RESUMO
OBJECTIVES: This European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position statement provides a comprehensive guide for health care providers to manage percutaneous endoscopic gastrostomy tubes in a safe, effective, and appropriate way. METHODS: Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of evidence, recommendations reflect the expert opinion of the authors. Final consensus was obtained by multiple e-mail exchange and during 3 face-to-face meetings of the gastroenterology committee of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. RESULTS: Endoscopically placed gastrostomy devices are essential in the management of children with feeding and nutritional problems. The article focuses on practical issues such as indications and contraindications. CONCLUSIONS: The decision to place an endoscopic gastrostomy has to be made by an appropriate multidisciplinary team, which then provides active follow-up and care for the child and the device.
Assuntos
Fenômenos Fisiológicos da Nutrição do Adolescente , Fenômenos Fisiológicos da Nutrição Infantil , Nutrição Enteral , Medicina Baseada em Evidências , Gastrostomia/reabilitação , Adolescente , Criança , Europa (Continente) , Gastrostomia/efeitos adversos , Humanos , Lactente , Fenômenos Fisiológicos da Nutrição do Lactente , Comunicação Interdisciplinar , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/terapia , Sociedades CientíficasRESUMO
OBJECTIVES: Eosinophilic esophagitis (EoE) represents a chronic, immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. With few exceptions, 15 eosinophils per high-power field (peak value) in ≥1 biopsy specimens are considered a minimum threshold for a diagnosis of EoE. The disease is restricted to the esophagus, and other causes of esophageal eosinophilia should be excluded, specifically proton pump inhibitor-responsive esophageal eosinophilia. This position paper aims at providing practical guidelines for the management of children and adolescents with EoE. METHODS: Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of an evidence base, recommendations reflect the expert opinion of the authors. Final consensus was obtained during 3 face-to-face meetings of the Gastroenterology Committee and 1 teleconference. RESULTS: The cornerstone of treatment is an elimination diet (targeted or empiric elimination diet, amino acid-based formula) and/or swallowed, topical corticosteroids. Systemic corticosteroids are reserved for severe symptoms requiring rapid relief or where other treatments have failed. Esophageal dilatation is an option in children with EoE who have esophageal stenosis unresponsive to drug therapy. Maintenance treatment may be required in case of frequent relapse, although an optimal regimen still needs to be determined. CONCLUSIONS: EoE is a chronic, relapsing inflammatory disease with largely unquantified long-term consequences. Investigations and treatment are tailored to the individual and must not create more morbidity for the patient and family than the disease itself. Better maintenance treatment as well as biomarkers for assessing treatment response and predicting long-term complications is urgently needed.
Assuntos
Esofagite Eosinofílica/terapia , Eosinófilos , Esôfago/patologia , Corticosteroides/uso terapêutico , Criança , Consenso , Esofagite Eosinofílica/complicações , Esofagite Eosinofílica/dietoterapia , Esofagite Eosinofílica/tratamento farmacológico , Estenose Esofágica/etiologia , Estenose Esofágica/terapia , Humanos , RecidivaRESUMO
OBJECTIVE: Primary gastrointestinal neuropathies are a heterogeneous group of enteric nervous system (ENS) disorders that continue to cause difficulties in diagnosis and histological interpretation. Recently, an international working group published guidelines for histological techniques and reporting, along with a classification of gastrointestinal neuromuscular pathology. The aim of this article was to review and summarize the key issues for pediatric gastroenterologists on the diagnostic workup of congenital ENS disorders. In addition, we provide further commentary on the continuing controversies in the field. RESULTS: Although the diagnostic criteria for Hirschsprung disease are well established, those for other forms of dysganglionosis remain ill-defined. Appropriate tissue sampling, handling, and expert interpretation are crucial to maximize diagnostic accuracy and reduce interobserver variability. The absence of validated age-related normal values for neuronal density, along with the lack of correlation between clinical and histological findings, result in significant diagnostic uncertainties while diagnosing quantitative aberrations such as hypoganglionosis or ultrashort Hirschsprung disease. Intestinal neuronal dysplasia remains a histological description of unclear significance. CONCLUSIONS: The evaluation of cellular quantitative or qualitative abnormalities of the ENS for clinical diagnosis remains complex. Such analysis should be carried out in laboratories that have the necessary expertise and access to their own validated reference values.
Assuntos
Doenças do Sistema Nervoso Autônomo/diagnóstico , Anormalidades do Sistema Digestório/diagnóstico , Sistema Nervoso Entérico/fisiopatologia , Gastroenteropatias/diagnóstico , Trato Gastrointestinal/inervação , Guias de Prática Clínica como Assunto , Adolescente , Adulto , Doenças do Sistema Nervoso Autônomo/congênito , Doenças do Sistema Nervoso Autônomo/patologia , Doenças do Sistema Nervoso Autônomo/fisiopatologia , Criança , Consenso , Anormalidades do Sistema Digestório/patologia , Anormalidades do Sistema Digestório/fisiopatologia , Neoplasias do Sistema Digestório/diagnóstico , Neoplasias do Sistema Digestório/patologia , Neoplasias do Sistema Digestório/fisiopatologia , Sistema Nervoso Entérico/anormalidades , Sistema Nervoso Entérico/patologia , Ganglioneuroma/diagnóstico , Ganglioneuroma/patologia , Ganglioneuroma/fisiopatologia , Gastroenterologia/métodos , Gastroenteropatias/congênito , Gastroenteropatias/patologia , Gastroenteropatias/fisiopatologia , Trato Gastrointestinal/anormalidades , Trato Gastrointestinal/patologia , Trato Gastrointestinal/fisiopatologia , Humanos , Lactente , Pseudo-Obstrução Intestinal/diagnóstico , Pseudo-Obstrução Intestinal/patologia , Pseudo-Obstrução Intestinal/fisiopatologia , Neoplasia Endócrina Múltipla Tipo 2b/diagnóstico , Neoplasia Endócrina Múltipla Tipo 2b/patologia , Neoplasia Endócrina Múltipla Tipo 2b/fisiopatologia , Pediatria/métodosRESUMO
OBJECTIVES: This guideline provides recommendations for the diagnosis and management of suspected cow's-milk protein allergy (CMPA) in Europe. It presents a practical approach with a diagnostic algorithm and is based on recently published evidence-based guidelines on CMPA. DIAGNOSIS: If CMPA is suspected by history and examination, then strict allergen avoidance is initiated. In certain circumstances (eg, a clear history of immediate symptoms, a life-threatening reaction with a positive test for CMP-specific IgE), the diagnosis can be made without a milk challenge. In all other circumstances, a controlled oral food challenge (open or blind) under medical supervision is required to confirm or exclude the diagnosis of CMPA. TREATMENT: In breast-fed infants, the mother should start a strict CMP-free diet. Non-breast-fed infants with confirmed CMPA should receive an extensively hydrolyzed protein-based formula with proven efficacy in appropriate clinical trials; amino acids-based formulae are reserved for certain situations. Soy protein formula, if tolerated, is an option beyond 6 months of age. Nutritional counseling and regular monitoring of growth are mandatory in all age groups requiring CMP exclusion. REEVALUATION: Patients should be reevaluated every 6 to 12 months to assess whether they have developed tolerance to CMP. This is achieved in >75% by 3 years of age and >90% by 6 years of age. Inappropriate or overly long dietary eliminations should be avoided. Such restrictions may impair the quality of life of both child and family, induce improper growth, and incur unnecessary health care costs.
Assuntos
Aleitamento Materno , Dieta , Fórmulas Infantis , Hipersensibilidade a Leite/dietoterapia , Hipersensibilidade a Leite/diagnóstico , Proteínas do Leite/imunologia , Fatores Etários , Algoritmos , Aminoácidos/administração & dosagem , Animais , Criança , Aconselhamento , Crescimento/efeitos dos fármacos , Transtornos do Crescimento/etiologia , Gastos em Saúde , Humanos , Lactente , Educação de Pacientes como Assunto , Hidrolisados de Proteína/administração & dosagem , Qualidade de Vida , Proteínas de Soja/administração & dosagemRESUMO
AIMS: To investigate the cause of grossly elongated villi in four children presenting with obstruction due to a novel form of eosinophilic gastroenteropathy in which there was profound hyperplasia of the intestinal villi with grossly increased villous/crypt ratio and prominent mucosal eosinophilia. Increased eosinophils were also present in the muscularis propria and submucosa. All had intermittent diarrhoea and signs of a protein-losing enteropathy. METHODS AND RESULTS: The cause of the grossly elongated villi was investigated by studying enterocyte proliferation (Ki67), survival factors (bcl-2) and apoptosis (TUNEL) in these patients (n = 4) and normal (jejunum n = 6, ileum n = 6) and disease (n = 6) controls. The most remarkable finding was that apoptotic enterocytes were undetectable in the elongated villi. CONCLUSIONS: It seems likely that a defect in the regulation of apoptosis of the epithelium occurs which could explain the remarkable hyperplasia of the villi seen.
Assuntos
Apoptose , Enterócitos/patologia , Eosinófilos/patologia , Adolescente , Estudos de Casos e Controles , Enterócitos/metabolismo , Feminino , Humanos , Hiperplasia , Hipertrofia , Íleo/metabolismo , Íleo/patologia , Lactente , Mucosa Intestinal/patologia , Jejuno/metabolismo , Jejuno/patologia , Antígeno Ki-67/metabolismo , Masculino , Microvilosidades/metabolismo , Microvilosidades/patologia , Enteropatias Perdedoras de Proteínas/fisiopatologia , Proteínas Proto-Oncogênicas c-bcl-2/metabolismoRESUMO
BACKGROUND: Involvement of the gut in chronic granulomatous disease (CGD) has been previously described and colitis highlighted. However, the nature and histopathology of the colitis are unclear and have been thought to be non-specific or similar to Crohn's disease. METHODS: Seven patients with CGD, suffering from gastrointestinal symptoms were prospectively studied. RESULTS: All patients had anaemia; other symptoms were failure to thrive (5/7) and diarrhoea (5/7). Most had microcytic anaemia (5/7), increased platelets (7/7), and increased erythrocyte sedimentation rate (6/6). Endoscopically there was a friable erythematous mucosa in 6/7. The histological features present in all patients consisted of a colitis with paucity of neutrophils, increased numbers of eosinophils, eosinophilic crypt abscesses, pigmented macrophages, and nuclear debris. In some granulomas were present (2/7). CONCLUSIONS: Colitis is a common cause of gastrointestinal symptoms in CGD and is caused by a non-infective inflammatory process. The histology has specific features, which are distinctive from those seen in Crohn's disease.
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Colite/etiologia , Doença Granulomatosa Crônica/complicações , Anemia/etiologia , Anemia/patologia , Biópsia , Criança , Pré-Escolar , Colite/tratamento farmacológico , Colite/patologia , Eosinofilia/etiologia , Eosinofilia/patologia , Insuficiência de Crescimento/etiologia , Insuficiência de Crescimento/patologia , Feminino , Fármacos Gastrointestinais/uso terapêutico , Doença Granulomatosa Crônica/tratamento farmacológico , Humanos , Macrófagos/patologia , Masculino , Neutropenia/etiologia , Neutropenia/patologia , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Measurement of faecal elastase (FE1) is used widely to screen for pancreatic exocrine insufficiency (PI). FE1 does not allow differentiation of primary from secondary PI. AIMS: To investigate the relation between duodenal morphology and FE1 in children with secondary PI resulting from primary gastrointestinal diseases. METHODS: A group of 51 children underwent small intestinal biopsy and FE1 measurement. Villus to crypt ratio (VCR) and inflammation within the lamina propria of duodenal mucosal biopsy specimens were scored and compared with FE1 values. RESULTS: In 51 children from nine diagnostic categories, a highly significant correlation between FE1 and both duodenal morphology and inflammation was found. CONCLUSION: Small bowel enteropathy is associated with low FE1 concentrations, indicative of secondary exocrine pancreatic insufficiency.
Assuntos
Duodenopatias/diagnóstico , Fezes/enzimologia , Elastase Pancreática/análise , Biomarcadores/análise , Biópsia , Criança , Pré-Escolar , Grupos Diagnósticos Relacionados , Duodenopatias/complicações , Duodenite/complicações , Duodenite/enzimologia , Ensaio de Imunoadsorção Enzimática , Insuficiência Pancreática Exócrina/enzimologia , Insuficiência Pancreática Exócrina/etiologia , Feminino , Humanos , Lactente , Recém-Nascido , Mucosa Intestinal/enzimologia , Modelos Lineares , Masculino , Estudos RetrospectivosRESUMO
The diagnostic features and clinical course of three children (aged 1 month to 15 years) with severe functional intestinal obstruction and inflammation of the colonic lamina propria and myenteric plexus are described. The myenteric inflammatory infiltrate was eosinophil predominant with none of the immunological characteristics of lymphocytic ganglionitis. Neurones in the myenteric ganglia expressed the potent eosinophil chemoattractant interleukin 5. None responded to dietary exclusion but all three responded symptomatically to immunosuppression/anti-inflammatory treatments. Eosinophilic ganglionitis is associated with a pseudo-obstructive syndrome which is amenable to anti-inflammatory treatment.