programs on the management of tuberculosis in children. 2006. (WHO/HTM/TB/2006.371).