Pneumatosis intestinalis and diarrhea in a child following renal transplantation.

Pneumatosis intestinalis is an uncommon finding beyond the neonatal period, but it has been reported in immunocompromized pediatric patients. The association of pneumatosis intestinalis in children following renal transplantation has to the best of our knowledge been only reported once in children. We describe a 4-year-old female who developed intermittent emesis, weight loss, and intermittently loose bloody stools after cadaveric renal transplantation at age 3.5 years. An abdominal x-ray demonstrated extensive pneumatosis in the colon. The infectious work-up was negative. Histologically, she had increased eosinophils throughout the lamina propria in the rectum. A glucose breath test was suggestive of small bowel bacterial overgrowth. She was treated with 10 days of metronidazole with resolution of the diarrhea and occult blood in stools. One month after the treatment she had radiologic resolution of her pneumatosis. Based on this report, pneumatosis intestinalis should be considered in the differential diagnosis of children after organ transplant suffering from diarrhea, abdominal pain, or blood in the stool.

Autonomic abnormalities in children with functional abdominal pain: coincidence or etiology?

BACKGROUND: There is increasing evidence that autonomic neuropathies may adversely affect gastrointestinal motility by involving the extrinsic nerves of the gut. The authors' hypothesize that functional abdominal pain in children is associated with generalized autonomic dysfunction. METHODS: The authors performed detailed autonomic testing in eight patients with functional abdominal pain, including deep breathing, Valsalva, tilting (to assess parasympathetic and sympathetic adrenergic function), and axon-reflex function and thermoregulatory sweat testing to assess sympathetic cholinergic function. Patients also completed a questionnaire regarding other autonomic symptoms. RESULTS: Results of autonomic testing were abnormal in seven patients. Parasympathetic function was normal in all, and the abnormalities were restricted to sympathetic cardiac, vasomotor, and sudomotor function. Abnormal results of axon-reflex testing in six were consistent with peripheral nervous system dysfunction. Five had decreased sweating over the abdomen, determined by thermoregulatory sweat testing. Five eight had nongastrointestinal autonomic symptoms, primarily palpitations and flushing. CONCLUSIONS: Functional abdominal pain in the current patients is associated with generalized dysfunction of the autonomic nervous system. This dysfunction can be peripheral or central in different individuals but seems to be restricted to the sympathetic branch. The known function of the sympathetic nervous system as the motility "brake" suggests that pain could be a manifestation of unmodulated peristalsis, resulting in abdominal cramps.

Techniques for the evaluation of dyspepsia in children.

Dyspepsia can describe a subset of children with episodic or persistent abdominal symptoms--often related to feeding--that are thought to be caused by disorders of the proximal part of the digestive tract. Symptoms, such as vomiting, early satiety, postprandial epigastric abdominal pain, heartburn, abdominal fullness, poor weight gain, and/or anorexia, have been incorporated into the definition of dyspepsia. Unfortunately, presenting signs and symptoms in children with dyspepsia are nonspecific and can occur as a result of many diseases, such as parasitic infections, esophagitis, eosinophilic gastroenteritis, Helicobacter pylori infection, Crohn's disease, biliary tract or hepatic disease, pancreatitis, and lactose intolerance. This lack of specificity makes the evaluation of dyspepsia more difficult. Here, we describe an approach for the evaluation of dyspepsia that correlates in part with the child's presenting symptoms.

Familial association of autonomic and gastrointestinal symptoms.

Autonomic dysfunction occurs in the adult population with irritable bowel syndrome, but this association is not recognized in children. A mother and son with functional abdominal pain unresponsive to conventional treatment had complete resolution of symptoms with treatment directed at the autonomic dysfunction identified by testing. The authors recommend autonomic testing in patients with functional abdominal pain and suggest that autonomic dysfunction plays a direct and intrinsic role in the mechanism of these disorders and their symptoms.

Helicobacter pylori infection in children: update.

Despite its worldwide distribution, the pathogenesis of Helicobacter pylori associated gastroduodenal disease remains poorly understood. What is clear is that H. pylori infection rarely resolves spontaneously and that the chronic gastritis that accompanies infection is typically maintained for the duration of infection. Ultimately, if untreated, this chronic inflammation predisposes a subset of individuals to develop gastric or duodenal ulcers and even gastric cancer. Chronic long-lasting H. pylori infection, particularly when acquired early in childhood, can predispose an individual to a significantly increased risk of developing gastric cancer. These studies were so compelling that the World Health Organization has recently classified H. pylori as a type 1 human carcinogen. Since the discovery of H. pylori less than 20 years ago, this infection has continued to generate considerable interest in the medical and scientific community. As we enter the new millenium, there are now a number of effective treatments for children in whom H. pylori-associated peptic ulcer disease is diagnosed. Although there is now overwhelming evidence to confirm that H. pylori plays an etiologic role in the development of peptic ulcer disease, only a small number of these children develop H. pylori disease. In this review, we highlight some of the recently published pediatric studies addressing the role H. pylori plays in the development of gastroduodenal disease in children.

Allergic colitis presenting in the first day of life: report of three cases.

Allergic colitis can occur within hours of birth and should be considered in the differential diagnosis of any newborn in whom hematochezia develops. This diagnosis should be considered after excluding infectious and anatomic disorders common to this age group. The diagnosis is supported by the healthy appearance of affected infants and specific proctosigmoidoscopic and histopathologic findings. Infants with allergic colitis usually respond to withdrawal of the offending antigen, by the use of hydrolyzed cow's milk protein formula or more elemental formulas, or if the infant has been breast fed, by the strict removal of the offending antigen from the breast-feeding mother's diet.

Urethral atresia and the prune belly syndrome. Report of 6 cases.

An association between urethral atresia and the prune belly syndrome (PBS) has been recognised, but few reports discuss the outcome of treatment for these gravely ill patients. Of the 34 patients with prune belly syndrome evaluated at our institutions, 6 had urethral atresia (3 males and 3 females). Two of these patients died as neonates as a result of pulmonary insufficiency and 1 was stillborn. The common feature of the 3 surviving patients (2 males and 1 female) was the presence of a vesicocutaneous fistula. As neonates, 2 suffered from pulmonary insufficiency due to oligohydramnios. The mean length of follow-up for these 3 patients was 37 months (range 13-58). The urinary tract was decompressed in 2 patients by a formal vesicostomy performed early in life. The surviving girl has normal renal function following reconstructive surgery. Because both the bladder and urethra were absent in this patient, an ileocaecal bladder substitute and an appendiceal urethra were constructed. The 2 surviving boys both have renal insufficiency. One has received a renal transplant from a living relative and is doing well. In one of the boys, urethral atresia was initially managed by perineal urethrostomy and then by reconstructive surgery. Progressive catheter dilation was used on the other boy. Urethral atresia occurred in 18% of our patients with PBS; the incidence was equal in males and females. Survival correlated with the development of a spontaneous vesicocutaneous fistula. Two-thirds of the survivors developed end-stage renal failure.