"Don't put that in your mouth." A Discussion of Button Battery Ingestions in the Pediatric Population.

Ingestions are a problem that plagues the pediatric population and can at times be life threatening. Signs, symptoms, and interventions for button battery ingestion will be summarized for the reader. A case presentation from practice will be given to help enhance readers experience and learning.

Pediatric Esophageal Disorders: Diagnosis and Treatment of Reflux and Eosinophilic Esophagitis.

Gastroesophageal reflux (GER) occurs frequently in infants, generally at its worst at 4 months of age, with approximately two-thirds of infants spitting up daily. GER typically improves after 7 months of age, with only ∼5% of infants continuing to have reflux at 1 year of age. The diagnosis can often be made based on clinical symptoms. Upper GI (UGI) study has low sensitivity and specificity and should not be ordered as a diagnostic test for reflux. UGI study is best for evaluating other anatomic causes of vomiting. GER becomes problematic gastroesophageal reflux disease (GERD) when complications are present, including feeding difficulties and poor weight gain. Conservative treatment and thickened formula can be helpful for treating GERD. Proton pump inhibitors (PPIs) are frequently prescribed for treating reflux. However, studies do not show a definite benefit in infants, and there are potential side effects. Older children with GERD may present with regurgitation, heartburn, chest discomfort, dysphagia, abdominal pain, vomiting, poor appetite, or poor weight gain. Upper endoscopy is considered for children with concerning symptoms, persistent symptoms despite treatment, and relapse of symptoms after treatment. Other esophageal disorders can have a similar clinical presentation as GERD, notably eosinophilic esophagitis (EoE). EoE is a chronic immune-mediated disorder of the esophagus, which may present as dysphagia, food impaction, heartburn, vomiting, abdominal pain, feeding difficulties, or failure to thrive. Diagnosis is made histologically by the presence of esophageal eosinophilia on endoscopic biopsies in the correct clinical setting.

Pediatric Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is a chronic immune-mediated esophageal inflammatory disease that is becoming more widely recognized as a cause of feeding difficulties in infants and young children, as well as gastroesophageal reflux disease (GERD)-like symptoms, dysphagia, and food impaction in children and adolescents. The diagnosis of EoE is clinicopathologic, based on endoscopic, histologic, and clinical findings. Patients with suspected eosinophilic esophagitis require an endoscopy with biopsies. The diagnosis requires the presence of 15 or more intraepithelial eosinophils/HPF in at least one endoscopic esophageal mucosal biopsy. Histology will reveal mucosal eosinophilia isolated to the esophagus, which does not improve following Proton Pump Inhibitor (PPI) trial. Other disorders causing esophageal eosinophilia, such as GERD, celiac disease, Crohn's disease, infection, hypereosinophilic syndrome, achalasia, and drug hypersensitivity must be ruled out. The goals of treatment should include both histologic healing of the esophageal mucosa, as well as resolution of clinical symptoms. Treatment options include food elimination diets, topical steroids, and/or esophageal dilatation. While the understanding of EoE has evolved over the past twenty years, it continues to be a challenging diagnosis due to the clinical and histopathologic similarities to GERD. Much remains to be studied regarding the underlying pathology, as well as appropriate biomarkers to better evaluate response to therapy.

Pediatric Celiac Disease - A Review.

Our understanding of celiac disease is rapidly expanding. Previously thought to be a rare food intolerance, celiac disease is now recognized as a multifactorial autoimmune disorder with a vast array of presentations. Symptoms range from classic diarrhea, weight loss, and abdominal pain to constipation and extra-intestinal manifestations including anemia, elevated transaminase levels, osteoporosis, or aphthous stomatitis. Some cases are "silent" with no apparent symptoms at all. Although endoscopic biopsy and histology findings remain the gold standard for confirmatory diagnosis, serologic testing options continue to advance. Tissue-transglutaminase (tTG) IgA antibody levels alone have shown high sensitivity and specificity in patients over 2 years of age. The mainstay of treatment remains strict lifetime adherence to a gluten-free diet. Further discussion on the prevalence, pathogenesis, presentation, testing, and management of celiac disease will follow.

Cyclic vomiting syndrome.

Cyclic vomiting syndrome (CVS) is characterized by stereotypical episodes of intense vomiting separated by periods where the individual feels completely well. There is a strong link between CVS and migraine headaches, with many overlapping symptoms and similarities in treatment. There are consensus criteria for CVS diagnosis, but there is no specific diagnostic test, and there is often a delay in diagnosis resulting in a high degree of morbidity. Recognizing the CVS vomiting pattern can facilitate earlier diagnosis and treatment, which can greatly improve the quality of life for CVS patients.

Incidence, clinical characteristics, and natural history of pediatric IBD in Wisconsin: a population-based epidemiological study.

BACKGROUND: Epidemiological studies of pediatric inflammatory bowel diseases (IBD) are needed to generate etiological hypotheses and inform public policy; yet, rigorous population-based studies of the incidence and natural history of Crohn's disease (CD) and ulcerative colitis (UC) in the United States are limited. METHODS: We developed a field-tested prospective system for identifying all new cases of IBD among Wisconsin children over an 8-year period (2000-2007). Subsequently, at the end of the study period, we retrospectively reconfirmed each case and characterized the clinical course of this incident cohort. RESULTS: The annual incidence of IBD among Wisconsin children was 9.5 per 100,000 (6.6 per 100,000 for CD and 2.4 per 100,000 for UC). Approximately 19% of incident cases occurred in the first decade of life. Over the 8-year study period, the incidence of both CD and UC remained relatively stable. Additionally, (1) childhood IBD affected all racial groups equally, (2) over a follow-up of 4 years, 17% of patients with CD and 13% of patients with patients with UC required surgery, and (3) 85% and 40% of children with CD were treated with immunosuppressives and biologics, respectively, compared with 62% and 30% of patients with UC. CONCLUSIONS: As in other North American populations, these data confirm a high incidence of pediatric-onset IBD. Importantly, in this Midwestern U.S. population, the incidence of CD and UC seems to be relatively stable over the last decade. The proportions of children requiring surgery and undergoing treatment with immunosuppressive and biological medications underscore the burden of these conditions.

One-day bowel preparation with polyethylene glycol 3350: an effective regimen for colonoscopy in children.

BACKGROUND: Polyethylene glycol (PEG) 3350 is commonly used and has been proven safe and effective for the treatment of chronic constipation and as a 4-day bowel preparation in children. A 1-day PEG 3350 bowel preparation regimen has been recently developed for adults; however, data regarding its use in children are lacking. OBJECTIVE: To evaluate the safety and effectiveness of a 1-day PEG 3350 regimen for bowel preparation in children before colonoscopy. DESIGN: Retrospective review. SETTING: Tertiary-care center. PATIENTS: This study involved all children prescribed a 1-day PEG 3350 bowel preparation regimen before colonoscopy at our center in 2008. INTERVENTION: We reviewed medical records of patients (< or = 18 years of age) who underwent colonoscopy during 2008 and received the 1-day bowel preparation regimen. MAIN OUTCOME MEASUREMENTS: Adequate preparation for colonoscopy, success of colonoscopy, and factors associated with inadequate bowel preparation. RESULTS: Inclusion criteria were met by 272 patients. The median age of the children receiving the 1-day PEG 3350 preparation regimen was 13.7 years (range 1.08-17.92 years). Fifty-two percent were male; 48% were female. The most common indications for colonoscopy included abdominal pain (65%), bloody stools (29%), diarrhea (21%), and weight loss (18%). The 1-day bowel preparation regimen was effective in 253 patients (93%). The indication for colonoscopy, the age of the child, or a history of constipation did not significantly alter the success rate of colonoscopy. LIMITATIONS: A retrospective study at one tertiary-care center. CONCLUSION: The 1-day PEG 3350 bowel preparation regimen is safe and effective and should be considered for use as preparation for colonoscopy in children.