New noninvasive biomarkers of intestinal inflammation and increased intestinal permeability in pediatric inflammatory bowel diseases and their correlation with fecal calprotectin: a pilot study

BACKGROUND

Increased intestinal permeability is considered to play a crucial role in the pathogenesis of inflammatory bowel diseases (IBD). Therefore, recently, the use of non-invasive biomarkers in both diagnosis and monitoring IBD is emphasized. The aim of this study was to investigate fecal and serum zonulin and serum I-FABP in pediatric IBD patients and their correlation with fecal calprotectin (FCP).

METHODS

Seventy-one individuals: 32 Crohn's disease (CD) patients, 33 ulcerative colitis (UC) patients and 6 controls were examined for fecal and serum zonulin and plasma I-FABP. Values were correlated to FCP and to each other for all children included in the study. A stool specimen and blood samples were collected during check-up visits at hospital. Then fecal and serum zonulin, I-FABP and FCP were tested by ELISA Test. Non-parametric statistical tests were used for data analysis.

RESULTS

The level of fecal zonulin and FCP were higher in IBD patients compared to control group (CG): median for CD - 46.0 (7.0-3854) ng/mL, 252.0 (77.0-1054.2) ug/g; UC - 115.3 (50.7-418.3) ng/mL, 40 (16.0-1883.0) ug/g; CG - 60.8 (31.8-123.0) ng/mL, 41.5 (31.0-323.0) ug/g, respectively, (P<0.05). No statistically significant difference in concentrations of serum zonulin and I-FABP was reported between patients and CG (P=0.55). The only correlation that has been reported was between fecal zonulin and FCP and the strongest one was in CD: CD-R =0.73, UC-R =0.67, All-R =0.67, CG-R =0.65.

CONCLUSIONS

According to our results it seems that only fecal zonulin may serve as another, next to FCP, biomarker of intestinal damage in IBD. However, both fecal and serum zonulin as well as I-FABP need further studies to assess their usefulness in diagnostics and monitoring in IBD.

Biological markers of disease activity in inflammatory bowel diseases

Inflammatory bowel diseases (IBD) are chronic intestinal conditions of multifactorial aetiology including genetic susceptibility, immunological impairment, dysbiosis, and environmental factors. The diagnosis is based on both clinical and endoscopic features, wherein histopathological evaluation remains a gold diagnostic standard. However, fast, reliable, and non-invasive biological markers have been used for years for diagnosis as well as for disease activity monitoring. Currently, commonly used faecal calprotectin is the only biomarker approved and recommended by the European Crohn's and Colitis Organization (ECCO). Nonetheless, other biological markers discriminating between functional and organic bowel conditions have been widely studied. Therefore, the aim of this manuscript was to review new potential biomarkers of inflammation in IBD. The aim of this study was to review currently available biomarkers of intestinal inflammation and increased gut permeability in IBD.

Usefulness of Colon Assessment by Magnetic Resonance Enterography in Pediatric Patients with Inflammatory Bowel Disease-Retrospective Case Series

Background: Magnetic resonance enterography (MRE) is an excellent way to study the small bowels. During such an examination, the colon is also seen within the field of study. The aim of this study was to evaluate the effectiveness of MRE in detecting characteristics of active inflammatory bowel disease (IBD) in the colon, in comparison to different features seen in colonoscopies. Methods: This retrospective study was conducted with 41 children. Features of active inflammation we considered were wall thickening; contrast enhancement; incorrect signal in the DWI sequence in the MRE; and presence of ulceration, erosion, erythema, spontaneous bleeding and a decrease of the vascular pattern seen in colonoscopy. The colon was divided into six segments: caecum, ascending, transverse, descending, sigmoid and rectum. Results: The sensitivity of MRE was, on average, 50–75%, and as high as 92–100%, depending on the segment. The most important feature for which there was the most dependencies was ulceration. In the analysis of intestinal wall thickness, the AUC value >0.8 was detected as ulceration (segments: cecum, ascending, descending colon, sigmoid), spontaneous bleeding (ascending colon and sigmoid) and decreased vascular pattern (ascending, transverse, descending colon). Conclusions: Evaluation of qualitative structural changes in MRE distinguishes patients with inflammation in colonoscopy from patients without lesions, with high diagnostic accuracy, albeit higher specificity than sensitivity.

Fecal Zonulin as a Noninvasive Biomarker of Intestinal Permeability in Pediatric Patients with Inflammatory Bowel Diseases-Correlation with Disease Activity and Fecal Calprotectin

Background: Recent data indicate that increased intestinal permeability plays a key role in the pathogenesis of inflammatory bowel diseases (IBD) and correlates with disease flare. Since zonulin related proteins (ZRP) are the proteins that increase permeability in the epithelial layer of the small intestine by reversibly modulating the intercellular tight junctions, they may serve as a new, noninvasive biomarker of disease activity. The aim of this study was to investigate fecal ZRP in pediatric IBD patients as well as its correlation with disease activity and fecal calprotectin (FCP). Methods: Ninety-four individuals: 47 Crohn’s disease (CD) patients, 41 ulcerative colitis (UC) patients, and 6 healthy controls were examined for fecal ZRP. Values were correlated to IBD type, disease activity for IBD patients, and FCP for all children included in the study. A stool specimen was collected the day before the visit to the hospital, then fecal ZRP and FCP were tested using the ELISA test. Non-parametric statistical tests were used for data analysis. Results: The level of fecal ZRP was higher among IBD patients compared to the control group (CG): medians for CD—113.3 (53.6–593.6) ng/mL; UC—103.6 (50.7–418.3) ng/mL; and CG—46.9 (31.8–123.0) ng/mL (p < 0.05). No difference in fecal ZRP concentration was observed between children with CD and those with UC (p = 0.55). A slight correlation between disease activity (PCDAI for CD and PUCAI for UC) and the fecal ZRP level was found for CD (p = 0.03/R = 0.33), but not UC (p = 0.62/R = 0.08), patients. A correlation between fecal ZRP and FCP was observed (R = 0.73, p = 0.00). Conclusions: Fecal ZRP levels are increased among those with IBD, are associated with CD activity, and strongly correlate with FCP. Further research into the role of intestinal permeability in IBD and the clinical usefulness of ZRP in IBD is warranted.

Evaluation of the effectiveness of biofeedback therapy for functional constipation in children

BACKGROUND/AIMS

Defecation disorders are one of the most common problems in pediatric gastroenterology. Treatment includes changes in the diet, pharmacotherapy, and biofeedback therapy. The aim of the present study was to evaluate the effectiveness of biofeedback therapy as assessed by clinical improvement as well as by changes in manometric parameters in children with constipation and pelvic floor dyssynergia (PFD).

MATERIALS AND METHODS

A total of 44 children with constipation and PFD hospitalized between 2000 and 2015 were enrolled in this retrospective study. All patients underwent anorectal manometry, and in case of diagnosed PFD, the patient qualified for biofeedback therapy. Amplitudes between extreme and basic pressures during defecation maneuvers in the first and last sessions as well as the difference between them were compared between groups with and without clinical improvement after the last session.

RESULTS

A clinical improvement was achieved in 38 (86%) patients. There were no significant differences found in the amplitudes in the first session (mmHg), 94, 65, 115 vs. 112, 55, 170 (median, first quartile, third quartile, respectively; NS: not significant); last session, 36, 27, 52 vs. 41, -38, 66, respectively; or between them, 71, 11, 124 vs. 81, 17, 109, respectively, in the group with versus the group without clinical improvement, respectively.

CONCLUSION

Biofeedback therapy has high clinical efficacy, and despite the lack of manometric improvement, it should be used as a treatment method in children in whom dietary and pharmacological procedures do not work, even if we consider the exercises more as a form of psychological training.

The clinical course of hereditary pancreatitis in children - A comprehensive analysis of 41 cases

BACKGROUND

Available data from adult patients do not reflect natural course of hereditary pancreatitis (HP) in children. To date, no study has assessed the clinical course of HP in children.

OBJECTIVE

To investigate the clinical course of HP in children and compare it to non-HP group with chronic pancreatitis (CP).

METHODS

A group of 265 children with CP, hospitalized from 1988 to 2014, were enrolled in the study. Medical records of those patients were reviewed for data on presentation, diagnostic findings and treatment. All children were screened for mutations in major pancreatitis-associated genes, i.e. PRSS1, SPINK1, and CFTR.

RESULTS

HP was diagnosed in 41 children (15.5%). Family history was positive in 88% of children with HP. Mutations of PRSS1 gene were found in 80% (33/41) of HP patients. We detected p.R122H, p.R122C, p.N29I, and p.E79K mutation in 34% (14/41), 27% (11/41), 12% (5/41), and 7% (3/41) of HP patients, respectively. Patients with paternal inheritance had first symptoms earlier than those with maternal inheritance (5.9 vs. 9.1 years; P < 0.05). Children with HP showed more severe changes in ERCP then those from non-HP group (2.05 Cambridge grade, vs. 1.6°; P < 0.05). ESWL was performed more frequently in HP group (12.2% vs. 3.1%; P < 0.05). There was no difference in age of disease onset (7.98 vs. 8.9 years; NS), pancreatic duct stenting (46.3% vs. 33%; NS), or number of surgical interventions (12.2% vs. 14.3%; NS) between both groups.

CONCLUSIONS

Children with HP reveal significantly more severe clinical presentation of the disease than non-HP patients, despite the same age of onset.

Histological healing after infliximab induction therapy in children with ulcerative colitis

AIM: To verify the impact of induction therapy with infliximab (IFX) on mucosal healing in children with ulcerative colitis (UC).

METHODS: The study included all UC pediatric patients treated with IFX at our center over the last 10 years. The data were collected from patients’ medical charts and analyzed retrospectively. A total of 16 patients with UC underwent colonoscopy with sample collection before and after three IFX injections. Pediatric Ulcerative Colitis Activity Index (PUCAI) was used to assess the clinical condition; endoscopic features were classified according to the Baron scale; and histological changes were evaluated according to the protocol of The British Society of Gastroenterology and Geboes Index. Clinical response was defined as a ≥ 20-point reduction in PUCAI index, and clinical remission as PUCAI index < 10 points. Endoscopic mucosal remission was defined as completely normal (score 0) on the Baron scale. Histological remission was defined as grade 0 in the Geboes Index. To assess correlation between variables, Spearman’s rank correlation coefficient was used.

RESULTS: Clinical remission (PUCAI < 10) at week 8 was achieved in 68.75% of investigated subjects. Endoscopic mucosal remission at week 8 (Baron 0) was observed in 12.5% of patients. Histological remission (Geboes 0) after induction therapy with IFX was noticed in 18.75% cases. A general histological improvement, expressed by normal surface and crypt architecture, number of crypts, and lamina propria cellularity, was observed in six (37.5%) patients; there was no improvement in nine (56.25%) individuals, and worsening was observed in one (3.75%) case. Changes were not related to UC location. A reduction of inflammatory process was observed in 10 (62.5%) patients; there were no changes in four (25%) individuals, and the inflammation became more severe in two (12.5 %) cases. Simultaneous clinical, endoscopic and histological improvement of parameters assessing disease activity at week 8 was noticed in six (37.5%) patients. 55.5% of investigated patients with normal mucosa seen on endoscopy showed no inflammation on histology. A Baron score of 2 and 3 showed a good correlation with histology results (78.2% of patients with a Geboes Index ≥ 3).

CONCLUSION: IFX has a positive histological effect in more than one-third of UC patients. IFX reduces intestinal inflammation and improves clinical condition.

Profile of infliximab in the treatment of pediatric Crohn's disease

In recent years, a novel biologic therapy with monoclonal antibodies against tumor necrosis factor-alpha has revolutionized the treatment of Crohn’s disease. Infliximab, the first biologic agent, has been demonstrated to considerably improve both clinical and endoscopic outcomes. In view of the growing popularity of infliximab in the management of Crohn’s disease, we review the profile of the agent in the treatment of this disease in a pediatric setting.

Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis

BACKGROUND

Chronic pancreatitis (CP) is a rare disease in childhood. Although ERCP is commonly performed in children, the effect of pancreatic duct stenting therapy in children with CP is unknown.

OBJECTIVE

To investigate the efficacy of pancreatic duct stenting in children with CP.

DESIGN

Retrospective analysis.

SETTING

National referral center.

PATIENTS

A total of 208 children with CP hospitalized between 1988 and 2012.

INTERVENTIONS

ERCP with pancreatic duct stenting.

MAIN OUTCOME MEASUREMENTS

Results of endoscopic therapy and number of pancreatitis episodes per year before and after treatment.

RESULTS

A total of 223 pancreatic duct stenting procedures were performed in 72 children. The median number of stent replacements was 3 (range 1-21). A statistically significant decrease in the number of pancreatitis episodes per year was observed: from 1.75 to 0.23 after endoscopic treatment (P < .05). Pancreatic duct stenting was performed more frequently in patients with hereditary pancreatitis (61.5%) and in children with CP and anatomic anomalies of the pancreatic duct (65%; P < .05).

LIMITATIONS

Retrospective analysis with the assessment of adverse events based on medical history.

CONCLUSION

Pancreatic duct stenting therapy is a safe and effective procedure in children with CP. This therapy should be recommended especially for children with hereditary pancreatitis and patients with anatomic anomalies of the pancreatic duct.

The nutritional status and factors contributing to malnutrition in children with chronic pancreatitis

BACKGROUND/OBJECTIVES

The present study was undertaken to determine the prevalence of malnutrition among children with chronic pancreatitis (CP). Furthermore, we aimed to evaluate the relationship between etiological factors of CP, its clinical characteristics, and the severity of malnutrition.

METHODS

The study included 208 children with CP (113 girls and 95 boys; mean age: 10.8 years, range: 1.6-18 years), hospitalized at our center between 1988 and 2012. The severity of malnutrition was graded on the basis of Cole's ratios, and its prevalence was analyzed according to the etiological factors of pancreatitis. Moreover, the analysis of discrimination was performed to identify the factors contributing to malnutrition among the following variables: age at CP onset, duration of CP, number of CP exacerbations, the number of ERCPs performed, the grade of pancreatic damage documented on imaging, co-occurrence of diabetes, and the results of 72-h fecal fat quantification.

RESULTS

We documented features of malnutrition in 52 (25%) children with CP, including 36 (17.3%) patients with moderate malnutrition, and 2 (0.96%) with severe malnutrition. There was no significant difference in the prevalence of malnutrition between groups of patients with various etiological factors of chronic pancreatitis. The age at CP onset showed the best discrimination ability of malnourished patients: the mean age at disease onset in a subgroup of malnourished children was significantly higher than in children with Cole's index >85%.

CONCLUSIONS

A considerable percentage of children with CP can suffer from clinically significant malnutrition. Later age at CP onset predisposes to development of malnutrition.

Bone mineral metabolism in children with biliary atresia after living related liver transplantation. Evaluation of selected parameters

BACKGROUND

Aim of the study was to analyze the effect of living related liver transplantation on selected parameters of bone formation and resorption in children with liver cirrhosis caused by biliary atresia.

MATERIAL/METHODS

20 children (13F/7M) with biliary atresia aged from 6 month to 2.4 years were enrolled into the study 4-9 days before liver transplantation. Osteocalcin, procollagen 1 aminoterminal propeptide, collagen type 1 crosslinked C-telopeptide, parathyroid hormone and metabolites of vitamin D: 25(OH)D3, 1,25(OH)2D3 were measured before, 3, 6 and 12 months after liver transplantation.

RESULTS

Three months after living related liver transplantation statistically significant increase of osteocalcin, collagen type 1 crosslinked C-telopeptide, parathyroid hormone and 1,25(OH)2D3 levels were found. We didn't observe further increase of these parameters during the next 9 months after liver transplantation. There was no difference in 25(OH)D3 levels in patients before and after liver transplantation.

CONCLUSIONS

In children after successful living related liver transplantation we observed improvement of selected parameters of bone formation and resorption which indicate stimulation of growing processes and mechanisms of bone geometry modelling.

[Prevalence of Kayser-Fleischer ring in patients with Wilson's disease]

The aim of the study was to assess prevalence of Kayser-Fleischer ring in children with Wilson's disease. 36 patients aged 7-17 years were enrolled into the study. All of them underwent ophthalmic examination by slit-lamp biomicroscopy. Kayser-Fleischer ring was found in 2 children (5.6%)--16 years old boy and girl with liver insufficiency. In addition, the girl had neurological symptoms. After 2 years of treatment K-F ring was not detected in the girl's eyes. Our data indicate that Kayser-Fleischer ring is rare in children and its absence does not exclude diagnosis of Wilson's disease.