Effect of Esophagogastroduodenoscopy Volume and Gastric/Esophageal Pathology on the Rate of Lymphocytic Duodenosis Reporting in Children and Adolescents.

Background It is not clear if the increase in the number of esophagogastroduodenoscopies (EGDs) performed has any significant effect on the rate of lymphocytic duodenosis (LD) reporting in children and adolescents and whether it correlates with abnormal gastric and/or esophageal pathology." Methods We performed a single-center retrospective study using the Mayo Clinic electronic health record and pathology database. We reviewed all EGD procedures performed in children and adolescents (<18 years) between January 1, 2000, and December 31, 2018, and identified two groups, the LD group and matched age and sex control group (normal duodenal biopsies). We evaluated the correlation of LD rate with the yearly number of EGDs performed and the presence of abnormal gastric and/or esophageal pathology. Results Of 11,870 EGDs performed, we identified 338 (3%) individuals with LD and 390 (3%) randomly selected controls, with a mean (SD) age of 9.6 (5.3) and 11.7 (5.0) years, respectively. Based on logistic regression analysis, abnormal gastric histology was associated with the presence of LD when compared with controls (odds ratio, 2.85; 95% CI, 2.05-3.97; P < 0.001). The rate of LD-positive biopsies per year was highly correlated with the number of EGDs performed (ρ = 0.931; 95% CI, 0.826-0.974; P < 0.001). Conclusion The rate of LD reporting is correlated with the number of EGDs performed and is more likely seen in children and adolescents with abnormal gastric histology.

Intrapyloric Botulinum Toxin A Injection for Gastroparesis and Functional Upper Gastrointestinal Symptoms in Children: Mayo Clinic Experience, Review of the Literature, and Meta-analysis.

OBJECTIVE: We aimed to assess the efficacy of intrapyloric botulinum toxin A injection (IPBTI) in children with and without gastroparesis and to perform a meta-analysis and review of the literature. METHODS: We retrospectively searched our electronic health records to identify children (aged < 18 years) who underwent an esophagogastroduodenoscopy with IPBTI between 2007 and 2018 for persistent upper gastrointestinal tract symptoms. We included children with and without gastroparesis and excluded children with a history of gastrointestinal surgery, gastrointestinal obstruction, or mucosal disease that could explain their symptoms. A meta-analysis including our study findings was performed. RESULTS: We identified 20 children (mean [standard deviation] age, 9.7 [5.8] years; 14 [70%] girls) with upper gastrointestinal symptoms who underwent IPBTI at our institution during the study period. Of the 20 children, 17 (85%) underwent gastric emptying scintigraphy, only nine (53%) of whom had gastroparesis. Response to IPBTI was reported in ten children (50%). Response to IPBTI did not differ by the presence of gastroparesis in included children (p = 0.64). Repeated IPBTI was performed in four children who had a response to the first injection; all four reported no benefit from the second IPBTI. There were no reported complications of IPBTI in our cohort. The meta-analysis indicated that 68% (95% confidence interval 59-78) of patients had a response to IPBTI, regardless of the presence of gastroparesis; 66% (95% confidence interval 53-78) of patients who had gastroparesis had a response to IPBTI. CONCLUSIONS: Intrapyloric botulinum toxin A injection is safe in children and can offer transient relief for patients with refractory upper gastrointestinal symptoms with and without gastroparesis.

Markers of Bile Acid Metabolism in Pediatric Diarrhea Predominant Irritable Bowel Syndrome and Healthy Controls.

OBJECTIVES: Excessive fecal bile acids in adults have been associated with diarrhea-predominant irritable bowel syndrome (IBS-D), but their role in pediatric IBS-D is unknown. Serum markers including 7α-hydroxy-4-cholesten-3-one (C4) and fibroblast growth factor-19 (FGF-19) were validated in adults to detect bile acid diarrhea (BAD) compared to 48-hour fecal bile acid collection (48FBA). Our aims were to assess fasting serum C4 and FGF-19 and 48FBA in a pediatric population, to compare measurements in IBS-D patients and healthy controls (HC), and to determine the prevalence of BAD among children with IBS-D. METHODS: Using a cross-sectional design, 26 patients with IBS-D and 56 HC were recruited in two pediatric tertiary care centers. Fasting serum C4 and FGF-19 and 48FBA were obtained. Participants completed a 7-day bowel diary coinciding with stool collection. Associations were analyzed using Spearman correlations. RESULTS: Mean age was 14.7 ±â€Š2.5 years (42.3% female) in IBS-D and 12.6 ±â€Š2.4 years (39.3% female) in HC. There was a significant correlation of C4 with 48FBA (r = 0.48, P < 0.05) and an inverse association with FGF-19 (r = -0.43, P < 0.05). No significant differences were noted in C4 (P = 0.32), FGF-19 (P = 0.1), or 48FBA (P = 0.5) between IBS-D and HC groups; however, 20% of IBS-D patients had elevated C4 and 28% had low FGF-19 values.Fecal primary BA was significantly correlated with stool frequency (r = 0.45, P < 0.002). CONCLUSIONS: Correlations of C4 with 48FBA and FGF-19 are confirmed in a pediatric population. Twenty percent of pediatric patients with IBS-D had abnormal fasting serum C4. This serum test could be applied to identify BAD in pediatric IBS-D.

Gastrointestinal motility evaluation in children with orthostatic intolerance: Mayo Clinic experience.

OBJECTIVE: Orthostatic intolerance (OI) and autonomic dysfunction (AD) are common in adolescents and young adults. Patients experience multisystem symptoms including gastrointestinal (GI), postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension (OH), or only symptoms of OI (SOI) without significant findings on 70-degree head-up tilt testing (HUT). We hypothesize that patients with POTS, OH, and SOI show differences in GI symptoms and motility test and that heart rate (HR) changes on HUT predict severity of GI dysmotility. STUDY DESIGN: From medical records of patients (<18 years) with OI, we collected demographics, presenting symptoms, GI manifestations, and GI motility testing. Data were compared between the 3 groups (POTS, OH, and SOI). We assessed changes in HR on HUT with changes on GI motility evaluation. RESULTS: Two hundred twenty-nine patients were included (73% females). Abdominal pain (65%), nausea (49%), vomiting (18%), and constipation (24%) were the most common GI symptoms. In patients who had motility evaluation, there were 27% (53/193) with delayed gastric emptying (GE) at 4 hours, 35% (32/92) with delayed colonic transit (CT), 55% (17/31) with reduced gastric accommodation (GA), and 75% (21/28) with dyssynergic defecation (DD). Among 100 POTS, 34 OH, and 95 SOI patients, no significant differences in GI symptoms or motility tests were identified and HR changes on HUT were not associated with changes on motility tests. CONCLUSION: GI symptoms are frequent in adolescents with OI and are associated with delayed GE, reduced GA, delayed CT, and presence of DD.

The Role of Oral Administration of Immunoglobulin in Managing Diarrheal Illness in Immunocompromised Children.

INTRODUCTION: Immunocompromised children are susceptible to infectious diarrhea. Oral administration of human serum immunoglobulins to treat immunocompromised patients with viral gastroenteritis caused by viruses like rotavirus and norovirus has been reported. OBJECTIVE: The aim of this study was to assess the efficacy of oral immunoglobulin (OIG) in treating hospitalized immunocompromised children with diarrheal illness. METHODS: We conducted a retrospective cohort review of the Mayo Clinic electronic medical records from January 1, 2005, through April 30, 2019. We included children who were immunocompromised and received OIG as a treatment for a diarrheal illness that was classified as acute (< 4 weeks) or chronic (> 4 weeks) at the time of their treatment. Response to therapy was defined by 50% reduction in stool output. RESULTS: Nineteen children were identified (11 males); average age at the time of treatment was 11 (0.25-18) years. In the acute diarrhea cohort, the mean duration of symptoms was 9.5 days (4-21). In the chronic diarrhea cohort, the mean duration of symptoms was 41 days (28-90). All 19 children were treated with OIG with doses in the range of 100-300 mg/kg/day for 1-5 days. Eighteen patients (95%) had improvement. Overall average time to response was 3.1 (1-9) days after receiving the OIG. CONCLUSION: Oral administration of human serum immunoglobulin in immunocompromised children presenting with acute and chronic diarrheal illness appeared helpful in reducing stool output by 50% in the majority of patients.

Application of Pyridostigmine in Pediatric Gastrointestinal Motility Disorders: A Case Series.

BACKGROUND: Gastrointestinal (GI) motility disorders are common in children. Treatment is challenging with limited medical and surgical options. Pyridostigmine, an acetyl cholinesterase inhibitor, increases acetylcholine at the neuromuscular junction promoting intestinal contractions. Little is known about the role and dosing of pyridostigmine in pediatric GI motility disorders. METHODS: We present a case series of children with GI dysmotility managed with oral pyridostigmine. Patients' diagnoses include chronic intestinal pseudo-obstruction, gastroparesis with delayed small bowel transit, chronic constipation with failure to thrive, and prolonged ileus after pelvic surgery with chronic opioid use. RESULTS: Pyridostigmine was effective and safe in all cases. Pyridostigmine decreased abdominal distention, increased bowel movement frequency, and improved enteral feeding tolerance. Effective dosing ranged between 0.25-2.0 mg/kg/day. One patient experienced cramping abdominal pain while on pyridostigmine, but pain resolved after medication was discontinued. CONCLUSION: We found oral pyridostigmine to be helpful in children with different GI motility problems. Pyridostigmine should be considered in such patients when other treatment interventions have not been beneficial.

Feasibility and application of 3-dimensional ultrasound for measurement of gastric volumes in healthy adults and adolescents.

OBJECTIVES: Abnormal gastric accommodation to a meal results in dyspepsia. Current methods to measure gastric volume (GV) are invasive or involve ionizing radiation. The aims of this study were to compare fasting and postprandial (PP) GVs measured by (99m)Tc-single photon emission computed tomography (SPECT) and 3-dimensional ultrasound (3D-US) in adults, to assess the performance characteristics of 3D-US measurement of GV during fasting and postprandially, and to develop normative data of GVs in 24 healthy adolescents. PATIENTS AND METHODS: Eleven adults underwent SPECT and 3D-US simultaneously to measure GV, and a second 3D-US alone within 1 week of the first study. Twenty-four adolescents underwent 1 3D-US measurement. Each study included fasting, a 300-mL Ensure meal, and 0 to 30-minute PP GV measurements. RESULTS: 3D-US identifies GV accommodation to 300mL Ensure. Delta (0-30 minutes average PP fasting) GV was 444mL (median, interquartile range [IQR]=422, 534) for 3D-US and 543mL (median, IQR=486, 564) for SPECT (P=0.15). There were larger interindividual coefficients of variation for GV by 3D-US (60.3% fasting and 21.3% average PP) compared with 19% fasting and 9.2% PP for SPECT. Intraindividual coefficients of variation for the 2 3D-US measurements in adults were 84% fasting and 44% average PP. The estimated GVs for the adolescent group (median [25th-75th IQR]) were 33 (18-53)mL fasting, 330 (284-357)mL 30 minutes PP, and 281 (240-324)mL for delta GV. CONCLUSIONS: 3D-US is a promising method to measure GV accommodation to a meal. Large coefficients of variation reflect the learning stage in development of this promising technique.