Use of a new thickened formula for treatment of symptomatic gastrooesophageal reflux in infants

BACKGROUND

Paediatricians are familiar with infants complaining of regurgitation and emesis from gastrooesophageal reflux. These subjects, usually growing satisfactorily and healthy, are affected by "functional" or "symptomatic" gastrooesophagel reflux and are treated with posture changes and thickened feedings.

AIM

To evaluate in infants with symptomatic gastrooesophageal reflux the effect of a new formula (Nutrilon AR), containing carob flour/locus bean gum as a thickening agent; both clinical features and oesophageal acid exposure were evaluated.

PATIENTS

Twenty-four infants (age range: 5-11 months; median age: 8 months; 8 females) presented at our Unit with a history of chronic postprandial regurgitation.

METHODS

During a 24-hour intraoesophageal pH test a traditional formula thickened with rice flour at a concentration of 5% was alternated with the formula Nutrilon AR; thereafter infants were randomly allocated to receive, for two weeks, either a traditional thickened formula or the new formula, in addition to posture changes.

RESULTS

Intraoesophageal acid exposure was significantly lower in the periods following the new formula than after traditional formula; at the end of the treatment period patients receiving the new formula had a more significant decrease of both symptomatic score and number of episodes of emesis than patients on traditional formula.

CONCLUSIONS

The new available formula, with the characteristics of a thickened meal, is better than a formula, traditionally thickened with added rice flour, in the conservative treatment of infants with symptomatic gastrooesophageal reflux.

Antroduodenal motor effects of intravenous erythromycin in children with abnormalities of gastrointestinal motility

BACKGROUND

The macrolide antibiotic erythromycin (EM) affects gastrointestinal motor activity by acting as agonist of motilin receptors located on the smooth muscle cells of the gastroduodenal tract. We studied the effect of intravenous EM on fasting antroduodenal motility in controls and children with gastrointestinal dysmotility.

METHODS

EM lactobionate (rate, 3.0 mg/kg/h) was infused intravenously while antroduodenal manometry was recorded in 10 controls, in 7 patients with functional dyspepsia and in 6 patients with gut pseudo-obstruction. The mean (SD) age (years) was 5.7 (1.4), 6.5 (2.4), and 6.7 (3.2), respectively. Manometry was performed by means of a four- or six-lumen catheter introduced through the nose and perfused with a low compliance pneumohydraulic system. Five controls received EM and five received saline.

RESULTS

EM, infused 5 minutes after passage of an activity front (AF), induced in controls a premature antroduodenal AF occurring 15.4 +/- 3.2 minutes after starting infusion; no motor changes were seen after saline; duration and propagation velocity of EM-induced AFs did not differ from spontaneous AFs. In patients with functional dyspepsia EM induced various patterns such as premature antroduodenal AFs, antral phase III-like pattern with short duodenal bursts or prolonged phasic antral waves and no duodenal activity. In patients with neurogenic pseudo-obstruction rare or absent antral activity with incoordinated or absent duodenal activity was induced; no contractions were elicited in two patients with myogenic pseudo-obstruction.

CONCLUSIONS

It is confirmed that EM, given at subtherapeutic doses, is a powerful prokinetic agent that can have clinical applications in patients with gastrointestinal dysmotility; however, the effect of the drug seems to be influenced by the nature of the underlying disorder.

Effects of omeprazole on mechanisms of gastroesophageal reflux in childhood

Prolonged recordings of esophageal motility have shown that dynamic changes of lower esophageal sphincter (LES) pressure such as transient LES relaxation and LES pressure drifts are the most common mechanisms underlying gastroesophageal reflux (GER). The coexistence of a delayed gastric emptying has also been reported in a high proportion of patients with reflux disease. However, not much information is available on the effects of antireflux therapy on the pathogenetic mechanisms of GER. The purpose of this study was to determine in a group of children with severe reflux disease the effect of omeprazole therapy on motor changes of LES underlying GER as well as on gastric emptying time. Twenty-two children (median age: 6.6 years) with GER disease, refractory to combined ranitidine and cisapride administration, entered into an eight-week omeprazole course. Ten subjects with moderate GER disease served as controls (median age: 6.0 years). Before and after omeprazole administration, the following variables were assessed: esophagitis grading, fasting and fed simultaneous prolonged recording of distal esophageal sphincter pressure (with a sleeve catheter) and intraesophageal pH, LES and esophageal peristalsis amplitude, and gastric emptying time of a mixed solid-liquid meal (measured with gastric ultrasound). As compared to controls, patients showed a higher rate of transient LES relaxation and LES pressure drift (P < 0.01), a reduced amplitude of basal sphincter pressure (P < 0.01) and peristalsis (P < 0.05), and a more prolonged gastric emptying time (P < 0.05). After ending omeprazole, there was no significant change in any of the motor abnormalities of the esophagus and in gastric emptying time despite a marked improvement of symptoms and esophagitis in all patients. Sixteen patients were symptomatic when reevaluated on a clinical basis two months after ending therapy. We conclude that in children with severe GER disease, an abnormally high rate of both transient LES relaxation and LES pressure drift and slow gastric emptying are not affected by omperazole treatment, even though esophageal mucosal damage is markedly improved or cured. These abnormalities represent a primary motor disorder and can be implicated in the refractoriness of reflux disease.

Helicobacter pylori gastritis and non-ulcer dyspepsia in childhood. Efficacy of one-week triple antimicrobial therapy in eradicating the organism

Efficacy of one-week triple antimicrobial therapy (bismuth, tinidazole, amoxicillin) as compared to the same drug combination given for 4 weeks was assessed in children with Helicobacter pylori (H. pylori) gastritis and non-ulcer dyspepsia. Twenty-six patients (group A) and 30 (group B) had one-week and four-week schedule, respectively. Eradication (absence of organism at endoscopy at least 1 month after ending treatment) was achieved in 84.6% of group A (22) and 83.3% of group B (25), with marked reduction of histological gastritis score in both groups. Among patients with eradicated H. pylori, symptoms improved significantly in 14 and 16 patients of group A and B, respectively, but were still present in 17 (8 group A, 9 group B). The latter showed gastroparesis and abnormal gastro-oesophageal reflux at a subsequent diagnostic work-up and improved with prokinetic therapy. In 3 patients of group A and 3 of group B, symptoms improved despite persistence of bacterium into the stomach. Finally, in 3 cases (1 group A, 2 group B) both symptoms and H. pylori infection were unchanged. At 6 month follow-up, symptoms were present in 7 patients (3 group A, 4 group B): 6 of them (3 group A, 3 group B) showed H. pylori gastritis at endoscopy. We conclude that in children with dyspepsia and H. pylori gastritis one-week triple antimicrobial schedule is effective in eradicating bacterium; however, detection of H. pylori gastritis in dyspeptic children does not invariably indicate a pathogenic role of the organism in these patients.

Predictive value of esophageal manometry and gastroesophageal pH monitoring for responsiveness of reflux disease to medical therapy in children

OBJECTIVES

The aim of the study was to evaluate, in 42 children with gastroesophageal reflux disease, the predictive value of both esophageal manometry and gastroesophageal intraluminal pH on the responsiveness of the disease to medical therapy.

METHODS

Motility of lower esophageal sphincter and esophageal body was carried out through a perfused pediatric sleeve-probe; prolonged recording of the sphincteric profile was evaluated at the occurrence of reflux episodes as detected by an esophageal electrode; intraluminal pH of the esophagus and stomach was also measured for 24-h through portable equipment. Children were treated for 8 wk with cisapride and ranitidine and were classified as healed or refractory after endoscopy and clinical evaluation.

RESULTS

Twenty one children healed, and 21 were refractory. Compared with healed patients, refractory patients showed, at basal evaluation, an increased esophageal acid exposure (p < 0.05), a reduced basal sphincteric pressure and peristalsis amplitude (p < 0.01), an increased rate of sphincteric pressure drifts (p < 0.01), and a higher rate of transient lower esophageal sphincter relaxations (p < 0.01). The following parameters contributed significantly (p < 0.01) to a multivariate discriminant analysis: peristalsis amplitude, basal sphincter pressure, rate of transient relaxations of the sphincter, and rate of sphincteric pressure drifts. A correct classification of virtually all cases (97.62%) was reached.

CONCLUSIONS

Motor dysfunctions of both lower esophageal sphincter and esophageal body are the major factors predicting refractoriness of reflux disease in children to a standard medical treatment. Of the two main mechanisms of reflux, i.e., transient lower esophageal sphincter relaxation and lower esophageal sphincter pressure drift, the latter had the highest predictive value for the refractoriness of reflux disease.

Real-time ultrasound reveals gastric motor abnormalities in children investigated for dyspeptic symptoms

Real-time ultrasonography (US) of the gastric antrum after ingestion of a mixed solid-liquid meal was performed in 60 patients (median age, 8.2 years; range, 3-17) being investigated for symptoms suggesting upper intestinal dysfunction (vomiting, regurgitation, abdominal pain, early satiety, and anorexia) and in 13 controls (median age, 5 years; range, 3-15). The diagnostic work-up allowed identification of 14 patients with esophagitis (group A) and 26 with Helicobacter pylori (HP) gastritis (group B); median age in group A was 9 years (range, 3-15) and in group B was 9.5 years (range, 3-17). Group A patients had significantly more prolonged gastric-emptying times (median, 180 min; range, 110-270) than did controls (median, 150 min; range, 110-180; p < 0.01); however, group A times were not significantly longer than those of group B patients (median, 160 min; range, 90-265). In the remaining 20 patients (group C; median age, 7.1 years; range, 3-15) without a specific diagnosis, markedly delayed gastric emptying was detected (median, 237 min; range, 165-270; p < 0.01 vs. group B patients and vs. controls; p < 0.05 vs. group A patients); in this group, GI manometry revealed findings of deranged motility of the gut. Distension of the antral area (percentage of increase vs. baseline values) 60 and 90 min after feeding was higher in group C (60 min: median, 185%; range, 70-614%; 90 min: median, 175%; range, 60-400%) than in both controls (60 min: median, 80%; range 26-148%; 90 min: median 90%; range 20-253%; p < 0.01) and HP patients (60 min: median, 120%; range, 35-311%; 90 min: median, 98%; range, 23-400%; p < 0.05); there was no significant difference versus esophagitis patients. The latter differed from controls only for the 60-min postfeeding antral distension (p < 0.01), whereas HP patients did not differ from controls. In group C patients, symptomatic dyspeptic score correlated with both 60- and 90-min fed antral distension (r = 0.61 and r = 0.64, respectively; p < 0.05), but no correlation was found with gastric-emptying time. In group A patients, histologic score of esophagitis correlated with 60-min postfeeding antral distension (r = 0.56; p < 0.05), whereas poor correlation was found with 90-min postfeeding antral distension and with gastric-emptying time. However, the latter significantly correlated with 90-min fed antral distension in esophagitis patients (r = 0.70; p < 0.01). We conclude that US imaging of the antral area of the stomach reveals abnormalities of gastric motility in most children referred for dyspeptic symptoms; this technique should be included among the investigative tools in the diagnostic approach to these patients.

Antroduodenojejunal manometry in the diagnosis of chronic idiopathic intestinal pseudoobstruction in children

We analyzed the antroduodenojejunal (ADJ) manometric patterns in a group of 19 consecutive children (mean age, 53 months; range, 5 months to 14 years) referred for suspected chronic idiopathic intestinal pseudoobstruction. Diagnosis was based on typical symptoms, absence of extraintestinal diseases, and structural lesions of the gut at endoscopy and radiology. Surgical full-thickness intestinal biopsies were evaluated in nine patients. Manometry of the stomach and small bowel was performed in the fasting and fed state with a multilumen perfused probe. All patients showed severe abnormalities of ADJ motor activity that were not seen in the eight controls (mean age, 38.2 months; range, 1-9 years). In 12 patients, manometric patterns suggesting neuropathic disease were detected with fasting and/or fed sustained and incoordinated duodenojejunal phasic waves, aberrant propagation and/or configuration of phase III of the inter-digestive motility complex, inability of a meal to convert a fasting into a fed pattern, and prolonged groups of fasting and fed nonpropagated phasic waves. In seven of these patients, histology revealed marked changes of the intrinsic neurons. In four cases, manometry disclosed features suggestive of a myogenic disease, including severe fasting and fed infrequent low-amplitude contractions, sometimes with some degree of propagation; in two of these cases, histology showed morphological abnormalities of smooth muscle cells of the gut wall. In three patients, manometry revealed signs suggestive of mechanical obstruction of the gut, such as repetitive post-feeding clusters and simultaneous repeated broad-based waves; in these patients, more detailed x-ray studies showed organic obstructive causes (ileal lymphoma, Hirschsprung's disease, and intestinal malrotation).(ABSTRACT TRUNCATED AT 250 WORDS)