Clinical Experience of Use of High-dose Intravenous Methylprednisolone in Children With Acute Moderate to Severe Colitis.

OBJECTIVES: Treatment of acute severe colitis (ASC) has been associated with high morbidity and high colectomy rate in children. In the prebiologics era, our centre used short-term high-dose intravenous corticosteroids (IVCS) at 2 to 30 mg ·â€Škg ·â€Šday. We conducted a retrospective review to compare efficacy of different dosing regimes of IVCS. METHODS: Thirty-four children treated with IVCS for ASC were included over 8 years. Patients were studied as 2 groups with similar pretreatment patient characteristics. Group 1 (standard dose) received IVCS at 2 mg ·â€Škg ·â€Šday and group 2 (high dose) received IVCS at 10 to 30 mg ·â€Škg ·â€Šday. Safety, efficacy, and follow-up of the entire cohort for >1 year were studied. The median IVCS dose in the standard- and high-dose cohort was 1.5 mg ·â€Škg ·â€Šday (maximum 60 mg ·â€Škg ·â€Šday) and 24.8 mg ·â€Škg ·â€Šday (maximum 1000 mg ·â€Škg ·â€Šday), respectively. RESULTS: Pediatric Ulcerative Colitis Activity Index scores at day 5 were significantly lower in high-dose (15, interquartile range 8.5-20) than in standard-dose IVCS (30, interquartile range 20-30). IVCS side effects were minor and reversible. Overall, medical salvage therapy was required in 5.8% (2 children) before discharge, and in 17% (6 children) at follow-up after 1 year. The colectomy rate of the entire cohort was remarkably low with 0% during admission and 11% (4 children) after 1 year, with a trend of less colectomies in high-dose (4.8%-1 child) than in standard-dose (23%-3 children). CONCLUSIONS: Our data show that in paediatric ASC, the short-term use of high-dose IVCS is safe and effective. Prospective studies are needed to define the role of IVCS within salvage therapy protocols.

A new method in the diagnosis of reflux esophagitis: confocal laser endomicroscopy.

BACKGROUND: The diagnosis of GERD is made by using a combination of clinical symptoms, pH study, endoscopy, and histology. Histologic changes include basal cell hyperplasia and papillary elongation. Confocal laser endomicroscopy (CLE) enables surface and subsurface imaging of living cells in vivo at ×1000 magnification and up to 250 µm below the tissue surface. In the esophagus, the distance between the surface to papillary (S-P) tip can be measured by using CLE. OBJECTIVE: To measure the S-P distance in the esophagus in patients with reflux esophagitis and controls by using CLE and comparing with histologic measurements. DESIGN: Retrospective analysis of a prospective database. SETTING: Endoscopy unit of a tertiary-care children's hospital. PATIENTS: This study involved 7 patients (5 female) with a median age of 7.6 years (range 1.8-15.5 years) and median weight of 23 kg (range 13.2-71 kg) and 16 controls with a median age of 12.0 years (range 2.2-15.3 years) and median weight of 38.2 kg (range 10.7-83 kg). INTERVENTION: S-P distance was measured both by CLE and histology and was corrected for height for both patients and controls and the results compared. MAIN OUTCOME MEASUREMENTS: To determine if there were significant differences in the S-P distance in patients with esophagitis and controls. RESULTS: The median confocal and histologic measurements for S-P distance, corrected for patient height, were 0.19 µm/cm (range 0.10-0.49 µm/cm) and 0.58 µm/cm (range 0.29-0.76 µm/cm) and for controls were 0.44 µm/cm (range 0.20-0.93 µm/cm) and 1.07 µm/cm (range 0.76-0.1.57 µm/cm), respectively. LIMITATIONS: Small numbers involved in the study, reliance on only papillary elongation in arriving at a diagnosis. CONCLUSION: Measurement of the S-P distance by CLE will enable real-time diagnosis of GERD-related esophagitis during ongoing endoscopy.

Role of confocal endomicroscopy in the diagnosis of celiac disease.

BACKGROUND AND AIMS: Confocal laser endomicroscopy (CLE) is a recent development that enables surface and subsurface imaging of living cells in vivo at 1000 x magnification. The aims of the present study were to define confocal features of celiac disease (CD) and to evaluate the usefulness of the CLE in the diagnosis of CD in children in comparison to histology. PATIENTS AND METHODS: Nine patients (8 girls) with a median age of 8.35 years (range 2-12.66 years) and a median weight of 28.3 kg (range 11-71 kg) were suspected with CD and 10 matched controls underwent oesophagogastroduodenoscopy using the confocal laser endomicroscope (EC3870CILK; Pentax, Tokyo, Japan). Histologic sections were compared with the confocal images of the same site by 2 experienced paediatric histopathologists and endoscopists, all of whom were blinded to the diagnosis. RESULTS: The median procedure time was 17 minutes (range 8-25 minutes). Confocal features of CD were defined and a score was developed. A total of 1384 confocal images were collected from 9 patients and 10 controls. Five images from each patient and control were selected and compared with the biopsy specimen of the same site. The sensitivity, specificity, and positive predictive value for the confocal images in comparison to the histology were 100%, 80%, and 81%. The kappa inter-observer agreement between the 2 endoscopists was 0.769 (P = 0.018) and between the 2 histopathologists was 0.571 (P = 0.05). CONCLUSIONS: Confocal endomicroscopy offers the prospect of diagnosis of CD during ongoing endoscopy. It also enables targeting biopsies to abnormal mucosa and thereby increasing the diagnostic yield, especially when villous atrophy is patchy in the duodenum.

Double balloon enteroscopy in children: diagnosis, treatment, and safety.

AIM: To assess the feasibility and utility of double balloon enteroscopy (DBE) in the management of small bowel diseases in children. METHODS: Fourteen patients (10 males) with a median age of 12.9 years (range 8.1-16.7) underwent DBE; 5 for Peutz-Jeghers syndrome (PJ syndrome), 2 for chronic abdominal pain, 4 for obscure gastrointestinal (GI) bleeding, 2 with angiomatous malformations (1 blue rubber bleb nevus syndrome) having persistent GI bleeding, and 1 with Cowden's syndrome with multiple polyps and previous intussusception. Eleven procedures were performed under general anesthesia and 3 with deep sedation. RESULTS: The entire small bowel was examined in 6 patients, and a length between 200 cm and 320 cm distal to pylorus in the remaining 8. Seven patients had both antegrade (trans-oral) and retrograde (trans-anal and via ileostomy) examinations. One patient underwent DBE with planned laparoscopic assistance. The remaining 6 had trans-oral examination only. The median examination time was 118 min (range 95-195). No complications were encountered. Polyps were detected and successfully removed in all 5 patients with PJ syndrome, in a patient with tubulo-villous adenoma of the duodenum, in a patient with significant anemia and occult bleeding, and in a patient with Cowden's syndrome. A diagnosis was made in a patient with multiple angiomata not amenable to endotherapy, and in 1 with a discrete angioma which was treated with argon plasma coagulation. The source of bleeding was identified in a further patient with varices. DBE was normal or revealed minor mucosal friability in the remaining 3 patients. Hence a diagnostic yield of 11/14 with therapeutic success in 9/14 was achieved. CONCLUSION: Double balloon enteroscopy can be a useful diagnostic and therapeutic tool for small bowel disease in children, allowing endo-therapeutic intervention beyond the reach of the conventional endoscope.

Feasibility of confocal endomicroscopy in the diagnosis of pediatric gastrointestinal disorders.

AIM: To evaluate the feasibility and utility of confocal laser endomicroscopy (CLE) in the description of normal gastrointestinal (GI) mucosa and in the diagnosis of GI disorders in children, in comparison to histology. METHODS: Forty-four patients (19 female) median age 10.9 years (range 0.7-16.6 years) with suspected or known GI pathology underwent esophago-gastro-duodenoscopy (OGD) (n = 36) and/or ileocolonoscopy (IC) (n = 31) with CLE using sodium fluorescein and acriflavine as contrast agents. Histological sections were compared with same site confocal images by two experienced pediatric and GI histopathologists and endoscopists, respectively. RESULTS: Duodenum and ileum were intubated in all but one patient undergoing OGD and IC. The median procedure time was 16.4 min (range 7-25 min) for OGD and 27.9 min (range 15-45 min) for IC. A total of 4798 confocal images were compared with 153 biopsies from the upper GI tract from 36 procedures, and 4661 confocal images were compared with 188 biopsies from the ileocolon from 31 procedures. Confocal images were comparable to conventional histology both in normal and in pathological conditions such as esophagitis, Helicobacter pylori gastritis, celiac disease, inflammatory bowel disease, colonic heterotopia, and graft versus host disease. CONCLUSION: CLE offers the prospect of targeting biopsies to abnormal mucosa, thereby increasing diagnostic yield, reducing the number of biopsies, decreasing the burden on the histopathological services, and reducing costs.