Clinical outcome of pediatric collagenous gastritis: Case series and review of literature

Collagenous gastritis (CG) is characterized by patchy subepithelial collagen bands. Effective treatment and the clinical and histological outcome of CG in children are poorly defined. The aim of this study is to summarize the published literature on the clinical outcome and response to therapy of pediatric CG including two new cases. We performed a search in Pubmed, OVID for related terms; articles including management and clinical and/or endo-histologic follow up information were included and abstracted. Reported findings were pooled in a dedicated database including the corresponding data extracted from chart review in our patients with CG. Twenty-four patients were included (17 females) with a mean age of 11.7 years. The clinical presentation included iron deficiency anemia and dyspepsia. The reported duration of follow up (in 18 patients) ranged between 0.2-14 years. Despite most subjects presenting with anemia including one requiring blood transfusion, oral iron therapy was only documented in 12 patients. Other treatment modalities were antisecretory measures in 13 patients; proton pump inhibitors (12), or histamine-2 blockers (3), sucralfate (5), prednisolone (6), oral budesonide in 3 patients where one received it in fish oil and triple therapy (3). Three (13%) patients showed no clinical improvement despite therapy; conversely 19 out of 22 were reported with improved symptoms including 8 with complete symptom resolution. Spontaneous clinical resolution without antisecretory, anti-inflammatory or gastroprotective agents was noted in 5 patients (4 received only supplemental iron). Follow up endohistopathologic data (17 patients) included persistent collagen band and stable Mononuclear cell infiltrate in 12 patients with histopathologic improvement in 5 patients. Neither collagen band thickness nor mononuclear cell infiltrate correlated with clinical course. Intestinal metaplasia and endocrine cell hyperplasia were reported (1) raising the concern of long term malignant transformation. In summary, CG in children is a chronic disease, typically with a variable clinical response and an indolent course that is distinct from the adult phenotype. Long term therapy usually inclused iron supplementation but cannot be standardized, given the chronicity of the disease, variability of response and potential for adverse events.

Management of pancreaticobiliary disease using a new intra-ductal endoscope:The Texas experience

AIM:To evaluate a new single-operator mini-endoscope, Spyglass,for its performance,feasibility and safety in the management of pancreaticobiliary disease. METHODS:In a multicenter retrospective analysis of patients undergoing intraductal endoscopy,we evaluated 128 patients(71 men,mean age 57.6 years).Indications were therapeutic(TX)in 72(56%) and diagnostic(DX)in 56(44%). RESULTS:Peroral endoscopy was performed in 121 and percutaneous in seven.TX indications included CBD stones in 41,PD stones in six,and biliary strictures in 25.DX indications included abnormal LFT’s in 15, abnormal imaging in 38 and cholangiocarcinoma staging in three.Visualization of the stone(s)was considered good in 31,fair in six,and poor in four. Advancement of the electrohydraulic lithotripsy probe was not possible in three patients and proper targeting of the lesion was partial in four patients.A holmium laser was used successfully in three patients.Ductal clearance was achieved in 37 patients after one procedure and in four patients after two procedures.Diagnosis of biliary strictures was modified in 20/29 and confirmed to be malignant in 10/23.Of the modified patients,no diagnosis was available in 17.Spyglass demonstrated malignancy in 8/17 and non-malignancy in nine.Suspected pathology by imaging studies and abnormal LFT’s was modified in 43/63(66%).Staging of cholangiocarcinoma demonstrated multicentric cholangiocarcinoma in 2/3.There was no morbidity associated with the use of Spyglass. CONCLUSION:Spyglass Spyscopeis a first generation, single operator miniature endoscope that can evaluate and treat various biliary and pancreatic tract diseases.

Endoscopic retrograde cholangiography for pediatric choledocholithiasis: Assessing the need for endoscopic intervention

AIM:To assess pediatric patients for choledocholithiasis.We applied current adult guidelines to identify predictivefactors in children.METHODS:A single-center retrospective analysis was performed at a tertiary children's hospital.We evaluated 44 consecutive pediatric patients who underwent endoscopic retrograde cholangiography(ERCP) for suspected choledocholithiasis.Patients were stratified into those with common bile duct stones(CBDS) at ERCP vs those that did not using the American Society of Gastrointestinal Endoscopy(ASGE) guidelines(Very Strong and Strong criteria) for suspected CBDS.RESULTS:CBDS were identified in 84% at the time of ERCP.Abdominal ultrasound identified CBDS in 36% of patients.Conjugated bilirubin ≥ 0.5 mg/d L was an independent risk factor for CBDS(P = 0.003).The Very Strong(59.5%) and Strong(48.6%) ASGE criteria identified the majority of patients(P = 0.0001).A modified score using conjugated bilirubin had a higher sensitivity(81.2% vs 59.5%) and more likely to identify a stone than the standard criteria,odds ratio of 25.7 compared to 8.8.Alanine aminotransferase and gamma-glutamyl transferase values identified significant differences in a subset of patients with odds ratio of 4.1 and 3.25,respectively.CONCLUSION:Current adult guidelines identified the majority of pediatric patients with CBDS,but specific pediatric guidelines may improve detection,thus decreasing risks and unnecessary procedures.

Liver transplantation and the management of progressive familial intrahepatic cholestasis in children

Progressive familial intrahepatic cholestasis(PFIC) is a constellation of inherited disorders that result in the impairment of bile flow through the liver that predominantly affects children. The accumulation of bile results in progressive liver damage, and if left untreated leads to end stage liver disease and death. Patients often present with worsening jaundice and pruritis within the first few years of life. Many of these patients will progress to end stage liver disease and require liver transplantation. The role and timing of liver transplantation still remains debated especially in the management of PFIC1. In those patients who are appropriately selected, liver transplantation offers an excellent survival benefit. Appropriate timing and selection of patients for liver transplantation will be discussed, and the short and long term management of patients post liver transplantation will also be described.

Diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography in biliary rhabdomyosarcoma

Biliary rhabdomyosarcoma (BRMS) is an uncommon childhood malignancy which has been managed surgically. We present a case of a 3-year-old boy with BRMS, in whom endoscopic retrograde cholangiopancreatography (ERCP) was successfully used both diagnostically and therapeutically, thus obviating the need for surgery and its attendant risks of morbidity and mortality. We conclude that ERCP is an effective alternative to surgery for BRMS in some patients.

Nutritional status of children with inflammatory boweldisease in Saudi Arabia

AIM: To assess the prevalence of nutritional disorders in children with inflammatory bowel disease(IBD) in Saudi Arabia.METHODS: The data from a national cohort of children newly diagnosed with IBD between 2003 and 2012 were analyzed. The diagnosis of IBD and the differentiation between Crohn's disease(CD) and ulcerative colitis(UC) were confirmed by gastroenterologists according to the standard criteria. The body mass index(BMI) of each child [weight(kg)/height^2(m)] was calculated at the time of diagnosis. The World Health Organization standards and references were used and the BMI for age > +1 and <-2 standard deviation score were used to define overweight and thinness, respectively. Age stratification analysis was performed to investigate any age-related variation in the prevalence of nutritional status between children < 10 years of age and older.RESULTS: There were 374 children from 0.33 to 17 years of age, including 119(32%) children with UC and 255(68%) with CD. All of the children were Saudi nationals, and 68(57%) of the UC and 150(59%) of the CD children were males. A positive history of anorexia at the time of diagnosis was found in 30(25%) patients with UC and 99(39%) patients with CD. The prevalence of thinness was 31%, 35% and 24% in children with IBD, CD and UC, respectively, with a significantly higher prevalence of thinness in children with CD than in children with UC(P = 0.037) only in the age group of 10-17 years(P = 0.030). The prevalence of overweight was 16 %, 15% and 20 % in the children with IBD, CD and UC, respectively, indicating a higher prevalence in UC that was statistically significant only in the age group of 10-17 years(P = 0.020). CONCLUSION: A high proportion of children with IBD presented with overweight instead of the classical underweight. Awareness of this finding is important for patient care.

Significance of feeding dysfunction in eosinophilic esophagitis

Feeding dysfunction is a frequent presenting symptom of eosinophilic esophagitis(EoE). Here we present 3 children of various ages whose manifestations of EoE associated feeding dysfunction led to significant and life altering impact on their growth and development. Early identification of presenting symptoms of EoE will allow for prompt diagnosis and initiation of appropriate treatments. Recognition of salient features of dysfunction and treatment by feeding therapists and nutritionists led to symptom resolution and growth.

Hirschsprung's disease associated enterocolitis:A comprehensive review

Hirschsprung’s disease(HSCR)is a congenital disorder characterized by failure of the neural crest cells to migrate and populate the distal bowel during gestation affecting different lengths of intestine leading to a distal functional obstruction.Surgical treatment is needed to correct HSCR once the diagnosis is confirmed by demonstrating the absence of ganglion cells or aganglionosis of the affected bowel segment.Hirschsprung’s disease associated enterocolitis(HAEC)is an inflammatory complication associated with HSCR that can present either in the pre-or postoperative period and associated with increased morbidity and mortality.The pathogenesis of HAEC remains poorly understood,but intestinal dysmotility,dysbiosis and impaired mucosal defense and intestinal barrier function appear to play a significant role.There is no clear definition for HAEC,but the diagnosis is primarily clinical,and treatment is guided based on severity.Here,we aim to provide a comprehensive review of the clinical presentation,etiology,pathophysiology,and current therapeutic options for HAEC.

为在小儿科的胃肠的混乱的肠的 microbiome 治疗的前景和挑战

Fecal microbiome(microbiota) transplantation is an emerging treatment not only for refractory/recurrent Clostridium difficile infections and chronic gastrointestinal diseases, but also for metabolic syndrome, and even possibly for neurological disorders. This non-conventional therapy has been perhaps more appropriately designated as fecal bacteriotherapy(FB) as well. The employment of FB is spreading into pediatric gastroenterology. This focused review highlights the pediatric applications of FB and discusses hypotheses for its mechanism of action. We propose that intestinal microbiome therapy may be a more appropriate term for FB, which integrates its potential future applications.

Acute Hepatitis of Unknown Origin in Children: Early Observations from the 2022 Outbreak

Recent reports of acute hepatitis of unknown origin in previously healthy children have been increasing worldwide.The main characteristics of the affected children were jaundice and gastrointestinal symptoms.Their serum aminotransaminase levels were above 500 IU/L,with negative tests for hepatitis viruses A–E.By 31 May 2022,the outbreak had affected over 800 children under the age of 16 years in more than 40 countries,resulting in acute liver failure in approximately 10%,including at least 21 deaths and 38 patients requiring liver transplantation.There was still no confirmed cause or causes,although there were several different working hypotheses,such as severe acute respiratory syndrome coronavirus 2(SARS-CoV-2),adenovirus serotype 41,or SARS-CoV-2 superantigen-mediated immune cell activation.Here,we review early observations of the 2022 outbreak which may inform diagnosis,treatment,and prevention in the context of an overlapping COVID-19 pandemic.