Brain Abscess due to Streptococcus intermedius after Spontaneous Esophageal Perforation in an Adolescent.

Streptococcus intermedius is an inhabitant of the oral cavity and gastrointestinal tract, known to cause deep-seated abscesses. Thereby, we present a previously healthy adolescent with esophageal perforation (EP) and secondary mediastinal and brain abscesses due to Streptococcus intermedius. EP is a potentially life-threatening condition that requires a prompt diagnosis.

Rumination Syndrome and Dental Erosions in Children.

Rumination syndrome is the effortless regurgitation of recently ingested food with subsequent reswallowing or spitting out. Dental erosion (DE) affects 2% to 5% of the population. DE is defined as loss of tooth structure by a chemical process that does not involve bacteria. Our objective was to compare the frequency of DE among children with rumination syndrome with healthy controls. We enrolled 30 patients 4 to 21 years of age diagnosed with rumination syndrome, and 30 age- and sex-matched healthy control subjects. Patients were evaluated by pediatric dentists for presence of DE with Taji et al a validated grading system. Patients with rumination were more likely to have DE (P < 0.001). Of patients with rumination syndrome, 23 (77%) had DE, compared with 4 (13%) control subjects. DEs are more frequent in patients with rumination syndrome.

Functional Gastrointestinal Disorders Dominate Pediatric Gastroenterology Outpatient Practice.

OBJECTIVES: Symptom-based diagnostic criteria have improved recognition and standardization of pediatric functional gastrointestinal disorders (FGIDs). We used Rome 3 diagnostic criteria to determine the prevalence of FGIDs in pediatric gastroenterology clinic. In the process, we developed a diagnostic questionnaire for infants and toddlers. METHODS: We enrolled new patients ≤18 years referred during 19 months to a pediatric gastroenterology clinic. Subjects or parents completed a demographic survey and a the Questionnaire on Pediatric Gastrointestinal symptoms, Rome 3 Version (if ≥4 years, or a new infant-toddler questionnaire) before their appointment. RESULTS: We acquired data from 976 subjects: 476 boys, 592 white. Of 332 subjects <4 years, 172 (52%) met diagnostic criteria for ≥1 FGIDs. Of 644 subjects ≥4 years, 486 (75%) met diagnostic criteria for ≥1 FGIDs. Thirty one (9%) subjects <4 years and 170 (26%) subjects ≥4 years met the criteria for ≥2 FGIDs. Of the total sample of subjects <4 years, common FGIDs included functional constipation (29%), infant regurgitation (13%), and cyclic vomiting syndrome (10%). Of the total sample of subjects ≥4 years, common FGIDs included irritable bowel syndrome (36%), abdominal migraine (19%), functional constipation (17%), cyclic vomiting syndrome (8%), functional abdominal pain syndrome (7%), aerophagia (7%), and functional dyspepsia (7%). CONCLUSIONS: More than half of new pediatric gastrointestinal clinic patients met the Rome 3 criteria for ≥1 FGIDs. Satisfying the criteria may facilitate diagnosis on the first visit.

Eliminating Rumination in Developmentally Disabled Children: A Case Report.

Rumination is the effortless regurgitation of food, with subsequent spitting out or rechewing and reswallowing. In developmentally delayed children, rumination is a pleasurable, self-stimulating habit. For 3 years, we evaluated and treated 2 nonambulatory, nonverbal 4-year-old children who ruminated frequently while awake. The social isolation caused by a child covered in regurgitated food prompted caregivers of these children to find a solution. We hypothesized that rumination would cease if the stomach stayed empty of food. We intervened by placing gastrojejunostomy tubes and then initiated continuous drip jejunal tube feedings over 12 waking hours to reduce hunger; the children's oral diet was also stopped. In both cases, these changes reduced episodes of rumination to 3 to 5 times daily. To eliminate rumination, unpleasant tasting substances (N-acetylcysteine or cayenne pepper-based hot sauce) were given through the gastrostomy tube every 4 hours while the children were awake. Within 1 week of adding the unpalatable substances, rumination ceased. After 2 months of no rumination, 1 mother restarted oral feeding. There was no recurrence of rumination, and 3 months after gastrojejunal tube placement, the tube was removed. In 1 year of follow-up, rumination did not recur. The second mother was pleased with the outcome with jejunal feedings and chose not to resume oral feedings. These results showed that jejunal tube feeding in combination with insertion of unpalatable contents into the stomach eliminated rumination in these developmentally delayed children.

Effect of colon transection on spontaneous and meal-induced high-amplitude--propagating contractions in children.

BACKGROUND: After Hirschsprung disease (HD) surgery, many children experience fecal incontinence caused by increased number of high-amplitude-propagating contractions (HAPCs) through the neorectum to the anal verge. The aim of this study was to determine whether children with HD have more HAPCs than children with colon transections for reasons other than HD. METHODS: We reviewed 500 colon manometries. Children (age 7.6 ±â€Š5.1 years, 275 boys) with functional constipation (n = 237, age 7.4 ±â€Š5.0 years, 126 boys) and chronic abdominal pain (n = 48, age 9.8 ±â€Š5.8 years, 25 boys) served as controls compared with subjects with HD (n = 56, age 6.9 ±â€Š4.1 years, 44 boys) and colon transection for other reasons (n = 24, age 6.1 ±â€Š5.8 years, 12 boys). We excluded 139 subjects without HAPCs. We documented HAPCs during 1-hour fasting and 1-hour postprandial. Results are in mean ±â€ŠSD. RESULTS: During fasting, HD subjects had more HAPCs (2.2 ±â€Š3.4/hour) versus functional constipation (0.8 ±â€Š2.2/hour, P = 0.0004) and chronic pain (0.5 ±â€Š1.1/hour, P = 0.001), but not more than colon transection (1.9 ±â€Š3.2/hour, P = 1.0). HD showed more postprandial HAPCs (4.0 ±â€Š5.4/hour) than functional constipation (1.5 ±â€Š2.5/hour, P < 0.0001) and chronic pain (0.9 ±â€Š1.6/hour, P < 0.0001), but not more than colon transection (2.4 ±â€Š3.0/hour, P = 0.6). There were more HAPCs fasting and postprandial after colon transection (1.9 ±â€Š3.2/hour and 2.4 ±â€Š3.0/hour) than functional constipation (0.8 ±â€Š2.2/hour, P = 0.3 and 1.5 ±â€Š2.5/hour, P = 1.0) and chronic pain (0.5 ±â€Š1.1/hour, P = 1.0 and 0.9 ±â€Š1.6, P = 1.0). HD subjects were divided by chief complaint: fecal incontinence or constipation. HD subjects with incontinence (n = 23) only had more HAPCs fasting (P = 0.01) and postprandial (P = 0.01) than HD subjects with constipation (n = 28) only. CONCLUSIONS: Increased HAPCs followed colon transection, regardless of a cause. HD subjects with incontinence had more HAPCs than subjects with colon transection for other reasons.

Colon manometry proves that perception of the urge to defecate is present in children with functional constipation who deny sensation.

BACKGROUND AND OBJECTIVE: Children with functional constipation often state an inability to sense an urge to defecate and/or inability to feel incontinence. We used colon manometry to assess whether there was a sensory abnormality in patients who denied sensation. METHODS: A physician observed all of the colon manometries in the preceding 20 years, and included behavioral observations in the procedure reports. We reviewed the charts of these patients. RESULTS: Of 150 subjects with normal manometry and a diagnosis of functional constipation, 56 volunteered that they had no urge to defecate or complained of abdominal pain. For all who denied sensation, the first high-amplitude propagating colonic contraction (HAPC) was associated with retentive posturing and facial grimaces. When queried, all reported they felt nothing. The examiner explained the HAPC was causing pain, and informed the child that the pain would resolve if they defecated. With subsequent HAPCs, every patient acknowledged an urge to defecate and successfully defecated. Most agreed that a similar pain sensation was present daily, but was misinterpreted to be abdominal pain. CONCLUSIONS: Colon manometry may be useful not only for objective findings to discriminate neuromuscular disease from functional symptoms but also to understand psychological issues and aid in helping the child and family understand the maladaptive behaviors in functional constipation.