Combined gray scale ultrasonography and doppler diagnostic tools with strain elastography in assessment of inflammatory bowel disease in pediatrics patients.

BACKGROUND: Intestinal changes in inflammatory bowel disease (IBD) are frequently observed on ultrasound. Invasive diagnostic procedures are often employed to differentiate between the main types of IBD and detect complications. Ultrasound Strain Elastography (SE) is a promising non-invasive technique for detecting intestinal changes and assessing inflammatory activity in pediatric IBD. AIM OF THE STUDY: This research aims to evaluate the diagnostic performance of conventional ultrasound, color Doppler, and SE in assessing inflammatory bowel disease in pediatric patients, both separately and in combination as additional tools. PATIENTS AND METHODS: Forty patients (18 females and 22 males) initially diagnosed with IBD through clinical and endoscopic biopsy, along with 20 healthy controls, underwent conventional ultrasound, color Doppler, SE, and laboratory evaluations, including CBC, ESR, CRP, Fecal calprotectin, and assessment of IBD activity using PIBDAI. RESULTS: Conventional ultrasound, color Doppler, and SE significantly contributed to detecting disease activity and intestinal changes in IBD (p < 0.001; 95% CI 0.79-1.100), demonstrating better sensitivity in combination compared to each method individually. The combined approach showed 100% sensitivity, 84% specificity, 78.6% precision (Positive Predictive Value), 100% Negative Predictive Value, and an overall accuracy of 92%. CONCLUSION: The addition of Color Doppler and SE parameters to grayscale ultrasound provides diagnostic value comparable to endoscopy, histopathology, and laboratory markers in detecting inflammatory activity and intestinal changes in IBD. This combined approach can help avoid unnecessary invasive techniques for follow-up.

Incidence of Low Seroimmunity to Hepatitis B Virus in Children with Inflammatory Bowel Disease: A Single Center Experience.

Purpose: Immunosuppressive therapy is frequently administered to patients with inflammatory bowel disease (IBD), which may make them more susceptible to infections like hepatitis B. Methods: A cross-sectional study was conducted on patients aged 5-18 years diagnosed with IBD who visited a gastroenterology clinic along with controls who were the same age as the patients with IBD and were healthy overall. A logistic regression analysis using the independent variables of age, sex, race, disease phenotype, surgery, and medications and the dependent variable of adequate hepatitis B surface antibody (HBsAb) titers (>10 mIU/mL) was performed on quantitative serum HBsAb titers. Results: The study enrolled 62 patients, including 37 males and 25 females. Crohn's disease, ulcerative colitis, and indeterminate colitis were diagnosed in 16, 22, and 24 patients, respectively. Thirty-nine patients were taking corticosteroids at the time of the study, 42 were taking immunomodulators, and four were taking biologics. Compared to 44.7% of the control group, 9.3% of the patients had protective titers. Only 12 out of 62 patients had HBsAb titers greater than 10 million IU/mL. None of the patients who received biologics or corticosteroids and 3.2% of those who received immunomodulators were found to be seroimmuned. Conclusion: The younger patients had the highest titers. Patient-specific factors that may impact these low titers include the length of the patient's illness and the use of immunosuppressants.

Very-early-onset inflammatory bowel disease versus late-onset inflammatory bowel disease in relation to clinical phenotype: A cross-sectional study.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic condition and children are affected by the disease's burden and therapeutic interventions for much longer than adults. Children of various ages can be diagnosed with IBD. METHODS: The research was carried out at the Pediatric Gastroenterology Clinic at Cairo University's Faculty of Medicine's Children's Hospital. From January 2013 to December 2017, this single-center observational cross-sectional study included 197 children aged 14 years and compared the clinical phenotypes of very-early-onset IBD (VEO-IBD) in patients aged six years and late-onset IBD (LO-IBD) in patients aged six to 14 years. RESULTS: Children with IBD at less than six years of age have a more colonic phenotype than children diagnosed later in life, who are more likely to have ileocolonic diseases (p = 0.002). In VEO-disease Crohn's (VEO-CD), growth failure/poor weight gain was 14%, while in LO-CD, it was 31%. Children with VEO-IBD do not always present with more severe disease than older children. Most clinical features in children with VEO-ulcerative colitis (VEO-UC) and LO-UC were similar at the first presentation, with the exception of abdominal pain, which was significantly less common in the VEO-UC group (p = 0.001) and hematochezia, which was significantly more common in the LO-UC group (p = 0.048). Children with VEO-disease Crohn's (VEO-CD) had a higher risk of bloody stools, diarrhea and fever (p = 0.013, p = 0.001 and p = 0.008, respectively), but a lower risk of abdominal pain (p = 0.000). CONCLUSIONS: Growth failure/poor weight gain occurred in 14% of VEO-CD patients and 31% of LO-CD patients. In LO-UC, abdominal pain and hematochezia were significantly more common. In LO-CD, hematochezia, diarrhea and fever were significantly more common. In LO-IBD-U, abdominal pain and diarrhea were significantly more common.

Thoracoscopic-Assisted Esophageal Replacement with a Detached Reversed Gastric Tube Pedicled Graft: Technical Report and Preliminary Outcomes.

BACKGROUND: Reflux is one of the most common late complications after gastric tube esophageal replacement in children. Herein, we report a novel approach for safely and selectively replacing the caustic strictured thoracic esophagus with a detached reversed gastric tube (d-RGT) pedicled graft with preservation of the cardia and implementation of thoracoscopy for optimizing the mediastinal pull-through process, and its outcomes. METHODS: All children who presented to our facility with an intractable postcorrosive thoracic esophageal stricture through 2020 and 2021 were enrolled in this study. The primary operational steps were thoracoscopic esophagectomy, laparotomy for d-RGT fashioning, and cervicotomy for anastomosis after the thoracoscopically monitored mediastinal pull-through process. RESULTS: Eleven children met the enrollment criteria, and their perioperative characteristics were assessed. The mean operative time was 201 min. The average duration of hospitalization was 5 days. There was no perioperative mortality. A transient cervical fistula was reported for one patient and a cervical side anastomotic stricture in another patient. A third patient developed kinking of the lower end of the d-RGT at the diaphragmatic crura level and this was treated satisfactorily by redoing the abdominal side surgery. After a mean follow-up of 8.5 months, none of the patients experienced reflux, dumping syndrome, or neoconduit redundancy. CONCLUSIONS: The pattern of vascular supply of the d-RGT allowed for its total irrigation. Thoracoscopy assisted in preparing the mediastinal path for a safe and precise pull-through process. The lack of reflux seen on imaging and endoscopy in these children suggests that retaining the cardia may be beneficial. LEVEL OF EVIDENCE: IV.

Risk factors for developing hyperoxaluria in children with Crohn's disease.

BACKGROUND: For the purpose of a better understanding of enteric hyperoxaluria in Crohn's disease (CD) in children and adolescents, we investigated the occurrence and risk factors for development of hyperoxaluria in those patients. METHODS: Forty-five children with CD and another 45 controls were involved in this cross-sectional study. Urine samples were collected for measurement of spot urine calcium/creatinine (Ur Ca/Cr), oxalate/creatinine (Ur Ox/Cr), and citrate/creatinine (Ur Citr/Cr) ratios. Fecal samples were also collected to detect the oxalyl-CoA decarboxylase of Oxalobacter formigenes by PCR. Patients were classified into 2 groups: group A (with hyperoxaluria) and group B (with normal urine oxalate excretion). The disease extent was assessed, and the activity index was calculated. RESULTS: According to the activity index, 30 patients (66.7%) had mild disease and 13 patients (28.9%) had moderate disease. There was no significant difference in Ur Ox/Cr ratio regarding the disease activity index. O. formigenes was not detected in 91% of patients in group A while it was detected in all patients in group B (p < 0.001). By using logistic regression analysis, the overall model was statistically significant when compared to the null model, (χ2 (7) = 52.19, p < 0.001), steatorrhea (p = 0.004), frequent stools (p = 0.009), and O. formigenes (p < 0.001). CONCLUSION: Lack of intestinal colonization with O. formigenes, steatorrhea, and frequent stools are the main risk factors for development of enteric hyperoxaluria in CD patients. Identifying risk factors facilitates proper disease management in future studies. A higher resolution version of the Graphical abstract is available as Supplementary information.

Prevalence of Celiac Disease in Children and Adolescents With Inflammatory Bowel Disease.

Introduction The association between inflammatory bowel disease (IBD) - particularly its two main subtypes, ulcerative colitis (UC) and Crohn's disease (CD) - and celiac disease (CeD) has been attributed to an overlap in the mechanism of immune dysregulation that characterizes these conditions. Owing to the paucity of studies that have explored this condition in pediatric patients, we examined the prevalence of CeD in children with IBD. Materials and methods This is a cross-sectional study of children aged two to 18 years with IBD that were diagnosed between 2016 and 2018. Clinical, demographic, laboratory, and endoscopic data were analysed. Serology for CeD measured the immunoglobulin A tissue transglutaminase (IgA-tTG) antibodies, and the diagnosis was confirmed histologically through small bowel biopsies. Results The study included 101 patients with IBD (83.2% with UC and 16.8% with CD). The mean age was 8.7±4.0 years. Males constituted 59.4% of the cohort, and only 3% had perianal disease. Ileocolonic involvement was reported in 64.7% and non-stricturing and non-penetrating behaviour in 76.7% of CD patients. Pancolitis constituted 45.2% of UC patients. Ten patients (9.9%) had positive serology based on IgA-tTG antibodies, three (approximately 3%) had CeD based on biopsy findings, two patients (2%) had CD, and one patient (1%) had UC. Patients with confirmed CeD had a significantly higher frequency of symptoms of gaseous sensation and bloating (P=0.003) and abdominal distension (P=0.04). Conclusions The prevalence of CeD in Egyptian children with IBD is higher than previously reported in a number of similar studies. Abdominal bloating and gaseous sensation were identified as associated symptoms.

Factors affecting the outcome of endoscopic dilatation in refractory post-corrosive oesophageal stricture in Egyptian children: a single-centre study.

BACKGROUND: An important complication of corrosive ingestion is oesophageal stricture. Improvements in endoscopes and accessories have supported an increase in the number of patients who are conservatively treated with endoscopic dilations. In this study, we aimed to detect factors affecting the outcome of endoscopic dilatation for refractory post-corrosive oesophageal stricture. METHODS: This study was carried out in the Paediatric Endoscopy Unit in the Children's Hospital and included 100 children older than 2 years of age of both sexes who had an established diagnosis of post-corrosive oesophageal stricture on repeated endoscopic dilatation sessions. The duration of the condition was more than 6 months, and dilatation failed to achieve a diameter of 14 mm during the first five sessions at 2-week intervals (refractory), excluding other causes of oesophageal stricture. RESULTS: Males represented 63% of patients. The mean age of enrolled children was 5.9 ± 2.6 years; 90% of patients ingested an alkaline corrosive substance (potash). The total number of dilatation sessions ranged from 16 to 100, with a mean number of sessions ranging from 37.2 ± 14.9. Fifty-four patients (54%) were well controlled by regular endoscopic dilatation with good clinical and endoscopic outcomes, and no more dilatations were needed. CONCLUSION: Endoscopic dilation is an effective method for managing refractory post-corrosive oesophageal strictures that require a long follow-up period. There are a lot of factors affecting the outcome.

Histopathological changes in the oesophageal mucosa in Egyptian children with corrosive strictures: A single-centre vast experience.

BACKGROUND: The caustic ingestion continues to be a major problem worldwide especially in developing countries. The long-term complications include stricture and increased life time risk of oesophageal carcinoma. Patients suffered from corrosive induced oesophageal strictures have more than a 1000-fold risk of developing carcinoma of the oesophagus. AIM: To determine the possibility of oesophageal mucosal dysplasia after prolonged dilatation in post corrosive stricture. METHODS: This observational study was conducted at the Paediatric Endoscopy Unit in Cairo University Children's Hospital. It included children of both sexes older than 2 years of age who had an established diagnosis of post-corrosive oesophageal stricture and repeated endoscopic dilatation sessions for more than 6 mo. All patients were biopsied at the stricture site after 6 mo of endoscopic dilatation. A histopathological examination of an oesophageal mucosal biopsy was performed for the detection of chronic oesophagitis, inflammatory cellular infiltration and dysplasia. RESULTS: The mean age of the enrolled children was 5.9 ± 2.6 years; 90% of the patients had ingested an alkaline corrosive substance (potash). The total number of endoscopic dilatation sessions were ranging from 16 to 100 with mean number of sessions was 37.2 ± 14.9. Histopathological examination of the specimens showed that 85% of patients had evidence of chronic oesophagitis (group A) in the form of basal cell hyperplasia, hyperkeratosis and subepithelial fibrosis. Thirteen percent of the patients had evidence of reactive atypia (group B) in the form of severe neutrophilic intraepithelial inflammatory cellular infiltration, and 2 patients (2%) had mild squamous dysplasia (group C); we rebiopsied these two patients 6 mo after the initial pathological assessment, guided by chromoendoscopy by Lugol's iodine. CONCLUSION: The histopathology of oesophageal mucosal biopsies in post-corrosive patients demonstrates evidence of chronic oesophagitis, intraepithelial inflammatory cellular infiltration and dysplasia. Dysplasia is one of the complications of post-corrosive oesophageal stricture.

Gastric antral vascular ectasia in portal hypertensive children: Endoscopic band ligation versus argon plasma coagulation.

BACKGROUND/PURPOSE: Gastric antral vascular ectasia (GAVE) can cause recurrent bleeding and chronic anemia in children with portal hypertension (PHT). We aimed to evaluate the efficacy of EBL in comparison to argon plasma coagulation (APC) in children with PHT, bleeding from GAVE. METHODS: This prospective comparative study included 40 children with PHT who presented with nonvariceal GIT bleeding from GAVE. Patients were divided into 2 groups, each including 20 cases: one group was managed with APC and the other with EBL. Endoscopy was repeated every 3-4 weeks until complete ablation of GAVE. Patients were reevaluated earlier in the event of recurrence of bleeding or in case of severe anemia necessitating blood transfusion. A follow-up endoscopy was done 6 months after the last APC or EBL session. RESULTS: The ages ranged between 2 and 16 years. The EBL group required a significantly lower number of sessions for complete obliteration of the lesions (1.85 ±â€¯0.81) as compared to APC group (4.15 ±â€¯1.22), p < 0.05. EBL was superior to APC as regards shorter procedure time (p = 0.001), lower blood transfusion requirement (p < 0.05), less hospitalization (p < 0.05) and significantly lower recurrence rate of GAVE after 6 months of follow up (p = 0.01) CONCLUSIONS: EBL is more effective and time saving when compared to APC in treatment of bleeding from GAVE in children. LEVELS OF EVIDENCE: Treatment study, Level II (prospective comparative study).

Foreign body ingestion in Egyptian children: a 10-year experience of endoscopic intervention in a tertiary hospital.

BACKGROUND: There is paucity of data regarding foreign body (FB) ingestion among Middle-Eastern children. We conducted a retrospective analysis of FB ingestion among Egyptian children and determined the predictors that affect the occurrence of complications. METHODS: This retrospective study was carried out on 1546 patients aged 13 years or younger presenting with FB ingestion and in need of endoscopic FB removal. RESULTS: There were 711 males (46%) and 835 females (54%) (mean age 4.56±2.26 years). Symptoms were present in 1414 patients (91.5%) while complications were present in 137 patients (8.9%). There was a significant difference between complicated and non-complicated cases with regard to higher age group, duration of impaction, site of impaction and type of FB (P=0.001, P=0.001, P=0.001, and P<0.001, respectively). CONCLUSIONS: The highest rate of complications was observed in FB impacted in duodenum and those without symptoms while symptomatic cases and impaction in upper esophagus were associated with higher success rate of removal.

Helicobacter pylori infection in children with portal hypertensive gastropathy.

BACKGROUND: Data about the association of Helicobacter pylori (H. pylori) and portal hypertensive gastropathy (PHG) are scarce in children. The present study aimed to fill the knowledge gap in this area. METHODS: The prevalence of H. pylori infection was studied in a group of infants and children with PHG using rapid urease test and histological demonstration of H. pylori in gastric mucosal biopsy obtained by upper gastrointestinal endoscopy. The results were compared to a control group who underwent endoscopy for other indications mainly hematemesis and/or dyspepsia. RESULTS: H. pylori was equally prevalent in both groups (~60%). Children with PHG were significantly stunted in height, had significantly lower hemoglobin, platelets and serum iron. Severe PHG was associated with higher grade of esophageal varices. Within the group with PHG, H. pylori infection was associated with lower hemoglobin, serum iron and serum ferritin. Moderate to severe PHG was more associated with H. pylori infection. CONCLUSIONS: H. pylori infection was not more commonly associated with PHG, however, it might contribute to the severity of PHG. The synergistic effect of PHG and H. pylori infection might contribute to the retarded growth and iron deficiency status noted in this group.

Does bloody aspirate reflect the state of upper gastrointestinal mucosa in a critically ill newborn?

BACKGROUND AND STUDY AIMS: Critically ill newborns have many risk factors to develop stress related mucosal lesions (SRML). We used upper endoscopy to evaluate the presence of SRML in these neonates, to know the specificity and sensitivity of the bloody gastric aspirate to detect SRML and to identify the risk factors associated with the presence of SRML and bloody gastric aspirate. PATIENTS AND METHODS: This is a cross-sectional study done on 100 critically ill newborn after becoming clinically stable. SRML were diagnosed if there is hyperaemia, erosions or ulcers in the oesophagus, stomach, and/or the duodenum. RESULTS: SRML were found in 77% of neonates in the NICU though frank bloody aspirate was detected in only 22% of neonates. The presence of bloody aspirate showed low sensitivity (24.68%) and high specificity (86.96%) for the presence of SRML. The presence of bloody gastric aspirate showed a double fold risk for the presence SRML (OR=2.184, CI=0.584-8.171). Factors associated with SRML included respiratory distress (p=0.000, risk=4.006), the use of nasogastric tube (p=0.017, OR=3.281) and the use of triple antibiotics (p=0.001, risk=1.432). Factors associated with the presence of bloody gastric aspirate included the use of nasogastric tube (OR=1.629, p=0.000) and the presence of haemostatic disorders (OR=3.143, p=0.039). It was also associated with lower haemoglobin levels (p=0.000). CONCLUSION: SRML represents an under-diagnosed problem in NICUs. Absence of bloody gastric aspirate does not exclude the presence of SRML.