Relationship between baseline impedance levels and esophageal mucosal integrity in children with erosive and non-erosive reflux disease.

BACKGROUND: Baseline impedance measurement has been reported to be related to esophageal acid exposure and hypothesized to be a marker of microscopic changes of the esophageal mucosa. Aims of the study were to establish whether any relationship existed between the magnitude of intercellular space diameter (ISD) of esophageal mucosa and baseline impedance levels in children with gastro-esophageal reflux disease (GERD), and to compare baseline impedance levels between children with non erosive (NERD) and erosive (ERD) reflux disease. METHODS: Fifteen children (median age: 11.2 years) with NERD, and 11 with ERD (median age: 9.6 years) were prospectively studied. All patients underwent upper endoscopy. Biopsies were taken 2-3cm above the Z-line, and ISD was measured using transmission electron microscopy. All patients underwent impedance pH-monitoring, and baseline impedance levels were assessed in the most distal impedance channel. KEY RESULTS: Mean (±SD) ISD did not differ between NERD (1.0±0.3µm) and ERD (1.1 ± 0.3 µm, ns). Considering all patients together, no correlation was found between distal baseline impedance and ISD (r: -0.15; ns). Conversely, negative correlations were found between distal baseline impedance and acid exposure time (r: -0.76; P<0.001), long-lasting reflux episodes (r: -0.78; P<0.001), acid reflux episodes (r: -0.62; P<0.001), and acid clearance time (r: -0.79; P<0.001). Distal baseline impedance was significantly lower in ERD [1455 (947-2338) Ω] than in NERD children [3065 (2253-3771) Ω; P<0.01]. CONCLUSIONS & INFERENCES: In children with GERD baseline impedance levels are not useful in predicting reflux-induced ultrastructural changes in the esophageal mucosa, despite their ability to discriminate between NERD and ERD.

Infliximab for pediatric ulcerative colitis: a retrospective Italian multicenter study.

BACKGROUND: Infliximab (IFX), the chimeric anti TNFalpha antibody, an established treatment for Crohn's disease in adults and in children, is used less frequently in ulcerative colitis (UC). AIM OF THE STUDY: To report the clinical course of pediatric patients with active UC receiving IFX. PATIENTS AND METHODS: Charts of 22 patients were reviewed (13 male, 9 female): 4 with a severe UC attack refractory to systemic corticosteroids (CS); 18 with a protracted course, of which 16 CS-dependent and 2 CS-resistant. The baseline therapeutic program consisted of 3 consecutive intravenous infusions (0, 2, 6 weeks) of IFX (5 mg/kg), followed by a retreatment schedule (infusion every 8 weeks); azathioprine (AZA) was administered chronically in all. Clinical evaluation was done with the Lichtiger Colitis Activity Index (LCAI). Follow-up was performed until week 54. LCAI >/= 9 was considered treatment failure; a LCAI 9: 12 had a full response and were on remission at week 54 and did not receive CS (8 on IFX re-treatment and AZA, 4 on AZA alone); 6 had a partial response; 4 were non responders. Colectomy was performed in 7 patients, beyond the period of the acute attack in all but one. CONCLUSIONS: In children with severe ulcerative colitis IFX is a valuable treatment for inducing remission, avoiding emergency colectomy; retreatment may be offered to maintain remission.

Inflammatory bowel disease in children and adolescents in Italy: data from the pediatric national IBD register (1996-2003).

BACKGROUND: The purpose was to assess in Italy the clinical features at diagnosis of inflammatory bowel disease (IBD) in children. METHODS: In 1996 an IBD register of disease onset was established on a national scale. RESULTS: Up to the end of 2003, 1576 cases of pediatric IBD were recorded: 810 (52%) ulcerative colitis (UC), 635 (40%) Crohn's disease (CD), and 131 (8%) indeterminate colitis (IC). In the period 1996-2003 an increase of IBD incidence from 0.89 to 1.39/10(5) inhabitants aged <18 years was observed. IBD was more frequent among children aged between 6 and 12 years (57%) but 20% of patients had onset of the disease under 6 years of age; 28 patients were <1 year of age. Overall, 11% had 1 or more family members with IBD. The mean interval between onset of symptoms and diagnosis was higher in CD (10.1 months) and IC (9 months) versus UC (5.8 months). Extended colitis was the most frequent form in UC and ileocolic involvement the most frequent in CD. Upper intestinal tract involvement was present in 11% of CD patients. IC locations were similar to those of UC. Bloody diarrhea and abdominal pain were the most frequent symptoms in UC and IC, and abdominal pain and diarrhea in CD. Extraintestinal symptoms were more frequent in CD than in UC. CONCLUSIONS: The IBD incidence in children and adolescents in Italy shows an increasing trend for all 3 pathologies. UC diagnoses exceeded CD.

Autoimmune enteropathy and rheumatoid arthritis: a new association in the field of autoimmunity.

We report the case of a 35-year-old woman with a diagnosis of coeliac disease at the age of 32 due to a severe malabsorption and flat mucosa without endomysial and tissue transglutaminase antibodies. The lack of clinical and histological improvement after 1 year of a gluten-free diet led to a diagnosis of refractory sprue. She had a good clinical response to steroids that were stopped after 3 months when she became pregnant. After delivery, she again started to complain of malabsorption with arthritis. Positivity for enterocyte autoantibodies together with a flat mucosa persistence allowed to identify a condition of autoimmune enteropathy; moreover, a rheumatological assessment gave evidence of an associated rheumatoid arthritis. Treatment by steroids and methotrexate brought to the remission of intestinal and articular symptoms together with an improvement of duodenal histology. This is the first description of an autoimmune enteropathy associated with rheumatoid arthritis. Autoimmune enteropathy should be always ruled out in patients with a villous atrophy unresponsive to a gluten-free diet, autoimmune manifestations and negativity of coeliac disease markers.

Response to infliximab is related to disease duration in paediatric Crohn's disease.

BACKGROUND: Infliximab is an effective therapy in adult patients with refractory and fistulizing Crohn's disease. Experience in children is still limited. AIM: : To evaluate the experience in 22 children and adolescents treated with infliximab with refractory and/or fistulizing Crohn's disease, and to compare duration of response in children between early Crohn's disease and late Crohn's disease. METHODS: The experience in 22 children and adolescents treated with a total of 73 infusions was evaluated retrospectively. Treatment indication was refractory Crohn's disease in 9/22 patients, fistulizing Crohn's disease in 7/22 patients and both these conditions in 6/22. All patients with refractory Crohn's disease had late Crohn's disease (> 1 year), whereas 6/13 patients with fistulas had early disease (< 1 year). RESULTS: Mean Paediatric Crohn's Disease Activity Index (PCDAI) decreased from 41.2 to 16.2 at 4 weeks (P < 0.01), and to 15.4 at 18 weeks (P < 0.01). Mean PCDAI at 18 weeks in children with early Crohn's disease and late Crohn's disease was 5.5 and 18.1, respectively (P < 0.05). Complete closure of fistulas was obtained in 5/6 children with early Crohn's disease and in 2/7 children with late Crohn's disease. Immediate adverse reactions were observed in two children. CONCLUSIONS: Infliximab is a highly effective treatment in children and adolescents with both severe refractory or fistulizing Crohn's disease. Children with early Crohn's disease have a higher chance of prolonged response to infliximab than children with late Crohn's disease.

Antibiotic resistance and antibiotic sensitivity based treatment in Helicobacter pylori infection: advantages and outcome.

AIMS: To compare two strategies for the eradication of Helicobacter pylori infection. METHODS: Groups 1 and 2 each consisted of 75 consecutive patients. Patients in group 1 were treated with two antibiotics based on antibiotic susceptibility testing; those in group 2 received amoxycillin and clarithromycin for eight days, together with either ranitidine or omeprazole. Eradication rate was assessed in both groups six months after treatment. RESULTS: In group 1, H pylori grew in culture in 63/75 cases. Susceptibility testing showed that 35/63 isolates were resistant to metronidazole, 10/63 to clarithromycin, 2/63 to ampicillin, 1/63 to tetracycline, and 5/63 to both clarithromycin and metronidazole. In group 1 the infection was eradicated in 96% of the initial 75 subjects, and in 98% of the subjects treated according to the antibiotic assay (62/63). As two patients were lost at follow up the overall eradication rate was 99%. In group 2, eradication was achieved in 61/75 subjects (81%). This was significantly lower than the percentage of eradication observed in group 1 (81% versus 99%). CONCLUSIONS: Antibiotic susceptibility tests are useful in childhood as a very high percentage of subjects are cured. This approach is costly, but selective antibiotic treatment contributes to limit further development of antibiotic resistance, and money is saved in terms of reinvestigation and further repeated treatments.

[Digestive endoscopy in children]. / L'endoscopia digestiva in età pediatrica.

Also in the pediatric population the digestive endoscopy became, at this point, a very good diagnostic and operative technique largement used. The endoscopy can explore the upper gastrointestinal tract (esophagus, stomach, duodenum and jejunum) and can investigate the colon and the terminal ileum regarding the lower gastrointestinal tract. Principally, the operative endoscopy concerns emostasis of gastrointestinal bleeding, polipectomy, extraction of foreign bodies, and intestinal dilatations. The patients population submitted to this investigation by now is very wide thanks to the modernization of the instruments and at specialization of gastroenterologist pediatricians: range from newborn, to childhood, adolescence and young adults. The gastroenterologist pediatricians specialization associated to a routine use of amnemonic drugs (benzodiazepine) reduced at the minimum the invasivity of endoscopy; this technique can be considered a good safe procedure and free of important physical and psychic side effects for the young patient.

[Digestive endoscopy in neonates. Personal experience]. / L'endoscopia digestiva in età neonatale. Esperienza personale.

Gastrointestinal (GI) endoscopy is actually considered an essential diagnostic and therapeutic technique both in pediatrician and in newborn infants. At the moment upper GI endoscopy in neonatal age allows to explore the esophagus, stomach and duodenum; instead lower GI endoscopy easily reaches sigmoid-colon junction. The exploration of other distal parts of bowel is more difficult and with more risks. Therefore it has to be make only if it is necessary. In the newborn this exam should be so fast not to require premedication. In our study, we considered every neonatal patient who underwent GI endoscopy at the "Digestive Endoscopy and Gastroenterology Service of Pediatric Clinic-University of Parma" (from September 1983 to June 2000). We considered two groups of patients: first group: early neonatal age (0-14 days) second group: late neonatal age (15-28 days). We made 127 endoscopies: 112 of these were upper GI. The most frequent symptoms that babies showed and indicated upper GI endoscopy were reflux and/or vomiting (86%). Upper operative GI endoscopies included also 7 esophageal dilatations. The lower GI endoscopies were 15 and in all the cases the indication was intestinal bleeding. We conclude that the GI endoscopy in the neonates shows a diagnostic sensibility and specificity really high and for sure better than the radiology for mucosal lesions. Also GI endoscopy can be not only a very precious diagnostic instrument but also therapeutic in neonatal disease. Considering the age of the little patients, it is very important that only endoscopists with large experience use this technique.

Comparison of two non-absorbable antibiotics for treatment of bacterial enteritis in children.

Thirty-one children with bacterial diarrhoea were administered an oral suspension of rifaximin (14 children, mean age: 4.3 yrs; dosage: 5 ml, equal to 100 mg, x 4/day for 3 days on average) or of neomycin + bacitracin (17 children, mean age: 3.6 yrs; dosage: 5 ml x 4/ day for 4 days on average). Etiologic agents were: minor Salmonella spp in 9 and 7 cases respectively; enteropathogenic E. coli in 5 and 10 cases. Rifaximin yielded bacteriological cure in 12/14 children; the reference drug in 13/17. With both antibiotics, stool number/day fell, after one day, from 6 on average, to normality (2-3 stools); within two days stool consistency and characteristics shifted to normal. Symptomatology was quickly eliminated in all of the cured children. Both treatments showed excellent systemic tolerability; rifaximin was completely tolerated also locally, while two cases of stomach ache were reported with the reference drug.

Cystic fibrosis: MR assessment of pancreatic damage.

PURPOSE: To evaluate magnetic resonance (MR) imaging for assessment of pancreatic damage in cystic fibrosis. MATERIALS AND METHODS: Twenty-seven patients with cystic fibrosis and 12 control subjects underwent T1-weighted imaging for visual assessment for pancreatic hyperintensity and mixed spin-echo-inversion-recovery imaging for quantitative measurement of T1. Pancreatic insufficiency, pulmonary status, and genotype were recorded. Statistical correlation was conducted. RESULTS: Four patterns of pancreatic involvement were noted: diffuse hyperintensity with a lobular pattern, diffuse homogeneous hyperintensity without residual lobular pattern, hyperintensity with focal areas of sparing, and no structural or signal intensity changes. Statistically significant reduction of the T1 was noted in 21 patients compared with that of controls. Statistically significant correlation between T1 shortening and pulmonary clinical-radiologic compromise and pancreatic insufficiency was found. CONCLUSION: MR imaging may offer further indication of pancreatic and, indirectly, pulmonary damage during the clinical course of cystic fibrosis. A pattern of fibrofatty infiltration of the pancreas, of undetermined clinical significance, is reported.

Latent coeliac disease. Personal experience.

Latent coeliac disease (L.C.D.) is an extremely rare condition to describe. In this study we analyzed three cases of patients affected by L.C.D.: two of them suffered from insulin-dependent diabetes mellitus (IDDM) and the other one from infantile cerebral palsy and eosinophilic gastroenteritis. We confirm the existence of this form of coeliac disease (C.D.), by means of duodenal biopsy, and stress the importance of an early diagnosis in order to prevent the serious consequences caused by untreated C.D.

[Dermatitis herpetiformis and latent celiac disease in two siblings]. / Dermatite erpetiforme e malattia celiaca silente in due fratelli.

The association between coeliac disease (CD) and dermatitis herpetiformis (DH) is well known. Moreover, this cutaneous disease may be the only sign of an otherwise asymptomatic CD. Subjects presenting with both CD and DH generally show an HLA pattern in which A1, B8, DR2, DR7, DQw2 are the most frequent antigens one can find. We report about 2 brothers presenting with DH, clinically asymptomatic, without antigliadin serum antibodies (AGA), but positive to the research of antiendomysial (EMA) ones. The biopsy performed by digestive endoscopy showed a complete atrophy of duodenal villi and the diagnosis of CD was confirmed according to the European Society for Pediatric Gastroenterology and Nutrition (ESPGAN) criteria. The diet without gluten caused the DH to recovery and the duodenal villi microscopic aspect to normalize as well. Both the brothers had the same HLA pattern: A1, B8, DR3-DR2, DQw2. Our clinical study suggests that it is very important, especially for the general practitioner, to recognize a DH and in every child presenting with a dermatitis like that it will be mandatory to perform a laboratory research of both AGA and EMA.

[Anti-gastric antibodies and gastritis in insulin-dependent diabetes in children]. / Anticorps antiestomac et gastrite au cours du diabète insulino-dépendant de l'enfant.

BACKGROUND: Adult patients with insulin-dependent diabetes mellitus frequently also show gastric disturbances. Knowledge of the prevalence of such abnormalities in children with insulin-dependent diabetes and the predictive value of anti-gastric parietal cell antibodies in blood may be of practical importance. PATIENTS AND METHODS: 68 patients (29 boys and 39 girls), aged from 5 yr 2 mo to 19 yr 10 mo, and treated for insulin-dependent diabetes from 1 mo to 14 yr 6 mo, were included in the study. Fasting blood concentrations of gastrin (G), pepsinogen (PG1), anti-gastric parietal cell antibodies (PCA) were measured. Fiberoptic endoscopy and biopsy of the gastroduodenal mucosa were performed in PCA+ patients and biopsy samples were examined for Helicobacter pylori (HP). RESULTS: 12 patients were PCA+; 3 of them had blood gastrin levels above 104 pg/ml and 4 had blood pepsinogen levels 24 ng/ml. Histologically, 3 patients had chronic diffuse gastritis (2 were HP+); 2 had chronic gastritis restricted to the antro-pyloric area (both were HP+); 3 had follicular lymphoid hyperplasia (without HP) and 4 had normal mucosa (without HP). CONCLUSION: The presence of PCA can predict the risk of chronic gastritis, possibly auto-immune in origin, in children with insulin-dependent diabetes.

[Cholestasis caused by ulcerative Vater's papillitis in a child with AIDS]. / Cholestase secondaire à une papillite ulcérative de Vater chez un enfant atteint de SIDA.

A case of cholestasis induced by ulcerative papillitis in an 11 month-old boy with AIDS is described. Resolution of cholestasis has been achieved with medical therapy. The authors underline the necessity of repeated endoscopic follow-up to evaluate the risk of secondary papillary stenosis, a complication usually observed in adults.

Gastric pepsin and acid secretion during total parenteral nutrition and constant-rate enteral nutrition in infancy.

Total Parenteral Nutrition (TPN) and constant rate enteral nutrition (CREN) are widely used: their effects on gastric function, especially pepsin secretion, are unknown. Basal and pentagastrin-stimulated pepsin (BPO, MPO) and acid (BAO, MAO) secretions were measured in three groups of infants: controls (14 infants fed normally), TPN groups (seven infants on TPN), CREN groups (14 infants on CREN). The MAO and MPO of the TPN group were significantly lower than controls (p less than 0.02), and the ratio of pentagastrin-stimulated PO/AO did not change, suggesting a large decrease of acid gastric function in the TPN group. BPO was not different from controls and BAO was significantly higher because of amino acids perfusion. The data for CREN group were not different from those of the control group, despite the fact that 11 infants were on TPN before CREN. These results demonstrate that TPN causes decreases in both acid and pepsin secretions in human infants. When TPN children are placed on CREN, these secretions return to normal.