A severe bleeding diathesis in a 6-year-old girl secondary to a composite diagnosis of splenic hemangiomatosis and small bowel lymphangiomatosis.

A 6-year-old girl presented with presumed relapse of childhood immune thrombocytopenia. Investigations revealed deranged coagulation parameters, abnormal small bowel thickening, and splenomegaly. A clinically significant bleeding diathesis emerged which was refractory to most hemostatic interventions. Laparatomy revealed a composite diagnosis of splenic hemangiomatosis and small bowel lymphangiomatosis. Splenectomy resulted in complete resolution of the coagulopathy. The diagnosis and management of these conditions is inherently complex and without clear guidance. We discuss our perioperative management of the bleeding diathesis. There is a need for long-term follow-up of the underlying pathologies particularly as potentially useful therapeutic agents have emerged.

Total Jejunoileal Intussusception: A Case Report and Literature review.

Small bowel intussusceptions are much less common than the ileocolic type, with jejunoileal intussusceptions being amongst the most rare1. We review the literature on small bowel intussuception, using a case of an 11-year-old girl with a jejunoileal intussusception involving the whole of the small bowel, from the level of the duodenojejunal flexure to the ileocaecal valve, as an illustrative history. The typical CT features of an intussusception and value of CT with regard to identification of complications are highlighted.

Peroperative Gastrograffin bowel lavage in gastroschisis.

AIMS: The aim of the study was to evaluate potential benefits in the use of peroperative bowel lavage with Gastrograffin in neonates with gastroschisis. METHODS: A retrospective analysis of newborns with gastroschisis was performed over a 10-year period in 2 centers in the United Kingdom. Two groups were studied wherein one had peroperative bowel lavage with Gastrograffin and the other did not. RESULTS: Data were collected on 116 patients of whom 93 were suitable for analysis. There were no statistically significant differences in primary closure rate, duration of ventilation, parenteral nutrition, or hospital stay. Intestinal obstruction occurred more frequently in the nonlavage group. CONCLUSION: Gastrograffin lavage peroperatively in gastroschisis offers no potential advantage in reducing ventilatory requirements, parenteral nutrition, and hospital stay. It also does not achieve greater primary closure rates, but may reduce the incidence of intestinal obstruction.

Pepsin in bronchoalveolar lavage fluid: a specific and sensitive method of diagnosing gastro-oesophageal reflux-related pulmonary aspiration.

OBJECTIVES: Gastro-oesophageal reflux (GOR)-related aspiration is associated with respiratory disease, but the current "gold standard" investigation, the lipid-laden macrophage index (LLMI), is flawed. A specific marker of GOR-related aspiration should originate in the stomach, but not the lung. An assay to detect gastric pepsin in the bronchoalveolar lavage (BAL) of children was developed and validated. METHODS: Gastro-oesophageal reflux was diagnosed in 33 children using intra-oesophageal pH monitoring. Thirteen asymptomatic negative controls requiring endotracheal intubation for elective surgery and 5 positive control patients with observed aspiration were recruited. All subjects received a BAL; the fluid obtained was analysed for the pepsin content and the LLMI. RESULTS: All subjects in the negative control group were negative for pepsin. The positive control group had a significantly greater median pepsin level (P < .01) compared with negative controls. Patients with proximal oesophageal GOR and chronic cough also had significantly elevated pepsin levels (P = .04). The LLMI was not significantly elevated by the presence of cough or GOR. CONCLUSIONS: This study suggests that GOR-related aspiration plays a role in chronic cough in children with known GOR. Detecting pepsin in BAL fluid may therefore become an important adjunct in patient selection for antireflux surgery.

Investigating painless rectal bleeding--is there scope for improvement?

INTRODUCTION: Most patients with recurrent painless rectal bleeding warrant endoscopic examination of the lower gastrointestinal tract. This is often limited to rectum or distal colon. The purpose of this study was to compare the diagnostic yield of limited colorectal endoscopy with total colonoscopy in children with recurrent painless rectal bleeding. METHODS: Retrospective review of 314 patients aged 1 to 15 years who underwent colorectal endoscopy for recurrent rectal bleeding. Two hundred six underwent total colonoscopy, whereas 108 patients had endoscopy limited to the rectum in 22, sigmoid colon in 34, descending colon in 43, and transverse colon in 9. Diagnoses were recorded according to the endoscopic and histological findings. RESULTS: After total colonoscopy, a diagnosis was established in 70% of children compared with 35% of those undergoing limited endoscopy (P < .001). This difference was most noticeable in children with inflammatory bowel disease. Juvenile polyps were diagnosed with similar frequency in both groups, reflecting the rectosigmoid distribution of most polyps. CONCLUSIONS: For children presenting with painless rectal bleeding, a diagnosis can be established in the majority if total colonoscopy is performed. This is particularly true for inflammatory bowel disease. Unless a rectal polyp is suspected, full colonoscopy should be planned.

Nonulcer dyspepsia and Helicobacter pylori eradication in children.

BACKGROUND: Controversy exists over Helicobacter pylori eradication therapy in the treatment of patients with nonulcer dyspepsia. The lack of pediatric studies has made it difficult to draw conclusions about the use of eradication in dyspeptic children. The aim of this study was to examine long-term symptom severity in pediatric patients with nonulcer dyspepsia and H pylori gastritis after H pylori eradication. METHODS: Thirty-nine children (mean age, 9.0 years) with dyspepsia and H pylori gastritis were prospectively recruited. Severity of symptoms was graded before H pylori eradication. Each patient was followed up at 6, 12, and on average, 61.6 months after eradication, with reassessment of symptoms and H pylori status. RESULTS: There was a significant reduction in the severity of symptoms at 6 and 12 months, and at long-term follow-up compared with the preeradication scores (all P < . 001). At long-term follow-up, reinfection with H pylori was associated with more severe symptoms than if the patients remained free of infection (P = .045). CONCLUSIONS: This study has demonstrated a significant long-term improvement in nonulcer dyspepsia in children after eradication of H pylori. This provides further evidence for the consideration of H pylori eradication in pediatric patients presenting with nonulcer dyspepsia.

Hypopharyngeal and distal esophageal pH monitoring in children with gastroesophageal reflux and respiratory symptoms.

PURPOSE: Fundoplication is frequently required for gastroesophageal reflux (GER)-related respiratory disease. Correlation between esophageal pH data and respiratory symptoms is poor but may be improved by monitoring hypopharyngeal pH. Reflux to the hypopharynx is underestimated by salivary bicarbonate. The aim of this study was to determine if hypopharyngeal pH monitoring using pH 4 and pH 5 as reflux thresholds could predict children with reflux-related respiratory disease. METHODS: One hundred five children aged 4 months to 12 years underwent esophageal and hypopharyngeal pH monitoring. Hypopharyngeal pH data were analyzed using pH 4 and pH 5 as reflux thresholds. pH data from 4 groups were compared: group A, control group, no GER, no respiratory symptoms (n = 20); group B, respiratory symptoms, no GER (n = 16); group C, GER, no respiratory symptoms (n = 26); and group D, both GER and respiratory symptoms (n = 37). RESULTS: Comparing groups C and D, there was no significant difference in hypopharyngeal pH data. Using pH 5 as the reflux threshold, children in group B refluxed to the hypopharynx significantly more frequently than controls. This was most evident in children with wheeze. CONCLUSION: Hypopharyngeal pH monitoring does not differentiate children with GER and respiratory symptoms from those with GER alone and is therefore of doubtful value in diagnosing recurrent aspiration.

Do major televised events affect pediatric emergency department attendances or delay presentation of surgical conditions?

OBJECTIVE: To investigate whether major televised sporting events influence the level of attendance at a pediatric emergency department or reduce subsequent surgical admissions. METHODS: A retrospective analysis of the number of emergency department attendances and subsequent surgical admissions on nights of televised Champions League soccer games, a major pan-European soccer tournament, was made. These figures were compared with paired nights with no live soccer television broadcast. RESULTS: In total, 2560 children and their care providers attended the emergency department between 5 PM on nights of televised Champions League soccer games and 9 AM the next morning (mean 40.0 per night, standard deviation 6.3). Out of these children, only 85 were subsequently admitted to the pediatric surgical department (mean 1.3 per night, standard deviation 1.1). There was no significant difference between these figures and the levels of attendance or admission on paired nights without a live broadcast. CONCLUSIONS: We have demonstrated that the live broadcast of soccer games from a major sporting tournament does not significantly decrease emergency department workload. In addition, it does not reduce the number of children who require admission to a pediatric surgical department. This suggests that the staffing organization of a pediatric emergency department cannot be altered on the basis that a major sporting tournament is being televised.

Risk factors for Helicobacter pylori infection in children: an examination of the role played by intrafamilial bed sharing.

BACKGROUND: The exact mode of transmission of Helicobacter pylori is yet to be established. Close personal contact among family members appears to be a key factor. The aim of this study was to establish whether sharing a bed or bedroom with an infected family member is an important risk factor for primary childhood H. pylori infection. METHODS: Fifty-two families with at least 1 child (the index case) with H. pylori infection were recruited. The resultant study population comprised 126 siblings of the index cases. H. pylori infection was established by culture or by histology and urease testing on antral biopsies in index cases and by C-urea breath testing in family members. Data regarding sleeping arrangements within the family were collected. RESULTS: Sharing a bed or bedroom with an infected sibling at the age of 3 years significantly increased the risk of childhood H. pylori infection [odds ratio, 4.84; 95% confidence intervals, 1.54-15.20; P < 0.01 and 3.68 (1.26-10.75), P = 0.017, respectively]. In addition, a child was at significantly increased risk of being infected if his/her mother or father was H. pylori-positive [odds ratio, 2.52; 95% confidence intervals, 1.03-6.13], P = 0.042 and 2.99 (1.04-8.61), P = 0.042, respectively). CONCLUSIONS: Sharing a bed or bedroom with an infected sibling in early childhood increases significantly the risk of childhood H. pylori infection. This provides evidence to support horizontal transmission of H. pylori among siblings.

Total family unit Helicobacter pylori eradication and pediatric re-infection rates.

BACKGROUND: Re-infection with Helicobacter pylori is more common in children than adults, and it is generally accepted that the family unit plays a significant role in primary childhood infection. We investigated whether the family unit plays a significant role in pediatric re-infection and if eradication of H. pylori from the entire family reduces the risk of childhood re-infection. METHODS: Fifty families, each with an H. pylori-infected pediatric index case (mean age 9.48 years), were recruited. A 13carbon urea breath test was performed on all family members in the same house as the index case. Each family unit was randomized into a 'family unit treatment' group (all infected family members treated) or an 'index case treatment' group (index case only treated). RESULTS: At long-term follow-up (mean 62.2 months), there were three re-infected children in the 'index case treatment' group compared with one in the 'family unit treatment' group. The re-infection rate was 2.4% per patient per year in the 'index case treatment' group and 0.7% per patient per year in the 'family unit treatment' group (p = .31). CONCLUSIONS: This study is the first to evaluate the effect of total family unit H. pylori eradication on pediatric re-infection rates and reports the longest period of re-infection follow-up in children. In childhood, re-infection with H. pylori is not significantly reduced by family unit H. pylori eradication.