Expression of CD25, mast cell markers and T-cell markers in eosinophilic esophagitis.

While eosinophilic esophagitis (EOE) is defined by histologic presence of eosinophils, a few studies have established the presence of mast cells in EOE and even shown their correlation with symptom persistence despite resolution of eosinophils. Expression of aberrant mast cell markers CD25 and CD2 have not been studied in EOE. This study quantifies the number of hotspot cells per high power field expressing CKIT/CD117, tryptase, CD25, CD2 and CD3 by immunohistochemical stains in endoscopic esophageal biopsies of the following three cohorts: (1) established and histologically confirmed EOE, (2) suspected EOE with biopsies negative for eosinophils, and (3) no history of or suspicion for EOE with histologically unremarkable biopsies. In this study, mast cells were highlighted by CKIT and tryptase in EOE, and not seen in other clinically mimicking cases. There were also significantly higher densities of CD25 and pan-T-cell marker staining in EOE cases. These findings suggest an inflammatory cellular milieu in EOE, beyond just eosinophils, that can be demonstrated by immunohistochemistry, and that invite further study into the role that these cells may play in EOE.

Appendiceal inflammation in colectomy is independently correlated with early pouchitis following ileal pouch anal anastomosis in ulcerative colitis and indeterminate colitis.

BACKGROUND: Appendiceal inflammation in colectomy is one of the histologic predictors of pouchitis in ulcerative colitis (UC) following ileal pouch anal anastomosis (IPAA). Fecal calprotectin level has been shown to increase 2 months prior to the onset of pouchitis. We evaluated whether inflammation and calprotectin expression in appendiceal specimens correlate with early-onset pouchitis in UC and indeterminate colitis (IC). MATERIALS AND METHODS: IPAA (2000-2018) cases with appendix blocks available in colectomy specimens were identified (n = 93, 90 UC, 3 IC). Histologic features thought to predict pouchitis were evaluated. The degree of appendiceal inflammation was scored. Calprotectin immunostain was performed on the appendix blocks and the extent of mucosal staining was quantified. Electronic medical records were reviewed for demographics, smoking history, clinical pouchitis, time of onset of pouchitis, and clinical and endoscopic components of the Pouchitis Disease Activity Index (PDAI) score. Follow-up pouch biopsies were reviewed and scored to generate histologic PDAI score, when available. RESULTS: Among the patients with clinical pouchitis (n = 73), moderate to severe appendiceal inflammation independently correlated with earlier pouchitis compared to no/mild inflammation (median time to pouchitis 12.0 vs. 23.8, log rank p = 0.016). Calprotectin staining correlated with inflammatory scores of the appendix (Spearman's rho, r = 0.630, p < 0.001) but not with early pouchitis (p > 0.05). CONCLUSIONS: The presence of moderate to severe appendiceal inflammation at the time of colectomy was associated with a shorter time to pouchitis following IPAA. Calprotectin immunostain may be used to demonstrate the presence of inflammation in the appendix but its role in predicting early pouchitis remains limited.

Pyloric gland metaplasia: Potential histologic predictor of severe pouch disease including Crohn's disease of the pouch in ulcerative colitis.

Crohn's disease of the pouch (CDP) is seen in a subset of ulcerative colitis (UC) patients following ileal pouch-anal anastomosis (IPAA). Histologic or clinical predictors of CDP are unknown. UC patients with subsequent CDP diagnosis were identified. The rationales for the diagnosis, the interval from the initial signs of CDP to the diagnosis, family history and smoking history were reviewed. Archived pathology materials were reviewed for the presence of pyloric gland metaplasia (PGM) and compared with those from UC with similar severity of pouchitis with CDP (matched UC controls), random UC controls, and ileocolectomies from primary CD patients. CDP diagnosis was made in 26 (18.1%) of 144 patients; all of them met commonly used diagnostic criteria for CDP. The diagnosis was rendered on average 15 months after the initial CD-like signs. PGM was found in 58% of CDP, more common than random UC controls but no different from primary CD and matched UC controls. PGM preceded first signs of CD in a subset. Patients with a family history of CD were more likely to develop CDP than those without a family history of any type of inflammatory bowel disease. Smoking status did not affect the likelihood of developing CDP. Finding PGM in proctocolectomy, ileostomy and follow-up biopsies in UC patients post IPAA may warrant close follow up for the potential development of pouchitis. Some of these patients, especially those with family history of CD, may further progress and develop severe disease meeting the clinical diagnostic criteria for CDP.

Review of Abdominal Migraine in Children.

Abdominal migraine is a type of functional abdominal pain disorder that affects 0.2% to 4.1% of children. It consists of paroxysmal, recurrent, and acute abdominal pain attacks with associated symptoms, including pallor, nausea, vomiting, anorexia, headache, and photophobia. In between episodes, patients return to their baseline health. Abdominal migraine is a clinical diagnosis. Its diagnostic criteria are outlined under the Rome IV criteria and the International Classification of Headache Disorders III criteria. Hypothesized contributors to its pathophysiology include a combination of visceral hypersensitivity, gut-brain enteric nervous system alterations, and psychological factors. Treatment is focused on preventive measures and mostly includes nonpharmacologic approaches. Possible pharmacologic treatments include abortive medications used for migraine headaches such as analgesics and antiemetics. Abdominal migraine is likely underdiagnosed and is poorly understood. Individuals who have abdominal migraine report a lower quality of life, rendering it an important diagnosis. The aim of this article is to review the epidemiology, clinical presentation, pathophysiology, diagnosis, and treatment of abdominal migraine in children.

Gastrointestinal Diaphragm Disease With Retained Capsule Endoscope, Associated With Crohn's Disease: A Case Report.

Gastrointestinal diaphragm disease is a rare entity characterized by the formation of thin membranous circumferential mucosal septa, resulting in marked narrowing of the intestinal lumen. The most frequent etiology is the chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs). Idiopathic cases and other possible etiologies have been reported. We present a rare association of diaphragm disease with Crohn's disease in a boy without a history of significant NSAID usage.

Pediatric gastroenterology fellows, class of 2007: how well are they prepared for the future?

OBJECTIVES: Pediatric gastroenterology fellows are expected to acquire skills as clinicians, researchers, and educators. An e-mail survey was conducted to examine training experiences of individual fellows; to understand how graduating fellows rate their abilities as clinicians, researchers, and teachers; and to answer whether the size of a pediatric gastroenterology training program affects a fellow's training and future position choice. MATERIALS AND METHODS: A survey was e-mailed to 76 third-year pediatric gastroenterology fellows. Respondents were ranked according to the size of their training program. RESULTS: Completed surveys were returned by 50 respondents. Of these, 75% planned to pursue careers in academic medicine and 16% in private practice. In all, 68% of trainees participated in some type of basic research and 64% in clinical research. As attending physicians, 22% of fellows hoped to conduct basic science research and 74% clinical research. The majority thought they were competent or proficient teachers, and rated themselves as advanced beginners or competent when asked to evaluate their research skills. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition recommends that fellows perform 100 colonoscopies, 20 liver biopsies, and 5 paracenteses to be considered competent. We found that regardless of program size, 48% of fellows performed fewer than 100 colonoscopies, 62% performed fewer than 20 liver biopsies, and 80% performed fewer than 5 paracenteses. CONCLUSIONS: The majority of fellows will pursue academic careers. Trainees may not be performing sufficient numbers of procedures. The number of procedures performed during fellowship was independent of program size.

A report of two children with Helicobacter heilmannii gastritis and review of the literature.

An 11-year-old boy with epigastric abdominal pain and a 2 year-old girl with failure to thrive underwent esophagogastroduodenoscopy. Endoscopic biopsies from the gastric antrum of both children revealed corkscrew-like spiral bacteria, consistent with the diagnosis of Helicobacter heilmannii infection. H. heilmannii is a rare finding in children and is thought to be present in approximately 0.3% of patients undergoing upper endoscopy. Clinical presentation, gross and histologic appearance, and treatment regimens are discussed. The clinical and histologic features of previously reported cases of H. heilmannii gastritis in children living in the United States are reviewed in table form.