Systematic Review and Meta-analysis of Histological Gastric Biopsy Aspects According to the Updated Sydney System in Children.

OBJECTIVES: A descriptive and comparative study of gastric histological aspects according to the updated Sydney classification (USC), obtained from Helicobacter pylori-positive versus H pylori-negative children referred for upper gastrointestinal endoscopy. METHODS: The Prisma method was used to perform a systematic review and meta-analysis. Selection criteria were based on following key words USC, H pylori, children, endoscopy, or biopsy. Publication biases were assessed according to the Newcastle-Ottawa Scale, and a meta-regression analysis was done. The study was registered on the PROSPERO platform. RESULTS: Between 1994 and 2017, 1238 references were found; 97 studies were retained for the systematic review with a total number of 25,867 children; 75 studies were selected for the meta-analysis concerning 5990 H pylori-infected and 17,782 uninfected children.H pylori-positive versus H pylori-negative children, according to the USC, showed significantly higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, and of lymphoid follicles, and gastric mucosa atrophy, whereas, intestinal metaplasia showed a significantly higher RR only in antral biopsies. The meta-regression analysis showed that H pylori-positive versus H pylori-negative children had significantly higher risk only for corpus activity according to age, recurrent abdominal pain, and geographical area of low H pylori prevalence. CONCLUSIONS: H pylori infection in children was associated with higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, lymphoid follicles, and rare gastric mucosa atrophy, whereas, rare intestinal metaplasia was only significantly higher in the antral area.

Is there any difference between the symptomatology and clinical findings of viral agents causing dehydration?

BACKGROUND: Acute gastroenteritis is responsible for dehydration in many children. The viruses like rotavirus, norovirus, and adenovirus are considered the main causative agents of gastroenteritis. The goal of this study is the evaluation of the symptoms, clinical findings and hospitalization requirements in pediatric patients with dehydration secondary to viral gastroenteritis. METHODS: The distribution of age, symptoms, clinical and laboratory findings and hospitalization requirements of 156 viral acute gastroenteritis patients with moderate dehydration were evaluated retrospectively. Patients were between 3 months to 16 years of age (mean: 38.7 months). The patients were categorized into four groups according to etiological agents as rotavirus, norovirus, adenovirus, and mixed infections for the comparison of symptoms, clinical characteristics, laboratory results, seasonal distribution, treatment requirements, hospitalization unit, and hospitalization period. Age groups were categorized as 0-24 months, 25-72 months, and >72 months. Clinical characteristics of patients were analyzed for hospitalization period as <24 hours, and ≥24 hours. RESULTS: Moderate-degree dehydration was detected in 156 patients with acute gastroenteritis (156/278) caused by rotavirus (60.5%), norovirus (58%) and adenovirus (42%) respectively. The common symptoms of all patients were vomiting, diarrhea, abdominal pain and malaise, although fever was seen mostly in the patients of rotavirus. Aspartat aminotransferase (AST) was elevated in rotavirus gastroenteritis (11.5%) more than norovirus (5.4%) and adenovirus (0.8%) infections. Elevated blood urea nitrogen (BUN) levels (>20 mg/dL) were shown in 79.3%, of patients especially in rotavirus (43.8%). CONCLUSIONS: The main agents of acute gastroenteritis which caused dehydration were norovirus and rotavirus in our patients. Rotavirus was detected in most of the hospitalized patients with severe symptoms. AST was prominently elevated in rotavirus gastroenteritis. The clinical characteristics and some laboratory findings including hyperglycemia, leukocytosis, and elevated AST may be helpful in differentiating rotavirus from norovirus gastroenteritis. BUN level was insignificantly elevated in patients with rotavirus.

Cystic lymphangiomatosis with severe intra-abdominal bleeding in a newborn: case report.

We report the case of a newborn girl with intestinal cystic lymphangiomatosis who presented with abdominal distension and intra-abdominal bleeding following a prenatal ultrasound diagnosis of intestinal anomaly. Postnatal abdominal ultrasound revealed disseminated submucosal and intramural cystic dilatations of various sizes in the bowel and intestinal lymphangiomatosis was diagnosed. The presence of severe bleeding diathesis and widespread disease led to conservative treatment. The patient died on postnatal day 7 and postmortem examination confirmed cystic lymphangiomatosis. Detection of intestinal hyperechogenicity and/or dilatation in prenatal ultrasonography and the persistence of these findings during pregnancy are suggestive for pathologies such as meconium ileus, meconium peritonitis, and intestinal atresia. Although rare, intestinal lymphangiomatosis should be kept in mind in patients whose prenatal sonographic findings persist until birth.

Surfactant replacement therapy in a pediatric near-drowning case in manure.

Drowning is defined as suffocation by submersion especially in water and is a leading cause of injury-related death in children. Age groups at greatest risk are toddlers and male adolescents. It is the second most common cause of accidental death in children after road accidents. Treatment consists of resuscitation and stabilization. The use of surfactant after near-drowning in water is reported in the literature in few case reports.We report here a boy whose condition did not get better with conventional treatment, but dramatically improved after surfactant treatment after near-drowning in a fluid with manure.

Turkish Translation, Validation, and Reliability Analysis of Pediatric Eosinophilic Esophagitis Symptom Severity Module Version 2.0.

The Paediatric Eosinophilic Esophagitis Symptom Severity Modules Version 2.0 (T-PEESv2.0) was developed in English as a valid, reliable questionnaire for follow up. This work aimed to develop a Turkish version of T-PEESv2.0 via translation and cultural adaptation and then to test its validation and reliability. Methods: The PEESv2.0 was translated into Turkish by standardized procedural steps completed in cooperation with the Mapi Research Trust. The final version of the questionnaire was submitted to eosinophilic oesophagitis patients or their parents at 2 times point separated by 1 week. An age-matched control group was used to test the discriminant validity. Construct validity was tested using the Wilcoxon test, and internal consistency was tested using Cronbach's alpha. Test-retest reliability was measured with Cohen's kappa and intraclass correlation coefficient. Results: One hundred twenty-eight participants (70 patients, 58 parents) were enrolled. Fifty-eight (39.1%) of them completed T-PEESv2.0-parent by proxy and 70 (54.7%) were T-PEESv2.0. The Cronbach's alpha coefficient and intraclass correlation coefficient for test-retest reliability were >0.70 for both questionnaires and for all domain (frequency and severity) and total scores. For discriminant validity analysis, subscale (frequency and domain) and total scores of the patient group were compared with those of the control group. The subscale and total scores were significantly different between the groups (P < 0.05). Conclusion: T-PEESv2.0 appeared to be valid and reliable, ready to be introduced as a clinical and research tool for the assessment of patients with eosinophilic oesophagitis.

Helicobacter pylori infection and peptic ulcer in eastern Turkish children: is it more common than known?

Helicobacter pylori (H. pylori) infection is mainly acquired in childhood and is frequent in developing countries. The infection is associated with chronic gastritis in all infected children, but peptic ulcer disease develops in a small number of them. In our country, H. pylori infection and associated peptic ulcer disease are common. In eastern Turkey, we found peptic ulcer disease in 13.2% of children who underwent endoscopic examination. Peptic ulcers were mostly gastric ulcers and H. pylori-positive in the studied population, and most of the children were admitted due to abdominal pain. As there are no well-established criteria leading directly to diagnosis, pediatricians should include H. pylori infection and peptic ulcer disease in the differential diagnosis list when evaluating children with abdominal pain, failure to thrive and upper gastrointestinal system bleeding.

Can the Reflux Finding Score and Reflux Symptom Index Be Used to Evaluate the Severity of Esophagitis in Children?

OBJECTIVES: Laryngopharyngeal reflux (LPR), a growing issue in ear, nose, and throat (ENT) and pediatric medicine, is the backflow of stomach contents into the laryngopharynx. Patients present with frequent upper and/or lower respiratory tract infections and coughs, associated with acid- and pepsin-mediated injury to the mucosae of the larynx and pharynx. LPR is associated with rhinosinusitis, laryngitis, pneumonia, and asthma. Children with LPR often fail to exhibit classic gastroesophageal reflux disease symptoms, or such symptoms may be intermittent. Only a few studies have sought correlations among symptoms, endoscopic findings, and the results of frequently used diagnostic tests. THE AIM OF OUR STUDY: We sought associations among the Reflux Finding Score (RFS), Reflux Symptom Index (RSI), and the pathological extent of esophagitis. METHODS: We reviewed data on children who underwent upper gastrointestinal tract endoscopy and showed LPR symptoms, as reported by the ENT department. The RSI was scored by pediatric gastroenterologists and the RFS by ENT doctors, via laryngoscopic examination. The pathological esophageal data were evaluated retrospectively. RESULTS: We treated 52 patients (29 boys) with a mean age of 11.4 ± 4.5 years. On pathological evaluation, one patient exhibited normal esophageal findings, while 28 showed mild esophagitis, 16 esophagitis, and 8 severe esophagitis. Thirteen patients showed esophageal pseudopolypoid lesions secondary to gastroesophageal reflux disease on endoscopic examination, but were human papilloma virus-negative. There was no correlation among the RFS, RSI score, and age, but there was a significant correlation between the pathological data and the RFS (P = 0.010; r = 0.461). CONCLUSIONS: The incidence of LPR/esophagitis in children may differ from that in adults. Therefore, ENT specialists should determine esophagitis status in children and, if necessary, consult pediatric gastroenterologists.

Familial Mediterranean Fever Mutation Analysis in Pediatric Patients With Inflammatory Bowel Disease: A Multicenter Study.

BACKGROUND: The aim of the study was to evaluate familial Mediterranean fever (FMF) mutation analysis in pediatric patients with inflammatory bowel disease (IBD). The relation between MEFV mutations and chronic inflammatory diseases has been reported previously. METHODS: Children with IBD (334 ulcerative colitis (UC), 224 Crohn's disease (CD), 39 indeterminate colitis (IC)) were tested for FMF mutations in this multicenter study. The distribution of mutations according to disease type, histopathological findings, and disease activity indexes was determined. RESULTS: A total of 597 children (mean age: 10.8 ± 4.6 years, M/F: 1.05) with IBD were included in the study. In this study, 41.9% of the patients had FMF mutations. E148Q was the most common mutation in UC and CD, and M694V in IC (30.5%, 34.5%, 47.1%, respectively). There was a significant difference in terms of endoscopic and histopathological findings according to mutation types (homozygous/ heterozygous) in patients with UC (P < .05). There was a statistically significant difference between colonoscopy findings in patients with or without mutations (P = .031, P = .045, respectively). The patients with UC who had mutations had lower Pediatric Ulcerative Colitis Activity Index (PUCAI) scores than the patients without mutations (P = .007). CONCLUSION: Although FMF mutations are unrelated to CD patients, but observed in UC patients with low PUCAI scores, it was established that mutations do not have a high impact on inflammatory response and clinical outcome of the disease.

1H magnetic resonance spectroscopy of the normal testis: preliminary findings.

PURPOSE: The purpose of this study was to determine the pre- and postpubertal 1H magnetic resonance spectroscopic characteristics of the normal testis to establish baseline values for further clinical studies. MATERIALS AND METHODS: The subjects consisted of male volunteers, of whom 19 were prepubertal with ages between 7 and 13 years and 24 were postpubertal with ages between 19 and 39 years. Their testes were evaluated at 1.5 T with magnetic resonance spectroscopy; in addition, testis volumes were measured. Major metabolite peaks were identified and their ratios were calculated. Metabolite differences of testis between pre- and postpubertal age were analyzed. RESULTS: Major constituents of spectra were 3.21 ppm choline and 0.9-1.3 ppm lipid peaks. At the echo time (TE) spectrum of 31 ms, choline/lipid ratios ranged from 0.35 to 8.30 (mean=1.87) in postpubertal males and from 0.06 to 5.45 (mean=0.88) in prepubertal males (P<.013). At the TE spectrum of 136 ms, choline/lipid ratios ranged from 0.66 to 15.42 (mean=4.09) in postpubertal males and from 0.05 to 4.91 (mean=0.9) in prepubertal males (P<.016). CONCLUSIONS: Choline/lipid ratio was higher in the postpubertal period. The existence of higher choline peak in that age group should be due to the initiation of spermatogenesis. The decrease in the lipid peak may represent the effect of testosterone on testicular tissue or may be due to histochemical changes initiated by puberty. The significant decrease in choline/lipid ratio noted after puberty could represent the presence of spermatogenesis. This hypothesis should be evaluated by further studies on postpubertal subjects with impaired spermatogenesis.

Superior mesenteric artery syndrome: A rare but life threatening disease.

Superior mesenteric artery syndrome was observed in an adolescent patient. He had a 1-day history of nausea, vomiting, and abdominal pain, without chronic or recurrent symptoms. Diagnosis was established by abdominal plain x-ray, contrast enhanced abdominal computed tomography, and endoscopic examination. The patient was hospitalized, monitorized, and decompressed by nasogastric tube without oral feeding. The symptoms of the patient were gradually relieved by conservative treatment and he was discharged after one week. Clinicians should be careful when facing upper gastrointestinal symptoms that are resistant and non-responsive to treatment, and this syndrome should be kept in mind. This case is presented to draw attention to this disease because of its rare incidence.

Comparison of the therapeutic effects of sildenafil citrate, heparin and neuropeptides in a rat model of acetic acid-induced gastric ulcer.

AIMS: The purpose of our investigative work has been to determine whether there can be therapeutic roles in the administration of sildenafil citrate, heparin and several neuropeptides on an animal model where gastric ulcers were induced with acetic acid, and to compare their efficacy. MATERIALS AND METHODS: The animals were divided into 13 groups, with 4 animals in each. Gastric ulcers was induced in the animals of 12 groups with one untreated group being left as the control (Group I - control; given normal saline (NS)). The other groups were: Group II (ulcer+NS); Group III (5mg/kg sildenafil citrate, low dose); Group IV (10mg/kg sildenafil citrate, high dose); Group V (0.6mg/kg heparin, low dose); Group VI (6mg/kg heparin, high dose); Group VII (20nmol/kg des-acyl ghrelin); Group VIII (40nmol/kg des-acyl ghrelin); Group IX (4nmol/kg acyl ghrelin); Group X (8nmol/kg acly ghrelin); Group XI (20pmol/kg Nesfatin-1); Group XII (15nmol/kg Obestatin) and Group XIII (5nmol/kg Neuropeptide Y). Gastric neuropeptide expression was measured using an immunohistochemical method, and the amount in circulation was detected using ELISA. To compare with no treatment, the controls and other treatment groups, we recorded loss of the surface epithelium of the stomach, erosion, bleeding and inflammatory cell infiltration in the upper halves of the gastric glands. KEY FINDINGS: The muscularis and the layers beneath it were, however, apparently normal. The gastric mucosa healed with little or no inflammation when sildenafil citrate, low dose heparin, ghrelin, NUCB2/Nesfatin-1, obestatin, Neuropeptide Y were administered. SIGNIFICANCE: Overall the data indicate that low dose heparin, and especially sildenafil citrate and neuropeptides, can be used clinically as an alternative approach in the treatment of the gastric ulcer.

Protein C, protein S and other pro- and anticoagulant activities among epileptic children using sodium valproate.

This study was conducted to evaluate some anticoagulants' (protein C, protein S and antithrombin) activities among epileptic children treated with VPA and to learn if thromboembolic events occur among these children or their parents. Twenty-five boys and 15 girls using VPA for at least 3 months were included in the VPA group. The control group consisted of 28 boys and 12 girls who had no infection and did not use any medication that could alter protein C activity. Complete blood counts, ALT, AST, PT, aPTT, fibrinogen, protein C, protein S and AT tests were studied in both groups. Serum VPA levels were determined in the VPA group. Protein C and protein S activities of the children in the VPA group were significantly lower than those in the control group (89.5+/-19.3% vs 104.9+/-21.7% and 44.6+/-16.3% vs 59.4+/-28.4%, respectively). Neither children using VPA, nor their parents had any thromboembolic events in medical history. Platelet counts, ALT and fibrinogen levels in the VPA group were significantly lower than those in the controls. A negative correlation was found between serum VPA level and platelet counts. There were also negative correlations between fibrinogen and serum VPA levels, and between fibrinogen level and protein S activity. The children in the VPA group had lower PT and higher aPTT levels than the children in the control group. Since other factors known to alter the anticoagulant activities and liver functions were eliminated initially, the decreases of protein C and protein S activities, thrombocyte counts, ALT, PT and fibrinogen levels and increase in aPTT level may be attributed to VPA. VPA hepatotoxicity can be the cause of decreased pro- and anticoagulant activities.

Hypertransaminasaemia in children with viral gastroenteritis.

We investigated the rates of increase in serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels of patients with rotavirus, norovirus and enteric adenovirus gastroenteritis. Two hundred children with viral gastroenteritis were evaluated for hypertransaminasaemia retrospectively. The patients were between 0 - 17 years (mean ± SD: 5.10 ± 3.01) of age. ALT was elevated up to 67 IU/L in 7 (8.5%) patients in the rotavirus group (n=82), whereas it was elevated in 3 (4.0%) and 1 (2.3%) patients in the norovirus (n=74) and adenovirus (n=44) groups, respectively. AST was elevated up to 89 IU/L in 20 (24.4%) patients in the rotavirus group, whereas it was elevated in 6 (8.1%) and 1 (2.3%) patients in the norovirus and adenovirus groups, respectively. Both transaminases were elevated in 7.3%, 1.4%, and 2.3% of patients in the rotavirus, norovirus, and adenovirus groups, respectively. The increases in ALT and AST levels were found to be significantly higher in the rotavirus group (n=27) than in the norovirus (n=9), and adenovirus group (n=2) (p<0.05). Mean serum ALT and AST levels in the rotavirus group were significantly higher than those in the norovirus and adenovirus group (p<0.05). Our study investigated the correlation between viral gastroenteritis and hypertransaminasaemia. When evaluating a patient with hypertransaminasaemia physicians should remember to consider acute gastroenteritis due to some viruses as a cause of elevated AST and ALT.

Report of data on children with non-typhi Salmonella gastroenteritis in a three-year period.

The purpose of this study was to evaluate the clinical and laboratory data of children with acute gastroenteritis caused by non-typhoid Salmonella spp. infections. Clinical (demographic data, symptoms and findings) and laboratory data (stool microscopy, rapid antigen tests, culture, multiplex polymerase chain reaction and blood test results) of children with acute gastroenteritis caused by non-typhoid Salmonella spp. between January 2010 and October 2012 were evaluated. Differences between the groups for categorical variables were estimated with a chi-square or Fisher exact test; for continuous variables with two independent samples a t test was used. P values < 0.05 were considered statistically significant. Sixty-seven children, 39 (58.2%) males and 28 (41.8%) females aged between 1 - 16 years (mean ± SD: 4.64 ± 2.91), were diagnosed with acute bacterial gastroenteritis caused by non-typhoid Salmonella spp. The main serotypes are Salmonella enteritidis (85%) and Salmonella typhimurium (7.5%). The presenting symptoms were diarrhoea (95.5%), fever (61.1%), vomiting (34.3%), abdominal pain (32.8%), loss of appetite (7.4%) and malaise (7.4%). Fever and dehydration (moderate and/or severe) were detected in 11 (16.4%) patients. The mean leukocyte count was 10.930/µL [95% confidence interval (CI), SD: ± 5.710/µL], neutrophil count was 7.880/µL (95% CI, SD: ± 4.960/µL), CRP was 64.16 mg/L (95% CI, SD: ± 76.24 mg/L), and erythrocyte sedimentation rate was 34.72 mm/hour (95% CI, SD: ± 13.64 mm/h). Stool microscopy was positive for leukocytes in 18 patients (26.8%). The definitive diagnosis was made with positive stool culture (n = 65) and/or PCR test (n = 4). Viral antigen positivity was detected in 10 patients (14.9%), evaluated as viral co-infection and false positive results. Antibiotic therapy and hospitalization were required in 26 (38.8%) and 23 (34.3%) patients, respectively. Salmonella carriage was detected in one patient (1.5%). Bloody diarrhoea, leukocytes in stool with an increased erythrocyte sedimentation rate and a CRP level without overt leukocytosis may indicate Salmonella infection. Viral antigens may cause false positive results in fast antigen tests in cases where clinical and laboratory findings indicate bacterial aetiology. Stool culture is a reference method in diagnosis whereas some agents may be detected via molecular techniques (polymerase chain reaction) in spite of negative culture. Multiplex polymerase chain reaction may be used to detect Salmonella spp. and may reveal false positivity for viruses as well as the detection of other bacteria.

Comparison of FISH, RFLP and agar dilution methods for testing clarithromycin resistance of Helicobacter pylori.

BACKGROUND/AIMS: Clarithromycin resistance is an important factor of Helicobacter pylori (H. pylori) eradication failure in adults and children. There are some tests to determine resistance such as restriction fragment length polimorphism (RFLP), fluorescence in situ hibridisation (FISH), PCR and (culture) agar dilution. Clarithromycin resistance is reported between 16.8%-48.2% in Turkey using PCR, 18% in Japan using RFLP. The aim of the study is to compare the efficacy of FISH, RFLP and culture. MATERIALS AND METHODS: Patients with gastric complaint underwent endoscopic examination. H. pylori status of all patients was tested with urea breath test. Gastric biopsy samples obtained from adult patients and children were studied. Each tissue was analised with FISH, PCR-RFLP anda gar dilution. RESULTS: A total 100 patients were positive by UBT and histology for H. pylori. Tissues from 89 adults and 11 children were evaluated. According to FISH and RFLP clarithromycin resistance was 26% and 16% respectively. Among 100 patients H. pylori was cultured in 52 tissue samples, among these samples 7 were resistant to clarithromycin. There was strong correlation between the results of FISH and RFLP; RFLP and culture; and FISH and culture. CONCLUSION: There is a high ratio of clarithromycin resistance in the studied population. All 3 tests are valuable, but FISH seems to be more sensitive among these tests. We suggest FISH should be used for detecting clarithromycin resistance among H. pylori infected patients before eradication therapy.

[The prevalence of intestinal parasites in children with Helicobacter pylori gastritis evaluated retrospectively]. / Helicobacter pylori Gastriti Olan Çocuklarda Intestinal Parazit Sikliginin Retrospektif Olarak Arastirilmasi.

OBJECTIVE: H. pylori infection is more frequent and is seen in younger ages in developing countries when compared to developed countries. Etiopathogenetic factors include living in crowded families, low educational level of mother, low income and infected drinking water. Intestinal parasites are more frequent in low socioeconomical populations. In this study, it was aimed to determine the prevalence of intestinal parasite in patients with H. pylori gastritis proven with endoscopic and histopathological study. METHODS: Parasitology laboratory results of children who had undergone upper gastrointestinal system endoscopy (UGE) and were proved to have H. pylori gastritis were evaluated retrospectively. Stool samples were examined using native lugol and precipitation by formol ethyl acetate methods. RESULTS: A total of 138 children had undergone upper GIS endoscopy. Among those children, 97,1% had H. pylori positive gastritis. Of those H. pylori positive gastritis children, we obtained the stool test results of 105 children. Six children (5.71%) had Blastocystis hominis and 2 (1.91%) had Giardia intestinalis so a total of 8 patients had (7.61%) intestinal parasites. CONCLUSION: H. pylori and intestinal parasites are frequent among individuals living in low socioeconomical countries. The co-existence of hp and intestinal parasites, which have a negative effect on thriving and iron status in a growing child is a very important public health problem. National sanitation education and methods may help decrease the co-existence of these synergistic microorganisms.

Varicella gastritis in an immunocompetent child.

The varicella zoster virus (VZV) is a very rare cause of gastritis. Gastritis caused by VZV can be presented as abdominal pain, vomiting. Most of the cases reported with varicella gastritis in the literature are immunocompromised patients with various kinds of malignancy, and most of these patients are adults. Here we report an adolescent girl with acute abdominal pain. The girl was immunocompetent. Her endoscopically taken biopsy material revealed varicella, and her gastritis was healed with acyclovir therapy. This is a very rare condition and not frequently reported in the literature. The authors want to drive attention to the fact that varicella gastritis can be seen in immunocompetent children, the presentation can be nausea, vomiting and/or (severe) abdominal pain. Serological studies may be less helpful than tissue studies, so interventional procedures should be done.