Epidemiologic trend of pediatric inflammatory bowel disease in Latin America: The Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) Working Group.

INTRODUCTION AND AIMS: The primary aim was to explore the epidemiologic trend of pediatric inflammatory bowel disease in Latin America, and the secondary aims were to obtain an overview of the diagnostic/therapeutic focus of the members of the LASPGHAN and examine the relation of case frequency to year, during the study period. MATERIALS AND METHODS: Latin American pediatric gastroenterologists participated in an online survey, conducted through the SurveyMonkey platform, that investigated the yearly frequency of new inflammatory bowel disease patients within the time frame of 2005-2016, their disease variety, the gastrointestinal segments affected, and the diagnostic and treatment methods utilized. The correlation of new case frequency with each study year was evaluated. RESULTS: A total of 607 patients were studied. The diagnoses were ulcerative colitis in 475 (78.3%) cases, Crohn's disease in 104 (17.1%), and inflammatory bowel disease D unclassified in 28 (4.6%). The trend in ulcerative colitis was a lineal increase in the frequency of new cases related to each study year, with a significant correlation coefficient. Pancolitis was found in 67.6% of the patients. The diagnostic methods included clinical data, endoscopy, and biopsies in more than 99% of the cases, and imaging studies were indicated selectively. Drug regimens were limited to 5-aminosalicylic acid derivatives, azathioprine, 6-mercaptopurine, infliximab, and adalimumab. CONCLUSIONS: Pediatric inflammatory bowel disease in Latin America appears to have increased during the years included in the study period, with a predominance of moderate or severe ulcerative colitis. That lineal trend suggests the predictive likelihood of a gradual increase in the coming years, with possible epidemiologic and clinical implications.

Epidemiologic trend of pediatric inflammatory bowel disease in Latin America: The Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) Working Group. / Tendencia epidemiológica de la enfermedad intestinal inflamatoria en pacientes pediátricos en América Latina: Grupo de Trabajo en Enfermedad Intestinal Inflamatoria, Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP).

INTRODUCTION AND OBJECTIVES: The primary aim was to explore the epidemiologic trend of pediatric inflammatory bowel disease in Latin America, and the secondary aims were to obtain an overview of the diagnostic/therapeutic focus of the members of the LASPGHAN and examine the relation of case frequency to year, during the study period. MATERIALS AND METHODS: Latin American pediatric gastroenterologists participated in an online survey, conducted through the SurveyMonkey platform, that investigated the yearly frequency of new inflammatory bowel disease patients within the time frame of 2005 to 2016, their disease variety, the gastrointestinal segments affected, and the diagnostic and treatment methods utilized. The correlation of new case frequency with each study year was evaluated. RESULTS: A total of 607 patients were studied. The diagnoses were ulcerative colitis in 475 (78.3%) cases, Crohn's disease in 104 (17.1%), and inflammatory bowel disease D unclassified in 28 (4.6%). The trend in ulcerative colitis was a lineal increase in the frequency of new cases related to each study year, with a significant correlation coefficient. Pancolitis was found in 67.6% of the patients. The diagnostic methods included clinical data, endoscopy, and biopsies in more than 99% of the cases, and imaging studies were indicated selectively. Drug regimens were limited to 5-aminosalicylic acid derivatives, azathioprine, 6-mercaptopurine, infliximab, and adalimumab. CONCLUSIONS: Pediatric inflammatory bowel disease in Latin America appears to have increased during the years included in the study period, with a predominance of moderate or severe ulcerative colitis. That lineal trend suggests the predictive likelihood of a gradual increase in the coming years, with possible epidemiologic and clinical implications.

Twenty-four-hour esophageal pH monitoring in children and adolescents with chronic and/or recurrent rhinosinusitis.

Gastroesophageal reflux (GER) disorder was studied in children and adolescents with chronic and/or recurrent rhinosinusitis not associated with bronchial asthma. Ten children with a clinical and radiological diagnosis of chronic and/or recurrent rhinosinusitis, consecutively attended at the Pediatric Otolaryngology Outpatient Clinic, Federal University of São Paulo, were evaluated. Prolonged esophageal pH monitoring was used to investigate GER disorder. The mean age of the ten patients evaluated (eight males) was 7.4 +/- 2.4 years. Two patients presented vomiting as a clinical manifestation and one patient presented retrosternal pain with a burning sensation. Twenty-four-hour esophageal pH monitoring was performed using the Sandhill apparatus. An antimony probe electrode was placed in the lower third of the esophagus, confirmed by fluoroscopy and later by a chest X-ray. The parameters analyzed by esophageal pH monitoring included: total percent time of the presence of acid esophageal pH, i.e., pH below 4 (<4.2%); total number of acid episodes (<50 episodes); number of reflux episodes longer than 5 min (3 or less), and duration of the longest reflux episode (<9.2 min). One patient (1/10, 10%) presented a 24-h esophageal pH profile compatible with GER disorder. This data suggest that an association between chronic rhinosinusitis not associated with bronchial asthma and GER disorder may exist in children and adolescents, especially in those with compatible GER disorder symptoms. In these cases, 24-h esophageal pH monitoring should be performed before indicating surgery, since the present data suggest that 10% of chronic rhinosinusitis surgeries can be eliminated.

Twenty-four-hour esophageal pH monitoring in children and adolescents with chronic and/or recurrent rhinosinusitis

Gastroesophageal reflux (GER) disorder was studied in children and adolescents with chronic and/or recurrent rhinosinusitis not associated with bronchial asthma. Ten children with a clinical and radiological diagnosis of chronic and/or recurrent rhinosinusitis, consecutively attended at the Pediatric Otolaryngology Outpatient Clinic, Federal University of São Paulo, were evaluated. Prolonged esophageal pH monitoring was used to investigate GER disorder. The mean age of the ten patients evaluated (eight males) was 7.4 ± 2.4 years. Two patients presented vomiting as a clinical manifestation and one patient presented retrosternal pain with a burning sensation. Twenty-four-hour esophageal pH monitoring was performed using the Sandhill apparatus. An antimony probe electrode was placed in the lower third of the esophagus, confirmed by fluoroscopy and later by a chest X-ray. The parameters analyzed by esophageal pH monitoring included: total percent time of the presence of acid esophageal pH, i.e., pH below 4 (<4.2 percent); total number of acid episodes (<50 episodes); number of reflux episodes longer than 5 min (3 or less), and duration of the longest reflux episode (<9.2 min). One patient (1/10, 10 percent) presented a 24-h esophageal pH profile compatible with GER disorder. This data suggest that an association between chronic rhinosinusitis not associated with bronchial asthma and GER disorder may exist in children and adolescents, especially in those with compatible GER disorder symptoms. In these cases, 24-h esophageal pH monitoring should be performed before indicating surgery, since the present data suggest that 10 percent of chronic rhinosinusitis surgeries can be eliminated.

Evaluación del conocimiento teórico de la enfermedad celiaca y práctico en la preparación de alimentos sin gluten por parte de los pacientes con enfermedad celiaca / Evaluation of the theoretical knowledge of celiac disease and practical knowledge in preparing gluten-free foods by celiac patients

El presente estudio fue elaborado para evaluar el conocimiento teórico acerca de la EC, cumplimiento de la dieta sin gluten y conocimiento práctico en la preparación de alimentos sin gluten por parte de los pacientes con EC. Se aplicó un cuestionario a los miembros de la Asociación de Celíacos do Brasil (ACELBRA) que recogía información acerca del conocimiento de la EC y cumplimiento de la dieta sin gluten. Fueron colectadas muestras de alimentos preparados en el domicilio de los pacientes con EC y analizado el contenido de gliadina por el método de ELISA. Según las respuestas señaladas en los 289 cuestionarios analizados, la mayoría tenía conocimiento de la EC. En cuanto al cumplimiento de la dieta, 65 por ciento señalaron que nunca comen gluten, 27 por ciento a veces ingieren, 6 por ciento no siguen la dieta y 2 por ciento incorporaron el gluten a la dieta, conforme orientación médica. El análisis de las 108 muestras de alimentos demostró que sólo uno contenía gliadina. Los datos obtenidos hacen suponer que los pacientes con EC tienen conocimiento teórico de la enfermedad y saben preparar alimentos sin gluten. Lamentablemente, a pesar del conocimiento teórico y práctico, 33 por ciento de las respuestas demostró consumo de gluten (AU)

Assessment of gliadin in supposedly gluten-free foods prepared and purchased by celiac patients.

BACKGROUND: The present study was designed to evaluate the presence of gliadin in homemade foods prepared by patients with celiac disease and/or their relatives, as well as in processed products consumed by such patients in São Paulo, Brazil, by enzyme immunoassay (EIA) and Western blot (WB) analysis. METHODS: One hundred ninety samples were analyzed: 108 homemade foods prepared in homes of patients with celiac disease, 81 processed products, and 1 positive control of homemade food. All samples were analyzed by EIA based on monoclonal antibodies to heat stable omega-gliadins and related prolamins from wheat, rye, and barley. Samples were also analyzed using the WB technique. RESULTS: Only one (0.9%) of 108 homemade foods contained detectable amounts of gliadin, as determined by EIA. Twelve of 81 processed products contained gliadin by EIA, as follows: 5 of 61 without gluten listed in the ingredients, 2 of 11 malt extracts, 1 of 2 wheat starches, 1 of 2 types of beer, and all 3 positive control products. Gliadin content of these products was between 4 and 10 mg of gliadin/100 g of product, except for the wheat starch sample (28 mg of gliadin/100 g) and all 3 samples with gluten (>4000 mg of gliadin/100 g). The positive control of homemade food contained 152 mg of gliadin/100 g. One hundred three of 190 samples were analyzed by WB, and 21 of these were gliadin positive. A comparison of results obtained by EIA and WB showed no statistical differences between the methods. CONCLUSIONS: The greater part of the foods prepared in homes of patients with celiac disease and most processed products supposed to be gluten-free did not contain gliadin. Therefore, celiac patients adequately prepare gluten-free homemade food and have the expertise to purchase processed gluten-free food in São Paulo, Brazil.

[Celiac disease: evaluation of compliance to gluten-free diet and knowledge of disease in patients registered at the Brazilian Celiac Association (ACA)]. / Doença celíaca: avaliação da obediência à dieta isenta de glúten e do conhecimento da doença pelos pacientes cadastrados na Associação dos Celíacos do Brasil (ACELBRA).

BACKGROUND: The compliance to a gluten-free diet may prevent the development of both non-malignant and malignant complications. AIM: To evaluate compliance to a gluten-free diet and knowledge of the disease in celiac patients registered at the Brazilian Celiac Association (BCA). METHODS: A structured questionnaire was designed to assess compliance to a gluten-free diet as well as knowledge of the celiac disease. It was mailed to 584 members of BCA. RESULTS: Five hundred and twenty nine (90.6%) of a total of 534 (91.4%) answered questionnaires were analyzed; 69.4% were classified as compliant patients whereas 29.5% were classified as noncompliant. The proportion of patients age 21 or older who consume gluten frequently or without any restriction is larger (17.7%) than those who were younger than 21 years (9.9%). Frequency of dietary compliance was higher when the diagnosis had taken less than 5 years to be established; 82% of the patients replied that the small intestine was the part of the body affected by the disease. The most common symptoms of the disease according to the answers were diarrhea (96.6%), weight loss (93.4%), protuberant abdomen (90.4%), anemia (68.1%) and vomiting (59.6%). Only 59.0% agreed with the existence of genetic predisposition; 90.4% answered that the disease is permanent and 96.2% stated that the diet should exclude gluten absolutely; 67.1% answered that the gluten is a protein and according to 92.1% questionnaires this protein is present in wheat, rye, barley and oat. Greater compliance was observed when there was an understanding of the disease and diet. The small intestine biopsy was considered necessary for just 67.5% of the patients, and greater compliance was observed in patients who had undergone at least one small intestine biopsy. CONCLUSION: Our findings indicate that the more the patients know and understand about the disease, the better able they are to comply with the diet.

[Celiac disease: clinical characteristics and methods used in the diagnosis of patients registered at the Brazilian Celiac Association] / Doença celíaca: características clínicas e métodos utilizados no diagnóstico de pacientes cadastrados na Associação dos Celíacos do Brasil.

OBJECTIVE: To evaluate the clinical characteristics and methods used in the diagnosis of patients registered at the Brazilian Celiac Association (BCA). METHODS: A questionnaire about clinical characteristics and diagnostic methods in celiac disease was mailed to 584 members of the BCA. RESULTS: We received 292 responses for 584 questionnaires mailed (49.5%). The clinical characteristics of celiac disease in the sample we analyzed showed that the most frequent type was the classical mode (88.9%), while the atypical mode was present in only 11.1% of patients at the time of diagnosis. Increased incidence of both late diagnosed classical mode (44.5% to 64.2%; P=.004) and atypical mode (5.2% to 16.8%; P=.005) has been observed in the last 5 years. Duration of symptoms before diagnosis was greater than 1 year in 75% patients with atypical manifestation. Intestinal biopsy was not performed in 19% of the cases at the time of diagnosis. It was observed that in the last 5 years intestinal biopsy was not performed for a larger number of patients (24.4%) than in the previous period (only 11.1%) (P=.007). CONCLUSIONS: Classical mode is still the most frequent clinical manifestation of celiac disease. The late diagnosed classical mode is predominant, but our findings show an increase in the proportion of the atypical mode. Although characterization of subtotal or total villous atrophy of the intestinal mucosa is of paramount importance to the diagnosis of celiac disease, 19% of the patients diagnosed for celiac disease did not undergo intestinal biopsy at the time of diagnosis, most notably in the last 5 years.

[Assessment of gliadin in pharmaceutical products - important information to the orientation of celiac disease patients]. / Pesquisa de gliadina em medicamentos--informação relevante para a orientação de pacientes com doença celíaca.

BACKGROUND: Some drugs might contain gliadin which can be dangerous for celiac disease patients. OBJECTIVE: Detect gliadin in pharmaceutical products commonly used in Brazil. METHODS: We analyzed 78 pharmaceutical products selected aleatory from a list of 180 products most frequently sold at Brazilian community pharmacies. The analyzed samples were analgesics (n = 9), anthelmintics (n = 3), antacids (n = 8), antibiotics (n = 13), anticholesteremics (n = 1), anticonvulsants (n = 2), antidepressants (n = 2), antiemetics (n = 3), antihypertensives (n = 3), antihistaminics (n = 3), anti-inflammatories (n = 7), antipyretics (n = 2), bronchodilators (n = 1), laxatives (n = 1), oral contraceptives (n = 5) and vitamins (n = 10). The samples were analyzed by enzyme immunoassay based on monoclonal antibodies omega-gliadins, the elected technique according to the Codex Alimentarius Commission WHO/FAO. All samples were analyzed in duplicate. The sensitivity of this test is 4 mg of gliadin/100 g of product. RESULTS: Only one (1.3%) out of 78 pharmaceutical products contained detectable amounts of gliadin (5.5 mg/100 g). The active ingredient of this drug is ranitidine. According to the Codex Alimentarius Commission WHO/FAO the intake of 10 mg of gliadin/day should not be exceeded by celiac disease patients. Considering the amount of gliadin in each capsule of ranitidine, the ingested quantity would be lower than the maximum allowed for celiac patients. CONCLUSIONS: In this study gliadin was not detected in pharmaceutical products in harmful amount for celiac disease patients.

[Celiac disease: evolution in knowledge since its original centennial description up to the present day]. / Doença celíaca: a evolução dos conhecimentos desde sua centenária descrição original até os dias atuais.

In the recent past, some celiac disease features have been discussed in literature specially related to genetic susceptibility, pathogenesis, clinical presentation and diagnostic criteria. Immunological abnormalities characteristic of celiac disease, such as circulating antibodies and increased numbers of intra-epithelial lymphocytes containing a high percentage of gamma-delta T cells have been demonstrated. Other pictures of clinical presentation besides the classical one deserve attention namely short stature, iron-resistant anaemia, enamel hypoplasia, constipation, neurological manifestation and osteoporosis, among others. Asymptomatic presentation has been recognized since development of serological markers such as anti-gliadin, anti-reticulin and anti-endomysium antibodies. Up to now, small intestinal biopsy is the only decisive diagnostic approach. A Federal law has recently imposed food manufactures to place labels informing the presence of gluten in industrialized foods in Brazil. Lately there has been an increase in celiac disease patients registered in the Brazilian Celiac Association.

Limitaçäo diagnóstica do exame físico na identificaçäo de crianças com anemia / Diagnostic restriction of the physical examination in the identification of children with anemia

Para avaliar a precisao e a reprodutibilidade dos sinais clínicos de anemia foram estudadas, no Ambulatório Geral de Pediatria da Escola Paulista de Medicina, uma amostra aleatória de 143 crianças, de seis a 68 meses de idade, analisadas por meio de dois exames clínicos independentes. A avaliaçao clínica de anemia baseou-se na presença de palidez cutânea, e de descoramento de conjuntiva, lábio-língua e palmas das maos. A prevalência de anemia, tendo como padrao de referência a hemoglobina venosa menor do que 11,0g/dL, foi de 41,3 por cento, predominando na faixa etária de seis a 24 meses (59,3 por cento). Obteve-se baixa sensibilidade tanto quando os quatro sinais clínicos foram analisados isoladamente (28,8 por cento a 52,5 por cento) como quando analisados em conjunto. Encontrou-se pelo menos um sinal clínico de anemia, na quase totalidade dos pacientes, somente quando o nível de hemoglobina foi inferior a 9,0g/dL. Verificou-se concordância leve entre os dois exames na avaliaçao da palidez cutânea (coeficiente de Kappa = +0,32) e corcordância moderada na avaliaçao da conjuntiva, do lábio-língua e das palmas das maos (coeficiente de Kappa entre +0,55 e +0,59). A reprodutibilidade do conjunto dos sinais clínicos foi maior quanto maior a gravidade de anemia. Concluiu-se que o diagnóstico clínico de anemia, considerando a precisao e a reprodutibilidade dos sinais clínicos, é limitado, sendo recomendável a dosagem rotineira da hemoglobina venosa nas faixas etárias com maior prevalência de anemia.

[Diagnostic limitations of the physical examination in the identification of children with anemia]. / Limitação diagnóstica do exame físico na identificação de crianças com anemia.

A total of 143 children was randomly selected from a Pediatric out-patients clinic in order to evaluate the accuracy and reproductibility of the clinical signs of anemia. The patients, who ranged from 6 to 68 months old, were assessed on the basis of 2 clinical examinations performed independently by 2 physicians. Clinical diagnosis of anemia relied upon the examination for the presence of pallor through an inspection of the skin, conjunctivaes, lips, tongue and palms. The reference standard taken into consideration was hemoglobin in venous blood samples. The prevalence of anemia (hemoglobin < 11.0 g/dL) consisted of 41.3%, predominating among patients who ranged from 6 to 24 months old (59.3%). The sensitivity of the different clinical signs for the 2 examinations was low ranged from 28.8% to 52.5%. Almost all the children with hemoglobin concentration lower than 9.0 g/dL presented at least one suggestive clinical sign of anemia. The Kappa coefficient (K) demonstrated a mild agreement between the 2 examinations for the assessment of cutaneous pallor (K = +0.32) and moderate agreement for the evaluation of the conjunctivaes, lips-tongue and palms (K from +0.55 to +0.59). In view of limitation of the accuracy and reproductibility of the clinical signs of anemia, we may state that the determination of hemoglobin concentration should be introduced as a routine procedure of major importance in health care services.