Gastritis and gastropathy of childhood

Epidemiological Characteristics of Helicobacter pylori Infection in Children in Northeast Romania

(1) Background: Although gastritis has been associated with multiple etiologies, in pediatrics the main etiology is idiopathic. Many studies have reported mild-to-severe gastritis Helicobacter pylori (H. pylori) as an etiological factor. We evaluated the distribution of the infection with H. pylori by age, gender and place of living; (2) Methods: A retrospective study was conducted over a period of 3 years, over a cohort of 1757 patients of both sexes, aged between 1 and 18 years, admitted to a regional gastroenterology center in Iasi, Romania, with clinical signs of gastritis which underwent upper gastrointestinal endoscopy. The research was based on the analysis of data from patient observation charts and hospital discharge tickets, as well as endoscopy result registers; (3) Results: Out of the 1757 children, in 30.8% of cases the H. pylori infection was present. Out of them, 26.8% were males and 73.2% females. The average age of children with an H. pylori infection was higher (14.1 + 2.8 DS), compared with children without H. pylori (12.8 + 3.7 SD), an average difference of 1.3 years (95% confidence interval 0.96 to 1.66; p < 0.001). By place of living, children with H. pylori infection were from urban areas at 24.7% and from rural areas at 75.3%; (4) Conclusions: H. pylori infection incidence is still high in children, especially in teenagers, so extensive prevention and treatment programs are needed.

Evolution of Helicobacter pylori associated with gastroduodenal ulcers or erosions in children over the past 23 years: Decline or steady state?

BACKGROUND

Recent data suggest that in children, the proportion of gastroduodenal ulcers/erosions associated with Helicobacter pylori infection is currently lower than expected. In this study, we trace this proportion over two decades.

METHODS

We reviewed the reports of all upper gastrointestinal endoscopies with biopsies for histology and culture over the past 23 years. H pylori status was assessed using several invasive methods. The infection rate during different time periods was compared between children with lesions and controls.

RESULTS

A total of 7849 endoscopies were performed in 5983 children (2874 F/3109 M, median age 7.6 years, range 0.1-17.9 years). The endoscopy report was missing in 316 patients. At the first upper gastrointestinal endoscopy, 12.1% of the children presented with gastric and/or duodenal ulcers or erosions with an H pylori infection rate of 35.4%, whereas no such lesions were observed in 87.9% of children in whom the H pylori infection rate was 21.3%. The risk factors associated with such lesions were older age (P < 0.001), male sex (P = 0.002), and H pylori infection (P < 0.0001). Gastric ulcers were not significantly associated with H pylori (24% infected), whereas 52% of duodenal ulcers, 33% of gastric erosions, and 38% of duodenal erosions were associated with H pylori. The proportion of gastroduodenal lesions associated with H pylori remained stable over time. Children with H pylori infection and ulcers were older than those with H pylori infection without ulcers (P < 0.001).

CONCLUSIONS

Our study indicates that in our pediatric population, the proportion of ulcers without H pylori infection is higher than previously suggested, and this prevalence has not changed over the past two decades.

Primary Eosinophilic Gastritis in a Child with Gastric Outlet Obstruction

A 3-year-old girl presented with multiple episodes of vomiting, fever, and hematemesis for the past 2 months. Except for hemoglobin, her rests of the laboratory tests were unremarkable. Her barium X-ray showed absence of the duodenal bulb and the C-loop. Her endoscopy showed deformed stomach with multiple ulcers and diverticuli. The gastric outlet was not visualized. Distal gastrectomy with gastro-duodenal anastomosis was performed. Histopathological findings revealed transmural dense infiltrates of eosinophils, consistent with eosinophilic gastritis.

Prevalence of infection with cagA-positive Helicobacter pylori strains among children and adolescents in southern Brazil

CONTEXT

Helicobacter pylori (H. pylori) has a worldwide distribution, but the prevalence of infection, virulence factors, and clinical presentation vary widely according to the studied population. In Brazil, a continental country composed of several ethnicities and cultural habits, the behavior of infection also appears to vary, as many other studies have shown.

OBJECTIVES

Describe the prevalence of infection with cagA-positive H. pylori strains in a group of children and adolescents who underwent esophagogastroduodenoscopy in Porto Alegre, Rio Grande do Sul.

METHODS

Fifty-four gastric biopsy specimens of children and adolescents with H. pylori infection demonstrated by histology, urease test and molecular analysis were tested for the presence of cagA positive H. pylori strains by the polymerase chain reaction method.

RESULTS

The prevalence of cagA-positive H. pylori was 29.6% (95% confidence interval, 18 to 43.6%). There were no statistically significant differences in clinical or demographic characteristics or in the endoscopic and histological features of patients infected with cagA-positive strains as compared with those infected by cagA-negative strains.

CONCLUSIONS

he study showed a low prevalence of infection with cagA-positive H. pylori strains among children and adolescents who underwent EGD in southern Brazil, in comparison to studies conducted with children from other regions of Brazil. There was no association between the presence of cagA-positive strains and more severe clinical presentations in the studied sample.

Non-Specific Gastric Inflammation in Children is Associated with Proton Pump Inhibitor Treatment for More than 6 Weeks

BACKGROUND AND AIMS

Non-specific gastric inflammation (NSGI) is a commonly reported pathological finding. We investigated if it is associated with the use of proton pump inhibitors (PPIs) in children at a single tertiary center.

METHODS

We performed an IRB-approved chart review of all endoscopy and biopsy reports of patients who underwent esophagogastroduodenoscopy between July 2009 and July 2010 (n = 310). Demographic data, dose, duration of exposure to PPI, and biopsy results were collected and analyzed. All esophageal, gastric, and duodenal biopsies were independently reviewed by a pathologist. Patients with acute gastritis, moderate/severe chronic gastric inflammation, or Helicobacter pylori infection were excluded. The presence of NSGI was compared between patients exposed and not exposed to PPI as well as between patients with different doses and durations of PPI exposure to assess for potential associations.

RESULTS

A total of 193 patients were included: 88 (46%) had a history of PPI use and 48 (25%) were found to have NSGI. Compared to patients not exposed to PPI, the odds ratio of NSGI in patients exposed to PPIs was 2.81 (95% CI: 1.36-5.93). The odds ratio of NSGI in patients exposed to PPI for >3 months was 4.53 (95% CI: 1.69-11.97). Gender, ethnicity, and age were not associated with NSGI. No histological differences were found in the esophagus and duodenum between patients exposed and not exposed to PPI.

CONCLUSION

This study found that PPI exposure is associated with NSGI with a higher risk for those exposed for >3 months. As the clinical implications of NSGI are not known, judicious use of PPIs is needed. Prospective studies are required to confirm and to determine the etiologic factors (i.e., alteration of the gastric pH, serum gastrin) that may be related with the presence of NGSI.

Diagnostic and therapeutic endoscopy in children and adolescents with cancer

Chemotherapy regimes in children with cancer often cause gastrointestinal side effects. Only limited data exist on the use of endoscopy in this group of patients.

METHODS

Retrospective review over a time period of 8.5 years identified 57 endoscopies (49 upper endoscopies, four colonoscopies, three sigmoidoscopies, one rectoscopy) in 38 patients (mean age 12.8 years). Seventeen children (45%) had hematological malignancies and 21 (55%) had solid tumors. In 12 children, platelet count was <50 × 10(9)/L and 10 children were neutropenic (ANC < 1 × 10(9)/L; absolute neutrophil count).

RESULTS

Forty diagnostic endoscopies, seven follow-up endoscopies, and 10 therapeutic endoscopies were performed. Biopsies were taken in 30 (75%) of 40 diagnostic endoscopies and microbiology samples in 17 (42.5%). Pathological findings identified in 33 (82.5%) diagnostic endoscopies: esophagitis 15 (37.5%)-two of them infections: 1 candida, 1 HSV (herpes simplex virus); Mallory-Weiss tears 5 (12.5%); gastritis 18 (45%; four Helicobacter pylori positive); ulcer 1 (2.5%); duodenitis 11 (27.5%); neoplasia 3 (7.5%); and colitis 5 (12.5%). Therapeutic endoscopies: Four PEG (percutaneous endoscopic gastrostomy) tube placements, one tube removal, two sclerotherapies for esophageal varices, three nasojejunal tubes for enteral nutrition (EN), and three additional tubes in primary diagnostic endoscopies.

COMPLICATIONS

One episode of fever (>38.5°C) after colonoscopy, one localized infection after PEG tube placement, and two episodes of temporary desaturation. No association of neutropenia with more infections was observed. No bleeding in thrombocytopenic patients was observed.

CONCLUSION

The data show that endoscopy in high-risk pediatric patients with malignant diseases is a safe procedure. Endoscopy reveals relevant information and have therapeutic impact with high probability. Tube placement techniques can help to maintain EN.

[Gastrointestinal bleeding following ingestion of low-dose ibuprofen]

INTRODUCTION

Ibuprofen is a non-steroidal anti-inflammatory drug frequently used in children for fever and pain. It is usually considered to be safe and of low risk at low doses and short-term use.

PATIENTS AND METHODS

The aim of our study was to review the cases of gastrointestinal bleeding and assessment of gastrointestinal bleeding after recommended doses of ibuprofen.

RESULTS

We describe 9 previously healthy patients with upper gastrointestinal bleeding after receiving weight-related doses of ibuprofen for fever.

Histological features of the gastric mucosa in children with primary bile reflux gastritis

BACKGROUND

Bile reflux is one of the primary factors involved in the pathogenesis of gastric mucosal lesions in patients with chronic gastritis; however, little is known about the exact histological features of bile reflux and its contributions to gastric mucosal lesions in this disease, especially in children with primary bile reflux gastritis (BRG). The aim of this study was to investigate the classic histological changes of the gastric mucosa in children with primary BRG.

METHODS

The Bilitec 2000 was used for 24 h monitoring of gastric bile in 59 children with upper gastrointestinal symptoms. The histological characteristics of the gastric mucosa were examined and scored.

RESULTS

Thirteen of the 59 patients had a helicobacter pylori infection and were excluded; therefore, 46 cases were included in this study. The positive rate of pathological duodenogastric reflux was significantly higher in patients with foveolar hyperplasia than those without foveolar hyperplasia; however, the rate was significantly lower in patients with vascular congestion than those without vascular congestion. The longest reflux time and the total percentage time of bile reflux were significantly lower in patients with vascular congestion than those without vascular congestion. A total of 9 types of histological changes were analyzed using a binary logistic regression. Foveolar hyperplasia and vascular congestion in the superficial layer became significant variables in the last step of the stepwise regression.

CONCLUSIONS

Foveolar hyperplasia was associated with the severity of bile reflux, suggesting that it is a histological feature of primary BRG in children, while vascular congestion may be a protective factor.

Peptic ulcers and erosions are common in Israeli children undergoing upper endoscopy

BACKGROUND

Peptic ulcers and erosions (PU&E) are thought to be uncommon in children. Patients with early exposure to Helicobacter pylori may be at a higher risk for early onset PU&E. Children in Israel have a high prevalence and early acquisition of Helicobacter pylori (H. pylori) and have easy access to pediatric gastroenterologists and endoscopy. Our aim was to describe the prevalence and characteristics of PU&E in this population referred by Pediatric Gastroenterologists for an upper endoscopy.

METHODS

We conducted a retrospective study over the years January 2003-May 2006. Over these years we had information on 751 diagnostic upper endoscopies. PU&E was regarded as erosive gastritis/duodenitis or ulcer in either the stomach or duodenum. H. pylori status was assessed using rapid urease test and gastric biopsies.

RESULTS

PU&E was detected in 169 (22.5%) patients (ulcers 51 (6.8%), erosions 118 (15.7%)). One hundred twenty-four had gastric PU&E and 58 had duodenal PU&E. H. pylori was positive in 112 (66.3%). H. pylori-associated PU&E becomes common after age 10 years, with gastric PU&E presenting much earlier than duodenal disease. Most of the H. pylori-negative PU&E were idiopathic and improved symptomatically on PPI treatment. Interestingly, 43% of patients with PU&E in our cohort were either immigrants from the former Soviet Union or of Israeli Arab origin.

CONCLUSIONS

PU&E appears to be common in this selected population with a relatively high incidence of gastric PU&E. H. pylori associated PU&E becomes common after age 10 years with gastric PU&E presenting much earlier than duodenal disease. Non H. pylori PU&E in children comprises approximately a third of all PU&E, are mostly idiopathic and appear earlier than H. pylori associated PU&E.

Does gastric atrophy exist in children?

Several clinical reports confirmed that gastric atrophy is a pathology not only limited to adult patients. In pediatrics, it is most often described in association with a H pylori infection but this bacteria does not seem to be the only etiological factor of this preneoplastic state in children. The frequency of gastric atrophy and intestinal metaplasia in children are unknown because they are not systematically sought during upper gastrointestinal endoscopy. The lack of specific histological classification of children’s gastropathies makes their diagnosis difficult for pathologists. Based on our knowledge to date, we think that it is necessary to describe, in detail, the natural course of this lesion during childhood. A close and prolonged clinical and endoscopic follow-up is important for children with gastric atrophy.

Atrophic gastritis in young children and adolescents

BACKGROUND

Helicobacter pylori associated gastric cancer arises via a multistage process, with atrophic gastritis being the precursor lesion. Helicobacter pylori is typically acquired in childhood, yet little is known of the prevalence of atrophic gastritis in childhood.

AIM

To study atrophic gastritis among children from countries with high gastric cancer incidence.

METHODS

Sections from topographically mapped gastric biopsy specimens from children undergoing clinically indicated endoscopy in Korea and Colombia were evaluated using visual analogue scales. Atrophy was defined as loss of normal glandular components, including replacement with fibrosis, intestinal metaplasia (IM), and/or pseudopyloric metaplasia of the corpus (identified by the presence of pepsinogen I in mucosa that was topographically corpus but phenotypically antrum).

RESULTS

One hundred and seventy three children, 58 from Korea (median age, 14 years) and 115 from Colombia (median age, 13 years), were studied. Helicobacter pylori was present in 85% of Colombian children versus 17% of Korean children (p<0.01). Atrophic mucosa near the antrum-corpus border was present in 16% of children, primarily as pseudopyloric metaplasia (31%, IM; 63%, pseudopyloric metaplasia; 6%, both). The median age of children with corpus atrophy was 15 (range, 7-17) years.

CONCLUSION

Gastric atrophy occurs in H pylori infected children living in countries with high gastric cancer incidence. Identification and characterisation of the natural history of H pylori gastritis requires targeted biopsies to include the lesser and greater curve of the corpus, starting just proximal to the anatomical antrum-corpus junction, in addition to biopsies targeting the antrum and cardia.

Comparaison des prescriptions des pédiatres et des médecins généralistes : une étude en population en Franche-Comté sur la base de données de la caisse régionale d'assurance maladie

OBJECTIVES

To compare the medical management of children by private pediatricians or by general practitioners.

POPULATION AND METHODS

A retrospective cohort study analyzed information from the automated database of the Regional Health Insurance Fund for salaried workers in Franche-Comté from January 2001 through December 2002 and compared the mean rates of prescriptions in the populations seen only by general practitioners or mainly by pediatricians.

RESULTS

Analysis concerned 1 535 208 visits (office and home). Management by pediatricians was associated with 25% fewer consultations and 6% fewer hospitalizations. Pediatricians also wrote 25% fewer prescriptions for drugs, 17% fewer for laboratory tests, and 42% fewer for speech and language therapy. Children seen by pediatricians took antibiotics much less often (penicillin: -24%; cephalosporins: -74%; macrolides: -53%) as well as half as many corticoids and NSAIDs. Their vaccination coverage was more complete (31% more hepatitis B vaccines, 7% more MMR), as was prevention against rickets and cavities (twice the rate of vitamin D and fluoride prescriptions). The population followed mainly by pediatricians included 25% more children with a chronic disease.

CONCLUSION

General practitioners and pediatricians appear to differ significantly in their management of children. Other studies that can take into account such confounding factors as health status are needed to confirm these results.

Esomeprazole therapy for gastric acid hypersecretion in children with cystinosis

Oral cysteamine therapy prevents natural disease progression in children with cystinosis, but it may cause severe gastrointestinal (GI) symptoms through gastric acid-hypersecretion. The purpose of this study was to assess the value of esomeprazole in controlling cysteamine-induced acid-hypersecretion and GI symptoms in children with cystinosis. Subjects underwent upper GI endoscopy and biopsy, serum gastrin and cysteamine measurements as well as acid secretion studies (basal, maximal and peak acid output, BAO, MAO, PAO) before and during esomeprazole therapy. A symptom score (maximum 14 points) was devised to monitor symptoms. Twelve children (mean age 5.8 years) were studied. Cysteamine ingestion resulted in mean MAO and PAO significantly higher than mean BAO, both before and during esomeprazole therapy. PAO was usually within 60 min of cysteamine ingestion. Esomeprazole therapy significantly reduced MAO (P<0.01) and PAO (P<0.01). The mean symptom score fell from 6.4 to 0.7 (P<0.0001) during esomeprazole therapy. The mean final dose of esomeprazole was 1.7 mg/kg per day (range 0.7 mg/kg per day to 2.75 mg/kg per day). Plasma cysteamine levels were not affected by acid-suppression therapy. One child had multi-nucleated parietal cells. Cysteamine-induced gastric acid-hypersecretion and GI symptoms are dramatically reduced with esomeprazole therapy. Esomeprazole does not alter cysteamine absorption and is very well tolerated in children.

Histologic findings in "ex- Helicobacter pylori" gastric biopsies of pediatric patients

Long-term sequelae of Helicobacter pylori-associated chronic gastritis (HpCG) have been described in adult patients. In the present study we report the histology of gastric mucosa biopsies in 6 asymptomatic pediatric patients (5 male and 1 female; mean age 9.5 years) with previous HpCG. Preceding H. pylori was histologically proved and confirmed by culture, direct visualization, and/or serology before delivering treatment. In 5 of 6 cases the HpCG followed a protracted clinical course, with various therapeutic series needed before H. pylori eradication. Time from final treatment for HpCG to actual biopsy ranged from 3 months to almost 3 years. Gastric mucosa showed mild chronic gastritis with absence of H. pylori organisms (6 of 6), focal loss of gland units with collagenous replacement (6 of 6), serrated foveolae (3 of 6), regenerative changes at elongated glandular necks with cells having enlarged and hyperchromatic nuclei (5 of 6), lymphoid aggregates (2 of 6), and presence of sulfomucins in isolated epithelial cells of glands and foveolae (2 of 6). None of these features were noticed in 10 normal gastric mucosa biopsies used as controls. The referred findings in "ex- H. pylori" pediatric patients may represent very early sequelae from HpCG at this age.

Chronic gastritis is not associated with gastric dysrhythmia or delayed solid emptying in children with dyspepsia

To determine if chronic gastritis (CG) is associated with gastric dysrhythmia or delayed solid emptying in children with dyspepsia, 22 patients (7-15 years of age) with dyspepsia and normal gross endoscopies were studied. Antral biopsies were evaluated for chronic gastritis, and immunohistology was performed to determine densities of CD3+, CD20+, CD25+, and tryptase-positive cells. Electrogastrography (EGG) and gastric scintiscan evaluation were performed within 2-7 days of endoscopy. CG and increased immune cell densities were not associated with altered gastric emptying. Mean CD3+ cell counts were positively correlated with the percentage normal slow waves, and patients with a normal EGG had increased CD3+ cell density. In children with dyspepsia, chronic antral inflammation in the setting of a normal gross endoscopy is not associated with EGG abnormalities or delayed solid emptying. Chronic gastritis and gastric dysrhythmia may simply be two separate and distinct mechanisms resulting in the clinical entity of dyspepsia.

Stool antigen test for diagnosis of Helicobacter pylori infection in children with symptomatic disease: a prospective study

OBJECTIVE

Noninvasive tests for the diagnosis of Helicobacter pylori (Hp) infection in children are limited by low accuracy rates and lack of validation. Existing studies indicate that the stool antigen test (HpSA) has an acceptable level of accuracy for the diagnosis of Hp infection in adults but not children. The aim of this study was to evaluate the accuracy of the HpSA test for the detection of Hp infection in U.S. children.

METHODS

Children requiring upper endoscopic procedures were prospectively recruited from two pediatric gastroenterology clinics. Stool samples were collected from each participant before endoscopy. The presence of Hp infection was determined by positive histologic findings and positive rapid urease test (RUT). The presence of Hp organisms in stool was determined by an enzyme-linked immunosorbent assay using a commercially available polyclonal antibody kit (Meridian Diagnostics, Cincinnati, OH, U.S.A.). Results of the stool antigen test were compared with histology findings and RUT results.

RESULTS

One hundred twenty-one children (mean age, 10.1 +/- 3.7 years) participated, of whom 9 (7.4%) had Hp infection. Histologic findings and RUT results were concordant in 95% of the children. Per study protocol, HpSA had a sensitivity, specificity, positive and negative predictive value, and accuracy rate of 67%, 99%, 86%, 97%, and 96.5%, respectively.

CONCLUSION

HpSA, a polyclonal antibody test, had a low sensitivity for infection in children in the United States and at present cannot replace histologic findings as the gold standard for the diagnosis of Hp infection in the pediatric population.

Focal-enhanced gastritis in regressive autism with features distinct from Crohn's and Helicobacter pylori gastritis

BACKGROUND

Immunohistochemistry allowed recent recognition of a distinct focal gastritis in Crohn's disease. Following reports of lymphocytic colitis and small bowel enteropathy in children with regressive autism, we aimed to see whether similar changes were seen in the stomach. We thus studied gastric antral biopsies in 25 affected children, in comparison to 10 with Crohn's disease, 10 with Helicobacter pylori infection, and 10 histologically normal controls. All autistic, Crohn's, and normal patients were H. pylori negative.

METHODS

Snap-frozen antral biopsies were stained for CD3, CD4, CD8, gammadelta T cells, HLA-DR, IgG, heparan sulphate proteoglycan, IgM, IgA, and C1q. Cell proliferation was assessed with Ki67.

RESULTS

Distinct patterns of gastritis were seen in the disease states: diffuse, predominantly CD4+ infiltration in H. pylori, and focal-enhanced gastritis in Crohn's disease and autism, the latter distinguished by striking dominance of CD8+ cells, together with increased intraepithelial lymphocytes in surface, foveolar and glandular epithelium. Proliferation of foveolar epithelium was similarly increased in autism, Crohn's disease and H. pylori compared to controls. A striking finding, seen only in 20/25 autistic children, was colocalized deposition of IgG and C1q on the subepithelial basement membrane and the surface epithelium.

CONCLUSIONS

These findings demonstrate a focal CD8-dominated gastritis in autistic children, with novel features. The lesion is distinct from the recently recognized focal gastritis of Crohn's disease, which is not CD8-dominated. As in the small intestine, there is epithelial deposition of IgG.

Clinical efficacy and pharmacokinetics of montelukast in dyspeptic children with duodenal eosinophilia

BACKGROUND

Montelukast, a competitive cysteinyl leucotriene-1 receptor antagonist, reduces airway eosinophilia in asthmatics. We evaluated the effect of this drug in children with eosinophilic duodenitis, defined histologically as duodenal mucosa with peak eosinophil count of more than 10 eosinophils/hpf.

METHODS

Forty children and adolescents (6-18 yr) with dyspepsia and duodenal eosinophilia were enrolled in a double blind, randomized, placebo-controlled, cross-over study of monteleukast therapy. Subjects were randomized to receive either 10 mg montelukast or an identical placebo once daily and were evaluated on day 14 for symptomatic and biochemical responses. Subjects were also randomized to one of two blood sampling schemes to evaluate montelukast pharmacokinetics.

RESULTS

Using a post treatment global pain assessment, a positive clinical response was observed in 62.1% of patients receiving montelukast compared with 32.4% on placebo (p < 0.02). Pain assessment score deteriorated in 45% of montelukast responders (5/11) after cross-over to placebo and improved in 62% (8/13) of placebo non-responders on cross-over to montelukast. In patients with peak duodenal eosinophil counts between 20-29/hpf (n=19), a positive pain assessment response was observed in 84% of patients receiving montelukast compared to 42% receiving placebo (p < 0.01). Response rate did not differ by age, gender or histologic findings at baseline. Pharmacokinetic analysis yielded parameter estimates for absorption rate constant (Ka), apparent volume of distribution (Vd/F) and elimination rate constant (Kel) of 0.42 h, 0.19 L/kg and 0.26 h, respectively. The relative extent of systemic drug exposure was comparable to that observed in previous pediatric investigations with similar weight-adjusted montelukast doses. Neither dose nor calculated drug exposure were associated with the level of post treatment pain assessment or the change in biochemical markers.

CONCLUSIONS

These data suggest a beneficial role for montelukast in the treatment of pediatric patients with dyspepsia associated with duodenal eosinophilia.

Expression of cytokeratins 7 and 20 in Helicobacter pylori-associated chronic gastritis in children

Helicobacter pylori gastric infection induces structural changes in the gastric epithelium. Among them, variations in the expression of cytokeratins have been reported in adult patients. In the present study, we describe the expression of CK7 and CK20 in gastric samples taken from the antrum in three groups of pediatric patients: (A) Helicobacter pylori-associated chronic gastritis (mean age: 11.4 years); (B) previous H. pylori chronic gastritis patients (mean age: 9.4 years); and (C) controls (mean age: 8.8 years). In all, the presence of sulfomucins was assessed with Alcian blue-periodic acid-Schiff pH 1.0. Immunoreactivity was graded as absent (0), weak (1+), moderate (2+), or intense (3+), in accordance with the intensity of the staining, and its distribution as focal or diffuse. CK7 reactivity was 2+ either focal or diffuse in all group A biopsies. The reactivity was more evident in the cells at the neck of the glands, in the areas with more inflammatory infiltrates, decorating long vertical segments of epithelium. In groups B and C, CK7 reactivity was also focal and 1+ at the cells of the necks of the glands. However, group B presented longer vertical segments of positive cells as compared to group C, and shorter than those of group A. The deeper glandular structures were focally 1+ in both groups. CK20 expression was comparable in all three groups, depicting a 2+ diffuse reactivity at the surface epithelium and interposed pits with absence or focal reactivity at the neck and coiled gland areas. Ki-67 immunostaining paralleled that of the CK7. Staining for sulfated mucosubstances was positive in two of five cases of groups A and B, and in none of the cases of group C. We conclude that: (1) the long segments of CK7-positive glandular necks in H. pylori cases most probably indicate intense regenerative activity during active inflammation; (2) eradication of H. pylori does not warrant ad integrum restitution since long segments of Ki-67+, CK7+ cells at the germinative compartment of the glands (as well as cells with sulfomucins) were still recognizable in ex- H. pylori patients; (3) finally, differing from what happens in adults, children somehow manage to maintain fully differentiated CK20+ superficial epithelium while the H. pylori is in action.

Inflammation of the gastric cardia in children with symptoms of acid peptic disease

OBJECTIVES

To assess the severity and causes of inflammation of the gastric cardia in children undergoing endoscopy for symptoms of acid peptic disease.

STUDY DESIGN

Patients undergoing upper gastrointestinal endoscopy for symptoms of acid peptic disease had biopsies from gastric cardia, gastric, and esophageal sites, and 24-hour intraesophageal pH monitoring. Gastric cardia was defined at endoscopy as the anatomic zone from the squamocolumnar junction to 0.5 cm below it. Severity of gastric cardia inflammation was scored 0 to 9 according to densities of inflammatory cells and epithelial abnormalities in surface and pit epithelium. A score > or =2 was considered positive.

RESULTS

Forty-seven children (median age, 6.5 years; range, 3-15) had Helicobacter pylori infection, gastroesophageal reflux disease (GERD), or both. In 22 patients, H pylori was detected in cardiac biopsies by rapid urease test and histology; it was detected also in the corpus and antrum in only seven of the 22. No patient had H pylori in gastric corpus/antrum without having the organism at the cardia as well. In 12 H pylori-positive patients, GERD was also diagnosed. Twenty-five patients had GERD and no H. pylori infection. Severity score was 3.8+/-0.8 in the H pylori group and 2.08+/-0.9 in the GERD alone group (P<.001); however, there was no difference in reflux index (24-hour % of gastroesophageal reflux) between the two groups. In neither group was correlation found between reflux index and severity score (H pylori, r=0.22; GERD alone, r=0.31; NS) nor between cardia inflammation and esophagitis grade (H pylori, r=0.37; GERD alone, r=0.22; NS).

CONCLUSIONS

In children with symptoms of acid peptic disease, inflammation of the gastric cardia does occur. It is more severe when the cardiac zone is infected with H pylori than in its absence. Of major practical significance is the finding that the gastric cardia is a highly sensitive site for the detection of H pylori infection.

The evaluation and treatment of gastrointestinal disease in children with cystinosis receiving cysteamine

OBJECTIVES

Cysteamine prevents organ damage in children with cystinosis, but may cause gastrointestinal (GI) symptoms. In this study we evaluated the nature of GI disease, and the value of omeprazole in controlling GI symptoms in these children.

STUDY DESIGN

Upper GI disease was evaluated with endoscopy, gastrin levels, and acid secretion studies after oral administration of cysteamine, before and after 16 weeks of therapy with omeprazole. A symptom score was devised.

RESULTS

Eleven children (mean age, 5.7 years) were studied. After cysteamine ingestion, before and after omeprazole therapy, the mean maximum acid output was significantly higher than the mean basal acid output. The maximum acid output was measured within 60 minutes of cysteamine ingestion and was reduced by omeprazole therapy (P<.01). The mean peak gastrin level was 30 minutes postcysteamine and was higher than baseline (P<.01). The initial mean symptom score (maximum score, 14) was 6.9 and fell to 0.7 (P<.0001) after 16 weeks of omeprazole therapy. At endoscopy, two children had diffuse gastric nodularity, and nearly all had cystine crystal deposits.

CONCLUSIONS

GI symptoms in children with cystinosis receiving cysteamine are often acid-mediated and improve with omeprazole. Cystine crystals were detected in the GI tract and may signify inadequate treatment with cysteamine.

Antimicrobial resistance in Helicobacter pylori isolates from children

OBJECTIVE

To determine the resistance rate to four antimicrobial agents commonly used in the treatment of Helicobacter pylori infection in children.

METHODS

Between July 1997 and January 2000, all H. pylori isolates from children undergoing gastroscopy were prospectively collected and subcultured to yield the susceptibility to four antimicrobial agents by E-test. In all, 23 isolates were tested. Demographic data, presenting symptoms, treatment regimen and clinical improvement after treatment were collected retrospectively.

RESULTS

The resistance rate of H. pylori to metronidazole and clarithromycin were 43.5% and 8.7%, respectively. No H. pylori strains were resistant to amoxycillin or tetracycline. There were no statistically significant differences in age, sex, ethnicity, presenting symptoms or clinical improvement after treatment between antimicrobial-susceptible and antimicrobial-resistant groups.

CONCLUSIONS

The frequent resistance of H. pylori to metronidazole and moderate resistance to clarithromycin in children are comparable with local adult data. The incidence of resistance tended to be higher in patients of non-European ethnicity, but this was not statistically significant. Given that the primary goal of therapy is eradication, and that local resistance rates are high, recommendations for H. pylori management may need to be modified to include sensitivity testing and/or determination of eradication in all patients.

Chemical gastropathy: a distinct histopathologic entity in children

BACKGROUND

Chemical gastropathy, also known as chemical or reactive gastritis, is a well-described histopathologic entity in adults. It is characterized by presence of foveolar hyperplasia, vascular congestion, lamina propria edema, and prominent smooth muscle fibers in the absence of inflammatory cells in the gastric antral mucosa. There are no data in children on this condition.

METHODS

All children showing features of chemical gastropathy in antral biopsy specimens were identified from pathology database from 1997 to 2000. Antral biopsy specimens were reviewed to assess the diagnosis of chemical gastropathy using standard diagnostic criteria. Charts of the children diagnosed with chemical gastropathy were reviewed for clinical course, endoscopic findings, and risk factors.

RESULTS

Twenty-one children (12 male, 9 female) with chemical gastropathy were identified. Common presenting symptoms were epigastric pain and vomiting. Eleven children were taking multiple medications, including nonsteroidal anti-inflammatory drugs. Endoscopy revealed esophagitis in 12, antral erythema in 7, and thick bile in the stomach in 7 children. Antral histology revealed foveolar hyperplasia in 19, congestion in 20, lamina propria edema and smooth muscle fibers in 16, and absence of inflammation in 19 patients. Acid suppression was the treatment in all patients. Mean follow-up duration was 11 months in 17 children. Symptoms resolved completely in 11 and partially in 6 patients.

CONCLUSIONS

As in adults, chemical gastropathy occurs in children. The factors associated with chemical gastropathy in this survey were gastroesophageal reflux disease and intake of multiple medications, including nonsteroidal anti-inflammatory drugs.

Activated duodenal mucosal eosinophils in children with dyspepsia: a pilot transmission electron microscopic study

BACKGROUND

Activated eosinophils can be identified by electron microscopy (EM) Previous studies have shown EM evidence of eosinophil activation in a variety of gastrointestinal conditions associated with inflammation. The purpose of this study was to evaluate the activation state by EM of duodenal mucosal eosinophils in children who presented with dyspepsia and to determine if eosinophils are activated in patients with normal eosinophil counts on routine histology.

METHODS

Twenty patients (ages 7-15 years) with dyspepsia were evaluated. All had normal gross endoscopies and was excluded. Each patient had two endoscopic forceps biopsies taken from both the duodenal bulb (DB) and the second portion of the duodenum (DS) for routine histology to determine eosinophil counts. Two additional biopsies were taken from the adjacent mucosa of each site for EM evaluation. The eosinophil activation state was determined for each specimen and a degranulation index was calculated for DB specimens.

RESULTS

On routine histology, peak eosinophil counts were greater than or equal to 20 per hpf in three patients, 11 to 19 per hpf in 12 patients, and less than or equal to 10 per hpf in 5 patients. All patients showed evidence of EM activation on DB specimens and 95% showed activation on DS specimens. The mean degranulation index was 50.5 + 12.0% with 65% of specimens revealing moderate (20 - 60%) degranulation and 30% of specimens revealing extensive (greater than 60%) degranulation.

CONCLUSIONS

Eosinophils present in the duodenal mucosa of children with dyspepsia are activated in a significant proportion of patients, even in those with normal eosinophil counts. The degree of degranulation is similar to that seen in other conditions where eosinophils have a pathogenic role.

Developmental changes in cyclooxygenase mRNA expression in the gastric mucosa of rats

BACKGROUND

In newborn rats, gastric mucosa is more susceptible to various damaging agents and recovers from injury more quickly than in older animals. To determine whether metabolism of prostaglandins is responsible for this mucosal protective mechanism in developing rats, we studied cyclooxygenase (COX) mRNA expression in the mucosa using quantitative real-time polymerase chain reaction (PRC).

METHODS

Cyclooxygenase-1 and COX-2 mRNA was extracted from the gastric mucosa of rats of various ages and quantitatively analyzed using real-time PCR with dual-labeled fluorogenic probes. The copy numbers of cDNA for COX-1 and COX-2 were standardized to glyceraldehyde-3-phosphate dehydrogenase from the same sample.

RESULTS

Cyclooxygenase-1 mRNA expression was lowest in 1-week-old rats and highest in 4-week-old rats. Mucosal damage produced by 150 mmol/L HCl and 60% ethyl alcohol did not increase COX-1 mRNA expression in any age group. Cyclooxygenase-2 mRNA expression increased significantly with age. Mucosal injury increased COX-2 mRNA in each age group, especially in 1-week-old rats. Intraperitoneal lipopolysaccharide also increased COX-2 mRNA in both 1- and 4-week old rats.

CONCLUSION

The high level of COX-2 mRNA expression in the gastric mucosa of 1-week-old rats may be responsible for the physiologic characteristics of gastric mucosal defenses in this age group.

Gastrointestinal problems in the handicapped child

Gastrointestinal issues are a major chronic problem in 80 to 90% of children with cerebral palsy and in children with neurodevelopmental disabilities who are at special risk of developing malnutrition because of uncoordinated swallowing, gastroesophageal reflux, and constipation. In addition to poor linear growth, there is a decrease in muscle strength and coordination, impaired cerebral function leading to decreased motivation and energy. Significant neurodevelopmental progress can be achieved with improved nutritional status. A multidisciplinary approach, with input from neurologists, gastroenterologists, nurses, occupational therapists, and dieticians, can make a major contribution to the medical wellbeing and quality of life of these children. Different neurological diseases ( eg, spinal dysraphism, syringomyelia, tethered cord syndromes) can give rise to gastrointestinal dysfunction and symptoms that may need different gastrointestinal or surgical management. The introduction of new drugs, including proton pump inhibitors and innovative endoscopic and surgical techniques in the management of gastroesophageal reflux disease and constipation also may have an impact on the treatment of neurologically handicapped children in the future.

A prospective study of a one-week nonbismuth quadruple therapy for childhood Helicobacter pylori infection

PURPOSE

In the eradication of Helicobacter pylori infection, a 1-week therapy improves patient compliance, but drug resistance may limit its efficacy. The effectiveness of the 1-week nonbismuth quadruple therapy was studied prospectively in children with proven H pylori infection in a population with a high rate of metronidazole resistance.

METHODS

All pediatric patients who presented to our institutions with acute and chronic upper gastrointestinal conditions requiring endoscopy from June 1997 to February 2000 were investigated prospectively for H pylori infection. Gastric biopsy specimens were analyzed with rapid urease test and histopathology, H pylori-positive children were treated with omeprazole, clarithromycin, amoxicillin, and metronidazole for 7 days. The result of treatment was assessed 1 month after treatment with endoscopy and biopsy. The same treatment was repeated for 2 weeks if H pylori was still present. In patients who needed a third endoscopy, their biopsy specimens were cultured to determine antibiotic sensitivity. Results were correlated with patients' symptoms and endoscopic findings.

RESULTS

Thirty-three children with acute (severe epigastric pain, n = 14; gastrointestinal bleeding, n = 9) and chronic (recurrent abdominal pain, n = 7; anemia, n = 3) conditions were treated for H pylori. Thirty-one (94%) were confirmed to have H pylori eradicated by a 1-week therapy, whereas 1 patient had eradication after a further 2-we'ek therapy (3.3%). The only unresponsive patient had H pylori resistant to both clarithromycin and metronidazole. All ulcers and erosions healed after the eradication of H pylori. Three patients had persistent recurrent abdominal pain despite H pylori eradication.

CONCLUSIONS

The 1-week therapy with omeprazole, clarithromycin, amoxicillin, and metronidazole is an effective treatment of H pylori in children in a population with a high incidence of metronidazole resistant strain of H pylori. Peptic ulcers and erosions healed with the eradication of the bacteria.

Omeprazole for treatment of chronic erosive esophagitis in children: a multicenter study of efficacy, safety, tolerability and dose requirements. International Pediatric Omeprazole Study Group

OBJECTIVES

To determine the efficacy, safety, and tolerability of omeprazole in children and to determine the doses required to heal chronic, severe esophagitis.

STUDY DESIGN

Open multicenter study in children aged 1 to 16 years with erosive reflux esophagitis. The healing dose of omeprazole used was that with which the duration of acid reflux was <6% of a 24-hour intraesophageal pH study. Follow-up endoscopy was performed after 3 months of treatment with the healing dose.

RESULTS

At entry, two thirds of 57 patients who completed the study had esophagitis grade 3 or 4 (scale 0-4); some 50% had neurologic impairment or repaired esophageal atresia. Of the 57 patients, 54 healed; 3 did not heal and left the study, and 3 healed with a second course. Doses required for healing were 0.7 to 3.5 mg/kg/d: 0.7 mg/kg/d in 44% of patients and 1.4 mg/kg/d in another 28%. Healing dose correlated with grade of esophagitis but not with age or underlying disease. Reflux symptoms improved dramatically in almost all of the 57 patients, including the unhealed patients.

CONCLUSIONS

Omeprazole is well tolerated, highly effective, and safe for treatment of erosive esophagitis and symptoms of gastroesophageal reflux in children, including children in whom antireflux surgery or other medical therapy has failed. On a per-kilogram basis, the doses of omeprazole required to heal erosive esophagitis are much greater than those required for adults.

Peptic ulcer disease in children

A peptic ulcer in a child looks the same as it does in an adult, and many of the aetiologies of peptic ulcer disease in children are similar to those in adults. However, there are many differences between children and adults, especially in the areas of clinical presentation, the prevalences of different types of ulcer disease, and the prevalence of complications of ulcer disease. Therefore the approach to diagnosis and management in children is often at variance with that in adults. One important example is the approach to suspected Helicobacter pylori (H. pylori) disease in children, in which consensus groups have advised a considerably different approach in children. While the chapter deals with the full range of peptic ulcer disease in children, the focus is on those aspects in which there are differences between adults and children.