Identification of Iatrogenic Perforation in Pediatric Gastrointestinal Endoscopy

OBJECTIVES

Iatrogenic viscus perforation in pediatric gastrointestinal endoscopy (GIE) is a very rare, yet potentially life-threatening event. There are no evidence-based recommendations relating to immediate post-procedure follow-up to identify perforations and allow for timely management. This study aims to characterize the presentation of children with post-GIE perforation to better rationalize post-procedure recommendations.

METHODS

Retrospective study based on unrestricted pooled data from centers throughout Europe, North America, and the Middle East affiliated with the Endoscopy Special Interest Groups of European Society for Paediatric Gastroenterology Hepatology and Nutrition and North American Society for Pediatric Gastroenterology Hepatology and Nutrition. Procedural and patient data relating to clinical presentation of the perforation were recorded on standardized REDCap case-report forms.

RESULTS

Fifty-nine cases of viscus perforation were recorded [median age 6 years (interquartile range 3-13)]; 29 of 59 (49%) occurred following esophagogastroduodenoscopy, 26 of 59 (44%) following ileocolonoscopy, with 2 of 59 (3%) cases each following balloon enteroscopy and endoscopic retrograde cholangiopancreatography; 28 of 59 (48%) of perforations were identified during the procedure [26/28 (93%) endoscopically, 2/28 (7%) by fluoroscopy], and a further 5 of 59 (9%) identified within 4 hours. Overall 80% of perforations were identified within 12 hours. Among perforations identified subsequent to the procedure 19 of 31 (61%) presented with pain, 16 of 31 (52%) presented with fever, and 10 of 31 (32%) presented with abdominal rigidity or dyspnea; 30 of 59 (51%) were managed surgically, 17 of 59 (29%) managed conservatively, and 9 of 59 (15%) endoscopically; 4 of 59 (7%) patients died, all following esophageal perforation.

CONCLUSIONS

Iatrogenic perforation was identified immediately in over half of cases and in 80% of cases within 12 hours. This novel data can be utilized to generate guiding principles of post-procedural follow-up and monitoring.

PLAIN LANGUAGE SUMMARY

Bowel perforation following pediatric gastrointestinal endoscopy is very rare with no evidence to base post-procedure follow-up for high-risk procedures. We found that half were identified immediately with the large majority identified within 12 hours, mostly due to pain and fever.

Biochemical and cardiovascular predictors of PIMS risk in children after COVID-19 recovery =- the results of the LATE COVID Kids study

Background

Unfortunately, the number of children with the pediatric inflammatory multisystem syndrome (PIMS) associated with previous coronavirus disease has been increasing significantly.

Purpose

The aim of the present study was to characterize biochemical and cardiovascular predictors of PIMS risk in children recovered from COVID-19 based on the data from the LATE-COVID-Kids study (NCT04799444).

Methods

131 consecutive COVID-19 convalescents (mean age: 8.89±4.91; 67 boys and 64 girls) hospitalized for the clinical evaluation after the acute phase of the COVID-19 were classified into two groups related to symptoms: 29 children finally diagnosed with PIMS and 102 children with no-PIMS. All patients had confirmed coronavirus infection based on the positive results of nucleic acid test (RT-PCR - reverse transcriptase-polymerase chain), and they were serologically tested for antibodies against SARS-CoV-2. They had detailed laboratory testing, electrocardiography, and echocardiography.

Results

The time from COVID-19 recovery was from 1 to 10 months (median 4.0 [3.00–5.00] months). Children with PIMS were significantly younger in comparison to those without (6.60±4.50 vs 9.50±4.80 years, respectively; p=0,005). In comparison to non-PIMS group, children with PIMS had higher level of antithrombin III (111±7.23 vs. 104±10.9; p=0.0015), CK-MB (29.0 [18.5–36.0] vs. 21.0 [15.0–30.7]; p=0.03) and heart rate [HR]/min (100 [89.0–112] vs. 90.0 [79.0–100]; p=0.006) but lower PQ interval (120 [110–120] vs. 130 [120–140]; p=0.023) on admission to hospital. Moreover, the immunological parameters: IgA and neutrophils were lower in children with PIMS vs. no-PIMS (0.69 [0.47–0.85] vs. 1.19 [0.71–1.50]; p=0.0001 and 37.4%±13.3 vs. 43.0±11.6; p=0.0045, respectively), but lymphocytes were significantly higher (50.6±13.6 vs. 43.7±10.9; p=0.002). Some acid-base balance parameters were higher in children following PIMS vs. no-PIMS children group: pCO2 (41.30±5.70 vs. 45.0±7.00; p=0.019), pO2 (50.1 [38.4–59.7] vs. 37.8 [27.9–49.9]; p=0.007), and O2Sat (84.2 [69.3–90.6] vs. 64.2 [44.3–82.6]; p=0.004); however, concentration of HCO3- (23.6 [22.2–24.4] vs. 24.3 [22.8–26.2]; p=0.023) was lower in group of PIMS children.

Conclusions

Based on our best knowledge, it is the first data on the possible predictors of PIMS risk in children recovered from COVID-19. We showed that children with PIMS have significantly higher levels of antithrombin III, CK-MB, HR, as well as lymphocytes, pCO2, pO2 and O2Sat on admission to hospital and lower levels of PQ interval, IgA, neutrophils and concentration of HCO3. We continue our research to confirm these results and to create the PIMS SCORE algorithm to allow prediction of children with the risk of PIMS occurrence after COVID-19 recovery.

Funding Acknowledgement

Type of funding sources: None.

Ghrelin, Obestatin and Their Receptors As Well As Metabotropic Glutamate Receptor Assessment in Chronic Functional Constipation in Children

OBJECTIVES

The aim of this study was to examine the role of ghrelin, obestatin, and glutamate and their receptors in the pathogenesis of children functional constipation.

METHODS

Children ages 4-17 were the subject of the study: 121 children with constipation (55 boys and 66 girls), 36 patients of the same age (26 boys and 10 girls) were the controls. Expression of ghrelin, obestatin, and glutamate receptors on gastric and colon specimens taken by endoscopy were assessed. The concentration of the above agents was estimated in serum by the enzyme-linked immunosorbent assay test.

RESULTS

The lower median serum concentrations of ghrelin, in the constipated children than in controls were confirmed (1.9 ng/mL vs 2.6 ng/mL, P < 0.05). The expression of the metabotropic receptor 7 for glutamate (mGlu7) RNA was higher in the stomach (32.49 vs 31.47, P < 0.05), and was lower in the rectum in constipated patients compared to the control group (31.76 vs 32.62, P < 0.05). A negative correlation between the concentration of ghrelin in serum and colonic transient time (P = 0.01, rho = -0.23) was shown in the study group.Higher median expression of obestatin receptor G protein-coupled receptor39 in rectal mucosae was found in a constipated group than in the controls (29.9 vs 26.9, P < 0.05).

CONCLUSION

Ghrelin, and receptors for ghrelin, obestatin, and glutamate in gastrointestinal mucosa play a role in the pathogenesis of functional constipation in children.

Gut response to pasteurized donor human milk in a porcine model of the premature infant

This study investigated the tolerance and safety of pasteurized donor human milk (PDHM) given either alone or together with commercially-used supplements in a porcine model of premature infants. A porcine model, mimicking human neonates at 30-32 weeks of gestational age, was used. The 7-day experiment was performed on 20 piglets. After birth, the piglets were infused with porcine immunoglobulins via the umbilical artery and surgically fitted with a stomach port. The piglets were then randomized into five groups and fed either PDHM, different variants of fortified PDHM or 'raw' human milk (RHM). Preterm piglets fed PDHM showed signs of gastrointestinal intolerance. Four piglets across the various PDHM-fed groups died, none of them were from the group fed PDHM supplemented with long-chain polyunsaturated fatty acids (LC PUFA). In all groups fed PDHM, macroscopic features of enterocolitis were observed, however, these pathological gut changes were less manifested in piglets receiving PDHM supplemented with LC PUFA. The piglets fed RHM had no specific signs of gut damage. The poor tolerance to PDHM suggests changes in milk composition caused by the Holder pasteurization. The supplementation with LC PUFA probably improves tolerance to PDHM.

The pig as a model for premature infants - the importance of immunoglobulin supplementation for growth and development

Preterm human neonates, contrary to preterm piglets, obtain immunoglobulins from their mothers via the placenta during intrauterine development. However, one should note that the majority of trans-placental transfer of immunoglobulins in humans takes place during the last trimester of pregnancy. It is also known that the feeding of limited amounts of colostrum or systemic infusion of small amounts of serum improves the survival of preterm and full-term piglets. Full-term piglets deprived of their mother’s immunoglobulins exhibit strong apathy and develop watery diarrhoea, often resulting in death. The aim of the current study was to determine if provision of immunoglobulins using different approaches would be beneficial for survival outcomes. To reach the immunological sufficient level we infused immunoglobulins intravenously in amount mimicking the blood level in piglets fed with sow colostrum. Intravenous infusion of immunoglobulins in both preterm and full-term newborn piglets fully ensured their survival, growth and blood immunoglobulin G and protein levels similar to those observed in piglets fed colostrum. Piglets completely deprived of immunoglobulins exhibited significantly lower blood levels of immunoglobulins and protein compared to colostrum-fed animals. Piglets infused with only serum exhibited significantly lower blood immunoglobulin G level compared to those infused with immunoglobulins. In conclusion, based on the data obtained, we suggest that passive immune support provided by colostrum intake or early systemic infusion of Ig’s in sufficient amounts is key to ensuring the general well-being of preterm and full-term new born piglets, used as an animal model for the human infant.

Prevalence of autoantibodies against some selected growth and appetite-regulating neuropeptides in serum of short children exposed to Candida albicans colonization and/or Helicobacter pylori infection: the molecular mimicry phenomenon

OBJECTIVES

Many of peptides synthesized in gastrointestinal tract (GI) and adipose tissues, regulate growth and food intake. The GI microflora is an antigenic source. Based on the molecular mimicry hypothesis, intestinal microbe-derived antigens may trigger the production of autoantibodies cross-reacting with some neuropeptides.

DESIGN

The aim of the study was to assess whether in idiopathic short stature (ISS) children with Candida albicans (C.albicans) colonisation and/or Helicobacter pylori (H.pylori) infection the autoantibodies (in positive levels) against selected neuropeptides [anti-NP Abs(+)]: ghrelin, leptin, orexin A, αMSH are more prevalent than in Controls.

SETTING

The study group comprised 64 children with ISS and 36 children with normal height (Controls). In each child, IgG antibodies against H.pylori, ghrelin, leptin, orexin A and αMSH were assessed in serum, while presence of C.albicans - in stool samples.

RESULTS

The higher prevalence of anti-NP Abs(+) in ISS children with C.albicans and/or H.pylori than in normal height children with the colonization in question (34.4% vs 21.1%, p<0.01) was found. The prevalence of anti-NP Abs(+) in groups of children without C.albicans and H.pylori were low, anti-NP Abs(+) were detected in 9.4% of ISS children only, while in Controls they were not found.

CONCLUSIONS

In short children with C.albicans and/or H.pylori the incidence of autoantibodies against selected neuropeptides is high. It probably is connected with molecular mimicry between antigens of these microbiota and the mentioned peptides. It is tempting to speculate that presence of cross-reacting autoantibodies against regulatory neuropeptides may results in worse growth velocity. However, further studies are necessary to elucidate this issue.

High Resolution Melting analysis as a rapid and efficient method of screening for small mutations in the STK11 gene in patients with Peutz-Jeghers syndrome

Background

Peutz-Jeghers syndrome (PJS) is a rare hereditary syndrome characterized by the occurrence of hamartomatous polyps in the gastrointestinal tract, mucocutaneous pigmentation and increased risk of cancer in multiple internal organs. Depending on the studied population, its incidence has been estimated to range from 1:200 000 even up to 1:50 000 births. Being an autosomal disease, PJS is caused in most cases by mutations in the STK11 gene.

Methods

The majority of causative DNA changes identified in patients with PJS are small mutations and, therefore, developing a method of their detection is a key aspect in the advancement of genetic diagnostics of PJS patients. We designed 13 pairs of primers, which amplify at the same temperature and enable examination of all coding exons of the STK11 gene by the HRM analysis.

Results

In our group of 41 families with PJS small mutations of the STK11 gene were detected in 22 families (54%). In the remaining cases all of the coding exons were sequenced. However, this has not allowed to detect any additional mutations.

Conclusions

The developed methodology is a rapid and cost-effective screening tool for small mutations in PJS patients and makes it possible to detect all the STK11 gene sequence changes occurring in this group.

Ghrelin concentration is correlated with IGF-I/IGFBP-3 molar ratio but not with GH secretion in children with short stature

OBJECTIVES

In children with growth hormone deficiency (GHD) and neurosecretory dysfunction (NSD) ghrelin concentrations are significantly higher than in children with idiopathic short stature (ISS), however the correlation between serum ghrelin and growth hormone (GH) is not observed. The aim of the study was to compare ghrelin concentrations with IGF-I/IGFBP3 molar ratio in children with short stature due to different etiology.

MATERIAL

Analysis comprised 136 children (58 girls and 78 boys), aged 3.86-16.82 years with short stature (below -2.0 SD); in 21 of them GHD was diagnosed, in 23 - NSD and 92 - ISS. In each child, fasting ghrelin, insulin-like growth factor type I (IGF-I) and its binding protein type 3 (IGFBP-3) concentrations were measured. The results were analysed separately in younger and in older children. Depending on IGF-I/IGFBP-3 molar ratio, children were divided into two (2) groups: with lower IGF-I/IGFBP-3 and with higher IGF-I/IGFBP-3 ratio value.

RESULTS

Both in younger and in the older age groups, ghrelin concentration was significantly higher in children with lower IGF-I/IGFBP-3 ratio than in children with higher IGF-I/IGFBP-3 value (1937.3±1232.4 vs 1365.3±632.1 pg/ml in younger children and 1205.4±548.8 vs 867.4±282.9 pg/ml in older children). The negative correlation between ghrelin and IGF-I/IGFBP-3 ratio was observed in both age groups. Not only children with GHD and NSD, but also as much as 39% out of all children with ISS were qualified into the subgroups with lower IGF-I/IGFBP-3 ratio.

CONCLUSIONS

Ghrelin secretion is elevated in children with lower IGF-I/IGFBP-3 ratio. It seems that lower bioactivity of IGF-I is stimulating factor for ghrelin synthesis.

[The occurrence of gallbladder contractility disorders in children with some diseases presenting as abdominal pain]

Gallbladder dyskinesia is not mentioned among current (ROME III) classification of the functional gastrointestinal disorders in children. However both own clinical experience and a few published data spike for the appearance these disturbances also in the developmental age.

AIM OF THIS STUDY

Ultrasound (US) evaluation of gallbladder (GB) contractility in children sick from some diseases presenting as abdominal ailments.

MATERIAL AND METHODS

113 children aged 2-17 yr. (among them 78 with different diseases expressed as upper/middle recurrent abdominal pain and 35 healthy patients, forming the control group) were examined by US (Toshiba SSA-270 and GE Logiq 500 Pro device) to establish their GB activity. Using US, length, width and height of GB were measured, before and after standard fatty meal stimulation. Collected data enabled to count primary volume of GB and to evaluate of its changes, depending on time, which passed since the standard fatty meal, provoking GB activity, has been eaten. The spectrum of co-existing diseases with GB activity disorders was analyzed.

RESULTS

Of 78 examined children with abdominal pains in 67 (86%) GB activity disorders were observed. The average GB volume value was decreased about 36%, in the examined group, whereas the change averaged about 71% in the control study (p < 0.01). From among the 78 of investigated children in 8 (10%) a total lack of GB reaction on the standard meal was stated. In healthy control group only in 4 children (11%) minimal disorders of GB activity were observed (p < 0.001) and none of healthy children has presented GB akinesia. After a year follows-up since the successful basic disease treatment has been applied, ultrasound GB activity examination showed generally improvement, except the cases permanently being obese. From among co-existed diseases most often obesity and other functional disorders as Helicobacter pylori related dyspepsia, constipation and GERD, as well as parasitic diseases and food allergy were notified.

CONCLUSIONS

Gallbladder activity disorders might be the origin of abdominal pains during the course of some other diseases and might concern various age including younger children even in kindergarten age. In children, weaken or abolished GB contractility most often co-exists with obesity, many other alimentary functional alimentary disorders, parasitosis and food allergy.

[Analysis of frequency, clinical course and treatment of Crohn's disease based upon the own material and experience]

AIM OF THE STUDY

a retrospective analysis of Crohn's patients remaining to be taken care in Gastroenterology Department of the Polish Mother's Memorial Hospital, in the period of time between 2002-2007.

MATERIAL AND METHODS

A five-year retrospective medical charts of patients with inflammatory bowel disease (IBD) in Gastroenterology Department were studied. The study group with proved CD underwent the analysis according to age, signs, clinical course and activity of the disease, complications, and the type of treatment application.

RESULTS

Among 62 children with inflammatory bowel disease 63% (39) patients (aged from 7 months to 18 years) were diagnosed as CD. Most of them were boys (62%), aged above 7 years old, but some cases of very young children (babies) were also noted as Crohn's disease. Among the symptoms most frequently abdominal aches concomitant by loose stools and growth impairment were observed. The most constant laboratory signs of the disease were lower iron concentration in the blood, anaemia and much higher platelets number. Pathology assessment of the biopsy specimens taken from terminal ileus during colonoscopy and the measurements of the thickness of ileum wall on ultrasound examination were the keys in making the final diagnosis, because this part of alimentary tract was most often the localisation of the disease in the study group. High activity index (PCDAI >51) and severe course of the disease were sticking features of most of our patients, especially in younger children. Some severe complications were developed particularly in young patients and in the children with delayed diagnose.

CONCLUSIONS

CD in children presents a wide heterogeneity of clinical signs and symptoms, high activity, may revealed at any age, more frequently affecting boys. Early age of the onset of the disease and delayed diagnosis and treatment are the risk factors of CD very severe complications developed.

[The role of selected risk factors in Barrett's esophagus development]

Barrett's esophagus is the proved stage of increasing risk for development of esophageal adenocarcinoma. Why among wide spread GERD, a few patients only develop Barrett's esophagus is still not clear.

AIM OF THE STUDY

To define the factors, which significantly increase the risk for development Barrett's esophagus.

MATERIALS AND METHODS

The study involved 36 patients hospitalized in the years 2005-2007 in the Department of Digestive Tract Diseases, Medical University in Lódź, with diagnosed Barrett's esophagus (based on gastroscopy with biopsy and histopathologic findings). For the analysis, two control groups of healthy subjects were chosen: I--35 patients (mean age 54.3 years) with normal gastroscopy, II--40 patients (mean age 54.2 years) who had not undergone gastroscopy Risk factors were evaluated according to the self-elaborated, filled-in questionnaire. The following risk factors were taken into consideration: age, sex, BMI, stimulants (cigarettes, alcohol and coffee), diet, eating habits (preferred food, fruit and vegetables consumption, regularity and quantity of meals), physical activity, heartburn sensation, swallowing disorders, nausea, other diseases and family history.

RESULTS

Mean age of patients with diagnosed Barrett's esophagus was 55.9 +/- 11.2 years; in men: 55.7 +/- 12.2 and in women: 56.3 +/- 9.2. In the analyzed group there were 25 men (69.4%) and 11 women (30.6%), the man/woman ratio was 2.3:1. In the group with diagnosed Barrett's esophagus the heartburn sensation was observed in 30 (83.3%) patients, overweight and obesity (BMI >25 kg/m2) in 22 (61.1%) patients, 16 (44.4%) patients smoked cigarettes, 11 (30.6%) had swallowing problems, 12 (33.3%) suffered from nausea. Factors and symptoms, mentioned above have been significantly more often observed, as compared to I and/or II control group (p < or = 0.05). Statistical significance for other analyzed factors was not reached (significance value p < or = 0.05).

CONCLUSIONS

Barrett's esophagus is associated with: male sex, overweight and obesity (BMI > 25 kg/m2), cigarette smoking, heartburn sensation, swallowing disorders and nausea.

[Lentigines as an important of Peutz-Jeghersa Syndrome]

Peutz-Jeghers syndrome is an autosomal dominant inherited disorder which is characterized by mucocutaneus melanocytic macules and intestinal hamartomatous polypus. The aim of our work is to underline the role of pigmented changes in the diagnostic process. Numerous lentigines should always lead to multiorgan investigations.

[Lentigines in different multiple organ defects syndromes]

The aim of our study is to introduce a larger number of doctors to the subject of lentigines. They may be a first syndrome coexistent with very rare multiple organ defects as syndrome Peutz-Jeghers, LEOPARD, LAMB and Carney syndrome.

Anti-phagocytic activity of Helicobacter pylori lipopolysaccharide (LPS)--possible modulation of the innate immune response to these bacteria

The Helicobacter pylori infections are followed by an infiltration of the gastric mucosa by neutrophils and macrophages. Accumulation of phagocytes enables them to interact with H. pylori, but a great number of infected subjects cannot eradicate these bacteria. The H. pylori inhibits its own uptake by blocking the function of phagocytes. The anti-phagocytic mechanism depends on bacterial surface structures and the presence of the cag pathogenicity island (PAI). The role of H. pylori lipopolysaccharide (LPS), during phagocytosis of these bacteria is not clear. LPS may mediate direct bacteria/phagocyte interactions and it may also regulate antibacterial activity of the phagocytes. In this study we investigated the influence of H. pylori LPS on phagocytosis of these bacteria. The H. pylori LPS inhibited an ingestion of these microbes by human peripheral blood granulocytes. This was correlated with a diminished ability of phagocytes to reduce MTT-tetrazolium salt. The anti-phagocytic effect of H. pylori LPS was reduced by recombinant lipopolysaccharide binding protein (rLBP). It is possible that in vivo H. pylori LPS may diminish elimination of these bacteria from the gastric mucosa promoting an infection persistence. However, LBP may modulate the uptake of H. pylori due to neutralization of anti-phagocytic effect of its LPS.

[The participation of some innate immunological defense components in children with chronic gastritis associated H. pylori infection in ultrastructure and function of the mast cells aspects]

It has been clearly established that Helicobacter pyloni (H. pylori) play an important role in the pathogenesis of some chronic diseases of upper gastrointestinal tract. A lot of attention to the complicated immunological processes induced by the infection was paid. The clinical outcome of the damage of gastric mucosa by H. pylori depends on the type and the intensification of these processes. During many years the acquired (specific) immunological response on the infection was analyzed by scientists, but much more researches on innate defense was done lately The mast cells constitute some important parts of the immunological innate defense. H. pylori colonization of gastric mucosal surface elicits a conspicuous infiltration comprising of lymphocytes, and plasma cells as well as neutrophils, eosinophils, macrophages and the granule cells of connective fissue. Some difficulties with the mastocytes visualization in conventional histological slides in light microscope caused so far the little attention of their participation in chronic gastritis. The aim of the study was the assessment of the mastocytes participation in the infiltration of immunological cells induced by H. pylonri in chronic gastritis.

MATERIAL AND METHODS

The subjects were twenty dyspeptic children aged 9-17 years underwent upper GI endoscopy procedure. Twelve children were H. pylori positive. Remaining eight children H. pylori negative composed a control group. Gastric antrum and corpus tissue specimens in the conventional (light) and electron microscopy were examined. The specimens intended for electron microscope assessment were fixed in the solution of 1% glutaraldehyde and 2.5% paraformaldehyde at 40 C (pH 7.4) for 24 hours, and postfixed in 2% osmium tetroxide at the same conditions. Ultrathin sections were contrasted with uranyl acetate and lead citrate. Results. Ultrastructural analysis revealed two distinct, morphological forms of mast cells in gastric mucosa. All mast cells contained multiple granules with fine-grained material but their appearance was distinct in both types of these cells. Statistical analysis revealed that the count of mast cells in gastric mucosa was increased in H. pylori positive when compared with H. pylori negative children. It was also affirmed that in specimens from H. pylori infected children mast cells more frequently were seen in the gastric epithelium.

[Risk of lithiasis and urolithiasis in children with unspecific inflammatory bowel disease]

Urolithiasis is a disease of a complex, often systemic and not fully unequivocal, etiopathological mechanism, resulting in concrement crystallization The aim of study was the evaluation of frequency of occurrences of crystallization risk states and urolithiasis in children with IBD.

MATERIAL AND METHODS

The study was conducted on 35 children aged between 12 and 18 with confirmed ulcerative colitis (25 children) and Crohn disease (10 children). In all children regiular urine examination and urine inoculation were conducted, as well as stimation of concrement crystallization risk index in a twenty-four hour urine collection. Urinary tract ultrasound as well as evaluation of erythrocytes in urine sediment in phase contrast microscope,have been performed. Control group consisted of 20 children without digestive tract complains.

RESULTS

In 13 (37%) of examined children, urolithiasis occured in family history. The general urine examination revealed in 27 (77%) examined children existence of erytrocyturia of various degree and the evaluation in phase contrast microscope indicated their extraglomucal origin. The ion-creatininal analysis of twenty-four hour urine collection revealed in 29 (82.2%) children risk of oxalate-calcium concrements crystallization and in 6 (17%) children--of oxalate concrements crystallization. USG examination revealed in 4 (11.4%) children existence of single or multiple concrements in urinary system. Analysis of 1 twenty-four hour urine collection indicated the decrease of magnesium ions in 27 (77%) examined children. In control group only in 2 (5.7%) children the risk of occurrence of phosphate-ammonium concrements crystallization, which was significantly lower in examined group (p < 0.01).

CONCLUSIONS

Unspecific intestine inflammations have an influence on the occurrence of crystallization risk states, as well as a fully symptomatic urolithiasis.

[Accidental ingestion of two magnets--aggresive or prolonged approach?]

Accidental ingestion of foreign bodies is a common pediatric problem. Non-sharp items like coins, jewelry, pieces of toys are most frequently found among swallowed objects. They usually pass through a child's digestive system without health consequences (40-90% of reported cases). Approximately 10% of children require endoscopic intervention and 1-3% undergoes a surgical treatment. Authors present a unique health hazard caused by multiple magnet ingestion and general management in these cases of this specific foreign body presence. A 6 y.o. boy, in excellent health has been admitted G.I. Dept. presenting a history of accidental ingestion of two magnets (size 1.5 x 0.5 cm) 4 days prior to hospitalization. On admission patient presented no symptoms of foreign body in GI tract, however his WBC was 15000/mm3, ESR-22mm. Foreign bodies have been removed under general anesthesia using endoscopic technique. Endoscopic view of the esophagus region from which magnet has been removed at first might have been identify as a perforation of the esophageal wall. Chest X-ray has not revealed symptoms of pneumothorax, as well as the contrast radiologic study showed symptoms of upper GI tract perforation. Conservative treatment has been administered. Patient has been discharged home with no complaints in general and local good condition. Ingestion of more than one magnets is an strong indication for an immediate endoscopic intervention. Such an algorithm is strongly advocated to prevent of lesion formation in the soft tissues located between two objects with paramagnetic properties which may cause ischemic necrosis and perforation of the GI tract wall.

[Detrusor pseudohyperactivity syndrome in children with constipation]

THE AIM OF THE STUDY

was the evaluation of dependencies occurring between constipation and observed nocturia, pressing tenesmus and daytime urinary incontinence.

MATERIAL AND METHODS

the studies were conducted in 51 children aged between 3 and 17 years including 25 girls and 26 boys hospitalized in the Clinical Department because of nocturia, pressing tenesmus and daytime urinary incontinence. In all children a complex diagnostic work up of the urinary system and the lower segment of alimentary tract was performed. Results of the examinations were compared to the control group.

RESULTS

analysis of the results of the conducted examinations indicates that the overblown rectal ampulla, through the pressure exerted on the urinary bladder, seemingly decreases its volume causing the occurrence of pressing tenesmus, nocturia and daytime urinary incontinence. This process leads to the formation of detrusor hyperactivity syndrome characterized by: chronic constipation, increase of miction frequency and simultaneous decrease of volume of each portion of urine, nocturia and/or daytime urinary incontinence.

CONCLUSIONS

chronic constipation disturbs the functional-morphological equilibrium between the end segment of alimentary tract and the urinary bladder. By influencing the process of filling and accumulation of urine in the bladder they lead to the formation of detrusor hyperactivity syndrome.

Potential role of LPS in the outcome of Helicobacter pylori related diseases

In this study we asked a question whether H. pylori LPS with or without LewisXY (Le) determinants as well as LBP (lipopolysaccharide binding protein) and sCD 14 molecules recognizing bacterial LPS may be involved in atherogenesis. Sera from 57 patients with coronary heart disease (CHD), 27 H. pylori infected dyspeptic patients-H.p.(+) and 49 healthy controls (HC) were tested for IgM and IgG to H. pylori LPS expressing LeX (LPS LeX) or LeXY (LPS LeXY) determinants and to a glycine acid extract (GE). Immune complexes (ICs) of Lewis antigens and specific IgM or IgG were also determined. The prevalence of anti-GE IgG and IgA was significantly higher in CHD as compared to HC and the same as in the H.p.(+) group. The highest levels of anti-GE IgG were detected only for CHD group. CHD patients showed upregulation of IgG to LPS LeX and LeXY. In contrast, an upregulation of IgM to such LPSs was found for healthy subjects. The levels ofLeY-anti-LeY IgG ICs were higher in CHD patients than in healthy controls similarly to the levels of LBP. There was no difference in sCD14 concentration between CHD and HC groups. The results obtained in this study indicate that H. pylori infections may be the risk factors of atherosclerosis due to: 1) an enhanced humoral response to H. pylori surface antigens, 2) a host predisposition to respond to Lewis determinants present in H. pylori LPS by IgG, 3) increased levels of serum LBP.

Natural mannose-binding lectin (MBL) down-regulates phagocytosis of Helicobacter pylori

Considering the role of lectin-carbohydrate interactions between Helicobacter pylori bacteria and the host cells we addressed the question on how mannose binding lectin - MBL, present in human plasma, may influence the phagocytosis of H. pylori by peripheral blood granulocytes. For phagocytosis assay the granulocytes separated from peripheral blood of healthy H. pylori-seronegative donors were used. Phagocytosis was estimated by fluorescence assay using FITC-labelled H. pylori cells. The MBL level in the serum samples as well as MBL-binding to H. pylori bacteria were estimated by ELISA. In this study all H. pylori isolates bound recombinant mannose binding lectin-MBL as shown by ELISA. The ingestion of H. pylori bacteria in the medium with human serum depleted in natural MBL (nMBL) was more intensive than in the medium with complete serum containing nMBL. Moreover, the ingestion of H. pylori bacteria in the medium with complete serum was increased by an addition of anti-rMBL IgG. The results indicate that interaction of bacterial and host lectins may regulate the phagocytosis of H. pylori bacteria and in this way influence an outcome of the infection caused by these microbes.

[The role of Candida sp. in etiopathogenesis of esophageal, gastric and duodenal mucosa inflammation in children]

The aim of the study was to demonstrate morphological traits of Candida-induced upper alimentary tract mucosa inflammation. The material for the study comprised 18 children aged 4 to 18 years treated at the I Department of Paediatrics and Gastroenterology, Institute Polish Mother Health Centre. In these children positive mycologic cultures were obtained from alimentary tract inflammed mucosa sections. Upper alimentary tract endoscopy was performed and macroscopic and microscopic evaluation was made. Children with excluded H. pylori infection, reflux disease, lambliosis and allergy were included into the investigated group. Savara-Muller's classification was used for oesophageal mucosa inflammation evaluation, whereas gastric and duodenal mucosa inflammation were assessed according to Tytgat.

RESULTS

the most frequent macro lesions concerned simultaneously gastric and duodenal mucosa (44.46%). 27.77% of patients demonstrated oesophagitis, gastritis and duodenitis. In histopathological examination inflammatory lesions in oesophageal mucosa were observed in 38.88% (most frequently I degree). Chronic gastritis was found in all children, non-active in 11 and active in 7. Duodenal mucosa demonstrated traits of chronic active inflammation in 8 children and chronic in 5 of them.

CONCLUSIONS

Candida fungi may be an etiopathogenetic factor of oesophageal, gastric and duodenal mucosa inflammation, Candida-induced mucosa inflammation is most frequently of chronic nature.

[Assessment of the response of peripheral blood mononuclear leukocytes on Helicobacter pylori infection in children]

In the study the proliferative response of peripheral blood mononuclear leukocytes (PBML) from children with chronic dyspepsia (chr. d) to H.p. antigens was investigated. From 38 children aged 7-18, with chr. d., blood was collected just before upper GI endoscopy. Twenty one patients were found to be H.p. (+). PBML were used for the cultures and were stimulated with heat-killed H.p. G27 bacteria, heated and unheated glycine extract (GE) of H.p. G27 or with H.p. LPS containing Lewis X and Lewis Y determinants, in the presence or absence IL-2. The cell proliferation was estimated on the basis of [3H] - thymidine incorporation. In the cultures, the phenotype of responding cells was determined by an EIA with monoclonal antibody to human CD3, CD4 and CD8. PBML from patients H.p. (-), responded to killed H.p. bacteria and to heated GE more frequently and more intensively than PBML from the H.p.(+). IL-2 enhanced PBML response to these antigens. Unheated GE did not induce PBML proliferation even in the cultures with IL-2. LPS alone induced proliferation of PBML from 3 patients (2 H.p. - and 1 H.p.+). However, in the presence of IL-2, LPS induced proliferation of PBML from 15 patients. In the cultures of PBML stimulated with whole bacteria or heated EG, T cells dominated. In the cultures of PBML from H.p. (+) we found a higher percentage of CD8 cells in comparison with the cultures of PBML from H.p. (-). Data demonstrate a significant variation in the response of PBML from dyspeptic children to H.p. antigens.

[Drug sensitivity of Helicobacter pylori strains in children and young people from the region of Łódź]

Combined therapy with a proton pump inhibitor and two antibiotics (metronidazole, clarithromycin and amoxicillin or tetracycline) is applied in the treatment of H. pylori infection. The effects of the treatment depend on drug sensitivity of H. pylori. Growing resistance to some of the applied antibiotics has been observed. The aim of the study was to assess drug sensitivity of Helicobacter pylori strains which were isolated from the gastric mucosa of children and young people living in the macroregion of Łódź. The study comprised 45 children aged between 5 and 18 years. Biopsy specimens were put on transport medium, incubated in microaerophilic environment, then identified. Drug sensitivity to metronidazole, clarithromycin, amoxicillin and tetracycline was assessed. We found resistance to metronidazole in 18% (8/45) children, resistance to clarithromycin in 16% (7/45) children and resistance to both antibiotics in 4% (2/45) children. No resistance to amoxicillin or tetracycline was noted.

A potential double role of anti-Lewis X antibodies in Helicobacter pylori-associated gastroduodenal diseases

In this study, we found Lewis X (Le(x)) determinants on 68% of Helicobacter pylori isolates from patients with chronic gastroduodenal diseases. Anti-Le(x) IgG were detected more frequently in the sera from dyspeptic children and adults (45 and 46%), with or without proved (culture) H. pylori infection, than in the sera from healthy individuals (14% and 25%). In contrast, the prevalence of anti-Le(x) IgM was higher in the groups of healthy individuals than in the groups of dyspeptic patients. Moreover, anti-Le(x) monoclonal antibody of IgM class enhanced the uptake of Le(x)(+) but not Le(x)(-) H. pylori isolates by phagocytes. In the sera from some dyspeptic patients, we detected Le(x)-anti-Le(x) IgG immune complexes (Le(x) ICs). There was a great difference between children and adults as regards the presence of Le(x) ICs. The immune complexes were found in the sera from nine out of 29 (27%) H. pylori-infected and three out of eight (37%) uninfected adult dyspeptic patients. In comparison, Le(x)-anti-Le(x) IgG ICs were detected only for two out of 18 (11%) H. pylori-infected children. Le(x) ICs were not found in the sera from healthy individuals. Our results suggest that anti-Le(x) IgM may play a protective role in H. pylori infections. In contrast, anti-Le(x) IgG and particularly Le(x)-anti-Le(x) IgG ICs might contribute to the pathogenesis of chronic H. pylori infections.

[IgG and IgA immunoglobulins in helicobacter pylori infections of children with chronic dyspepsia before and after two week triple drug therapy]

The aim of this study was to investigate whether serological techniques, ELISA and Western blot, are useful in monitoring treatment of H. pylori-associated chronic dyspeptic symptoms in children. We observed a correlation between a decrease in the anti-H. pylori IgG titer and an effective treatment. So, our results suggested that the ELISA assay conducted with a glycine H. pylori extract can be a good noninvasive assay for monitoring the effectiveness of the therapy. By using the Western blot method, we showed some variation in the specificity of anti-H. pylori IgG produced before and after treatment. However, this variation was not correlated with the effectiveness of the therapy.

Proliferative activity of gastric epithelial cells in Helicobacter pylori infected children

Helicobacter pylori infection has been associated with gastric carcinogenesis. Gastric epithelial cells proliferative rate is accelerated in H. pylori infected adult patients. Our study was performed to evaluate proliferative cell activity in gastric epithelium in the course of H. pylori infection in the early stage of its natural history. Gastric antral biopsy specimens were obtained from thirteen H. pylori positive and seven negative children. To assess replication rates we used nucleolar organiser regions staining with colloidal silver nitrate technique (AgNOR). The number of AgNORs per nucleus, area of single AgNOR, and the quotient of these two parameters (AgNOR content) were analysed. The mean area of AgNOR was lower in H. pylori positive than in negative children. Conversely, both the mean number of AgNOR per nucleus and AgNOR content were higher in infected than non infected subjects. These results show accelerated proliferation of gastric antral epithelial cells in the course of H. pylori infection in children. Such alteration of cell replication occurring in an initial phase of natural history of long lasting infection provides an explanation for the association between acquisition of H. pylori infection in the first years of life and the development of gastric cancer.

Mallory-Weiss syndrome in children

The aim of the study was to evaluate the incidence and the etiology of Mallory-Weiss syndrome in children. The study population comprised 2720 children aged 5 months to 18 years who had undergone upper gastrointestinal endoscopy. Mallory-Weiss syndrome was diagnosed in eight (0.3%) of the examined children. Endoscopic examination in five of them revealed linear mucosal tears, mostly above and in one case also below the gastroesophageal junction. In three children a linear scar in the lower portion of the esophagus was seen. No signs of active bleeding were revealed in any of the cases. In four children, Mallory-Weiss syndrome was accompanied by gastritis and duodenitis; two of these children had Helicobacter pylori infection. The concomitant diseases were H. pylori-positive duodenal ulcer (1), bronchial asthma and gastroesophageal reflux disease (1), carbon monoxide poisoning (1). In one case Mallory-Weiss syndrome was diagnosed in early pregnancy. Mallory-Weiss syndrome should be considered, along with others, as a cause of acute upper gastrointestinal bleeding in children. There is a great variety of etiologic factors in Mallory-Weiss syndrome in children.

Anti-Lewis X IgM and IgG in H. pylori infections in children and adults

A role of autoimmune processes in the pathology of Helicobacter pylori infections has been suggested. The Lewis determinants present in LPS molecule of H. pylori bacteria have been indicated as the cause of antigenic mimicry. In this study, the prevalence of IgM and IgG antibodies to Lewis X antigen in the sera from children and adults, with or without dyspepsia, infected or not infected with H. pylori, seropositive and seronegative for anti-H. pylori IgG were determined immuno-enzymatically (ELISA). Our results revealed that humans may produce anti-Lewis X antibodies, particularly of IgM class, in the absence of H. pylori infection or H. pylori independent dyspepsia. The production of such antibodies, by healthy children who had never been infected with H. pylori suggested that anti-Lewis X antibodies may occur naturally.

Systemic humoral response to Helicobacter pylori in children and adults

In this study we compared the development of anti-H. pylori humoral response in adults and children. Two antigens: H. pylori acid glycine extract (GE) and recombinant cagA were used for ELISA and Western blot. Anti-GE IgG were detected in all and anti-cagA IgG in about 50% of H. pylori infected adults and children. The prevalence of anti-GE and anti-cagA IgG in the sera from H. pylori-uninfected children with gastritis/gastroduodenitis was lower than in the sera from healthy adult blood donors. Serum IgA were demonstrated for 71% of H. pylori-infected adults and for a smaller proportion (about 30%) of uninfected adult patients or normal subjects. Such antibodies were detected neither for infected nor for uninfected children. There was an evident difference between the proteins of H. pylori glycine extract recognized by antibodies present in the sera from H. pylori-infected children and adults. The antigen of molecular weight over 107 kDa was recognized exclusively by the sera from 30% of H. pylori-infected adults. The 80-107 kDa bands were recognized more frequently by the sera from adults than from children. In contrast, sera from infected children more frequently than sera from infected adults reacted with the bands of 14 kDa, 19 kDa and 26 kDa. The H. pylori antigens recognized by IgG, produced by infected children and adult patients, should be taken into consideration in the developing of tests for serodiagnosis of H. pylori infection.

Serum IgG antibodies in children and adults reacting with Helicobacter pylori lipopolysaccharides

The presence of IgG antibodies reacting with Helicobacter pylori lipopolysaccharides (LPSs) in sera from children and adults diagnosed as H. pylori-infected, as well as healthy persons, was tested. There was no correlation between the production of antibodies reacting with H. pylori surface proteins and LPSs. Also no correlation between reactivity of tested sera with H. pylori antigens and deep rough mutant (Re types) enterobacterial LPSs was revealed. The prevalence of anti-LPS IgG in randomly selected children was relatively high.

Anti-Lewis X antibody and Lewis X-anti-Lewis X immune complexes in Helicobacter pylori infection

A molecular similarity of Lewis antigens expressed by Helicobacter pylori bacteria and those present in human gastric mucosa has been recognised as a cause of autoimmunity involved in the pathogenesis of chronic type B gastritis and gastric and duodenal ulcers. In this study, the expression of Lewis X determinants was found on 56% of H. pylori strains isolated from patients with chronic gastritis/gastroduodenitis. Anti-Lewis X IgG as well as Lewis X-anti-Lewis X IgG complexes were detected in the sera from patients and even more frequently in the sera from healthy blood donors producing antibodies against surface antigens of H. pylori. It suggested that the initial H. pylori-induced lesions were independent of anti-Lewis X antibody production. When H. pylori bacteria expressing Lewis X antigen were treated with anti-Lewis X monoclonal antibody (mAb) of IgM isotype, they were more susceptible to ingestion by polymorphonuclear leukocytes (PMN) than untreated bacteria. This fact may lead us to believe that anti-Lewis X antibody limits the growth of H. pylori on gastric mucosa.

Attachment of Helicobacter pylori strains to human epithelial cells

The aim of the study was to characterize several clinical isolates of H. pylori as regards the activity and specificity of their haemagglutinins and the involvement of surface sialic acid-specific and heparin-binding compounds in the adhesin of the bacteria to human epithelial cell lines. Although H. pylori strains caused haemagglutination (HA) of sheep erythrocytes, they differed markedly by activity and specificity. On the basis of haemagglutination inhibition study three types of H. pylori strains could be distinguished. The HA of Type I strains was inhibited with fetuin/mucin but not asialofetuin/asialomucin. The HA activity of Type II strains was inhibited with fetuin/mucin and asialofetuin/asialomucin. The HA of Type III strains was not influenced by any of these inhibitors. In vitro, H. pylori strains bound to the cells of human epithelial lines: HeLa, Kato-3, Ags. However, various compounds mediated the binding of H. pylori types distinguished by HA, to epithelial cells. The interaction of some of H. pylori strains with epithelial cells was mediated by bacterial sialic acid-binding compounds. The majority of H. pylori strains used heparin-binding surface compounds to attach to epithelial cells. Clinical H. pylori strains differ by the compounds used in adhesin to epithelial cell lines, however, this process also depends on the expression of appropriate receptors on the host cells.

Role of Helicobacter pylori surface structures in bacterial interaction with macrophages

BACKGROUND

Helicobacter pylori infection is associated with a marked infiltration of the gastric epithelium by neutrophils, macrophages, lymphocytes, and plasma cells. Despite the presence of phagocytes in close vicinty to H pylori microbes a great number of people are unable to eradicate bacteria.

AIMS

To investigate the involvement of multiple bacterial 'adhesins' and some phagocytic receptors in the process of the ingestion of H pylori by macrophages. BACTERIA: H pylori strains differing in the expression of sialic acid dependent (sHA) or sialic acid independent (HA) haemagglutinin and heparan sulphate binding were selected for the study.

METHODS

The uptake of fluorescein labelled H pylori bacteria by a homogenous macrophage cell line J 774A.1 was estimated in a quantitative fluorometric assay.

RESULTS

The ingestion of H pylori 17874 and 25 strains expressing sHA was inhibited by the pretreatment of the bacteria with anti-sHA antibodies or fetuin as well as by treatment of the macrophages with neuraminidase. In contrast the uptake of H pylori 17875 strain expressing HA remained unchanged. The phagocytosis of all investigated bacteria was inhibited after the treatment with heparin, hyaluronic acid or vitronectin with fresh but not heat inactivated serum.

CONCLUSIONS

The results suggest that H pylori surface compounds binding host proteins such as fetuin, heparin/haparan sulphate, hyaluronic acid, and vitronectin in the presence of complement, could allow the bacteria to avoid phagocytosis.

Helicobacter pylori infection in the etiopathogenesis of duodenal ulcer in children

The study evaluates the frequency of Helicobacter pylori (H. pylori) infection, as well as systemic cellular immune response to H. pylori in children with duodenal ulcer (DU). The study group comprised 47 children with DU, aged 6-17 (mean 13, 1 +/- 4, 2). H. pylori detection was based on urease test, histology, culture and serologic tests. Endoscopic and morphologic findings were analysed according to Sydney System criteria. In 12 children from the overmentioned group subsets of blood lymphocytes B and T (CD3, CD4, CD8, CD3/DR, CD19) and NK cells, some neutrophils functions (phagocytosis, chemiluminescence) and phagocytes receptors before and one month after H. pylori triple treatment were investigated. H. pylori infection was detected in 44 of the investigated children. In addition, pathologic examination revealed chronic gastritis in 44 children and chronic duodenitis in 42 of them. In immunosystemic examination decreased percentage of CD8 lymphocytes and NK cells, increased CD4/CD8 ratio, decreased mitogen-induced response and changes of function and receptor expression of neutrophils were found. After H. pylori treatment in follow-up endoscopy no ulcers were found and histologic examination did not reveal chronic active gastroduodenitis, while the rate of nonactive gastritis was increased. Eradication of H. pylori infection in 41 children and normalisation of immune parameters in 11 children were obtained. The results of our investigation indicate, that H. pylori infection plays an important role in the pathogenesis of DU in children.

Prevalence of Helicobacter pylori in children dependently on age and living conditions

The aim of the study was to examine the prevalence of Helicobacter pylori (H. pylori) in children in Lódź (Poland). The study was a serological survey of IgG antibodies to H. pylori in randomly chosen 240 children aged 6 months to 17 years. The serum was tested by ELISA technique (Porton-Cambridge, England) and by immunoenzymatic test (Quidel, USA). Some aspects of the family environment were studied. We found 15% infected children under 2 years, 16.6% infected children aged 3-5 years, 28.3% aged 6-10 years and 41.6% aged 11-17 years. We observed much higher prevalence of H. pylori infection in children from poor living conditions and in children from families with seropositive adults.

Electron microscopic study of association between coccoid forms of Helicobacter pylori and gastric epithelial cells

OBJECTIVE

To investigate the relationship between helical and coccoid forms of Helicobacter pylori and gastric epithelial cells.

METHODS

Gastric antral and body biopsies were obtained from eight children, aged 10-17 yr, who underwent diagnostic gastroscopy. Specimens were processed for electron microscopy. The location of organisms and ultrastructural features were assessed with a transmission electron microscope.

RESULTS

We observed two morphological forms of bacteria in three of eight H. pylori-positive patients. Helical forms were localized only in the proximity to unchanged or variously damaged mucous cells, but coccoid forms were present only above strongly damaged epithelial cells.

CONCLUSION

Coccoid forms of H. pylori are closely associated with damaged gastric mucous cells. Possible explanations for this phenomenon are discussed.

Morphological and immunohistochemical examinations of the dynamic changes of gastric mucosa associated with the treatment of helicobacter pylori infection in children

The aim of this study was to investigate the consequence of Helicobacter pylori eradication on gastric mucosa and antral G and D-cells. Forty children, aged 5-17 years with Helicobacter pylori infection were assessed. Helicobacter pylori was detected by a urease test and identified by serological and microbiological methods. Twenty children were again assessed after the therapy (the combination of colloid bismuth subcitrate, amoxycillin and metronidazole). Gastroscopic examination was performed and at least six bioptic specimens were taken from the antrum, body and fundus. Tissue samples, processed with the paraffin method and stained with hematoxyllin and eosin, were assessed. Monoclonal antiserum Gastrin PAP kit 516 and somatostatin PAP kit 512 (DAKO) in the peroxidase-antiperoxidase technique (PAP) have been used to detect G and D-cells. Helicobacter pylori in the gastric mucosa was demonstrated with the Giemsa method. The results show the coincidence of Helicobacter pylori infection and the count of antral G and D-cells and active chronic gastritis in children. After the treatment Helicobacter pylori was eradicated in 70% of children. In 34% of these cases the eradication was followed by a diminution of activity of gastric antral mucosa inflammation and in 20% of these children the resolution of the inflammatory infiltration in the gastric mucosa was seen. A decrease of the antral G and D-cells count and also a diminution of G/D index in these cases were observed.