[Diagnosis and management of a particular caseof intractable constipation]. / Diagnostic et gestion d'un cas particulier de constipation opiniâtre.

Constipation is a very common pattern in childhood. There are multiple reasons for constipation including one very rare : chronic intestinal pseudo-obstruction syndrome. We report the case of a young patient monitored for multiple incidents of intestinal pseudo- obstruction with intractable constipation. The patient underwent several surgical interventions to relieve his symptoms because the non operative treatments, based on liquid diet and laxatives, didn't show great effectiveness. We will review the differential diagnosis of chronic constipation and we will discuss the particular diagnostic entity of this patient. We will also discuss the different treatments that allowed to provide tolerance to oral feeding.

La constipation est un motif de consultation pédiatrique très courant. Les étiologies sont multiples mais le syndrome de pseudo- obstruction intestinale chronique, une cause de constipation chronique, est très rare. Nous rapportons le cas d'un jeune patient suivi pour de multiples épisodes de pseudo- obstruction intestinale avec une constipation opiniâtre. Le patient a subi plusieurs interven- tions chirurgicales pour soulager ses symptômes car les traitements à base de diète liquide et de laxatifs ne se sont pas toujours montrés efficaces. Nous reverrons les diagnostics différentiels d'une constipation chronique et nous discuterons de l'entité diagnostique particulière de ce jeune patient. Nous discuterons également des différents traitements entrepris pour lui permettre de continuer à s'alimenter normalement.

[Management of Acute Gastroenteritis in Children]. / Traitement de la gastro-entérite aiguë chez L'Enfant.

Acute gastroenteritis remains one of the most frequent disorders in infants and children. The cornerstone of the treatment is oral rehydration, although the latter does not reduce the duration of the diarrhea, which is about four days. As a consequence, this quite benign condition of acute gastroenteritis in our countries still does have an important socio-economic impact. Therefore, recent European guidelines and recommendations consider the use of different medications and agents that reduce the duration of diarrhea.

[Neurogastroenterology: focus on pediatric digestive motility diseases]. / La neurogastroentérologie: focus sur les troubles de la motricité digestive en pédiatrie.

The enteric nervous system exercises a key role on the gastrointestinal tract (GIT) motility, sensibility, secretions and absorption. This "Little brain of the gut" consists of numerous autonomic neurones located in the GIT, influenced by luminal and intrinsic factors. A new science, the neurogastroenterology, explores the modulation of the GIT functions and the interactions between the central, autonomic and enteric nervous systems forming the brain-gut axis. It works to understand the role of the glial and Cajal's cells, of chemical mediators, hazards of the GIT ontology, influence of inflammation stress and early childhood environment. Motility disorders are congenital or acquired and can persist with more or less severe impairment of quality of life or be a life threatening condition. They are consequences of impaired embryonic development, genetic disorders, systemic diseases, toxic effects, normal or pathologic immunologic reactions acting on the nervous systems or the myocytes. Advances in the understanding of the pathogenesis of uncommon disorders (Hirschsprung disease, achalasia, chronic intestinal pseudo-obstruction) or more prevalent functional disorders (regurgitations, chronic constipation or diarrhoea, functional abdominal pain) contribute to improve the care of such patients. Multidisciplinary team is sometimes mandatory as a holistic approach and the use of sophisticated techniques are important. Improvement of the efficacy of the drugs could by obtained. For clinical works, we need a common language, for this purpose the paediatric Rome III classification of GIT functional disorders is proposed, we need also more consensus on paediatric GI motility exploration protocols.

[gastroesophageal reflux in children, a curiosity or a disease?]. / Reflux gastro-oesophagien chez l'enfant, curiosité ou maladie?

The development of new techniques and their adaptation (miniaturization) to paediatric patients increase the understanding of the underlying pathogenic mechanisms of the classical gastro-oesophageal reflux (GOR) in infancy and childhood (mainly regurgitation). The more reliable detection of GOR is important in some non-digestive manifestations of disease. In the vast majority of infants, GOR follows a transitory and unconsequent course. However, in some cases, it can persist beyond the normal limit of time for maturation of the gastro-oesophageal junction (18-24 months), and is responsible for chronic complaints. In rare cases it can cause severe morbidity and mortality in the first months of life.

Profile of pediatric Crohn's disease in Belgium.

AIM: A Belgian registry for pediatric Crohn's disease, BELCRO, was created. This first report aims at describing disease presentation and phenotype and determining associations between variables at diagnosis and registration in the database. METHODS: Through a collaborative network, children with previously established Crohn's disease and newly diagnosed children and adolescents (under 18 y of age) were recruited over a 2 year period. Data were collected by 23 centers and entered in a database. Statistical association tests analyzed relationships between variables of interest at diagnosis. RESULTS: Two hundred fifty-five patients were included. Median age at diagnosis was 12.5 y (range: 1.6-18 y); median duration of symptoms prior to diagnosis was 3 m (range: 1-12 m). Neonatal history and previous medical history did not influence disease onset nor disease behavior. Fifty three % of these patients presented with a BMI z-score < -1. CRP was an independent predictor of disease severity. Steroids were widely used as initial treatment in moderate to severe and extensive disease. Over time, immunomodulators and biological were prescribed more frequently, reflecting a lower prescription rate for steroids and 5-ASA. A positive family history was the sole significant determinant for earlier use of immunosuppression. CONCLUSION: In Belgium, the median age of children presenting with Crohn's disease is 12.5 y. Faltering growth, extensive disease and upper GI involvement are frequent. CRP is an independent predictive factor of disease activity. A positive family history appears to be the main determinant for initial treatment choice.

Safety and cost of infliximab for the treatment of Belgian pediatric patients with Crohn's disease.

Biologicals have become an important component in the treatment of Crohn's disease in children. Their increased and long term use raises safety concerns. We describe safety and cost of infliximab in Belgian pediatric Crohn's disease patients. All patients on infliximab as part of the present or past treatment for Crohn's Disease until January 1st 2011 were selected from an existing database. Information on disease phenotype, medication and adverse events were extracted. Adverse events occurred in 25.9% of patients exposed to infliximab of which 29.6% were severe. In total 31.7% of patients stopped infliximab therapy. The main reasons for discontinuation were adverse events in 45.4% and loss of response in 30.3%. No malignancies or lethal complications occurred over this 241 patient year observation period. Immunomodulators were concomitant medication in 75% of patients and were discontinued subsequently in 38.4% of them. The cost of infliximab infusions per treated patient per year in the Belgian health care setting is approximately 9 474 euro, including only medication and hospital related costs. Even though infliximab is relatively safe in pediatric CD on the short term, close follow-up and an increased awareness of the possible adverse reactions is highly recommended. Adverse reactions appeared in 25.9% of all patients and were the main reason for discontinuation. Treatment cost has to be balanced against efficacy and modifications in disease course. In the Belgian health care system, the medication is available to all patients with moderate to severe CD.

Naso-oesophageal probes decrease the frequency of sleep apnoeas in infants.

The objective of the study was to determine whether a naso-oesophageal probe modifies sleep and cardiorespiratory patterns in infants with repeated obstructive apnoeas. Two polygraphic recording sessions were conducted in random order for 2 nights on 35 infants suspected to have repeated obstructive sleep apnoeas. One sleep study was performed with a pH probe inserted through the nasal passage down to the distal portion of the oesophagus. The other session was conducted without any naso-oesophageal probe (the baseline study). For the 25 infants who presented repeated obstructive apnoeas during baseline studies, the presence of the probe was associated with a small, but significant, decrease in the number of central apnoeas (median frequency of 18.5 apnoeas per hour without a probe; 16.1 per hour with the probe; P=0.040), and obstructive apnoeas (median of 1.9 apnoeas per hour without a probe; 0.6 per hour with the probe; P=0.016). The presence of the probe was also associated with a small increase in percentage non-rapid eye movement (NREM) sleep frequency. The changes were statistically significant only for infants who had no obstructive apnoea during baseline studies (29 vs. 31%). The presence of a naso-oesophageal probe significantly modifies the infants' respiratory characteristics during sleep. These findings should be considered when reporting and interpreting sleep studies in infants.

The 1998 national Belgian consensus meeting on HP-related diseases: an extensive summary. The HP Belgian contact group organized in CHU Brugmann, Brussels.

"HP testing must be regarded as ONE of the important elements of the proper diagnostic work-up of a DISEASE, managed in close cooperation between GP's and specialists": that's the key message of the national consensus meeting held in CHU Brugmann on February 6th and 7th 1998. HP testing (usually by 2 direct methods: RUT-histology) and eradication treatment (ER), in infected patients, are strongly recommended in: 1. Past or current GDU (absolute indication), regardless of activity, complication(s), NSAID intake; 2. Low-grade MALT Lymphomas (Stage IE1) unequivocally diagnosed, managed and followed-up in specialised centers; 3. Post endoscopic resection of EGC. ER is advisable in HP carriers with a family history of gastric cancer. Chronic atrophic-, lymphocytic-, giant folds gastritis and hyperplastic polyps are acceptable indications for ER as well as scheduled long-term NSAID treatment in individuals with known HP status. Systematic ER in HP+ patients with fully investigated NUD is not indicated but could be considered in individual patients. Extra alimentary disorders and auto immune gastritis are no indication and there was no consensus for a "test and treat" policy in patients under 45 yrs old without alarm symptoms. Systematic screening of asymptomatic individuals is not recommended. A correct monitoring of eradication after treatment is recommended, mainly by UBT. In severe or refractory PUD, symptom recurrence and follow-up of EGC and Maltomas, endoscopic follow-up with HP testing is mandatory. The recommended first line treatment course (except known allergy or intolerance) is PPI full dose bid, Clarithromycin 500 mg bid Amoxycillin 1000 mg bid (7 days minimal 10 days maximal). RBC-based schemes must be locally validated and quadruple therapy is proposed when retreatment is needed. Culture, optional after the first treatment failure, is strongly recommended after a second failure. Overall, ER therapies are safe and neither the decreased efficacy of acid-lowering drugs, nor the possible increased risk of peptic oesophagitis are considered as contra-indications to eradicate. ER is cost-effective and cost-beneficial in PUD and adjusted number of pills delivered would cut costs. No clear economic data are currently available for a potential benefit of ER in GC prevention or NUD management. A national monitoring of HP resistance (Macrolides and Imidazoles) must be organized by specialised centers.

Chronic intestinal pseudoobstruction syndrome: clinical analysis, outcome, and prognosis in 105 children. French-Speaking Group of Pediatric Gastroenterology.

Our aim was to collect a large number of cases to characterize clinical presentation, outcome, and prognosis of chronic intestinal pseusoobstruction in children. We conducted a retrospective multicenter study that included children treated for chronic intestinal pseusoobstruction defined as recurrent episodes of intestinal obstruction with no mechanical obstruction, excluding Hirschsprung's disease. In all, 105 children, 57 boys and 48 girls, were studied, including five familial forms. Prenatal diagnosis was made in 18 patients. Eighty patients were less than 12 months old at onset; the disease began at birth for 37 patients. The most frequent signs were abdominal distension, vomiting, and constipation. Megacystis was noted in myopathies (7 cases), neuropathies (10 cases) and unclassified forms (13 cases). For all but three cases (two patients with CMV infection, one with Munchhausen-by-proxy syndrome), the associated diseases and disorders could not account for chronic intestinal pseusoobstruction as a secondary disorder. At least one full-thickness biopsy from the digestive tract was studied for 99 patients. The diagnosis recorded was visceral neuropathy in 58 cases, visceral myopathy in 17 cases, and uncertain or normal biopsy results in 24 cases. Seventy-eight children were fed intravenously, and only 18 were able to be fed orally throughout their illness. Seventy-one patients underwent surgery during their illness, and 217 surgical procedures, a mean of 3 per patient, were performed. Ostomy was the most performed procedure. Follow-up continued in 89 patients for 3 months to 16 years (mean 85 months). Forty-two patients were still fed by parenteral (39 patients) or enteral nutrition (3 patients) at the time of the study. Eleven patients died between the age of 1 month and 14 years 7 months.