Helicobacter pylori Infection in Children with Concurrent Celiac Disease and Type 1 Diabetes Mellitus.

OBJECTIVES: Data regarding Helicobacter pylori (Hp) infection frequency in concurrent celiac disease (CD) and type 1 diabetes mellitus (T1DM) (CD + T1DM) are anecdotal. This study aimed to evaluate the association between Hp and concomitant CD + T1DM in children. METHODS: In this 2-center, case-control study, children who underwent esophago-gastro-duodenoscopy (EGD) were studied. CD diagnosis was established by favorable histology and serology. Hp infection was confirmed by both histology and the rapid urease test. Patients were divided into 3 groups as CD only (CDo), CD + T1DM, and non-CD children who underwent endoscopy as controls. RESULTS: Among the 1,431 EGDs performed, 783 cases were eligible. Overall, 215 cases had CDo (mean age: 9.12 ± 4.18 years, 58.1% girls), 63 cases had CD + T1DM (mean age: 9.29 ± 4.46 years, 50.8% girls), and 505 cases were controls (mean age: 9.69 ± 4.52 years, 56.6% girls). Hp infection rate was significantly lower in CD + T1DM group (controls: 49.7% vs. CDo: 32.1% vs. CD + T1DM: 20.6%, p < 0.01). After adjustment for age, gender, and socioeconomic status, the Hp infection rate was still significantly low (adjusted odds ratio [aOR]: 1.57, 95% confidence interval (CI): 1.35-1.83, p < 0.01). A difference in Hp infection rate between controls and CDo group (aOR: 1.43, 95% CI: 1.09-2.12, p < 0.05), and between CDo and CD + T1DM (aOR: 0.89, 95% CI: 0.65-1.54, p < 0.05) group was significant. The severity of duodenal lesions and the presence of Hp infection were not correlated in all celiac children (r: 0.113, p > 0.05). CONCLUSION: The frequency of Hp infection was significantly lower in CD + T1DM children, compared to the CDo group and the controls.

The frequency of and factors affecting functional gastrointestinal disorders in infants that presented to tertiary care hospitals.

This study aimed to determine the prevalence of infantile functional gastrointestinal disorders (FGIDs) based on Rome IV diagnostic criteria, and to determine the associated patient demographic and nutritional characteristics. A total of 2383 infants aged 1-12 months which were evaluated by 28 general pediatricians and pediatric gastroenterologists on the same day at nine tertiary care hospitals around Istanbul, Turkey, between November 2017 and March 2018, were included in the study. Patients included consulted the pediatric outpatient clinics because of any complaints, but not for vaccines and/or routine well child follow-ups as this is not part of the activities in the tertiary care hospitals. The patients were diagnosed with FGIDs based on Rome IV diagnostic criteria. The patients were divided into a FGID group and non-FGID group, and anthropometric measurements, physical examination findings, nutritional status, risk factors, and symptoms related to FGIDs were evaluated using questionnaires. Among the 2383 infants included, 837 (35.1%) had ≥1 FGIDs, of which 260 (31%) had already presented to hospital with symptoms of FGIDs and 577 (69%) presented to hospital with other symptoms, but were diagnosed with FGIDs by a pediatrician. Infant colic (19.2%), infant regurgitation (13.4%), and infant dyschezia (9.8%) were the most common FGIDs. One FGID was present in 76%, and ≥2 FGIDs were diagnosed in 24%. The frequency of early supplementary feeding was higher in the infants in the FGID group aged ≤6 months than in the non-FGID group (P = 0.039).Conclusion: FGIDs occur quite common in infants. Since early diversification was associated with the presence of FGIDs, nutritional guidance and intervention should be part of the first-line treatment. Only 31% of the infants diagnosed with a FGID were presented because of symptoms indicating a FGID. What is Known: • The functional gastrointestinal disorders (FGIDs) are a very common disorder and affect almost half of all infants. • In infants, the frequency of FGIDs increases with mistakes made in feeding. When FGIDs are diagnosed in infants, nutritional support should be the first-line treatment. What is New: • This study shows that only a third of children presented to hospital because of the symptoms of FGIDs, but pediatricians were able to make the diagnosis in suspected infants after appropriate evaluation. • The early starting of complementary feeding (<6 months) is a risk factor for the development of FGIDs.

Helicobacter pylori infection in children with celiac disease: Multi-center, cross-sectional study.

BACKGROUND: An inverse association has been suggested between celiac disease (CD) and Helicobacter pylori (Hp) infection in children; however, there are inconsistent data. The purpose of this multi-center study is to evaluate the association between Hp and CD in childhood. METHODS: Children who underwent endoscopy between July 2016 and November 2017 in four pediatric gastroenterology centers were included in the study. Patients with a history of previous Hp eradication, antibiotic or acid-suppressive drug therapy in the last 4 weeks, and any underlying chronic disease were excluded. The presence of Hp infection was confirmed by both histopathology and the rapid urease test. The ones who had the diagnosis of CD were compared with the children who underwent endoscopy during the same period and had another diagnosis. Duodenal histopathology of children with CD was categorized according to the modified Marsh classification. RESULTS: Of 3056 endoscopies performed in the study period, 2484 cases were eligible for the study. A total of 482 CD patients (mean age: 9.71 ± 4.63 years, 58.5% girls) and 2060 controls (mean age: 9.92 ± 4.66 years, 54.6% girls) were included in the study. The rate of Hp infection was significantly lower in CD group (26.3% vs 50.1%, P < .01). The difference was prominent even in children younger than 6 years old (P < .01). There was no correlation between Hp infection and the modified Marsh scores in CD (P > .05). CONCLUSION: In this cross-sectional study, where Hp infection is common even in the pediatric population, the frequency of Hp infection was significantly lower in children with CD compared with the controls. Systematic cohort studies are necessary to clarify causal association between Hp infection and the development of celiac disease.

Bowel Preparation for Colonoscopy in Children: 1 Day PEG-3350 with Bisacodyl versus 3 Day Sennosides.

BACKGROUND AND OBJECTIVES: Bowel preparation (BP) for colonoscopy is a challenging procedure in children and different regimens have been used for this purpose. Polyethylene glycol (PEG) is the most preferred agent in recent years. The primary aim of this study was to evaluate the efficacy of 1-day PEG-3350 with bisacodyl (PEG-B) and comparing it with 3-day sennosides A+B. METHOD: In this prospective, randomized, and single-blinded study, children aged 2-18 years were included in the PEG-B group for 1 day or in Senna group for 3 days. The effectiveness of BP was assessed according to the Ottawa and Boston BP scales, compliance and adverse effects were also recorded. Pre- and post-preparation biochemistry were obtained for investigation of safety of both regimens. RESULTS: Successful BP was observed in 88.3% (n = 53/60) of PEG-B and 86% (n = 55/64) of Senna groups according to Boston scale, and it was 85% (n = 51/60) and 84.4% (n = 54/64), respectively, according to Ottawa scale. The cecal intubation rate was 96.7% (n = 58/60) in the PEG-B group and 93.8% (n = 60/64) in the Senna group. Ease of administration and disturbance in regular daily activities was better in the PEG-B group (p < 0.05). There was no major adverse event and biochemical abnormality in both groups. The correlation between Ottawa and Boston scales was found to be excellent (r2 = -0.954, p < 0.01). CONCLUSIONS: The efficacy, safety, and adverse effect profile of 1-day BP with PEG-B regimen was found to be similar to 3-day sennosides regimen, however, the PEG-B regimen had advantages such as short duration, ease of administration, and better patient comfort. Also, high correlation rate between the Boston and Ottawa scales in pediatric patients was remarkable.

Anxiety and Salivary Cortisol Levels in Children Undergoing Esophago-Gastro-Duodenoscopy Under Sedation.

OBJECTIVES: Esophagogastroduodenoscopy (EGD) can cause fear and anxiety in children. Cortisol, which is the most important glucocorticoid hormone in humans, can increase under physiological stress. The purpose of this study was to measure the salivary cortisol level (SCL) and anxiety level in patients undergoing EGD and evaluate their effects on the procedure. METHODS: Children undergoing EGD under sedoanalgesia with propofol for various reasons were included. Their basal SCLs were compared with those of healthy age- and sex-matched controls. Moreover, SCL of the patient group at 30 minutes before EGD and 2 hours after the procedure were measured. Their anxiety scores were calculated using the modified Yale Preoperative Anxiety Scale before EGD. Duration of endoscopy, sedation, and recovery and total propofol doses were recorded. RESULTS: Demographic properties of the patient group (n = 119; 10.9 ±â€Š3.2 years; 43.7% boys) and control group (n = 85; 11.8 ±â€Š2.8 years; 45.1% boys) were not significantly different. Basal SCLs of both groups were similar (16.9 ±â€Š0.7 vs 19.7 ±â€Š1.8 ng/mL, P = 0.16). SCL before EGD in the patient group was significantly higher than basal and post-EGD values (P < 0.001 for each). Pre-EGD SCL was positively correlated with anxiety level, propofol dose, and duration of sedation, procedure, and recovery. Anxiety levels of patients were positively correlated with propofol dose and duration of sedation and recovery, and negatively correlated with age. CONCLUSIONS: Childhood EGD is a significant stress factor, which was reflected by the pre-procedural SCL in this study. Increased anxiety resulted in increased propofol doses and sedoanalgesia-related procedural durations, which may cause potential complications.

Long-Term Follow-Up and Outcome of Pediatric Acute Pancreatitis: A Multicenter Study.

OBJECTIVE: Over the past decades, the incidence of acute pancreatitis is increasing, but the progression of acute recurrent pancreatitis and chronic pancreatitis is still not well documented in children. The aim of this multicenter study is to delineate the changes that occur in a certain time period in the course of childhood pancreatitis. MATERIALS AND METHODS: The data of consecutive patients hospitalized with acute pancreatitis between 2010 and 2017 in 4 different pediatric gastroenterology units were reviewed. The clini- cal characteristics of the disease were defined. RESULTS: A total of 165 patients (55.2% female) were included. Over the years, the rate of acute pancreatitis admissions increased while the duration of hospitalization decreased (P < .05). Nearly two-thirds of the patients with acute pancreatitis resolved spontaneously, 30.9% and 4.3% of the cases developed acute recurrent pancreatitis and chronic pancreatitis, respectively. Furthermore, 27.4% patients with acute recurrent pancreatitis progressed to chronic pancre- atitis, and eventually, 12.7% of cases developed chronic pancreatitis within 3-4 years. Local complications developed in 13.3% of the patients with pancreatitis in this cohort. CONCLUSION: The result of this study confirmed the increased incidence of acute pancreatitis in recent years. Conversely, the length of hospital stay decreased over the years. Patients with pancreaticobiliary abnormalities or genetic risk factors had a higher rate of progression to acute recurrent pancreatitis or chronic pancreatitis. Therefore, genetic testing and radiological imaging should be considered early in the follow-up of patients with acute pancreatitis having risk factors for progression to acute recurrent pancreatitis/chronic pancreatitis.

Advancing dentistry: fractal assessment of bone health in pediatric patients with celiac disease using dental images.

OBJECTIVES: To assess the effects of a gluten-free diet on bone structure in children with celiac disease using fractal analysis on panoramic radiographs. METHOD AND MATERIALS: A total of 49 patients with celiac disease aged 6 to 13 years, separated into two groups as previously and newly diagnosed, and a control group of 32 healthy individuals were evaluated. In previously and newly diagnosed patients with celiac disease, body mass index Z-scores were calculated, calcium, alkaline phosphatase, vitamin D3, and parathormone levels were measured, and bone mineral density Z-scores were obtained from dual energy x-ray absorptiometry. In all patients, the fractal dimensions of the right and left temporomandibular condyles were evaluated with the fractal analysis method on panoramic radiographs. RESULTS: The mean values of serum biomarker levels and the body mass index and bone mineral density Z-scores for both celiac groups were within the normal reference range. No statistically significant difference was determined between right and left condyle fractal dimensions values in the three groups examined. In terms of both right and left condyle fractal dimensions values, there was a statistically significant difference between groups. The highest fractal dimensions values were determined in the previously diagnosed group. CONCLUSIONS: Differences in fractal dimensions values were observed among patients with celiac disease following the gluten-free diet. Utilizing fractal analysis on panoramic radiographs can prove valuable for dental practitioners in evaluating bone mineral density due to its cost-effectiveness, easy accessibility, and reduced radiation exposure for patients, enabling them to provide comprehensive oral health care and potential early interventions for patients with celiac disease.

The frequency of Duchenne muscular dystrophy/Becker muscular dystrophy and Pompe disease in children with isolated transaminase elevation: results from the observational VICTORIA study.

Introduction: Elevated transaminases and/or creatine phosphokinase can indicate underlying muscle disease. Therefore, this study aims to determine the frequency of Duchenne muscular dystrophy/Becker muscular dystrophy (DMD/BMD) in male children and Pompe disease (PD) in male and female children with isolated hypertransaminasemia. Methods: This multi-center, prospective study enrolled patients aged 3-216 months with serum alanine transaminase (ALT) and/or aspartate transaminase (AST) levels >2× the upper limit of normal (ULN) for ≥3 months. Patients with a known history of liver or muscle disease or physical examination findings suggestive of liver disease were excluded. Patients were screened for creatinine phosphokinase (CPK) levels, and molecular genetic tests for DMD/BMD in male patients and enzyme analysis for PD in male and female patients with elevated CPK levels were performed. Genetic analyses confirmed PD. Demographic, clinical, and laboratory characteristics of the patients were analyzed. Results: Overall, 589 patients [66.8% male, mean age of 63.4 months (standard deviation: 60.5)] were included. In total, 251 patients (188 male and 63 female) had CPK levels above the ULN. Of the patients assessed, 47% (85/182) of male patients were diagnosed with DMD/BMD and 1% (3/228) of male and female patients were diagnosed with PD. The median ALT, AST, and CPK levels were statistically significantly higher, and the questioned neurological symptoms and previously unnoticed examination findings were more common in DMD/BMD patients than those without DMD/BMD or PD (p < 0.001). Discussion: Questioning neurological symptoms, conducting a complete physical examination, and testing for CPK levels in patients with isolated hypertransaminasemia will prevent costly and time-consuming investigations for liver diseases and will lead to the diagnosis of occult neuromuscular diseases. Trial Registration: Clinicaltrials.gov NCT04120168.

Knowledge regarding celiac disease among healthcare professionals, patients and their caregivers in Turkey.

BACKGROUND: Celiac disease (CD) is one of the most prevalent chronic disorders. The clinical manifestations of CD are diverse and may present with gastrointestinal findings, extra-intestinal findings or no symptoms. Although there has been a marked increase in the prevalence of CD in the past 30 years, up to 95% of patients with CD remain undiagnosed. As most cases have atypical signs or no symptoms, the diagnosis of CD is either missed or delayed. In addition, one of the most important reasons for the delay in diagnosis may be the poor knowledge of healthcare professionals (HCPs) regarding CD. AIM: To evaluate the knowledge of HCPs, patients and their caregivers (parents) regarding CD. METHODS: The current study was carried out between June 2021 and February 2022 prospectively, as part of the Focus IN CD project. Patients with CD and their caregivers participated in the study from 6 different cities in Turkey. General practitioners, pediatricians, pediatricians with other subspecialities and pediatric gastroenterologists from different cities participated in the study. RESULTS: The questionnaire was completed by 348 HCPs, 34 patients with CD, and 102 mothers and 34 fathers of patients with CD. Most of the participants were general practitioners (37.07%). There were 89 (25.57%) pediatricians and 72 (20.69%) pediatric gastroenterologists in the study. The highest score in all categories was achieved by pediatric gastroenterologists. There were significant differences between the four groups of HCPs in terms of the subsections of overall mean score, epidemiology and clinical presentation, treatment and follow-up. No significant difference was found between the groups (patients with CD, mothers of patients with CD and fathers of patients with CD) in terms of the questionnaire subsections. CONCLUSION: The level of knowledge on CD among HCPs, patients and their caregivers was unsatisfactory. We consider that it is necessary to increase awareness and to develop e-learning activities on CD among HCPs, patients and their caregivers. Consequently, they may benefit from e-learning programs similar to the one created as part of the EU-funded project Focus IN CD (https://www.celiacfacts.eu/focusincd-en).

Cytomegalovirus Colitis in Immunocompetent and Immunocompromised Children: A 2-Center Study.

BACKGROUND: Data about cytomegalovirus (CMV) colitis in children are scarce. We aimed to describe the characteristics of childhood CMV colitis in terms of risk factors, clinical symptoms, diagnosis, therapeutic approaches, and outcomes. METHODS: Inflammatory bowel disease (IBD) and non-IBD patients with CMV colitis diagnosed by histology and tissue CMV PCR at 2 tertiary centers between January 2017 and November 2019 were studied. Clinical and laboratory data were retrieved from medical records. Underlying conditions, immune status, response to therapy and outcomes were described and followed up to 6 months after diagnosis. RESULTS: A total of 16 children (8 non-IBD, 7 ulcerative colitis and 1 Crohn's disease) with CMV colitis were included. All patients had persistent diarrhea (bloody in 13 cases). There was a significant age difference between IBD and non-IBD children (P < 0.05). The final diagnosis in 1 patient was immunodeficiency with a mutation in JAK1 gene. Three children were categorized as apparently immunocompromised and 4 children as apparently immunocompetent. Ulcer was not visible in 2 children from the non-IBD group. The mean fecal calprotectin level of IBD children was significantly higher than that of non-IBD children (376.12 ± 231.21 µg/g vs. 160.96 ± 69.94 µg/g, P < 0.05). After follow-up, 1 patient died because of another reason. Ganciclovir was used in 14 of 16 children for 3 weeks and the treatment was continued with valganciclovir in selected 6 children. CONCLUSIONS: CMV colitis is a rare but overlooked cause of prolonged diarrhea in immunocompetent and immunocompromised children. CMV colitis might present without any ulcer formation at colonoscopy in infants.

The effect of celiac disease and gluten-free diet on pubertal development: a two-center study.

Objectives We aimed to assess whether age at menarche and pubertal development (Tanner stage) are related to gluten-free diet (GFD) adherence, hormonal status, micro-nutrient levels and body mass index (BMI) in children with celiac disease (CD). Methods In this two-center, cross-sectional study, CD patients and healthy individuals were studied. CD patients were re-evaluated after 1 year of follow-up. Height, weight, Tanner stage, age at menarche and diet compliance were recorded. Blood samples for anti-tissue transglutaminase IgA (TTG), pituitary gonadotropins, gonadal hormones, prolactin and micronutrients (folate, vitamin B12, vitamin D, ferritin, iron and, iron-binding capacity [IBC]) were assayed. Results Consecutive age- and sex-matched 228 celiac patients (12.92 ± 2.35 years; 67.9% female) and 135 non-celiac healthy individuals (12.77 ± 2.25 years; 65.2% female) were studied. Tanner stage was significantly higher in the control group for both girls and boys (p < 0.05). The mean age at menarche was significantly lower in healthy individuals (13.13 ± 1.01 vs. 12.15 ± 0.97, p < 0.001). By multivariate analysis, GFD adherence, transferrin saturation (sTrf), total IBC (TIBC) and vitamin D status were found to be positively correlated with Tanner stage (p < 0.05). After 1 year, 192 of the CD patients were re-evaluated. GFD compliance was better (TTG levels: 135.59 ± 73.88 vs. 71.53 ± 69.40, p < 0.001) and it was correlated with Tanner stage (r = 0.49, p < 0.01), sTrf (r = 0.66, p < 0.01) and IBC (r = 0.23, p < 0.05). Conclusions Our data show that adequate weight gain, adherence to GFD, sufficient iron and vitamin D status are essential factors for salubrious puberty in CD patients.

Preparatory information reduces gastroscopy-related stress in children as confirmed by salivary cortisol.

BACKGROUND/AIMS: This study aimed to determine whether the anxiety levels of pediatric patients who undergo endoscopy are reduced after receiving preparatory information about the endoscopic procedure by monitoring their salivary cortisol (s-cortisol) levels. PATIENTS AND METHODS: A total of 184 children undergoing gastroscopy under sedoanalgesia were included in the study. All the patients received a brief explanation of the endoscopic procedure. Patients were divided into two groups; Group Unexplained did not receive any further information other than a brief explanation of the procedure, Group Explained received more detailed explanation of the procedure. To determine anxiety levels, saliva specimens were taken on the day before the procedure to examine cortisol levels before and after endoscopy. Anxiety scores before endoscopy were calculated by the modified Yale Preoperative Anxiety Scale. Patients were monitored throughout sedoanalgesia, including during the endoscopy, sedation and recovery, and total propofol dosages were recorded. RESULTS: Eighty-nine children undergoing gastroscopy (age 11.55 ± 2.52 years; 50.5% girls) constituted Group Explained and 95 children undergoing gastroscopy (age 11.44 ± 2.66 years; 56.8% male) constituted Group Unexplained. The anxiety score, duration of sedation, endoscopy and recovery, propofol dose, pre- and post-endoscopy s-cortisol levels were significantly reduced in Group Explained. CONCLUSIONS: We demonstrated that when endoscopic procedure is explained broadly to a child, the procedural stress is significantly less, as measured by the s-cortisol levels and the anxiety questionnaire. It is important for the attending physician to explain all aspects of examination carefully.

What is the diagnostic utility of endoscopic scoring systems in children?

BACKGROUND/AIMS: The aim of this study was to evaluate the consistency of the Savary-Miller, the Hetzel-Dent and the Los Angeles endoscopic classification systems and to compare them with the esophageal histopathology in children. MATERIAL AND METHODS: Children between the ages of 5-17 years who underwent esophagogastroduodenoscopy were included in the study. The endoscopic reports and the still images of the esophagus were reclassified by the same gastroenterologist according to the Savary-Miller, Hetzel- Dent and Los Angeles scoring systems. The esophageal biopsies were also reevaluated by the same pathologist and the consistency between endoscopic and histopathologic esophagitis was evaluated. RESULTS: A total of 113 out of 192 pediatric patients were included in the study. Seventy-three patients (64.6%) had esophagitis according to the Hetzel-Dent classification, whereas only 20 (17.7%) patients were defined as having esophagitis according to the other two classification systems. The consistency between the Savary-Miller and Los Angeles classifications was excellent (κ: 0.92) but the agreement between the Hetzel-Dent and Savary-Miller and between the Hetzel-Dent and Los Angeles classifications were poor. A total of 82 patients (72.6%) had histopathological esophagitis, and there was a weak consistency between all 3 endoscopic scoring systems and the histopathology. CONCLUSIONS: Since pediatric patients have milder esophagitis than in adults, the use of endoscopic scoring systems developed for adults seems to be inapplicable for children. The inclusion of minimal endoscopic changes in endoscopic scoring systems by using more sensitive and novel endoscopic techniques would increase the sensitivity of these scoring systems in children.