Gastro-oesophageal reflux associated with duodenum inversum: two case reports and a review of the literature.

Gastro-oesophageal reflux disease (GORD) is a very common paediatric disorder and the majority of patients are treated successfully by primary care physicians. Two infants aged 2 months with GORD which did not respond to conventional medical management are reported; they were diagnosed with duodenum inversum. The first infant failed medical management and required Nissen's fundoplication to control his symptoms. The second infant improved on maximizing medical management without the need for a surgical procedure. These two cases highlight the need for further work-up in patients who do not respond to conventional GORD therapy and/or present with atypical clinical symptoms.

Short article: Risk of small intestinal bacterial overgrowth with chronic use of proton pump inhibitors in children.

BACKGROUND: Some theorize that prolonged use of proton pump inhibitors (PPIs) may increase the risk of small intestinal bacterial overgrowth (SIBO). Chronic acid suppression and resultant hypochlorhydria may lead to an altered intraluminal environment, which, in turn, may promote the growth of bacteria in the small intestine. A handful of studies measured the risk of SIBO in adults taking PPIs and obtained mixed results; however, this risk has not been exclusively measured in children. AIM: This study aimed to measure the risk of SIBO in children taking PPI versus those not taking PPI. PATIENTS AND METHODS: This was a prospective cohort study. Evaluation of SIBO was performed using the glucose hydrogen breath test. Patients younger than 18 years of age taking a PPI longer than 6 months were compared with healthy control participants. After ingestion of glucose substrate, breath samples were obtained every 15 min for 2 h. An increase in breath hydrogen or methane above 12 ppm was considered diagnostic of SIBO. RESULTS: Overall, 83 participants were tested, of whom 56 were taking PPIs. SIBO was detected in five (8.9%) of the 56 participants taking PPI versus one (3.7%) of the 27 participants in the control group (P=0.359), with a relative risk of 2.4 (95% confidence interval: 0.29-19.6). CONCLUSION: To our knowledge, this is the first study in the English literature measuring the risk of SIBO in children taking PPIs. Our results indicate a potential risk of SIBO in chronic PPI users; however, this is not statistically significant. This is an important finding as PPIs are readily prescribed for children and are often taken longer than 6 months' duration.

Analysis of the effect of intestinal resection on rat ileal bile Acid transporter expression and on bile Acid and cholesterol homeostasis.

Ileal reclamation of bile salts is mediated in large part by an apical sodium-dependent bile acid transporter (ASBT) located in the terminal ileum. The following studies were performed to elucidate the adaptive response of ASBT to intestinal resection. Two separate series of intestinal resections were performed: 1) limited (25%) ileal and 2) massive (70%) intestinal resection. The boundaries of the resections were varied to examine differences in compensation when variable amounts of endogenous transporter activity were resected. Previously demonstrated supraphysiologic expression of ASBT, which was seen after proximal ileal resection, led to a contraction in the bile acid pool size and a paradoxical reduction in bile acid (cholesterol 7alpha-hydroxylase and sterol 27-hydroxylase) and cholesterol (hydroxymethylglutaryl coenzyme A reductase) biosynthetic enzyme activities. Massive intestinal resection resulted in ileal hypertrophy and an apparently maladaptive specific down-regulation in ASBT protein expression. In this model bile acid pool size correlated with the amount of residual ASBT-expressing terminal ileum. Cholesterol and bile acid biosynthetic enzyme activities were inversely related to bile acid pool size. Adaptive changes in ASBT expression and alterations in bile acid and cholesterol homeostasis are dependent on the type and location of intestinal resection.