Baclofen for the treatment of pediatric GERD.

BACKGROUND AND AIM: Baclofen, a γ-aminobutyric acid receptor agonist, has been shown to reduce the episodes of gastroesophageal reflux (GER) by reducing the incidence of transient lower esophageal sphincter relaxations. Although baclofen has been shown to reduce reflux symptoms in adults, data in pediatric patients are limited. The aim of the study was to evaluate the efficacy of baclofen in children with refractory GER. METHODS: Medical charts of patients 1 to 18 years of age treated with baclofen for persistent GER symptoms were reviewed retrospectively. Short-term (at first clinic visit) and long-term (12 months) clinical responses were assessed. RESULTS: A total of 53 patients were included in the final analysis. The mean duration of illness was 1.5 years and the mean age was 6.1 years. All of the patients were taking either once- (53%) or twice-daily (47%) doses of proton pump inhibitors (PPIs) at the time of initiation of baclofen. Thirty-five (66%) patients experienced a significant reduction in clinical symptoms at their first follow-up visit. In the remaining 18 patients, however, baclofen was stopped because of either no response (n = 15) or adverse events (n = 3). A total of 27 patients continued treatment and were assessed for long-term response. Of those, 22 (81%) had a sustained response to baclofen at 12 months, whereas 5 (19%) lost response. We recognized no clinical characteristic differences between those with and without a response to baclofen at either time point. CONCLUSIONS: Baclofen can be used as supplemental therapy to proton pump inhibitors in children with refractory GER; however, prospective trials are needed to further validate our results and assess safety.

Ileoscopy via stoma after diverting ileostomy: a safe and effective tool to evaluate for Crohn's recurrence of neoterminal ileum.

BACKGROUND: Recurrence of Crohn's disease (CD) most commonly occurs in the neoterminal ileum near the stoma after fecal diverting ileostomy. Methods used to assess CD recurrence include small bowel series, ileostomy injection, computed tomography (CT) enterography, and capsule endoscopy. Retrograde ileoscopy via stoma is also a valuable tool for recognition of CD recurrence; however, this technique has not been formally studied. OBJECTIVE: To evaluate the safety and utility of retrograde ileoscopy via stoma in patients with CD. METHODS: Patients with CD who underwent ileoscopy via stoma between January 1, 2001, through December 31, 2008 were included. This was a retrospective study in a tertiary referral center. The main outcome measures were procedural complications and findings. RESULTS: A total of 243 ileoscopies were performed on 99 patients. The most common indications for ileoscopy were CD activity assessment in 34.5% and abdominal pain in 33.3%. The procedure was outpatient in 75.8%. Meperidine and midazolam were most commonly used. Average depth of intubation was 28.4 cm. CD recurrence was detected in 70% of patients. Biopsies were obtained during ileoscopy in 117 studies, and biopsy and ileoscopy findings correlated in 111 studies (94.8%). One polypectomy, 24 balloon stricture dilations, and 8 intralesional steroid injections were performed. All patients tolerated the procedure well without procedure- or anesthesia-related complications. No hospital admissions or procedure-related deaths occurred. CONCLUSIONS: Retrograde ileoscopy via stoma is a safe and effective procedure for evaluating recurrence of CD of the neoterminal ileum. It also allows for therapeutic interventions such as balloon dilatation of ileal strictures and steroid injections.

Cryptosporidial infection in children with inflammatory bowel disease.

BACKGROUND AND AIMS: Cryptosporidiosis is usually a self-limiting illness in healthy patients. However, it can cause severe life threatening complications in immunocompromised patients. The effect of cryptosporidial infection on inflammatory bowel disease (IBD) has not been well studied and available literature is largely restricted to adult case reports. The purpose of this study is to describe the clinical characteristics of cryptosporidial infection in children with IBD. METHODS: Stool studies from children with IBD presenting with presumed relapse during the period 2005-2011 were reviewed retrospectively. Cryptosporidial infection was diagnosed by stool enzyme immunoassay. An age matched control group of IBD patients without cryptosporidial infection was used for comparison. RESULTS: Medical records of 170 IBD patients were reviewed and a total of 149 presumed relapses were identified. Cryptosporidial infection was found in seven of the 39 patients with positive stool studies (four ulcerative colitis/three Crohn's disease) presenting with relapse. The median age was 13 years (range: 3-17) and five patients were female. The median duration of the IBD was 18 months (range 2-48 months). All but one patient had stable disease prior to acquiring infection. Five patients required hospitalization due to significant dehydration. Three of the five patients treated with nitazoxanide had significant clinical improvement in 3 days. All patients had complete resolution of symptoms by three weeks and no infection related complications were noted. In comparison to patients with cryptosporidial infection, the control group required an increased need for escalation of therapy (71% vs. 0.0%, p=001) and higher re-hospitalization rates (24% Vs.0.0%, p=0.54) within 6 months following indexed relapse. CONCLUSION: In IBD patients, cryptosporidiosis can cause significant illness leading to increased need for hospitalization. In the absence of appropriate stool studies, cryptosporidiosis can be misdiagnosed as disease relapse and lead to inappropriate therapy. Nitazoxanide appears to be effective along with supportive therapy.

Crohn's disease with pulmonary manifestations in children: 2 case reports and review of the literature.

Crohn's disease (CD) is a chronic granulomatous disease of unknown etiology that affects primarily the gastrointestinal system but can be associated with extraintestinal manifestations. Latent pulmonary involvement in children with CD has been described, but symptomatic pulmonary disease has rarely been reported in children. In this review, we report two pediatric cases, one with pleural effusion at the time of CD diagnosis and the other with bilateral cavitary lesions in a previously diagnosed CD patient. We review the current literature and summarize the diagnosis and management of pulmonary involvement in CD. Awareness of these pulmonary complications of CD in children may lead to more prompt diagnosis, guide appropriate therapy, and decrease morbidity.