Increased plasma levels of pancreatic polypeptide and decreased plasma levels of motilin in encopretic children.

OBJECTIVE: Abnormalities of hormones affecting gastrointestinal motility have been found in "functional" disorders of the gastrointestinal system in adults. One such disorder of childhood, encopresis, is frequently associated with constipation, the treatment of which often eliminates the soiling. We hypothesized that hormones affecting gastrointestinal motility were different between encopretic patients and matched controls. METHODS: Ten encopretic patients were matched by age, race, and sex with controls who had no history of encopresis or constipation. After an overnight fast, each child consumed a meal of Ensure, the amount of which was based on body weight. Plasma levels of gastrin, pancreatic polypeptide, cholecystokinin, motilin, thyroxine, estrogen, and insulin were measured 20 and 5 minutes before the meal, and 5, 10, 15, 30, 45, 60, 90, 120, 150, and 180 minutes after the meal. RESULTS: Postprandial levels of pancreatic polypeptide remained consistently higher and peaked earlier (P < .05) for encopretic patients. The motilin response was lower (P < .03) for encopretic children than for controls. CONCLUSIONS: We conclude that pancreatic polypeptide and motilin responses to a meal are different in encopretic children than in children in the control group. These gastrointestinal hormone findings may in part explain and/or be the result of the severe constipation that frequently underlies the fecal soiling found in these patients. These findings also suggest the motility of the stomach and small intestine may be abnormal in encopresis.

Prospective oral food challenge study of two soybean protein isolates in patients with possible milk or soy protein enterocolitis.

The soybean protein isolate used in powdered soybean formula is hydrolyzed more extensively than the isolate which is used in liquid soybean formula in most commercial soybean formulas. Previous in vitro studies have shown differences in human antibody response to these soybean protein isolates. Therefore, a prospective clinical study was undertaken to determine if there were differences in adverse reaction rates to these soybean protein isolates. Forty-three patients with possible milk- and/or soy-protein enterocolitis were enrolled in this study. Patients had 3 separate oral food challenges; using milk formula, soybean powder formula and soybean liquid formula. Ten (23%) patients challenged with milk had positive challenges. Fourteen (33%) patients challenged with powdered soy formula had positive challenges while thirteen (30%) challenged with liquid soy formula had positive challenges. In the 10 patients with positive milk challenges, 6 (60%) had a positive soy challenge. In the group with positive soy challenges, 5 reacted to the powdered soy challenge done first, but not the second challenge with the liquid soy formula, and 4 patients reacted to the liquid soy formula challenge done first, but not the second challenge with the powdered soy formula. These results indicate that a significant number of patients with milk protein enterocolitis have soy protein enterocolitis. In addition, an order effect can be demonstrated in the soy challenges because of the tendency to react to the first soy challenge regardless of the type of isolate. These results suggest that a local immune effect caused by the protein may be present.

Olsalazine versus sulfasalazine in mild to moderate childhood ulcerative colitis: results of the Pediatric Gastroenterology Collaborative Research Group Clinical Trial.

The safety and efficacy of olsalazine sodium was compared to sulfasalazine over 3 months in a multicenter, randomized, double-blind study of 56 children with mild to moderate ulcerative colitis. Twenty-eight children received 30 mg/kg/day of olsalazine (maximum, 2 g/day) and 28 received 60 mg/kg/day of sulfasalazine (maximum, 4 g/day). Side effects were frequent in both groups. Eleven of 28 patients (39%) on olsalazine reported headache, nausea, vomiting, rash, pruritus, increased diarrhea, and/or fever. Thirteen of 28 on sulfasalazine (46%) reported similar side effects and/or neutropenia, and four patients had the drug stopped because of an adverse reaction. After 3 months, 11 of 28 (39%) on olsalazine were asymptomatic or clinically improved, compared to 22 of 28 (79%) on sulfasalazine (p = 0.006). In addition, 10 of 28 patients on olsalazine versus one on sulfasalazine required prednisone because of lack of response or worsening of colitis (p = 0.005). The dose of olsalazine used in this clinical trial was thought to be equivalent to a standard dose of sulfasalazine, but fewer patients on olsalazine improved and a greater number had progression of symptoms when compared to sulfasalazine. Although side effects were slightly less frequent for olsalazine, the number of patients was too small to detect a clinically significant difference.

The role of Helicobacter pylori in recurrent, functional abdominal pain in children.

Recurrent abdominal pain in children usually is considered to be functional in nature. We hypothesized that Helicobacter pylori infection might be the etiology of abdominal pain symptoms in some children with presumed functional abdominal pain. Therefore, we studied 20 children with a previous diagnosis of functional abdominal pain, using a 13C-urea breath test and an enzyme-linked immunosorbent assay for antibody to the H. pylori high molecular weight, cell-associated antigens. Two children had evidence of H. pylori infection, and both had clinical histories that suggested an acute H. pylori infection, at the onset of their abdominal pain. Seven children who had abrupt onset of their chronic abdominal symptoms were then identified prospectively. None of these patients had evidence of active H. pylori infection. We conclude that H. pylori infections are not common among children with recurrent abdominal pain, and are not predictable in such children, based on symptom patterns.

Factors influencing the epidemiology of Helicobacter pylori infection in children.

The epidemiology of Helicobacter pylori infection was studied in 245 healthy children (between 3 and 20 years of age) who presented for day surgery at Arkansas Children's Hospital. H pylori infection was identified serologically using an enzyme-linked immunosorbent assay to detect the presence of IgG against the high molecular weight, cell-associated antigens of H pylori. Demographic information collected included age, gender, race, family income, type of housing, location of housing, water supply, health status, upper gastrointestinal symptoms, and keeping pets. One hundred eighty-nine white children and 56 black children were studied; 139 were boys and 106 were girls. The data were analyzed by logistic regression analysis. H pylori infection increased significantly with age (P less than .05). The frequency of H pylori infection was higher in blacks than whites (P less than .01), and this difference remained after adjusting for age, gender, and family income. Family income was used as a measure of socioeconomic class and was an important factor related to infection; the rate of acquisition of H pylori in those children with family income less than +5000/year was twice that of those with incomes greater than +75,000/year (P less than .001). There were no significant differences in H pylori infection related to gender, type of housing, location of housing, or source of water supply. It is concluded that the rate of acquisition of H pylori infection increases with age, is higher in blacks than whites, and is inversely related to socioeconomic class.

Unidirectional water absorption as a measure of intestinal surface area in rats.

Methods to measure expeditiously the anatomic and functional mucosal surface area of the small intestine are needed. We postulated that passive, unidirectional water flux would assess the anatomic mucosal surface area and that the increase in unidirectional flux that occurs in the presence of glucose would correlate with functional surface area. These hypotheses were tested in control and methotrexate-treated rats. A single-pass perfusion technique was used in vivo. Methotrexate treatment reduced anatomic and functional surface area (p less than 0.05) as measured by computerized planimetry, wet mucosal weight, sucrase activity, and sucrase activity normalized to mucosal DNA content. A formula to predict anatomic surface area was derived from control animal data. The best model used passive, unidirectional water flux as the independent variable, but this model overestimated mucosal surface area in the methotrexate-treated animals (p less than 0.01). Mean unidirectional water flux increased by 45% (p less than 0.01) in controls during glucose perfusion, but did not increase in methotrexate-treated animals (p greater than 0.37). Thus, unidirectional water flux cannot be used as a universally applicable method to assess the anatomic mucosal surface area, but glucose-enhanced unidirectional water flux should be evaluated further as an indirect measure of functional surface area.

Porcelain gallbladder in a child: a case report and review.

Calcification of the gallbladder wall (porcelain gallbladder; PGB) is a rare form of gallbladder disease not previously described in a child. A 10-year-old girl is presented with PGB that was discovered incidentally during intravenous urography. Computed tomography localized the calcification to the gallbladder wall. Cholecystectomy was performed due to the associated increased incidence of biliary tract carcinoma reported in adult patients. The etiology, diagnosis, and management of PGB and its significance in a pediatric patient are discussed.

Arterial blood oxygen desaturation in infants and children during upper gastrointestinal endoscopy.

Arterial blood oxygen desaturation and abnormal electrocardiographic changes have been reported in adults undergoing upper gastrointestinal endoscopy. We studied 32 infants and children less than 12 years of age using pulse oximetry and continuous electrocardiography before, during, and after upper gastrointestinal endoscopy performed under intravenous sedation. Sinus tachycardia was the most common electrocardiographic change, and no clinically significant electrocardiographic abnormalities were induced by the procedure. Desaturation to less than or equal to 90% was found in 37.5% of the patients and was most commonly noted during the endoscopy procedure and in patients with cardiopulmonary disease. The desaturation was unpredictable because there was no correlation between desaturation and medication, tolerance to the procedure, weight, or age of the child. Some patients who subjectively appeared to tolerate the procedure well had significant desaturation. The use of pulse oximetry should be considered for all children undergoing upper gastrointestinal endoscopy.

Antibody response to milk proteins in patients with milk-protein intolerance documented by challenge.

To evaluate the role of specific antibody response to milk proteins in patients with milk-protein intolerance, allergen-specific IGE, IgG, and IgG4 to these proteins were measured by ELISA. Bovine casein, gamma globulin (GG), beta-lactoglobulin, and lactalbumin were the milk proteins used. Antibody production to these proteins were analyzed in 18 patients who underwent milk-protein challenges (eight positive and 10 negative) and in five normal children used in the analysis. ELISA results for specific IgE, IgG, and IgG4 to these specific proteins demonstrated no statistically different response to the four milk proteins among the three patient groups by multivariate analysis. When the specific antibody results from the positive challenge group, the negative challenge group, and the normal group were combined, the IgE and IgG4 to GG and the IgG to casein were significantly higher (p less than 0.01) than the corresponding specific antibody to the other proteins tested. The IgG or IgG4 to GG would differentiate the positive from the negative challenge group (p less than 0.05) but were not significantly different from the normal control group. Contrary to previously published studies, these results indicate IgG specific for the milk proteins are not increased in patients with milk-protein intolerance. The data also support the concept that IgE and IgG4 are not elevated in these patients. Therefore, there appears to be no pathogenic role for these specific immunoglobulins in milk-protein intolerance.

Breath methane production in children with constipation and encopresis.

Breath methane excretion is uncommon in children compared with adults. Certain intracolonic conditions, however, have been associated with enhanced methane generation. We hypothesized that encopretic and constipated children, who have abnormal colonic transit times, more likely would excrete methane than healthy children. To determine the prevalence of methane excretion among children with encopresis or simple constipation, we performed breath methane analysis on such patients and age-, race-, and sex-matched control subjects. Encopretic patients (mean age, 8.3 +/- 3.0 years) had daily, involuntary passage of feces and clinical evidence of constipation. Constipated patients (mean age, 7.1 +/- 2.9 years) had a history of hard stools and at least one of the following symptoms: infrequent defecation, dyschezia, hematochezia, difficult stool expulsion, or abdominal pain during bowel movements. Methane excretion was present in 26 of 40 (65%) encopretic patients versus 6 of 40 (15%) control patients (P less than 0.001). In contrast, 3 of 27 (11%) constipated patients were methane excreters, versus 2 of 27 (7%) controls (P = 0.4). Fourteen asymptomatic encopretic patients were retested after successful therapy; eight were methane excreters initially, but five of eight did not excrete methane after treatment. We conclude that methane is produced in a large number of children with encopresis. Treatment appears to alter methanogenesis in such patients. The prevalence of methane producers among constipated children is not different from the prevalence in healthy subjects. Methanogenesis in encopretic patients may be enhanced by prolonged colonic transit time or abnormal intracolonic conditions.

Oral rehydration therapy.

Diarrhea is a major cause of mortality and morbidity affecting infants and children in many parts of the world. Research and understanding of normal and abnormal gastrointestinal physiology allowed the development of oral electrolyte solutions to treat dehydration. These solutions were initially used for treatment of cholera in areas with poor access to medical care and are now used extensively by the WHO. Therapy with OES has expanded to other nonsecretory causes of diarrhea. Two types of solutions are available in the United States. Maintenance solutions contain 40 to 60 mEq per liter of sodium and are used for prevention of dehydration or after rehydration. Rehydration solutions contain 60 to 90 mEq per liter of sodium and are effective for the oral repletion of fluid and electrolyte deficits in both secretory and nonsecretory diarrhea.

Rectal anticonvulsants in seizure patients undergoing gastrointestinal surgery.

Gastrointestinal (GI) surgery in children with seizure disorders is often complicated by difficulties in administering oral anticonvulsant medications in the preoperative and postoperative periods. Because many newer anticonvulsants do not have parenteral formulations, intravenous phenobarbital, phenytoin, and benzodiazepines may appear necessary in the perioperative period. Eight children with neurologic disease with severe seizure disorders underwent gastrostomy placement and Nissen fundoplication. Perioperatively, their anticonvulsants were given successfully via the rectum. Rectal administration of anticonvulsants is a useful alternative route for drug therapy in seizure patients who are undergoing GI surgery.

Enzyme-linked immunosorbent assay and immunoblotting determination of antibody response to major component proteins of soybeans in patients with soy protein intolerance.

To evaluate the role of food-specific antibody response to soy protein and its fractions in patients with soy protein intolerance, allergen-specific IgG and IgE to these proteins were measured by enzyme-linked immunosorbent assays (ELISAS) and immunoblotting. A crude soy extract and the 7S, 11S, and whey fractions were isolated from commercial defatted soy flakes. Of 23 patients who underwent standardized soy challenges, seven were positive. The ELISA results showed no statistically different responses between the challenge-positive and challenge-negative groups in IgG or IgE specific to either the crude soy extract or the 7S, 11S, and whey fractions (p greater than .3 for all variables). In comparing the soy-positive patients, the level of IgE specific for 7S and 11S was significantly different compared with whey; the level of IgE specific for crude soy extract and 7S was significantly different compared with whey. The immunoblots reveal that IgG and IgE are present in varying amounts to multiple fractions of the soy protein. The study does not provide evidence for a pathogenic role of serum food-specific antibodies in soy protein intolerance.

Endoscopic detection of peptic ulcer disease in cystic fibrosis.

Abdominal pain is common among cystic fibrosis (CF) patients and may be caused by a variety of conditions. Although peptic ulcer disease (PUD) has not been emphasized as a common cause of abdominal symptoms in CF, the risk for the development of PUD may be increased because of abnormal physiology. Contrast radiography appears to be an especially inaccurate method to document PUD in CF because the duodenal mucosa typically appears nodular and distorted with poor definition of the mucosal folds. These findings may obscure or mimic PUD. The first endoscopic diagnosis of PUD is reported in a CF patient. Based on this case and a review of the literature, endoscopy is the procedure of choice for evaluation of a CF patient who is suspected of having PUD.