El espectro clinico-endoscopico de la gastritis asociada a Helicobacter pylori en pediatria / Endoscopic spectrum of gastritis associated with Helicobacter pylori in pediatrics

Con el objeto de analizar el espectro clinico y endoscópico de la enfermedad "gastritis crónica asociada a Helicobacter pylory (H py)" realizamos el estudio retrospectivo de 81 casos pediátricos. En todos la biopsia gástrica fue positiva. La población se dividió en dos periódos: el grupo 1 (1988-1992) incluyó 21 casos y representó la etapa inicial del reconocimiento clínico de la enfermedad. El grupo 2 (1993-1995) incluyó 60 casos representó el periódo en que la enfermedad era buscada en forma activa en la endoscopía. El número promedio de casos que se registraron en el período 1 y 2 correspondió a 4.2 y 20 casos/año, respectivamente. El exámen conjunto de ambos períodos reveló que los signos clínicos más frecuentes fueron el dolor abdominal recurrente (DAR) (74/81; 91 por ciento) y la hemorragia digestiva alta (HDA) (34/81; 41.9 por ciento). La combinación de reflujo gastro-esofágico (RGE) y esofagitis ("E") se presentó en 52/81 (64.2 por ciento) de la población estudiada. El hallazgo de mucosa granular en la endoscopía fue más común en los casos con DAR (47/74), RGE (28/36) y "E"(14/16), mientras que la mucosa lisa predominó en los pacientes con HDA (23/34). Concluímos que la infección gástrica asociada a H py en la población pediátrica estudiada mostró un espectro clínico endoscópico peculiar. EL DAR fue referido como síntoma principal en el 91 por ciento de los casos. Consideramos que este hecho sustenta la inclusión de la gastritis por H py entre las posibles etiologías del DAR. Un hecho notable fue la estrecha asociación de RGE y "E" con la gastritis crónica por H py. Un mejor conocimiento del espectro clínico y endoscópico de la gastritis crónica con H py redundar en tratamiento adecuados y, posiblemente en la prevención de las enfermedades gástricas (y esofágicas) de los pacientes adultos. (AU)

Anticuerpos antimúsculo liso en la detección y seguimiento del enfermo celiaco. / [Antibodies against smooth muscle in the detection and follow-up of the celiac disease patient]

The presence of smooth muscle antibodies (SMA) as determined by indirect immunofluorescence was investigated in the serum of 40 patients, 36 out of which were children. Group I included patients having celiac disease (diagnosed by three biopsies). 7/7 (Group Ia) showed no SMA on gluten-free diet while antibodies were present after challenge. 4/6 (Group Ib) were positive also after challenge (these had not had previous determination). Group II was composed by patients presumed to have celiac disease for they had only one biopsy showing grade IV villous atrophy. 5 patients were of recent diagnosis (group IIa) and showed SMA. 4/5 (Group IIb) who admitted not to had been able to follow the gluten-free diet were also positive for SMA. 6/6 (Group IIc) patients on strict gluten-free diet and showing good clinical response had no detectable SMA. Group III included relatives of patients having celiac disease. 5/6 with SMA showed pathologic small bowel biopsies; only 1/4 with no SMA had mucosal alterations. It is concluded that the presence of serum SMA can be considered a useful marker in the follow-up of cases of celiac disease already diagnosed and to investigate presumed cases of such disease.

Atrofia focal con cicatrices estrelladas en niños con gastritis crónica asociada con Helicobacter pylori. Gastritis atrófica inicial? / Focal atrophy with stellate scars in children with chronic gastritis associated to Helicobacter pylori. Is this early atrophic gastritis?

Background: Atrophic gastritis has not been described in children in the setting of Helicobacter pylori infection. Methods: Gastric biopsies of six children (7 to 11 years old) with history of HpCG and recent therapeutic eradication of H. pylori, were reviewed. In the 6 H. pylori was documented with histology, culture, direct visualization and/or serology before treatment. Cases were compared with five biopsies of age-matched patients showing none of the above-mentioned clinical data. All the biopsies were formalin-fixed, paraffin embedded and stained with hematoxilin-eosin, Masson trichrome and reticulin stain. Results: The biopsies of the six treated patients showed variable-in-size stellate-shaped spots of glandular loss replaced by dense connective tissue with few inflammatory cells. The fibrous tissue showed a central area of scaring and radially oriented spikes extending to adjacent interglandular tissue, more evident with the Masson trichrome stain. Density of inflammatory cells in the lamina propria was variable. H. pylori organisms were consistently absent. On the reticulin stain the atrophic areas showed coarser and compacted reticulin. Stellate scars were not present in the five controls. Conclusions: Small foci with fibrous scars may be found in children with long standing HpCG, perhaps as an early sequel of it. We hypothesize that if the chronic gastritis-gastric atrophy process is a continuum, these stellate scars may be representing the very beginning of the multifocal atrophic gastritis usually seen in adult patients. (Au)

Virus papiloma humano, hepatitis gigantocelular neonatal y atresia de vias biliares / Human papillomavirus, neonatal giant cell hepatitis and biliary duct atresia

En trabajos previos hemos relatado el reconocimiento de la presencia de ADN del HPV en casos de hepatitis gigantocelular neonatal idiopática (HGNI) y atresia de vías biliares (AVB) en material de archivo usando la técnica de PCR. A fin de investigar una posible transmisión vertical estudiamos la presencia de ADN del HPV en hisopados cervicales de madres así como un tejido hepático fijado en formol e incluído en parafina, de 3 lactantes con HGNI y 4 con AVB mediante la técnica de nested-PCR. En dos casos los extendidos cervicales presentaron coilocitos, compatibles con infección por HPV. Excepto en uno el parto fué por vía vaginal en todos. Todos los lactantes eran del sexo masculino. En todos los casos se demostró amplificación del ADN del HPV, siendo concordante los tipos en los lactantes y sus madres. Aunque este es un grupo pequeño los hallazgos están de acuerdo con nuestros datos previos. La presencia del mismo tipo de HPV en el hígado de los lactantes y en hisopados de sus madres es otro argumento que apoya la posibilidad de una transmisión vertical del virus. (AU)

Evaluación de la utilidad del sistema Sydney en la gastritis asociada a Helicobacter pylori en niños / Assessment of the Sydney system in Helicobacter pylori associated gastritis in children

Objetivo: Establecer la utilidad de la escaa visual del "Sistema Sydney"actualizado (Ssa) para calificar las biopsias con gastritis crónica en la edad pediátrica. Material y métodos: Se analizaron 79 biopsias gástricas de 15 pacientes con gastritis crónica asociada con H. Pylori. Se obtuvieron biopsias de antro y cuerpo de todos los pacientes, y en 13 series de biopsias de 11 pacientes (dos con dos series), se realizaron cinco biopsias siguiendo la propuesta del Ssa: dos del antro a 2-3 cm proximales al piloro (una de la curvatura menor y otro de la curvatura mayor), dos del cuerpo a 8 cm del cardias (una de la curvatura menor y otro de la curvatura mayor), y una de la incisura angularis. La presencia de sulfomucinas se detectó mediante la coloración de azul Alcian-PAS a pH 1,0, preferentemente en las muestras de la incisura angularis. En cada muestra se calificó la densidad de H. pylori, infiltrados de neutrófilos y células mononucleadas, atrofia y metaplasia intestinal como: normal (ausencia), leve moderada o marcada, y se determinó la presencia o no de folículos linfóides. Resultados: Diez pacientes fueron mujeres y cinco, varones; la edad osciló entre 2 y 16 años (promedio: 10.8 años). Los principales síntomas de presentación fueron dolor abdominal recurrente (10 casos), hemorragia gastrointestinal (4 casos), pirosis (2 casos), vómitos y anemia (uno cada uno). Un paciente tenía hipertensión portal. En los 15 pacientes, se efectuaron en total 79 biopsias. La evaluación de esas muestras siguiendo la escala de analogía visual del Ssa mostró las siguientes calificaciones morfológicas: no hubo infiltrados de neutrófilos en 27 biopsias; fueron leves en 35 y moderados en 17. No se halló ninguna biopsia con marcada cantidad de neutrófilos. Los infiltrados mononucleares fueron leves en 38 biopsias, moderados en 36, y abundantes en 5. La densidad de H. pylori fue considerada leve en 39 biopsias, moderada en 27 y marcada en dos. En tres biopsias postratamiento del mismo paciente (caso 8) no se encontró H. pylori. Otras ocho biopsias (7 del cuerpo y una del antro) revelaron ausencia de H. pylori, aunque los gérmenes estuvieron presentes simultáneamente en otros sitios del estómago...(AU)

Assessment of the Sydney System in Helicobacter pylori-associated gastritis in children.

OBJECTIVE: The aim of our study was to establish the usefulness of the Sydney System in grading H. pylori-associated chronic gastritis in biopsies from pediatric patients. STUDY DESIGN: Fifteen children (average age: 10.8 years) with histologically-proven gastritis were studied. Classification and grading of gastritis were performed according to the analogue visual scales described in the updated version of the Sydney System. A chart was specially designed to record the morphological grading in this study. Altogether, we studied 79 gastric biopsies. RESULTS: Neutrophilic infiltrates were absent in 27 biopsies, mild in 35, and moderate in 17. This feature was not marked in any of the biopsies. Mononuclear infiltrates were mild in 38 biopsies, moderate in 36, and marked in 5. Density of H. pylori was mild in 39 biopsies, moderate in 27, and marked in 2. In three post-treatment biopsies belonging to the same patient, no H. pylori was observed. Additional 8 biopsies (7 from the body and 1 from the antrum) showed no H. pylori, although organisms were simultaneously present in other stomach sites. Lymphoid follicles were present in 19/79 biopsies. Intestinal metaplasia was not seen on slides stained with hematoxylin-eosin (HE). However, the Alcian blue-PAS stain revealed isolated positive cells in 8 out of 15 patients. None of the gastric biopsies showed mucosal atrophy. CONCLUSION: The results show that the Sydney System is applicable for pediatric patients in case of H. pylori-associated gastritis. However, the number of biopsies recommended in the Sydney System seems excessive for this age group.

Atrofia focal con [quot ]cicatrices estrelladas[quot ] en niños con gastritis crónica asociada con Helicobacter pylori. Gastritis atrófica inicial? / [Focal atrophy with stellate scars in children with chronic gastritis associated to Helicobacter pylori. Is this early atrophic gastritis?]

BACKGROUND: Atrophic gastritis has not been described in children in the setting of Helicobacter Pylori infection. METHODS: Gastric biopsies of six children (7 to 11 years old) with history of HpCG and recent therapeutic eradication of H. Pylori, were reviewed. In the 6 H. Pylori was documented with histology, culture, direct visualization and/or serology before treatment. Cases were compared with five biopsies of age-matched patients showing none of the above-mentioned clinical data. All the biopsies were formalin-fixed, paraffin embedded and stained with hematoxilin-eosin, Masson trichrome and reticulin stain. RESULTS: The biopsies of the six treated patients showed variable-in-size stellate-shaped spots of glandular loss replaced by dense connective tissue with few inflammatory cells. The fibrous tissue showed a central area of scarring and radially oriented spikes extending to adjacent interglandular tissue, more evident with the Masson trichrome stain. Density of inflammatory cells in the lamina propria was variable. H. Pylori organisms were consistently absent. On the reticulin stain the atrophic areas showed coarser and compacted reticulin. Stellate scars were not present in the five controls. CONCLUSIONS: Small foci with fibrous scars may be found in children with long standing HpCG, perhaps as an early sequel of it. We hypothesize that if the chronic gastritis-gastric atrophy process is a continuum, these stellate scars may be representing the very beginning of the multifocal atrophic gastritis usually seen in adult patients.

Toxocariasis con afectación Hepática. / [Toxocariasis with liver involvement]

We are reporting 16 cases of toxocariasis found in a two year period. Mean age was 2 years and 9 months. Sex distribution was 1:1. Thirteen (81

) children presented pica, 8 (50

) had pets at home, 10 (62.5

) presented anemia and long standing fever, and all eosinophilic leukocytosis. Fundoscopy was normal in all. Toxocara antibodies (Through ELISA) were increased in all of them. High resolution ultrasonography revealed hypoechoic areas in the liver in 50

of the cases. Therapeutic response was good, the clinical signs and symptoms disappearing at the end of treatment. The eosinophilic leukocytosis, ELISA serum positivity for toxocara and ultrasound findings persisted approximately for a year. Toxocariasis is a common parasitosis in our setting. It must be regarded as the first diagnosis when confronted with eosinophilic leukocytosis and abnormal liver findings by ultrasound.