Reversible Atrioventricular Block after Electrical Injury / 대한내과학회지

Here, we report a case of electrical injury-induced reversible advanced second-degree atrioventricular (AV) block. A 28-year-old male visited the emergency department for palpitations 3 days after receiving an electrical injury from 220 volt alternating current. The initial electrocardiogram (ECG) showed sinus rhythm and first-degree AV block with a prolonged PR interval of 400 ms. There was no structural heart disease or electrolyte imbalance. Follow up ECGs acquired 4-6 days after the electrical injury showed intermittent AV block with a prolonged PR interval of 400-460 ms. Exercise treadmill and atropine provocation tests performed 6 days after electrical injury induced advanced second-degree AV block. His bundle electrogram showed intermittent AH block in a Wenckebach pattern with a prolonged AH interval of 220-360 ms and a normal HV interval. Episodes of AV block decreased remarkably 4 weeks after the electrical injury, and the prolonged PR interval returned to 220 ms after 5 months.

The Significance of Gastric Juice Analysis for a Positive Challenge by a Standard Oral Challenge Test in Typical Cow's Milk Protein-Induced Enterocolitis

This study was performed to investigate the significance of gastric juice analysis (GJA) as a diagnostic criterion of a positive challenge in a standard oral cow's milk challenge (OCC) to confirm typical cow's milk protein-induced enterocolitis (CMPIE). Data from 16 CMPIE patients (aged 14 to 44 days) were analyzed. A standard OCC was openly executed using 0.15 g/kg of protein. Three symptoms (vomiting, lethargy, and bloody or pus-like stool), and four laboratory findings (GJA [3 hr], changes in peripheral blood absolute neutrophil count [ANC] [6 hr], C-reactive protein [6 hr], and stool smear test for occult blood or leukocytes) were observed after OCC. Before OCC, baseline studies were conducted; a stool smear test, blood sampling, and GJA. Positive OCC results were; vomiting (87.5%) (observed 1-3 hr after OCC), lethargy (62.5%) (1-3 hr), bloody or pus-like stool (43.8%) (6-10 hr), abnormal GJA (93.8%), an ANC rise >3,500 cells/microliter (93.8%), and an abnormal stool smear test (75.0%). A single GJA test after a standard OCC is a sensitive diagnostic criterion of a positive challenge, and may provide an early confirmatory diagnosis of CMPIE. An investigation of positive OCC outcomes helps to find out a diagnostic algorithm of criteria of a positive challenge in CMPIE.

A Case of Belsey Mark IV Fundoplication after Failed Nissen Antireflux Surgery / 대한소아소화기영양학회지

Antireflux surgery has been indicated in gastroesophageal reflux disease (GERD) that does not respond to medical treatments. Although the most commonly performed operation is Nissen fundoplication, Belsey Mark IV fundoplication is indicated for more complicated cases, such as, in cases of a failed Nissen operation or a long lasting hiatal hernia. Here, we report a case of Belsey Mark IV fundoplication for a failed Nissen fundoplication. The infant developed frequent times of aspiration pneumonia after initial Nissen for a hiatal hernia with GERD during the newborn period. At 15 months of age, a 2nd Nissen operation was attempted, but fundoplication was not available because of excessive mesenteric adherence to the liver and cardia. Therefore, Belsey Mark IV fundoplication was performed via trans-thoracic approach, which can provide full esophageal mobilization and better visualization of the herniated fundus and the surrounding tissues. Subsequently, she has shown an improved general condition without GERD.

A Case of Isolated Rice Allergy / 대한소아소화기영양학회지

Rice allergen has low antigenicity, and thus, anaphylactoid reactions to rice are exceedingly rare. We experienced a case of isolated rice allergy in a 5 month-old girl who had been fed a milk formula without incident. However, after feeding a powdered weaning milk formula containing rice, she developed symptoms of projectile vomiting and diarrhea, at this time rice specific antigen tests were all negative. One month later a challenge test was performed using a rice gruel, and her symptoms recurred. Endoscopic and microscopic findings showed hyperemic mucosa in the duodenum and subtotal villous atrophy. Thereafter, she showed no adverse reaction to almost all foods appropriate for her age, but after feeding rice gruel at 10 months, she developed symptoms of cyanosis and vomiting. However, none of the allergic symptoms were demonstrated at 13 months upon repeated challenge test. Currently, she is 28 months old and tolerates all foods including rice.

A Suggested New Clinical Classification for Pediatric Intussusception / 대한소아소화기영양학회지

PURPOSE: We proposed a new classification of pediatric intussusception based on clinical and radiologic findings. METHODS: Data from 88 consecutive patients with intussusception were reviewed. We retrospectively analyzed six factors; patient age, sites of intussusception, symptoms, therapeutic methods, existence of enlarged mesenteric lymph nodes, and ultrasonographic (US) findings from clinical records. RESULTS: 1) There was one neonatal case (1.1%), the others (98.9%) were infants and children. 2) These 87 infant and child cases consisted of 14 cases (16.1%) of small bowel intussusception (SBI) and 73 cases (83.9%) of ileo-colic intussusception (ICI). Of the 14 SBI cases, 12 cases were symptomatic and 2 cases were asymptomatic. The symptomatic group comprised 8 transient cases (66.7%), 3 operative cases (25.0%), and 1 enema-reduction case (8.3%). Two asymptomatic cases were incidentally captured by computed tomography. Of the 73 ICI cases, 19 cases (26.0%) required operation, and 54 (74.0%) enema-reduction. 3) When transient SBI cases were compared with operated SBI cases, enema-reduced and operated ICI cases, the age (38.0+/-22.9 months) of transient SBI cases were significantly higher than those of the others (p=0.003). Mean mass size (20.8+/-2.7 mm) in transient SBI was significantly smaller than in the others (p=0.0001). 4) No correlation was found between the existence of enlarged mesenteric lymph nodes and therapeutic method or concomitant illness. 5) Most of the target types observed by US were in transient SBI cases, the remainder were in the enema-reduced ICI cases. In terms of the doughnuts type, all 8 cases (34.8%) with an external hypoechoic rim thickness of >8.9 mm were treated surgically. CONCLUSION: Pediatric intussusception may be classified based on clinical and radiologic findings, which are likely to indicate appropriate therapies.

Dumping Syndrome in a Child with Gastrojejunal Tube Feeding / 대한소아소화기영양학회지

Dumping syndrome is a known complication of gastric surgery in adults, but a very rare disease in the pediatric population. We report on a case of dumping syndrome in a 19-month-old child, who underwent gastrojejunal feeding tube insertion for the treatment and prevention of gastroesophageal reflux and frequent aspiration pneumonia. At 17 months of age, 2 months after the beginning of gastrojejunal tube feeding, postprandial diaphoresis, palpitation, lethargy, bloating, and diarrhea occurred, and a single episode of convulsion with hypoglycemia were noted. Early and late dumping syndrome was confirmed by an abnormal oral glucose tolerance test with early onset hyperglycemia followed by delayed onset hypoglycemia. Diet therapy including uncooked corn starch then improved the postprandial diaphoresis, abnormal glucose levels, and her nutritional status. We conclude that dumping syndrome may be considered as a complication of gastrojejunal tube feeding in a child.

Risk Factors for the Early Recognition of Cow's Milk Protein-induced Enterocolitis / 소아과

PURPOSE: Cow's milk protein-induced enterocolitis (CMPIE) is a symptom complex of vomiting and/ or diarrhea caused by delayed hypersensitivity and may result in serious complications. This study was undertaken to identify high risk factors to facilitate the early recognition of CMPIE. METHODS: We reviewed the data of 101 patients, aged 15 to 45 days, admitted due to vomiting and/ or diarrhea between 2003 and 2004. After excluding 13 patients absolutely breast-fed and 2 patients transferred from other hospitals with the impression of CMPIE, the 86 study subjects were divided into three groups based on the underlying etiologies; CMPIE, infectious and non-infectious group. RESULTS: CMPIE was diagnosed in 11 patients (12.8%). On admission, failure to gain weight (P= 0.003), hypoalbuminemia (P=0.003), peripheral leukocytosis (P=0.015), and metabolic acidosis (P=0.014) were more significant in the CMPIE group than in the others. Multiple logistic regression analysis showed that the independent predictors of high risks for CMPIE were failure to gain weight < 10 g/day (OR, 10.25[95% CI, 1.62-65.06]) and serum hypoalbuminemia < 3.5 g/dL (OR, 9.18[95% CI, 1.69- 49.74]). Cow's milk challenges were performed in the 11 CMPIE patients; vomiting (81.8%), abnormal stool test (80.0%), peripheral leukocyte count and absolute neutrophil count (ANC) increase (100.0%) (P< 0.05), and enteropathy (100.0%). CONCLUSION: CMPIE is not a rare clinical disease in early infancy. The high risk factors of CMPIE were identified as follow: failure to gain weight below 10 g/day, hypoalbuminemia on admission and a rapid decrease during admission. Cow's milk challenge test with endoscopic duodenal biopsy was helpful to confirm CMPIE.

A Case of Neonatal Cholestasis Associated with Congenital Adrenal Hyperplasia / 대한소아소화기영양학회지

It has been suggested that cortisol deficiency may be responsible for the cholestasis. Although congenital hypopituitarism was reported as a possible cause of neonatal cholestasis, congenital adrenal hyperplasia with neonatal cholestasis is a very rare report in the literature. We experienced a case presenting with neonatal cholestasis associated with congenital adrenal hyperplasia. This case provides a clinical evidence supporting the notion that cortisol has an important physiological role in bile acid synthesis and transport.

Topical Tacrolimus Resulting in a Marked Resolution of Perianal Crohn's Disease / 대한소아소화기영양학회지

Crohn's disease of the perineum is notably resistant to treatment. We describe our experiences of tacrolimus ointment application in three patients with intractable perianal Crohn's disease. At the time of diagnosis patients showed anal fissure with ulcer, anal fistula, or perianal abscess, respectively. These lesions did not respond to steroid, metronidazole, mesalazine, or azathioprine, though the pediatric Crohn's disease activity index was markedly improved during the treatment period (4 to 12 months). Topical tacrolimus was applied and resulted in marked healing and a rapid granulation of cavity edges within 6 weeks to 3 months. Topical tacrolimus at a low dose shows a promise for the management of childhood perianal Crohn's disease. Further controlled studies are required to assess the efficacy and safety of this treatment.

Clinical Features and the Natural History of Dietary Protein Induced Proctocolitis: a Study on the Elimination of Offending Foods from the Maternal Diet / 대한소아소화기영양학회지

PURPOSE: The aim of this study was to identify the clinical features and natural history of dietary protein induced proctocolitis (DPIPC) and to detect the causative foods of DPIPC, and to evaluate the effect of elimination of the foods on the course of the disease. METHODS: Between March 2003 and July 2004, data from 30 consecutive patients with DPIPC who were followed for over 6 months, was reviewed. The diagnostic criterion used for DPIPC was an increase in the number of eosinophils in the lamina propria (> or =60 per 10 high-power fields). In breast feeding mothers, 5 highly allergenic foods were eliminated from the maternal diet for 7 days, namely, allergenic food groups such as dairy products, eggs, nuts and soybean, fish and shellfish, and wheat and buckwheat. We observed the disappearance or appearance of hematochezia after elimination or challenge with the offending foods. RESULTS: Before diagnosis infants were breast-fed (93.3%) or formula-fed (6.7%). Mean age at symptom onset was 11.5+/-5.1 (5~24) weeks, and mean age at diagnosis was 17.8+/-9.5 (8~56) weeks. Duration from symptom onset to diagnosis was 6.3+/-6.7 (0~36) weeks. Mean peripheral blood eosinophil count was 478+/-320 (40~1,790)/mm3 and eosinophilia (>250/mm3) was observedin 90.0% of patients. None of patients were found to have an increased serum IgE level. Of 15 patients that received sigmoidoscopy, nodular hyperplasia with erosion was observed in 93.3%. Of 27 patients whose mother ate the diet eliminated the 5 food groups, hematochezia diappeared in 74.1% of patients. Offending foods were identified as dairy products (37.5%), wheat and buckwheat (27.5%), fish and shellfish (20.0%), nuts and soybean (7.5%) and eggs (7.5%). A free maternal diet without patient's clinical symptoms was achieved at 29.4+/-8.7 (9~44) weeks of patient's age, and a free baby diet without blood in stools was achieved at 37.5+/-9.7 (12~56) weeks of age. CONCLUSION: DPIPC commonly occurs in exclusively breast-fed babies. Elimination of the above-mentioned 5 hyper-allergenic food groups from the maternal diet for 7days enables the detection of the offending foods. DPIPC is a transient disorder and 96.0% of patients can tolerate the offending foods at 12 months of age.

Significance of Cytokine Levels in Neonates with Severe Fetal Distress

PURPOSE: To determine the relation between the initial plasma cytokine response and the neurological prognosis in term infants with severe fetal distress. METHODS: Infants with severe fetal distress at birth (n=23) were studied prospectively. Cytokine concentrations were measured from umbilical cord blood at 3 and 12 hours of life by enzyme-linked immunosorbent assays for interleukin (IL)-1beta, IL-6, and IL-18. The study groups were divided into good (n=14) or poor prognostic group (n=9) according to survival and presence of cerebral palsy (CP) later and correlations with afore mentioned cytokine levels were determined. RESULTS: Cord blood IL-1beta and IL-18 concentrations were similar in both groups. However, infants with poor prognosis had significantly higher median (range) IL-6 concentration than infants with good prognosis at 3 hours [323.6 (32.6-812.8) vs. 38.4 (6.3- 322.7) pg/mL] (P=0.001), and 12 hours of life [287.1 (16.4-769.1) vs. 66.2 (8.8-757.8) pg/mL] (P200 pg/mL) may be a useful indicator of poor neurological outcome in infants with severe fetal distress.

Cytomegalovirus-induced Childhood Menetrier's Disease with Peripheral Eosinophilia / 대한소아소화기영양학회지

Herein, the case of a 5-year-old boy with cytomegalovirus-induced Menetrier's disease, with peripheral eosinophilia, presenting with abdominal pain and vomiting, followed by generalized edema, is reported. The initial laboratory findings, hypoalbuminemia and peripheral eosinophilia were noted, with no evidence of renal, hepatic, cardiac or allergic diseases. Gastrofiberscopy was performed under the suspicion of eosinophilic gastroenteritis with protein losing gastropathy. The gastrofiberscopy showed the characteristic features of giant hypertrophy of the gastric rugae, with large quantities of adherent gelatinous material on the gastric fundus and body. The histological findings revealed foveolar hyperplasia, compatible with Menetrier's disease, with massive eosinophilic infiltrations. The presence of cytomegalovirus infection was identified by serology and confirmed by urine PCR. His symptoms, gastrofiberscopic findings and peripheral eosinophilia resolved spontaneously, and he has remained well for 10 months.

The Significance of the Early Electroencephalographic Findings in Severely Asphyxiated Newborn Infants

PURPOSE: Perinatal asphyxia occurring in newborn is one of the major causes of acute mortality and chronic neurological disability in survivors. We have studied the relationship between early electroencephalography(EEG) findings and clinical course and neurologic outcome in severe asphyxiated neonates. METHODS: Between the period of July 1999 and June 2002, 25 neonates who were diagnosed with severe perinatal asphyxia(1-minute Apgar score of < or =3 and initial pH is less than 7.2) at NICU in Dongsan Medical Center were enrolled. An EEG was recorded and analyzed within three days of life and divided into two groups - group 1(normal or focal change on EEG) and group 2(generalized abnormal EEG). Between the two groups, clinical courses and neurologic outcomes were compared. RESULTS: Fifteen infants(60%) were group 1 and ten infants(40%) were group 2(polyspikes, burst- suppression, generalized low voltage). Associated maternal disease, days of hospitalization, need for ventilator support, delay of oral feeding and convulsion duration are significantly higher and longer in group 2. Also, poor neurologic outcome(expire, developmental delay) was significantly higher in group 2(60%) than group 1(13.3%). CONCLUSION: Thus, the early neonatal EEG in asphyxiated newborn can be a predictable diagnostic tool in assessment of neurologic outcome.