One step minilaparotomy-assisted transmesenteric portal vein recanalization combined with transjugular intrahepatic portosystemic shunt placement: A novel surgical proposal in pediatrics

Transjugular intrahepatic portosystemic shunt(TIPS) placement is a standard procedure for the treatment of portal hypertension complications. When this conventional approach is not feasible, alternative procedures for systemic diversion of portal blood have been proposed. A one-step interventional approach, combining minilaparotomy-assisted transmesenteric(MAT) antegrade portal recanalization and TIPS, is described in an adolescent with recurrent esophageal varice bleeding and portal cavernoma(PC). A 16-yearold girl was admitted to our Unit because of repeated bleeding episodes over a short period of time due to esophageal varices in the context of a PC. A portal vein recanalization through an ileocolic vein isolation with the MAT approach followed by TIPS during the same session was performed. In the case of failed portal recanalization, this approach, would also be useful for varice endovascular embolization. Postoperative recovery was uneventful. Treatment consisting of propanolol, enoxaparin and a proton pump inhibitor was prescribed after the procedure. One month post-op, contrast enhanced computed tomography confirmed the patency of the portal and intrahepatic stent grafts. No residual peritoneal fluid was detected nor opacification of the large varices. Endoscopy showed good improvement of the varices. Doppler ultrasound confirmed the accelerated flow in the portal stent and hepatopetal flow inside the intrahepatic portal branches. Three months post-op, TIPS maintained its hourglass shape despite a slight expansion. Portal hypertension and life threatening conditions related to PC would benefit from one-step portal recanalization. MAT-TIPS is feasible and safe for the treatment of PC even in children. This minimally invasive procedure avoids or delays surgical treatment or re-transplantation when necessary in pediatric patients.

Furazolidone-based triple therapy for H pylori gastritis in children

AIM： To evaluate the furazolidone-based triple therapy in children with symptomatic H pylori gastdtis. METHODS： A prospective and consecutive open trial was carried out. The study included 38 patients with upper digestive symptoms sufficiently severe to warrant endoscopic investigation. H pylori status was defined based both on histology and on positive ^13C-urea breath test. Drug regimen was a seven-day course of omeprazole, clarithromycin and furazolidone （100 mg, 200 mg if over 30 kg） twice daily. Eradication of H pylori was assessed two months after treatment by histology and ^13C-urea breath test. Further clinical evaluation was performed 7 d, 2 and 6 mo after the treatment. RESULTS： Thirty-eight patients （24 females, 14 males） were included. Their age ranged from 4 to 17.8 （mean 10.9 ± 3.7） years. On intent-to-treat analysis （n = 38）, the eradication rate of H pylori was 73.7% （95% CI, 65.2%-82%） whereas in per-protocol analysis （n = 33） it was 84.8% （95% CI, 78.5%-91%）. All the patients with duodenal ulcer （n = 7） were successfully treated （100% vs 56.2% with antral nodularity）. Side effects were reported in 26 patients （68.4%）, mainly vomiting （14/26） and abdominal pain （n = 13）. Successfully treated dyspeptic patients showed improvement in 78.9% of H pylori-negative patients after six months and in 50% of Hpylori-positive patients after six months of treatment. CONCLUSION： Triple therapy with furazolidone achieves moderate efficacy in H pylori treatment. The eradication rate seems to be higher in patients with duodenal ulcer.

Association of Helicobacter pylori infection and giardiasis: Results from a study of surrogate markers for fecal exposure among children

AIM: To investigate whether Helicobacter pylori (H pylori) infection is associated with hepatitis A virus (HAV) infection, presence of enteroparasites, and other surrogates of fecal exposure. METHODS: We conducted a cross-sectional study in 121 children consecutively admitted at a pediatric hospital in Salvador, Brazil. H pyloriand HAV infection were identified by the presence of serum antibodies. Stool specimens were examined for the presence of ova and parasites. A structured questionnaire inquiring about sanitary conditions and life style was applied to each subject. RESULTS: Fifty-one of the 121 children (42.1%) were found to be seropositive for H pylori, and 45 (37.2%) for HAV. The seroprevalence of Hpyloriand HAV both increased significantly with age. Cross-tabulation of data showed that 26 (21.5%) were seropositive and 51 (42.1%) were negative for both H py/lriand HAV antibodies (x^2=7.18, OR=2.8, CI 1.30-5.97). The age adjusted OR for an HAV-infected child being H pylori positive was 2.3 (CI 1.02-5.03). The agreement between H pylori and HAV seropositivity was fair (k=0.24). After controlling for possible confounding, the variables remaining independently associated with seropositivity to H pylori were age, presence of Giardia lamblia in feces (OR=3.2, 95%CI, 1.1-9.5) and poor garbage disposal quality (OR=2.4, 95%CI, 1.1-5.1). CONCLUSION: Our data suggest that H pylori infection is associated with surrogate markers of fecal exposure. Thus, we conclude that the fecal-oral route is relevant in the transmission of HP among children in an urban setting of a developing country. The association observed between G. lamblia and H pylori infection may have several explanations. Further studies to investigate this relationship are warranted.

Eradication of Helicobacter pylori increases childhood growth and serum acylated ghrelin levels

AIM: To determine whether Helicobacter pylori (H. pylori)infected children have reduced body weight (BW) and height (BH) growth, and if H. pylori eradication may restore growth while improving serum acylated ghrelin. METHODS: This longitudinal cohort study with oneyear follow-up enrolled 1222 children aged 4 to 12 years old into an observation cohort (18 with and 318 without H. pylori ) and intervention cohort (75 with and 811 without). The 7-d triple therapy was used for eradication in the intervention cohort. The net increases of BW and BH as well serum acylated ghrelin after oneyear follow-up were compared between successful eradicated H. pylori-infected children and controls. RESULTS: In the observation cohort, the H. pylori - infected children had lower z score of BW (-1.11 ± 0.47 vs 0.35 ± 0.69, P = 0.01) and body mass index (BMI) (0.06 ± 0.45 vs 0.44 ± 0.73, P = 0.02) at enrollment and lower net BW gain after one-year follow-up (3.3 ± 2.1 kg vs 4.5 ± 2.4 kg, P = 0.04) than the non-infected controls. In the intervention cohort, the H. pylori - infected children had lower z score of BMI (0.25 ± 1.09 vs 0.68 ± 0.87, P = 0.009) and serum acylated ghrelin levels (41.8 ± 35.6 pg/mL vs 83.6 ± 24.2 pg/mL, P < 0.001) than the non-infected controls. In addition to restoring decreased serum ghrelin levels (87.7 ± 38.0 pg/mL vs 44.2 ± 39.0 pg/mL, P < 0.001), the H. pylori - infected children with successful eradication had higher net gains (P < 0.05) and increase of z scores (P < 0.05) of both BW and BH as compared with non-infected controls after one-year follow-up. CONCLUSION:H. pylori-infected children are associated with low serum acylated ghrelin and growth retardation. Successful eradication of H. pylori restores ghrelin levels and increases growth in children.

Influence of Helicobacter pylori infection on ghrelin levels in children

AIM:To compare ghrelin levels in plasma and gastric mucosa before and after Helicobacter pylori(H.pylori) treatment in children with H.pylori-associated functional dyspepsia.METHODS:Children with H.pylori-associated functional dyspepsia were enrolled in this study.H.pylori infection was confirmed by positive bacterial culture results.All of the children received triple H.pylori eradication therapy(a 2 wk course of omeprazole,amoxicillin,and clarithromycin).The children were divided into two groups based on the success of the H.pylori treatment:group 1(eradicated)-patients who had a negative 13C-urea breath test 2 mo after the end of therapy;and group 2(non-eradicated)-patients who had a positive 13C-urea breath test.Plasma ghrelin,gastric ghrelin mRNA,and the body mass index were evaluated in both groups before and after the H.pylori treatment.The plasma ghrelin levels were measured by a radioimmunoassay.The expression of gastric ghrelin mRNA was determined by real-time reverse transcription polymerase chain reaction.RESULTS:A total of 50 children with H.pylori-associated functional dyspepsia were treated with triple H.pylori eradication therapy.The mean age of the children was 5.52 ± 0.83 years,and there were 28 males and 22 females.Among the 50 H.pylori-positive children,30 successfully achieved eradication,and 20 did not.The mean plasma ghrelin levels of group 1 were 22.17 ± 1.73 ng/L and 26.59 ± 2.05 ng/L before and after the treatment,respectively,which was a significant increase(P = 0.001).However,the mean plasma ghrelin level of group 2 before and after the H.pylori treatment was 21.34 ± 2.40 ng/L and 22.24 ± 2.10 ng/L(P = 0.785).The plasma ghrelin levels increased substantially after treatment in group 1 but showed only minor changes in group 2.Similarly,the gastric ghrelin mRNA expression in group 1 before treatment was 2.84 ± 0.08.After treatment,the level was 3.11 ± 0.65,which was significantly different(P = 0.023).The gastric ghrelin mRNA expression in group 2 did not change significantly during the treatment(2.82 ± 0.44 vs 2.79 ± 0.31,P = 0.875).The plasma ghrelin and gastric ghrelin mRNA levels in group 1 increased substantially after the treatment but did not do so in group 2.In addition,the body mass index the two groups did not differ significantly 2 mo before and after the H.pylori treatment.CONCLUSION:H.pylori eradication increases the plasma and tissue ghrelin levels in children with H.pylori-associated functional dyspepsia.

Soluble adhesion molecules ICAM-1,VCAM-1,P-selectin in children with Helicobacter pylori infection

AIM: To assess the sICAM-1, sVCAM-1, and sP-selectin levels in children withHelicobacter pylori(H pylori)infection and to evaluate their significance for the morphological changes found in gastric mucosa.METHODS: The study included 106 children: 59children (55.7%) with chronic gastritis and positive IgG against H pylori, 29 children (27.3%) after previous H pylori infection without the bacterium colonization but with positive IgG against H pylori, and 18 children (17%) with functional disorders of the gastrointestinal system but with normal IgG against H pylori. Endoscopic and histopathological evaluation of gastric mucosa was performed based on the Sydney System classification.The evaluation of sP-selectin, sIC AM-1, sVCAM-1 levels in the sera of children was carried out using ELISA test.RESULTS: The assessment of gastritis activity degrees indicated statistically significant values in the antrum and corpus (P＜0.001) of children examined. Serum sVCAM-1 levels were higher in group with gastritis due to H pylori infection than in group without infection and differed statistically (P＜0.05). Serum sVCAM-1 levels proved to be the highest among other adhesive molecules in infected children and decreased after eradication of H pylori. Serum sICAM-1 levels were similar in all examined groups. Serum sP-selectin levels were similar in children with and without H pylori infection.CONCLUSION: Assessment of adhesive molecules (sPselectin, sICAM-1, sVCAM-1) in the sera of children with active H pylori infection can show the participation of sVCAM-1 in the pathogenesis of gastric mucosal inflammation, sP-selectin and sICAM-1 concentrations in the sera of children with H pylori infection after eradication cannot reveal any significant differences as compared to healthy children.

Detection of T lymphocyte subsets of children with Helicobacter pylori infection

AIM: To study the transformation of T lymphocyte subsets in children with Heliobacter pylori (H pylori) infection. METHODS: The H pylori infection status were determined by a combination of ELISA and Western blot (immunoblot) technique in 98 children and T lymphocyte subsets in peripheral blood were determined by flow cytometrical analysis.RESULTS: There were 75 children positive with H pylori infection and 23 negative in 98 children. Comparing the proportion of peripheral blood T lymphocytic subsets in children with H pylori infection and without H pylori infection, it was found that a higher proportion of CD4 T-cells in infected children (39.02±7.71 vs34.25±10.73,t = 2.246,P＜0.05) and higher value of CD4 to CD8 T-cells ratio (1.51±0.52 vs 1.25, t= 2.104,P＜0.05) were present, but there were not significant differences in CD3 T-cells and CD8 T-cells (73.11±10.02 vs69.49±17.08, 27.22±6.07vs 28.27±8.67, P＞0.05).CONCLUSION: Th1 cell-mediated immune responses may be induced by H pylori infection in children.

Evaluation of Atypical Lymphocyte Warnings of Sysmex XE-4000 in Outpatient Children

This study aimed to evaluate the atypical lymphocyte warnings of Sysmex XE-4000 in outpatient children. [Method] Randomly 280 specimens of outpatient children were selected to analyze atypical lymphocytes with Sysmex XE-4000 and artificial smear microscopy simultaneously. [Result] With artificial smear microscopy as the gold standard, the atypical lymphocyte warnings of Sysmex XE-4000 in outpatient children exhibited a sensitivity of 97.4%, specificity of 69.3%, positive predictive value （PPV） of 55%, and negative predictive value （NPV） of 98.5%. [Conclusion] Sysmex XE-4000 shows a high sensitivity in atypical lymphocyte warnings, which can reduce the number of blood smears, improve the specificity of microscopy, and decline the labor intensity of inspection personnel. However, there are stil certain false positives to be confirmed by artificial microscopy.

Specific serum immunoglobulin G to H pylori and CagA in healthy children and adults(south-east of Iran)

AIM. To evaluate the serologic IgG response to Hpylori and CagA across age groups and in healthy children and adults.METHODS： Totally, 386 children aged 1-15 years and 200 adults aged 20-60 years, were enrolled to study. The serum samples of participant were tested for presence of antJ-Hpylori and anti-CagA IgG by using ELISA method.RESULTS： The seroprevalence of Hpylori in adults was significantly higher than that observed in children （67.5% vs 46.6%; P 〈 0.000003）. In children, the seropositivity rate in males （51.9%） was significantly （P 〈 0.05） higher than that observed in females （41.7%）. The prevalence of serum anti-CagA antibody was 72.8% and 67.4% in infected children and adults, respectively. The mean titer of serum anti-CagA antibodies was significantly higher among children in comparison to adults （64.1 Uarb/mL 30.7; P 〈 0.03）. In infected children and adults the prevalence of serum anti-CagA antibody was higher in males compared to females （78.4% vs 66.3%; P = 0.07 and 75.6% vs 54.71%; P 〈 0.04, respectively）. The age-specific prevalence of anti-H py/or/and anti-CagA antibody （in infected subjects） was 37.6% and 59.57% at age 1-5 years, 46.9% and 75% at age 6-10 years, 54.9% and 79.45% at age 11-15, 59.01% and 83.33% at age 20-30 years, 66.6% and 60.52% at age 31-40 years, 73.46% and 63.88% at age 41-50 years and 75.75% and 60% at age 51-60 years with mean titer of anti-CagA antibody of 75.94, 63.32, 57.11, 52.06, 23.62, 21.52 and 21.80 Uarb/mL, respectively. There was significant difference between mean serum anti-CagA antibody in age subgroups （P 〈 0.001）.CONCLUSION： These results showed that anti-Hpylori and anti-CagA antibodies were common in the children and adults. The Hpylori-specific antibodies influenced by age and sex of subjects. Moreover, it seems that males are more susceptible to infection with CagA^＋ strains compared to females. The seroprevalence of anti-CagA antibody was increased with age, up to 30 years and then decreased. It was also found that the magnitude of the IgG response to CagA decreased with advanced age.

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 rain） 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.

志学坚心境不易

示儿庄德芬范相未遇时,帐中盈烟迹。贵盛相门儿,贫贱无家客。青云与泥涂,勤苦同一辙。志学抱坚心,岂为境所易。庄德芬,清代女诗人。字端人,江苏吴县(今属苏州)人。河南提学道(官名)庄朝生之孙女.

Efficacy evaluation and influencing factors analysis of combined estrogen in the treatment of labial adhesion in children

In the present study, we aimed to assess the effect of combined estrogen cream on young girls’ labial adhesions, and to identify the possible factors affecting the treatment outcome. We retrospectively included 123 children with labial adhesions.Variables were collected, including treatment outcomes, conjugated estrogen usage, and dosage, whether it was combined with manual or surgical separation, whether to use erythromycin, and whether to be accompanied with vulvitis. Chi-square test, Fisher’s exact test, and t-test were used to analyze the correlation between influencing factors and treatment outcome in univariate analysis.We used logistic regression analysis to explore the key influencing factors. The use of conjugated estrogen in combination with manual or surgical separation(P = 0.001), and the degree of labial adhesions(P = 0.011) had significant effects on the final treatment outcome.The frequency of conjugated estrogen treatment, whether erythromycin was used in combination during treatment, and whether the children were accompanied by vulvitis had no significant effect on the treatment outcome(P > 0.05). After the logistic regression,we found that whether it was combined with manual or surgical separation(P = 0.000, OR = 0.078, 95% CI = 0.030–0.203), and the degree of labial adhesions in children(P = 0.003, OR = 5.324, 95% CI = 1.767–16.041) were independently related to the effect of conjugated estrogen treatment. The therapeutic effect of conjugated estrogen alone was better for mild adhesion. However,severe adhesions need to consider with manual or surgical separation in combination with conjugated estrogen treatment. It is not recommended to combine erythromycin with routine clinical treatment. Conjugated estrogen once a day can also achieve a good therapeutic effect.