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Kocic M, Rasic P, Marusic V, Prokic D, Savic D, Milickovic M, Kitic I, Mijovic T, Sarajlija A. Age-specific causes of upper gastrointestinal bleeding in children. World J Gastroenterol 2023; 29:6095-6110. [PMID: 38186684 PMCID: PMC10768410 DOI: 10.3748/wjg.v29.i47.6095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/05/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023] Open
Abstract
The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.
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Affiliation(s)
- Marija Kocic
- Department of Gastroenterology, Hepatology and Nutrition, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
| | - Petar Rasic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
| | - Vuk Marusic
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Dragan Prokic
- Department of Gastroenterology, Hepatology and Nutrition, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Djordje Savic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Maja Milickovic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Ivana Kitic
- Department of Gastroenterology, Hepatology and Nutrition, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Tanja Mijovic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
| | - Adrijan Sarajlija
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
- Pediatric Day Care Hospital Department, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Eastern Sarajevo, Foča 73300, Bosnia and Herzegovina
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Sabe R, Hiremath G, Ng K. Endoscopy in Pediatric Eosinophilic Esophagitis. Gastrointest Endosc Clin N Am 2023; 33:323-339. [PMID: 36948749 DOI: 10.1016/j.giec.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergen-mediated clinicopathologic condition that currently requires esophagogastroduodenoscopy with biopsies and histologic evaluation to diagnose and monitor its progress. This state-of-the art review outlines the pathophysiology of EoE, reviews the application of endoscopy as a diagnostic and therapeutic tool, and discusses potential complications related to therapeutic endoscopic interventions. It also introduces recent innovations that can enhance the endoscopist's ability to diagnose and monitor EoE with minimally invasive procedures and perform therapeutic maneuvers more safely and effectively.
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Affiliation(s)
- Ramy Sabe
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Rainbow Babies and Children's Hospitals, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 11226, 2200 Children's Way, Nashville, TN 37232, USA
| | - Kenneth Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, 600 North Wolfe Street, CMSC 2-116, Baltimore, MD 21287, USA.
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Oral Immunotherapy and Risk of Eosinophilic Esophagitis in Children: 15 Years' Experience. J Pediatr Gastroenterol Nutr 2023; 76:53-58. [PMID: 36190840 DOI: 10.1097/mpg.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Oral immunotherapy (OIT) is an effective treatment for children with persistent food allergy, and has concerns about its safety, including eosinophilic esophagitis (EoE). The aim of this study was to evaluate the prevalence of EoE in a large cohort of children who underwent OIT in our center, and to determine if there were any clinical, endoscopic, or histologic differences depending on the food employed for the OIT. METHODS A retrospective study was performed over a 15-year period (2005-2020). Children who underwent cow's milk (CM), egg, and/or peanut OIT and developed EoE were included. RESULTS Six hundred and seven OIT were carried out (277 CM-OIT, 322 egg-OIT, and 8 peanut-OIT). Seventeen patients (2.8%) had a confirmed histologic diagnosis of EoE with a higher prevalence for patients who underwent CM-OIT (3.9%) than egg-OIT (2.2%). Symptoms suggestive of EoE and a confirmed diagnosis occurred at median times of 25 and 36 months, respectively, after the build-up phase of the OIT was completed. Choking, abdominal pain, and dysphagia were the most frequent symptoms and lamina propria fibrosis was observed in 41.2% of patients. No significant differences in clinical symptoms, endoscopic, or histologic findings between patients under CM or egg-OIT were found. One-third of patients reported mild symptoms suggestive of EoE before the OIT. CONCLUSIONS EoE appears to be a rare but important adverse event that can occur even years after OIT. Validated questionnaires to screen EoE before the OIT and in the follow-up of these patients may be the main tool for an early diagnosis.
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Ng LQ, Loh W, Ong JX, Merchant K, Chiou FK. Clinical, histopathological features and efficacy of elimination diet and proton-pump inhibitor therapy in achieving histological remission in Asian children with eosinophilic gastritis. J Paediatr Child Health 2022; 58:1244-1250. [PMID: 35388934 DOI: 10.1111/jpc.15969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 11/27/2022]
Abstract
AIM Paediatric eosinophilic gastritis (EG) is a rare disorder and existing literature on diagnostic criteria and management remains lacking. We aim to describe the clinical spectrum and assess the efficacy of dietary elimination and proton-pump inhibitor (PPI) therapy, with particular emphasis on histologic remission in children with primary EG. METHODS We performed a retrospective study of patients aged 0-18 years diagnosed with EG at a single centre in Singapore from 2013 to 2021. EG was diagnosed based on histological criteria of infiltration of >30 eosinophils per high-power film (HPF) in >5 separate HPFs from gastric biopsies, in the absence of other causes. First-line treatment consisted of PPI therapy and empiric 1-6 food elimination diet (FED). Outcomes measured were clinical, endoscopic and histological remission (defined as eosinophil count <20/HPF in gastric biopsies). RESULTS Twenty-one (66.7% females) patients were included with median age at diagnosis of 15 months (range:3-192). Majority presented with vomiting (76.2%) and gastrointestinal bleeding (71.4%). Twenty patients were initiated on FED+PPI and 16 had post-treatment biopsies. Clinical, endoscopic and histologic remissions were achieved in 94.7%, 81.3% and 68.8% respectively following FED+PPI. Histologic remission was significantly associated with younger age (9 vs. 132 months; P = 0.026). Four patients who did not respond to FED+PPI were started on oral viscous budesonide, of whom one achieved histological remission and two had clinical improvement. CONCLUSIONS FED+PPI is effective as first-line treatment in achieving histological remission in paediatric EG particularly in younger patients. Topical corticosteroids can be considered for those who have failed FED+PPI therapy.
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Affiliation(s)
- Lay Q Ng
- Gastroenterology, Hepatology and Nutrition Service, Pediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Wenyin Loh
- Allergy Service, Pediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jia X Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Khurshid Merchant
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Fang K Chiou
- Gastroenterology, Hepatology and Nutrition Service, Pediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
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