Case Report: The importance of early intervention for gastroesophageal reflex disease caused by hiatal hernia.

Background: Gastroesophageal reflux (GER) disease (GERD) is a condition wherein GER causes troublesome symptoms that can affect daily functioning and/or clinical complications within the esophagus or other systems. To avoid this, patients with GERD often require treatment; hence, it is important to distinguish GER from GERD. Patients with GERD exhibiting alarm signs should be examined early to differentiate it from GER and treated accordingly. Herein, we present a case of GERD caused by a hiatal hernia that required surgical intervention for esophagial cicatrical stenosis despite oral treatment. We also discussed how to choose the appropriate acid suppressants for GERD. Case presentation: A 1-year-old boy was referred to our hospital for repeated vomiting and poor weight gain. He received histamine 2 receptor antagonists (H2RAs) that contributed slightly to the decreased frequency of vomiting and aided weight gain; however, he soon stopped gaining weight and had bloody vomit. His upper gastrointestinal series revealed hiatal hernia, a 24 h impedance pH monitoring test indicated abnormal values for acid reflux, and esophagogastroduodenoscopy (EGD) revealed esophagitis. He was subsequently diagnosed with GERD associated with hiatal hernia. A proton pump inhibitor (PPI) was intravenously administered to him, following which his medication was changed to a potassium-competitive acid blocker (P-CAB). Thereafter, his vomiting episodes significantly decreased and his weight increased. However, 6 months after starting P-CAB, his vomiting episodes suddenly increased in frequency. EGD revealed the presence esophageal stricture due to scarring from GERD. He was then treated via laparoscopic fundoplication, gastrostomy, and esophageal balloon dilation. Thereafter, his vomiting episodes stopped and food intake improved, leading to weight gain. Conclusion: It is essential to identify the cause of GERD early and take an appropriate treatment approach depending on the cause of GERD with alarm signs. Further, as a drug therapy for GERD as a clear acid mediated disease or in children with alarm signs, PPIs or P-CAB should be used from the beginning instead of H2RAs.

Natural excretion of a metallic susceptor originating from an ingested heated tobacco stick.

Key Clinical Message: Clinicians should not only consider the presence of metallic foreign bodies within the digestive tract but also contemplate the possibility of nicotine poisoning during the diagnostic process. Abstract: When clinicians encounter cases of accidental ingestion of some types of heated tobacco, they must consider not only nicotine poisoning but also the possibility of a metallic foreign body within the digestive tract during diagnosis. In children, even sharp or relatively large ingested foreign bodies can spontaneously pass below the esophagus. Considering that this 12-mm metal piece is small, natural excretion may be considered rather than endoscopic removal.

Fecal calprotectin measurement to detect recurrence of solitary juvenile polyps: A case report.

RATIONALE: Juvenile polyps (JPs) are the most common polyp type and can be observed in 1% of all preschoolers. The peak incidence is observed at ages 3 to 5 years, constituting 90% of all polyps in children. Elevated levels of fecal calprotectin (FC) are often seen in children with JPs. PATIENT CONCERNS: A 15-month-old girl was referred to our hospital for blood on the stool surface persisting for 3 months. She was healthy, with no abdominal pain, diarrhea, anorexia, or weight loss and no complaints other than hematochezia. Her physical examination, vital signs and laboratory date were unremarkable. DIAGNOSIS: JPs. INTERVENTION: Total colonoscopy for her found 2 JPs in the sigmoid colon, which were subsequently resected endoscopically. OUTCOMES: At the age of 5 years, this patient again had bloody stools. Her FC measurement at that time was 1020 mg/kg, which normalized to 42 mg/kg 3 months after her second resection. LESSONS: Single or multiple solitary JPs require follow-up that fully considers the possibility of recurrence. Establishing a method for early confirmation of JP recurrence based on bloody stools, fecal occult blood testing, and FC measurement is necessary.

Case report: A pediatric case of repeated false-positive urea breath test for Helicobacter pylori without decreased gastric acid secretion.

The urea breath test (UBT) is often used to diagnose Helicobacter pylori infection and for its eradication. However, this text can give positive results even for other urease-active bacteria other than H. pylori. Even after the successful eradication of H. pylori, the presence of other urease-active bacteria in the gut and oral cavity can lead to positive UBT results in patients with decreased gastric acid secretion. Herein, a 15-year-old boy was diagnosed with H. pylori infection through the testing and treatment program for H. pylori for third-year junior high-school students in Saga Prefecture initiated in 2016. He underwent triple therapy comprising vonoprazan; however, UBT was found to be positive even after therapy. The results remained positive even after fourth-line eradication therapy. Stool antigen, PCR using gastric fluid, microscopy, culture, and rapid urease tests were all negative. Pepsinogen levels were normal, and none of the findings suggested autoimmune gastritis. Gastric microflora analysis revealed oral flora showing urease activity. UBT is considered useful for determining the successful eradication of H. pylori; however, it may give false-positive results for both H. pylori infection and eradication judgment. Although the patient did not have autoimmune gastritis or decreased gastric acid secretion, it is presumed that oral commensal bacteria showing urease activity inhabited the stomach, resulting in the persistently positive UBT results. In conclusion, repeated false-positive UBT results for H. pylori may occur even without gastric acid hyposecretion. If H. pylori eradication is unsuccessful based on UBT, additional test by stool H. pylori antigen tests should be considered.

Middle-term natural course after acute pancreatitis associated with pancreas divisum.

Invasive treatment might be taken into consideration at the time of initial acute pancreatitis in patients with pancreas divisum who do not complain of abdominal pain to prevent progression to chronic pancreatitis.

Juvenile polyp presenting as prolapsed mass per rectum in a 5-year-old child.

Juvenile polyps typically present as painless rectal bleeding after defecation, but a small portion of them may manifest with prolapse.

The Effect of Acotiamide on Nausea as a Symptom of Chronic Nausea and Vomiting Syndrome after Coronavirus Disease 2019.

Chronic nausea and vomiting syndrome (CNVS), one of a functional gastroduodenal disorder, was identified in an 8-year-old girl and a 13-year-old boy who had complained of nausea for more than 4 months following coronavirus disease 2019 (COVID-19) due to normality of their head computed tomography and upper gastrointestinal tract images. The patients' symptoms responded quickly to acotiamide, a medication that is effective for treating functional dyspepsia (FD). Despite being a distinct illness from FD, CNVS is also a functional gastrointestinal disorder, and acotiamide may be just as effective for CNVS following COVID-19 as for FD.

Japanese pediatric patient with refractory steroid-resistant ulcerative colitis successfully treated with Tofacitinib: A case report.

RATIONALE: Tofacitinib is an orally administered selective Janus kinase inhibitor. Its efficacy and safety in adults with moderately to severely active ulcerative colitis (UC) have been evaluated in clinical trials; however, its efficacy in pediatric patients with UC is limited. PATIENT CONCERNS: A 9-years-old boy was referred to our hospital with chief complaints of diarrhea and bloody stool for 2 months. Colonoscopy revealed total colitis-type UC. His pediatric UC activity index score was 40, indicating moderately active UC. DIAGNOSIS: UC. INTERVENTIONS: Vedolizumab, golimumab, and ustekinumab were introduced because of steroid-resistant refractory UC; however, none of these biologics were effective or the effect was short-lived. Therefore, tofacitinib was administered 5 mg twice a day. OUTCOMES: The patient achieved UC remission after tofacitinib treatment, leading to maintained remission without adverse events. LESSONS: To the best of our knowledge, this is the first pediatric case of moderately active UC that was successfully treated with tofacitinib in Japan. Tofacitinib is a safe drug for pediatric patients with moderately active UC. Even in steroid-dependent cases refractory to other biologics, tofacitinib can result in remission induction and maintenance effects. In children and adults, high-dose tofacitinib during induction therapy may be unnecessary to reduce adverse events.

Vedolizumab as the First-Line of Biologicals for Pediatric Patients With Ulcerative Colitis.

PURPOSE: Vedolizumab (VDZ) was reported to be effective as a first-line biological in adult ulcerative colitis (UC). The aim of this study was to investigate the safety and effectiveness of VDZ as the first-line biological in pediatric refractory UC. METHODS: We retrospectively extracted data from pediatric patients with UC who received first-line VDZ. The following were recorded: baseline characteristics; clinical activity of intestinal disease, levels of fecal calprotectin (FC), C-reactive protein, and serum amyloid A; and erythrocyte sedimentation rate. Clinical effectiveness, biochemical remission, and safety of VDZ were also investigated. FINDINGS: Eight patients were identified (median age, 12 years). FC levels were abnormal in all cases and were remarkably elevated in 3 patients. C-reactive protein, serum amyloid A, and erythrocyte sedimentation rate values were abnormal in 2, 4, and 5 patients, respectively. According to the pediatric UC activity index score, 1, 5, and 2 patients had mild, moderate, and severe disease. Fourteen weeks after VDZ administration, 5 patients achieved remission, and 3 remained in remission until week 52. Of the 3 patients who did not reach remission in week 14, two achieved remission by week 52. In week 52, five of the eight patients continued receiving VDZ and maintained remission. All patients achieved clinical remission without corticosteroid use. No adverse events were observed in any patient. IMPLICATIONS: VDZ may serve as a safe and effective first-line biological option for treating pediatric patients with UC. FC levels before VDZ administration may be predictive of long-term remission.

Japanese pediatric patient with moderately active ulcerative colitis successfully treated with ustekinumab: A case report.

RATIONALE: Ustekinumab is effective in the treatment of adult Crohn disease (CD) and ulcerative colitis (UC). However, data on its efficacy and safety in pediatric CD and UC are limited. To the best of our knowledge, there are no reports of Japanese children with UC treated with ustekinumab in the long-term. PATIENT CONCERNS: A 14-year-old man with diarrhea and bloody stools was referred to our hospital. Colonoscopy revealed total colitis-type UC. His pediatric UC activity index score was 50, indicating moderately active UC. DIAGNOSES: Ulcerative colitis. INTERVENTIONS: Infliximab was introduced because of steroid-resistant refractory UC; however, secondary ineffectiveness was observed 17 months later. Therefore, ustekinumab was administered along with prednisolone (16 years of age). OUTCOMES: The patient achieved UC remission after ustekinumab treatment, leading to maintained remission without side effects. LESSONS: To the best of our knowledge, this is the first pediatric case of moderately active UC successfully treated with ustekinumab in Japan. Ustekinumab combined with steroids is an effective and safe induction therapy for UC.

Pediatric case of Crohn's disease with preceding vulvitis granulomatosa.

Crohn's disease (CD) of the vulva is a rare and under-recognized condition. Since vulvar lesions may precede the diagnosis of digestive CD in approximately 25% of all cases, the coexistence or future onset of CD should be considered regardless of the gastrointestinal symptoms, even for pediatric patients.

Need for liver biopsy in pediatric nonalcoholic steatohepatitis diagnosis regardless of improvement in liver damage through weight loss.

Liver biopsy is recommended for obese children with fatty liver disease to ensure that nonalcoholic steatohepatitis (NASH) is not overlooked. Even in pediatric cases, regardless of the improvement in liver damage through weight loss, children should be tested and treated with the possibility of NASH in mind.