High rate of clinical and endoscopic relapse after healing of erosive peptic esophagitis in children and adolescents.

OBJECTIVES: The aim of the present study was to estimate the rate of clinical and endoscopic relapse after initial treatment of erosive peptic esophagitis in children and adolescents. METHODS: A total of 24 patients (2.1-16.4 years old, mean ± standard deviation [SD] 9.9 ± 3.1; male:female 3) with healed endoscopic erosive esophagitis and without gastroesophageal reflux disease (GERD)-predisposing conditions were followed up for 4 to 32.9 months (mean 20.8 ± 10.6 years). Structured clinical evaluation was performed every other week during the initial treatment and maintenance, and every 3 months after that. Whenever a clinical relapse happened, a new endoscopic evaluation was performed. Severity and frequency were scored on 10-point and 6-point semiquantitative scales, respectively. RESULTS: At baseline, epigastric pain was the most reported symptom (70.8%), with intensity scored as >5 in 88.3% of patients, and median frequency of 3 (weekly; daily in 5, 20.8%). Clinical relapse was detected in 20 of 24 (83.3%) patients after a median period of 14.65 months (95% confidence interval [CI] 6.7-25.7 months). Endoscopic relapse was observed in 9 of 20 (45%) patients after a median of 25.7 months. The dose of lansoprazole needed to heal the esophagitis was not significantly associated with the risk for clinical relapse (hazard ratio [HR] 1.74, 0.94, 7.72, P = 0.06), whereas the body mass index (BMI) was directly associated with endoscopic relapse (HR 1.3, 1, 1.69, P = 0.05). CONCLUSIONS: Children with healed erosive esophagitis have up to 83% clinical relapse and of the 83%, 45% had endoscopic relapse. Correlation of endoscopic relapse with clinical symptom is poor. Higher grades of esophagitis and higher BMI are risk factors for endoscopic relapse.

High Helicobacter pylori resistance to metronidazole and clarithromycin in Brazilian children and adolescents.

OBJECTIVE: The aim of the present study was to assess the primary and secondary resistance of Helicobacter pylori strains to clarithromycin, amoxicillin, furazolidone, tetracycline, and metronidazole, the conventional antibiotics presently used in Brazilian children and adolescents. METHODS: Seventy-seven consecutive H pylori strains, 71 of 77 strains obtained from patients without previous eradication treatment for H pylori infection, and 6 strains from patients in whom previous eradication treatment had failed. RESULTS: Global rate of resistance was 49.3% (38/77): 40% of strains were resistant to metronidazole, 19.5% to clarithromycin, and 10.4% to amoxicillin. All of the tested H pylori strains were susceptible to furazolidone and tetracycline. Multiple resistance were detected in 18.2% (14/77 patients) of the strains: 6 of 14 (43%) simultaneously resistant to clarithromycin and metronidazole; 5 of 14 (36%) to amoxicillin and metronidazole; 2 of 14 (14%) to amoxicillin, clarithromycin, and metronidazole; and 1 of 14 (7%) to clarithromycin and amoxicillin. CONCLUSIONS: The high resistance rate to metronidazole and clarithromycin observed in clinical H pylori isolates can exclude these antimicrobials in empirical eradication treatment in Brazil. Otherwise, furazolidone and tetracycline presented no resistance. Properly assessing the risks and benefits, these 2 antimicrobials and their derivatives could be used in empirical eradication schedules, both associated with amoxicillin, which showed a low resistance rate despite its wide use in pediatric patients.

Diagnosis of Helicobacter pylori infection by means of reduced-dose ¹³C-urea breath test and early sampling of exhaled breath.

OBJECTIVE: The aim of this study was to evaluate the accuracy of reduced-dose ¹³C-urea breath test (¹³C-UBT) and early sampling of exhaled breath for the detection of Helicobacter pylori infection in children and adolescents. METHODS: Patients up to 20 years old that underwent upper gastrointestinal endoscopy with gastric biopsies were included. The ¹³C-UBT was performed after a 4-hour fasting period with 4 points of collection: baseline (T0), and at 10, 20, and 30 minutes (T10, T20, and T30) after ingestion of 25 mg ¹³C-urea diluted in 100 mL of apple juice. The infection status was defined through 3 invasive methods, and a patient was considered infected with a positive culture or concomitant positive histology and rapid urease test. The absence of infection was defined by all negative histology, rapid urease test, and culture. Analysis of exhaled breath samples was performed with an isotope-selective infrared spectrometer. A receiver-operating characteristic curve analysis was done to define cutoff delta over baseline (DOB) values. RESULTS: A total of 129 patients between the ages of 2.1 and 19 years (median 11.6 years; mean age ± standard deviation 11.5 ± 3.8 years; F:M 85:44) were included. The prevalence of infection was 41.1%. The sensitivity (S) and specificity (Sp) were at T10 (cutoff DOB 2.55‰), S 94.7% (95% confidence interval [CI] 90.9-98.5) and Sp 96.8% (95% CI 93.4-100); at T20 (DOB 2.5‰), S 96.2% (95% CI 92.9-99.5) and Sp 96.1% (95% CI 93.7-99.8); and at T30 (DOB 1.6‰), S 96.2% (95% CI 92.9-99.5) and Sp 94.7% (95% CI 90.8-98.6). CONCLUSIONS: Low-dose ¹³C-UBT with early sampling is accurate for diagnosing H pylori infection in children and adolescents.

Evaluation of invasive methods to diagnosis Helicobacter pylori infection in children and adolescents with dyspepsia invasive methods to diagnose Hp infection

Apesar do uso rotineiro de biópsias endoscópicas para o diagnóstico da infecçäo por Helicobacter pylori, em nosso meio, há poucos estudos pediátricos, avaliando a acurácia dos métodos invasivos. Métodos: Foram avaliados prospectivamente 120 pacientes submetidos à endoscopia para investigaçäo de sintomas dispépticos. Foram obtidos seis biópsias de regiäo antral para detecçäo do Helicobacter pylori através do teste rápido da urease, histologia e cultura. Os pacientes foram considerados infectados, se a cultura ou a histologia e o teste rápido da urease resultaram positivos. Resultados: A idade variou de 3m a 17anos (média: 10a1m); 54 por cento do sexo feminino e 46 por cento masculino; 44 por cento (53/120) estavam infectados. O exame endoscópico foi normal em 54 por cento (65/120) e anormal em 46 por cento (55/120). O diagnóstico foi gastrite - 69 por cento (38/55), esofagite - 13 por cento (13/55), úlcera duodenal - 13 por cento (7/55) e duodenite - 5 por cento (3/55). Os 3 métodos concordaram em 72,5 por cento (87/120), foram todos negativos em 48 por cento (58/120) e todos positivos em 24,5 por cento (29/120). A melhor concordância ocorreu entre a histologia e o teste rápido da urease (91,7 por cento), seguido pela cultura e histologia (78,3 por cento) e, finalmente, a cultura e o teste rápido da urease (75 por cento). A sensibilidade do teste rápido da urease foi 100 por cento, seguido pela histologia (98,1 por cento) e pela cultura (56,6 por cento). A especificidade da histologia foi de 97 por cento, seguida pelo teste rápido da urease (89,5 por cento). Conclusäo: A associaçäo histologia e o teste rápido da urease mostraram maior acurácia na detecçäo da infecçäo por Helicobacter pylori devido a sua alta sensibilidade (teste rápido da urease) e alta especificidade (histologia), além do baixo custo e praticidade. A cultura isolada näo deve ser utilizada como padräo-ouro devido à baixa sensibilidade