Duodenal tube test in the diagnosis of biliary atresia.

BACKGROUND: Biliary atresia (BA) is the main cause of severe liver damage in infants. Successful surgical treatment is related directly to an early and rapid diagnosis. The aim of this study was to determine specificity, sensitivity, and predictive value of the duodenal tube test (DTT) in the diagnosis of BA in a series of infants with cholestatic jaundice. METHODS: This was a descriptive study of a series of infants with cholestatic jaundice created to validate the sensitivity, specificity, and predictive value of the DTT in the diagnosis of BA. A total of 254 patients were identified from 1988 to 1998. The study cohort included 137 male infants (53.9%), and the mean age on admission was 8.3 weeks +/- 2.47 weeks (standard deviation). Study protocol included liver function tests, liver ultrasound, metabolic screening and serology for viral hepatitis, and toxoplasma, rubella, cytomegalovirus, herpes, and others. A nasoduodenal tube was, placed at the distal duodenum and the fluid was collected for 24 hours. DTT was considered bile positive when yellow biliary fluid was observed; the test was concluded at this time. When no yellow biliary duodenal fluid was observed, the collection was continued for 24 hours and, if negative, was reported as bile negative. The patients with a bile-positive DTT were not explored surgically, and the cholestasis workup was completed. Laparotomy and a surgical cholangiogram were indicated in patients with bile-negative DTT. If BA was verified, portoenterostomy was performed. The gold standard for BA diagnosis was the following: obstruction of the biliary tract confirmed by laparotomy and a surgical cholangiogram, and clinical outcome in patients without laparotomy (followed for a minimum of 18 months). RESULTS: The results are as follows. BA: bile-positive DTT, n = 3; bile-negative DTT, n = 108. No BA: bile- positive DTT, n = 134; bile-negative DTT, n = 9. The following values were also determined: sensitivity, 97.3%; specificity, 93.7%; positive predictive value, 92.3%; and negative predictive value, 98.5%. The final diagnoses were as follows: BA, n = 111 (43.7%); neonatal hepatitis syndrome, n = 103 (40.6%); cholestasis associated with inspissated bile syndrome, n = 13 (5.1%); choledochal cyst, n = 11 (4.3%); galactosemia, n = 9 (3.5%); cirrhosis of unknown etiology, n = 5 (2%), and Alagille syndrome, n = 2 (0.8%). CONCLUSIONS: The data obtained from this series validate the DTT as a useful clinical tool for the differential diagnosis of the infant with cholestasis, particularly for indicating laparotomy and cholangiogram to substantiate BA. This diagnostic test is quick and simple, and offers the clinician valuable information with which to determine whether surgical intervention is necessary.

[Usefulness of endoscopy in the differential diagnosis of hemorrhage of the upper digestive tract in children]. / Utilidad de la endoscopia en el diagnóstico diferencial de la hemorragia del tubo digestivo alto en niños.

One hundred and sixty two patients with upper and intermediate gastrointestinal hemorrhage studied under a prospective protocol are reported. Upper endoscopy revealed lesions of the upper gastrointestinal tract in 137 patients (89%); a barium swallow performed to 92 of them failed to confirm the endoscopic diagnosis in 66 (71.7%). In 99m Tc scan suggested ectopic gastric mucosa in 9 cases; Meckel's diverticulum was confirmed by laparotomy in 7 and gastrointestinal duplication in two of them. Selective mesenteric arteriography demonstrated bleeding ileo-cecal varices in one patient. The main causes of gastrointestinal hemorrhage in the current series were duodenal ulcer (22.8%), esophageal varices (14.8%), stress ulcers (14.2%), reflux esophagitis (7.4%), aspirin-induced gastritis (6.8%), gastric ulcer (5.6%) and ectopic gastric mucosa (5.6%). These diagnosis were characteristically distributed according to pediatric age-groups. The source of bleeding could be detected in 90% of the patients studied. A clinical approach to differential diagnosis of patients with gastrointestinal bleeding is presented.

Cryptosporidium sp in 300 children with and without diarrhea.

Cryptosporidium sp was searched prospectively by means of the Ziehl-Nielsen acid fast staining of stools in 403 samples obtained from patients with diarrhea (n =/152) or other non-gastrointestinal diseases (n =/152) in a six month period. Cryptosporidium was present in 11/304 samples (3.6%), 9 (81%) were taken from patients with diarrhea. Oocysts were detected in 5% of stools form malnourished (II or III) children with diarrhea; 10/11 (91%) with positive-cryptosporidium stools occurred in children less than one year of age. Cryptosporidium was present with increased frequency in malnourished children with diarrhea (p < 0.05).

Gastrointestinal occult hemorrhage and gastroduodenitis in cow's milk protein intolerance.

We are reporting on four infants with cow's milk protein intolerance who presented with hypochromic anemia and occult gastrointestinal hemorrhage. Esophagogastroduodenoscopy revealed erosive gastritis or gastroduodenitis in all cases. Management with a cow's milk-free diet led to a favorable clinical and hematological outcome; the endoscopic inflammatory image disappeared after the cow's milk-free diet trial. Challenge with cow's milk led to gastrointestinal symptoms and to impaired D-xylose absorption. The data presented suggest that some patients with cow's milk intolerance may have gastroduodenitis resulting in occult gastrointestinal hemorrhage and hypochromic anemia.

[Acute infectious gastroenteritis. Etiology and its correlation with clinical manifestations and fecal mucus]. / Gastroenteritis infecciosa aguda. Etiología y su correlación con las manifestaciones clínicas y el moco fecal.

343 children with acute diarrhea were studied from january 1976 to september 1977. Rotavirus was the agent most frequently isolated (18 per cent) followed by Shigella (12 per cent) and Salmonella (10 per cent). Enterotoxigenic E. coli was identified in 8 per cent and invasive E. coli only in two cases. 80 per cent of isolated rotavirus fell in the neonate group and 25 per cent in the infant group. Diarrhea caused by rotavirus had a short duration, fever was negligible and abundant liquid stools were present without leukocytes in the fecal mucus and with a high percentage (48 per cent) of transient lactose intolerance. Polymorphonuclear leukocytes were found in fecal mucus in 75 per cent of cases caused by Shigella and only in 40 per cent of cases where the causal agent was Salmonella.

Prospective study of enteropathogens in children with diarrhea in Houston and Mexico.

During a 22-month period, 595 children with diarrhea and 210 age-matched controls attending clinics in Houston (367 children) and Mexico (438) were prospectively evaluated for enteric pathogens. Enteropathogens associated with disease were Shigella (18%), rotavirus (14%), Salmonella (9%), toxigenic Escherichia coli (6%), and others (12%), including 14 Proteus isolates that caused rounding of adrenal cells. Enteropathogens were isolated from a greater (P less than 0.001) number of children with diarrhea (59%) than from asymptomatic controls (6%). Paired sera tested for antibody to heat-labile toxin of E. coli rarely demonstrated a fourfold rise during episodes of diarrhea. This study demonstrates: (1) more striking illness in children from Mexico; (2) more common occurrence of Shigella in Houston, and of rotavirus and Salmonella in Mexico; (3) lack of seasonal occurrence of rotavirus isolation in either population and a summertime occurrence of Shigella in Houston; (4) lack of toxigenic E. coli isolation in endemic diarrhea of either population; and (5) a significant (P less than 0.001) age-related acquisition of E. coli LT antibodies.

[Proctologic examination in pediatrics]. / Exploración proctológica en pediatría.

The study included 873 rectal examinations carried out in children where inspection, rectal examination and endoscopy were performed in each case. Most examinations were done in children complaining of gastroenterocolitis. Inspection of gluteal, perianal and sacrococcygeal areas was normal in most cases: however, ammoniacal erythema was frequently found (44.2%). Rectal examination showed hypotonicity of the external sphincter in 146 cases which was linked to prolonged diarrhea and malnutrition. At the endoscopy, the rectal mucosa showed ulcerations, congestion, friability, edema and bleeding; however, it was considered normal in 274 occasions. In 540 patients, the endoscopic diagnosis was colitis of different types. In 54 cases, the endoscopic examination, plus the examination of fecal mucus taken directly from the rectal mucosa led to the diagnosis of amebic colitis. In opposition with adults, neoplastic lesions were uncommon and usually corresponded to leukemic infiltration or tumoral metastases. There were no complications attributable to the process.

[Cholestyramine in a case of a prolonged diarrhea after a partial ileocolectomy]. / Empleo de colestiramina en una niña con diarrea prolongada secundaria a ileocolectomía parcial

The author reports the case of a 10 years old female child with history of retrocecal appendicular abscess complicated with terminal ileum and right colon necroses which called for partial ileocoletomy. Following this operation, the patient presented diarrhea which caused a loss in weight of 6 kgs. in two months. Antiacids and diphenoxylate were given with negative results. A low fat diet was then given and the patient recovered 1 kg. in weight, but the diarrhea persisted with high excretion of fats. Thereupon, cholestyramine and a normal diet were given followed, within the next 48 hours, by a remission of the diarrhea; the weight loss was recovered within the next 3 months. At present, the patient is still taking very small doses of cholestyramine with a normal diet.

[Acrodermatitis enteropathic treated with zinc sulfate. Report of a case]. / Acrodermatitis enteropática tratada con sulfato de zinc. Reporte de un caso

A case is reported of a girl with acrodermatitis enteropathica who was treated succesfully with zinc sulfate at 75 mg/day PO. A remarkable increase in weight was evident through the course of 12 months of treatment, reaching the percentile 50 by the age of 3 years; however the height remained close to percentile 3. Possibly, the zinc deficiency is secondary to a selective defect in the metal absorption. Treatment with zinc sulfate in these patients substitutes with greate advantages the use of diiodohydroxyquin. Possibly, zinc supplements must be given for a life time to these patients.

[Intestinal immunoglobulins in children without infection]. / Inmunoglobulinas intestinales en niños sin infección

Immunoglobulins in duodenal content were measured by immunodiffusion in children without infection. Two groups were studied: group I with 11 infants 1 to 35 months old without infectious problems and group II with 14 children 3 to 13 years old who one month previously had suffered typhiod fever. Two groups of commercial plates were used both designed to detect low levels. The plate for values of 1 to 10 mg. % was selected for the study. Secretory IgA (IgAS) was determined using a standard of human colostrum. Total proteins were measured by Biuret's method. The values obtained in Group I were: 2.3 +/- 0.44 for IgAS, 4.9 +/- 1.29 for IgM, 2.3 +/- 1.0 for IgG and 461.09 +/- 160.89 mg. % for total proteins. In Group II, in the same order, the values were: 2.28 +/- 0.59, 3.70 +/- 0.98, 1.57 +/- 0.37 and 333.91 +/- 64.63 mg.%. No sataistically significant difference was found for any of the values mentioned when comparison between the two groups was made; therefore, when values for the two groups were added, the final results were: 2.29 +/- 0.35 for IgAS, 4.23 +/- 0.74 for IgM, 1.89 +/- 0.45 for IgG and 389.86 +/- 70.53 for total proteins. Between serum and intestinal IgA (r = 0.11), there was no correlation. No statistical difference was either found when grouped by sexes or ages (less than 3 and greater than 3 years). It is concluded that the method applied allows the use of very small amounts of the sample, avoids the inconveniences of concentration, is available to any laboratory and permits detection of values as low as 0.5 mg. %.