An international multidisciplinary consensus on pediatric metabolic dysfunction-associated fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in children and adolescents, particularly those with obesity. NAFLD is considered a hepatic manifestation of the metabolic syndrome due to its close associations with abdominal obesity, insulin resistance, and atherogenic dyslipidemia. Experts have proposed an alternative terminology, metabolic dysfunction-associated fatty liver disease (MAFLD), to better reflect its pathophysiology. This study aimed to develop consensus statements and recommendations for pediatric MAFLD through collaboration among international experts.

METHODS

A group of 65 experts from 35 countries and six continents, including pediatricians, hepatologists, and endocrinologists, participated in a consensus development process. The process encompassed various aspects of pediatric MAFLD, including epidemiology, mechanisms, screening, and management.

FINDINGS

In round 1, we received 65 surveys from 35 countries and analyzed these results, which informed us that 73.3% of respondents agreed with 20 draft statements while 23.8% agreed somewhat. The mean percentage of agreement or somewhat agreement increased to 80.85% and 15.75%, respectively, in round 2. The final statements covered a wide range of topics related to epidemiology, pathophysiology, and strategies for screening and managing pediatric MAFLD.

CONCLUSIONS

The consensus statements and recommendations developed by an international expert panel serve to optimize clinical outcomes and improve the quality of life for children and adolescents with MAFLD. These findings emphasize the need for standardized approaches in diagnosing and treating pediatric MAFLD.

FUNDING

This work was funded by the National Natural Science Foundation of China (82070588, 82370577), the National Key R&D Program of China (2023YFA1800801), National High Level Hospital Clinical Research Funding (2022-PUMCH-C-014), the Wuxi Taihu Talent Plan (DJTD202106), and the Medical Key Discipline Program of Wuxi Health Commission (ZDXK2021007).

Impact of COVID-19 on Pediatric Inflammatory Bowel Diseases-From Expectations to Reality

Viral infections have always been considered a threat to global health, with numerous outbreaks across time. Despite the relative recent experience with coronavirus-associated diseases such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), severe acute respiratory syndrome-2's (SARS-CoV-2) continuous evolution displays a different behavior. With a tropism for both respiratory and digestive mucosa, coronavirus disease 2019 (COVID-19) and inflammatory bowel disease (IBD) seem to share a particular common background. Current literature offers evidence that viral alteration of the immune system, inflammatory intestinal tissue damage, increased intestinal permeability, incomplete viral clearance with viral antigen persistence, and intestinal dysbiosis, might explain SARS-CoV-2-IBD relationship in terms of etiopathogenesis and evolution. The hyperinflammatory state that both entities have in common explains the lack of success of current IBD therapy, raising the need for new personalized therapeutic options, with better outcomes for IBD and COVID-19 as well. This review aims to summarize the current available data on pediatric IBD evolution, management, and outcomes in the post-COVID period, with an emphasis on the particular aspects of the SARS-CoV-2-IBD relationship in children.

Pattern of Primary Resistance of Helicobacter pylori to Clarithromycin among Pediatric Patients from North-Eastern Romania

BACKGROUND

Helicobacter pylori antibiotic resistance has increased worldwide and affects the effectiveness of current therapies. The recommended first-line empiric treatment should be tailored to the local clarithromycin resistance rate. This study aimed to determine the pediatric patient profile and rate of clarithromycin resistance for patients diagnosed with Helicobacter pylori by gastric biopsy.

METHODS

We studied 84 positive gastric samples for Helicobacter pylori. Positive results were confirmed by a rapid urease test and histopathological examination, with the type of gastritis established according to the Sydney System. Gastric biopsy samples were stored in RNA saver. Clarithromycin resistance was determined by a real-time polymerase chain reaction-based molecular assay after RNA-DNA extraction.

RESULTS

Of the 84 biopsy samples analyzed, 35 (41.6%) were resistant to clarithromycin. Clarithromycin resistance was found mainly in girls (80%) with a mean age of 15 years (range 6-17 years). The history of prior exposure to clarithromycin was 91.6%. The concordance between the histopathological examination and the PCR test was 100%.

CONCLUSIONS

One in 2.4 children infected with Helicobacter pylori had a strain resistant to clarithromycin. This resistant strain may be a reason for treatment failure in Romanian children, yet this is uninvestigated. The high rate of bacterial resistance to this antibiotic among children indicates the need for susceptibility testing before therapy.

Predicting Hospitalization, Organ Dysfunction, and Mortality in Post-Endoscopic Retrograde Cholangiopancreatography Acute Pancreatitis: Are SIRS and qSOFA Reliable Tools?

Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has shown constant incidence throughout time, despite advances in endoscopic technology, devices, or personal skills of the operating endoscopists, with prevention and prediction of severity in PEP being constant concerns. Several prospective studies have investigated the role of systemic inflammatory response syndrome (SIRS) criteria or the quick Sequential Organ Failure Assessment (qSOFA) score in the PEP severity assessment. However, there are no clearly defined tools for the prediction of PEP severity. Methods: A total of 403 patients were prospectively monitored 60 days after ERCP for the detection of PEP development. Consequently, we evaluated the lengths of stay, incidence of organic dysfunction, and mortality rates of these patients. The predictive power of the univariate model was evaluated by using the receiver operating characteristic curve and analyzing the area under the curve (AUC). Results: Incidence of PEP was similar to that reported in the majority of trials. The 60-day survival rate of PEP patients reached 82.8%. A qSOFA score ≥ 1 is a very good predictor for organ dysfunction (AUC 0.993, p < 0.0001). SIRS can also be considered a significant predictor for organic dysfunctions in PEP patients (AUC 0.926, p < 0.0001). However, only qSOFA was found to significantly predict mortality in PEP patients (AUC 0.885, p = 0.003), with SIRS criteria showing a much lower predictive power. Neither SIRS nor qSOFA showed any predictive value for the length of stay of PEP patients. Conclusion: Our study offers novel information about severity prediction in PEP patients. Both SIRS criteria and qSOFA showed good predictive value for organic dysfunction, mortality, and hospitalization.

Self-Medication Patterns during a Pandemic: A Qualitative Study on Romanian Mothers’ Beliefs toward Self-Treatment of Their Children

Self-medication represents a significant healthcare and health policy issue worldwide, both in developed and underdeveloped countries. Currently, the COVID-19 pandemic is considered a relevant context that could subtly trigger self-medication behavior because of limited access to health care services and the threat of infection with the SARS-CoV-2 virus. While the previous research conducted with quantitative methodologies reported a dramatically increased rate of self-medication around the world, qualitative inquiries on the subjective experience with self-medicine remain scarce in medical and related fields of study. For this purpose, a qualitative study with semi-structured interviews was undertaken to better understand how Romanian mothers (n = 18) applied self-treatment with their children by avoiding medical advice during the COVID-19 pandemic. The results showed that the COVID-19 pandemic did not affect the prevalence of self-medicine among the pediatric population as parents achieved a degree of awareness of self-treatment of their children due to the general context of the outbreak of the COVID-19 pandemic.

Magnesium Orotate and the Microbiome–Gut–Brain Axis Modulation: New Approaches in Psychological Comorbidities of Gastrointestinal Functional Disorders

Magnesium orotate has been cited in the medical literature for the past three years as a possible adjuvant in some pediatric and adult gastroenterological disorders associated with dysbiosis. Studies also focus on the possibility of adding magnesium orotate in psychiatric disorders’ treatment, such as major depression and anxiety. The most relevant element in these studies is the efficiency of magnesium orotate therapy in cases with both gastroenterological and psychiatric symptoms. This article proposes a literature review, focused on the studies published in the last three years, targeting magnesium orotate treatment and probiotic supplementation in patients with both digestive and psychiatric symptoms. Moreover, this review will compare the efficiency of magnesium orotate and probiotics within both the pediatric and adult communities, focusing on the possibility of gut–brain axis modulation and its involvement in the clinical evolution of these patients.

Assessing the Opinion of Mothers about School-Based Sexual Education in Romania, the Country with the Highest Rate of Teenage Pregnancy in Europe

Background and Objectives: Without mandatory school-based education, Romania is a leading European country in teen pregnancy. This survey aimed at assessing the level of knowledge and the opinions about sexual education and sexual-related issues among mothers of female teenagers aged 13–18 years old. Material and Methods: The survey was conducted between 2015 and 2017 and had four parts, collecting data about sociodemographic variables, the level of knowledge about sexuality, sexually transmitted diseases, and contraception. The respondents were mothers of female teenagers hospitalized in a tertiary pediatric clinic. Data were analyzed using IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, version 25 (Inc., Chicago, IL, USA). Results: One hundred and thirty-five mothers (42.46 ± 6.81 years old) were included in the research. Most of them were from rural areas, had graduated secondary school, were Christian-orthodox, married, and with a stable job. More than half of the mothers (61.42%) declared that they personally knew adolescents that were already mothers. In great proportion, mothers proved good knowledge about sexual education, contraception, and STDs. They considered that the minimum age for becoming married, in general, is about M = 18.62 ± 2.09 years old but in the case of their daughters, mothers appreciated that the best age would be 23.56 ± 9.37. Mothers considered that they had good communication with their daughters (M = 4.28 ± 0.99) and two-thirds sustained that they had discussed with them about sexual activity, pregnancy, sexually transmitted diseases, and contraception. In case of unwanted pregnancy of their daughters, one-third of the mothers (38.50%) would advise their girls to continue the pregnancy and 7.40% mentioned the termination of pregnancy. Two-thirds of them (74.10%) agreed to school-based sexual education. In the order of preferred sources for sexual education, mothers mentioned parents (85.90%), teachers (33.30%), and family doctors (24.40%). Comparative results regarding their own sex life and that of their daughters are presented. Conclusions: School-based programs should meet parental beliefs about sexuality and sexual education. School, as a creator of values and models, should find the golden ratio to better shape the personal, familial, and social needs for the healthy sexual behavior of the new generation.

Polyacrylamide Gel Electrophoresis of Proteins Method versus Enzyme-Linked Immunosorbent Assay and Immunochromatography with Monoclonal Antibodies in Pediatric Infection with Helicobacter Pylori

The current methods for the diagnosis of Helicobacter pylori infection in children include invasive (direct) methods, that enable the detection of the bacteria or the bacterial urease in gastric biopsies, or noninvasive (indirect) methods, which consist of researching specific antibodies, antigens and urease in other different samples (serum, saliva, urine, stool, exhaled air). The urease functions in H. pylori infection is to neutralize gastric acid by producing NH3 through the hydrolysis of urea. Monochloramine, a NH3-derived compounds has cytotoxic effects on host cells. The Western Blot method refers to the extraction of a a sodium dodecyl sulphate from a Helicobacter pylori strain followed by a separation of the solubilised protein using discontinous polyacrylamide gel electrophoresis according to molecular mass and transfer of the separated proteins to nitrocellulose. The ELISA (enzyme-linked immunosorbent assay) technique refers to the detection of Anti-Helicobacter pylori antibodies type Ig G. We also used an immunochromatographic system with the lateral leakage test strip based on the principle of the sandwich technique with monoclonal antibodies. As a result, more than two types of reactions can be detected on a single assay device by the combination of colloidal gold �labelled antibodies and complementary oligonucleotide-labelled immobilized at different places on a nitrocellulose membrane. Our study aims to assess the performances of the Western Blot method for determining anti-Helicobacter pylori Ig A and Ig G antibodies in correlation with clinical data and other available diagnosis methods. For validation purposes, the results were compared to those obtained using the enzyme-linked immunosorbent assay technique, gastric biopsy and immunochromatography.

DIAGNOSIS AND TREATMENT IN GASTROESOPHAGEAL REFLUX DISEASE – POSSIBILITIES AND LIMITATIONS

In children’s first year of life it is mandatory to make a difference between physiological gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD), in order to avoid an aggressive pharmacologic therapy. All ages of childhood benefit from modern criteria of clinical evaluation, by corroborating the digestive or extra digestive symptoms with the results of modern investigations. The dietary measures (sufficient in GER but mandatory in all cases) together with proton pump inhibitors administration after one year of age induce remission in majority of GER cases. The chronic and recurrent evolution of the disease or failure of the common treatment require surgical intervention, recently enriched in children with peroral endoscopic myotomy (POEM).

DIAGNOSTIC ŞI TRATAMENT ÎN BOALA DE REFLUX GASTROESOFAGIAN – POSIBILITĂŢI ŞI LIMITE

Departajarea refluxului gastro-esofagian (RGE) fiziologic (cel mai frecvent) de boala de reflux gastro-esofagian (BRGE) în primul an de viaţă este obligatorie pentru a evita farmacoterapia agresivă. La toate vârstele copilăriei se aplică criterii moderne de evaluare clinică, sumând simptome digestive şi/sau extradigestive şi rezultatele unor investigaţii moderne. Tratamentul igieno-dietetic (suficient in RGE fiziologic), obligatoriu în toate cazurile, şi inhibitorii de pompă protonică dupa vârsta de un an induc remisiune în majoritatea cazurilor de RGE. Evoluţia cronică/recidivantă şi rezistenţa la tratamentul comun impun intervenţia chirurgicală, domeniu îmbogaţit recent la copil cu miotomia perorală endoscopică (POEM).

Upper gastrointestinal bleeding in children from a hospital center of Northeast Romania

BACKGROUND

The aim of this study was to investigate the common etiologies, clinical and biological patterns of upper gastrointestinal bleeding (UGIB) in children from a hospital center in Northeast Romania.

METHODS

This seven-year retrospective study was performed from 2007 to 2013 in St. Mary Children's Emergency Hospital, Jassy, Romania and included all children who referred to our center with UGIB exteriorized by hematemesis or melena. Endoscopy was performed under conscious sedation/general anesthesia after the informed consent was obtained.

RESULTS

One hundred and three patients aged 1-18 years were included in this study. There were 57 males and 46 females with male to female ratio 1.2:1; 43.69% presented with hematemesis, 31.07% had melena and 25.24% had both. The most common causes of UGIB were erosive gastritis (33.98%), followed by esophagitis (14.56%), duodenitis (11.65%), duodenal ulcer (10.68%), gastric ulcer (5.83%), esophageal varices (4.85%), Mallory-Weiss syndrome (1.94%); multiple etiologies counted for 16.50% cases. A certain bleeding source was found in 34.95% cases, a possible one in 39.81% of the patients; the source could not be ascertained in 25.24% of cases. Nonsteroidal anti-inflammatory drug (NSAID) consumption was documented in in 17.51% of patients. The incidence of H. pylori infection was 36.89%.

CONCLUSIONS

The most common cause of of upper GI bleeding in our series was gastritis, followed by oesophagitis and duodenitis. Most of the patients presented with hematemesis; previous consumption of NSAIDs and H. pylori infection were associated with gastroduodenal ulceration and bleeding. Early endoscopy was associated with a higher detection rate of the bleeding source.

Unusual Endoscopic Findings in Children: Esophageal and Gastric Polyps: Three Cases Report

Isolated polyps of the upper digestive tract are rarely diagnosed in children, being usually an incidental finding during endoscopic exploration.The diagnostic, therapy, and outcome of these lesions are based on endoscopy and pathology.In a 5-year period, clinical features, topography, size, pathology, therapeutics, and progression of esophagogastric polyps founded in children addressed to our pediatric gastroenterology unit were studied.The authors encountered 3 lesions in teenagers aged 13 to 17 years two males (2M), from a total number of 2140 upper digestive endoscopies (0.14%). All patients presented with pirosis, epigastric pain, and vomits; one of the children had end-stage renal disease and Kabuki syndrome. Endoscopic and pathologic findings were 2 esophageal polyps, an inflammatory one, and another containing goblet cells and a double-headed hyperplastic gastric polyp. Two patients received proton pump inhibitors without any improvement in subsequent endoscopic evaluations.The difficulties related to age group, underlying conditions, debatable response to acid suppression, and limited experience in pediatric therapeutic endoscopy selected significantly the effectiveness of treatment.The rarity of these lesions requires an individualized management, the endoscopic diagnostic, and therapeutic gesture depending on the symptoms, type, location, comorbidities, and team experience.

PRE-PROCEDURAL RECOMMENDATIONS IN PEDIATRIC GASTROINTESTINAL ENDOSCOPY

Gastrointestinal endoscopy is one of the most common invasive procedures carried out in pediatric gastroenterology and is not without risk. The range of necessary measures for the purpose of this procedure includes: the accurate assessment of the patient considering the endoscopy-related indications and contraindications, obtaining the informed consent, the psychological preparation of the parents/child, applying some dietary restrictions, and infection prophylaxis. It is also necessary to choose the type of sedation and ensure the constant monitoring during and after the procedure so as to avoid any complications related to the procedure or to the side effects of drugs.

RECOMANDĂRI PRE-PROCEDURALE ÎN ENDOSCOPIA DIGESTIVĂ LA PACIENTUL PEDIATRIC

Endoscopia digestivă, una dintre cele mai frecvente investigaţii invazive în gastroenterologia pediatrică, nu este lipsită de riscuri. Complexul de măsuri necesare acestei manevre cuprinde: evaluarea corectă a bolnavului ţinând seama de indicaţiile şi contraindicaţiile endoscopiei, obţinerea consimţământului informat, pregătirea psihologică a părinţilor/copilului, aplicarea unor restricţii dietetice, profilaxia infecţiilor. De asemenea, trebuie ales tipul de anestezie, monitorizarea continuă intra şi post-procedurală pentru evitarea complicaţiilor legate de procedură sau de reacţii adverse medicamentoase.

GASTRITELE ŞI HELICOBACTER PYLORI LA COPIL – DIAGNOSTICUL ENDOSCOPIC PRIMAR ŞI SECUNDAR

Infecţia cu Helicobacter pylori (H. pylori) este o problemă comună şi semnificativă de sănătate publică. Obiectiv. Determinarea prevalenţei infecţiei cu H. pylori la copiii cu simptomatologie sugestivă şi conturarea cazurilor în funcţie de tipul şi felul gastritei prin efectuarea de endoscopii digestive superioare. Material şi metodă. Studiu retrospectiv realizat pe o perioadă de 5 ani pe 1.269 de copii cu simptomatologie gastrică, la care s-au efectuat endoscopii cu biopsie, stabilindu-se rata de infecţie cu H. pylori prin examen direct sau testul ureazei. Rezultate. Frecvenţa H. pylori în cazul gastritei acute a fost semnificativ mai mică (34,78%) comparativ cu frecvenţa acesteia în cazul gastritei cronice (54,94%). În cadrul celor 10 tipuri de gastrită, cele mai frecvente sunt formele purpurice (43,66%), nodular purpurică (25,93%) şi nodular antrală (15,84%), la polul opus situându-se gastrita atrofi că şi hipertrofică. Asocierile cele mai frecvente decelate endoscopic sunt cu esofagita gr I în 51,6%, duodenita în 45,07% şi forma purpurică în 24,74%. Concluzii. Infecţia cu H. pylori este cel mai frecvent asociată gastritei cronice (54,94%). Identificarea precoce a infecţiei este esenţială pentru eradicarea bacteriei şi prevenirea apariţiei diferitelor tipuri de gastrită identifi cate endoscopic.

GASTRITIS AND HELICOBACTER PYLORI IN CHILDREN – PRIMARY AND SECONDARY ENDOSCOPIC DIAGNOSIS

The infection with Helicobacter pylori (H pylori) represents an important issue of public health. Aim. Establishing the prevalence of H. pylori infection in children and presenting the cases according to the gastritis type by performing upper digestive endoscopies. Material and method. The retrospective study referred to a period of 5 years and included 1269 children evaluated by upper endoscopy to establish the H. pylori infection rate. Results. The frequency of H. pylori in the case of acute gastritis was significantly more reduced (34.78%) than in the case of chronic gastritis (54.94%). Referring to the 10 types of gastritis, the most frequent ones are purpuric (43.66%), nodular purpuric (25.93%) and nodular antral (15.84%). At the other end, atrophic and hypertrophic gastritis were positioned. The most frequent associations pointed out endoscopically are those with 1st degree esophagitis - 51.6%, duodenitis – 45.07% and purpuric duodenitis – 24.74%.Conclusions. The H. pylori infection is the most frequent etiologic factor for chronic gastritis (54.94%). The early identification of the infection is essential to destroy the bacteria and to prevent the development of various types of gastritis that are later on endoscopically identified.

ABORDAREA MULTIDISCIPLINARĂ A CONSTIPAŢIEI CRONICE ASOCIATĂ CU INCONTINENŢA FECALĂ LA COPIL

Constipaţia este un simptom comun în practica clinică. Definiţia include frecvenţa anormală a tranzitului, dificultate în timpul defecării şi consistenţă anormală a scaunului. Metodele de diagnostic limitate precum şi numeroasele afecţiuni care conduc la apariţia simptomatologiei, duc la creşterea numărului de cazuri cu rezistenţa la tratament. Tratamentul include abordări dietetice şi comportamentale, terapie farmacologică şi în cazuri atent selectate intervenţie chirurgicală. Tratamentul chirurgical este recomandat la pacienţii cu constipaţie severă rezistentă la tratamentul conservator. Confirmarea indicaţiei pentru tratament chirurgical necesită studii privind tranzitul colonic, funcţia de defecare, precum şi efectuarea manometriei anorectale. De aceea, colaborarea strânsă între pediatru, gastroenterolog şi chirurgul pediatru este absolut necesară pentru o evaluare preoperatorie atentă şi corectă a funcţiei gastro-intestinale. Complicaţiile postoperatorii includ obstrucţie intestinală, dureri abdominale, meteorism şi diaree. Eficacitatea intervenţiei chirurgicale şi prevalenţa complicaţiilor postoperatorii sunt determinate de evaluarea atentă preoperatorie a funcţiei gastro-intestinale.

ETIOLOGIA SÂNGERĂRILOR GASTROINTESTINALE LA COPIL

Obiective. Identificarea caracterelor clinice, endoscopice, etiologice la copiii diagnosticaţi cu hemoragie digestivă superioară şi inferioară. Material şi metodă. S-a efectuat un studiu retrospectiv descriptiv pe o perioadă de 3 ani (ianuarie 2010-decembrie 2012) pe 107 copiii cu vârsta între 1 şi 18 ani, internaţi pentru hemoragii digestive în Spitalului Clinic de Copii „Sf. Maria“ Iaşi. Lotul de studiu nu cuprinde hemoragii digestive din urgenţe chirurgicale, boli infecţioase, boli intestinale cu mecanism imunologic sau toxic. Analiza retrospectivă individualizată prin studiul foii de observaţie a cuprins date anamnestice, clinice, endoscopice şi histologice orientate pentru diagnosticul etiologic al hemoragiilor digestive. Toţi pacienţii au fost investigaţi prin endoscopie digestivă superioară/colonoscopie după ce procedura a fost explicată şi s-a obţinut consimţământul informat. Rezultate. Din lotul de 107 copii luaţi în studiu 39 (36,4%) au reprezentat hemoragia digestivă superioară (HDS), dintre care 6 cazuri (5,1% ) de cauza variceală iar 33 (94,8%) de cauză non variceală; şi 68 (63,5%) au prezentat hemoragia digestivă inferioară (HDI). În etiologia HDS gastrita erozivă a reprezentat 12 (30,8%) cazuri, esofagita 6 (15,4%), duodenita 6 (15,4%), ulcerul duodenal 4 (10,3%), ulcerul gastric 2 (5,1%), sindrom Mallory Weiss 1 (2,6%), etiologie multiplă 6 (15,4%) cazuri. Principalele aspecte etiologice ale HDI au fost polipul colo-rectal în 28 (41,2%) cazuri, colită ulcerativă 14 (20,6%), leziuni nespecifice 12 (17,6%) fisuri anale 9 (13,4%), sindroame de polipoză intestinală 3 (4,4%), malformaţie vasculară 1 (1,5%), diverticul rectal 1 (1,5%) caz. S-au practicat intervenţii endoscopice concomitente în cazul polipilor colo-rectali. Concluzii. Hemoragia digestivă inferioară a fost cea mai frecventă, corelată cu cauze minore: polipi colorectali, fisuri anale, leziuni nespecifice. Hemoragia digestivă non-variceală forma cea mai frecventă s-a asociat cu gastrita erozivă, esofagita, duodenita, ulcerul gastric. Endoscopia digestivă s-a dovedit a fi o investigaţie utilă în diagnosticul hemoragiilor digestive şi cu aport terapeutic în anumite cazuri.

ETIOLOGY OF GASTROINTESTINAL BLEEDING IN CHILDREN

Objectives. Identification of clinical, endoscopic, etiological characteristic of children diagnosed with upper and lower gastrointestinal bleeding. Material and methods. It was conducted a descriptive retrospective study over a 3 year period (January 2010 to December 2012) on 107 children aged 1-18 years hospitalized for gastrointestinal bleeding in ”St. Mary” Children’s Emergency Hospital, Iasi. The study group does not include gastrointestinal bleeding from surgical emergencies, infectious diseases, intestinal diseases with immunological or toxic mechanism. Individualized retrospective analysis included historical data, clinical, endoscopic and histological targeted for etiologic diagnosis of gastrointestinal bleeding. All patients were investigated by upper gastrointestinal endoscopy/colonoscopy after the procedure was explained and informed consent was obtained. Results. From the batch of 107 children, 39 (36.4%) presented with upper gastrointestinal bleeding (UGIB) 6 (5.1%) was variceal, non-variceal in 33 (94.4%) cases, and 68 (63.5%) presented with lower gastrointestinal bleeding (LGIB) The main etiological aspect of UGB was erosive gastritis 30.8%, esophagitis in 15.4%, duodenitis in 15.4%, gastric and duodenal ulcers 5,1% and respectively 10.3% of cases, Mallory-Weiss syndrome in 2.6%, multiple etiology in 10 cases 15.4%. Causes of LGIB were colorectal polyps in 41.2.%, ulcerative colitis 20.6%, non specific lesions in 17.6% anal fissures 13.2%, intestinal polyposis 4.4 %,rectal diverticula 1.5% and vascular malformations 1.5%. It was practiced concomitant endoscopic surgery for rectal polyps. Conclusions. Lower gastrointestinal bleeding was the most common causes related to minor conditions: colorectal polyps, anal fissures, nonspecific lesions. Non-variceal gastrointestinal bleeding the most common form associated with erosive gastritis, esophagitis, duodenal ulcer, gastric ulcer. Endoscopy proved to be a useful investigation in the diagnosis of gastrointestinal bleeding and a therapeutic useful tool in certain cases.

MULTIDISCIPLINARY APPROACH TO CHRONIC CONSTIPATION ASSOCIATED WITH FECAL INCONTINENCE IN CHILDREN

Constipation is a common symptom in clinical practice. Definition include abnormal transit difficulty during defecation and abnormal stool consistency. Limited diagnostic methods and the many diseases that lead to symptoms, leading to more cases of drug resistance. Treatment includes dietary and behavioral approaches, pharmacological therapy and surgery in carefully selected cases. Surgery is recommended in patients with severe constipation resistant to conservative treatment. Confirmation of indication for surgical treatment requires colonic transit studies, defecation function and conducting anorectal manometry. Therefore, a close collaboration between pediatric gastroenterologists and surgeon pediatricians is essential for the careful preoperative evaluation and gastrointestinal function. Postoperative complications include intestinal obstruction, abdominal pain, flatulence and diarrhea. The effectiveness of surgery and prevalence of postoperative complications are determined by a careful preoperative evaluation of the gastrointestinal function.

The diagnosis and management of an iatrogenic esotracheal fistula in a pediatric patient: Case report

Iatrogenic esotracheal fistula in pediatric patients is an extremely rare complication, and appears either because of the pressure exercised by the tracheostomy cannula or in patients that are long-term bearers of esogastric tubes, which will cause, together with the cannula, ischemic injuries and necrosis of the tissue. The treatment of these lesions is controversial. The paper presents the management of a pediatric patient with an acquired esotracheal fistula, secondary to a tracheostomy.

Predisposing factors for chronic constipation in children – 2-year clinical study

In the last decade constipation has become a current problem addressed in the pediatric gastroenterology departments. Objectives. We propose a study to establish the prevalence of constipation and the correlations between diet and the socio-familial environment in children aged from 1 to 17 years old, hospitalized in the Gastroenterology Department, „Saint Mary“ Emergency Hospital for Children of Iasi, between 1 January 2012 and 1 January 2014. Results. The study group consisted of 994 patients, representing 9.6% of all hospitalized children. Regarding the prevalence of constipation, we did not notice a significant difference between the sexes, the ratio F/M was 1.3/1, but we found a significantly higher proportion of patients from urban areas 68% (676) versus 32% (318) from rural areas. In terms of social and family environment: 34% (338) of children live with grandparents, 13.9% (139) come from single-parent families, 6.7% (67) are in the care of a foster parent and 2.6% (26) come from orphanages. In the group studied a low percentage of children were breastfeed, respectively 26.2% (261) in the first month, 10.7% (107) for 3 months, while at 6 months 98.1% (976) of children received a milk formula. Diversification was done incorrectly in the case of 41% (408) patients. Only 14.6% (145) reported daily consumption of fruits and vegetables, while 51.1% (508) had dinner at least once a week at fast food restaurants. 21.6% (214) practice sport at least 2 hours/week, while 48.7% (484) spend at least 3 hours/day watching television. 12.8% (128) of patients are overweight and 5.7% (57) obese. Conclusions. Constipation is a condition that affects children of all ages. There are not notable differences between the sexes. An increased proportion of urban patients with predominance of inadequate diet, physical inactivity and an increased proportion of overweight patients was found. The socio-familial environment has an important role in the psychological changes.

Factori predispozanţi ai constipaţiei cronice la copil – studiu clinic pe 2 ani

În ultimul deceniu constipaţia a devenit o problemă actuală de adresabilitate în serviciile de gastroenterologie pediatrică. Obiective. Ne-am propus un studiu pentru a identifica prevalenţa constipaţiei şi stabilirea unor corelaţii între dietă şi mediul socio-familial la copii cu vârste cuprinse între 1 şi 17 ani, internaţi în serviciul de Gastroenterologie, Spitalul Clinic de Urgenţă pentru Copii „Sfânta Maria“ Iaşi, în perioada 1 ianuarie 2012 – 1 ianuarie 2014. Rezultate. Grupul de studiu a constat dintr-un lot de 994 de pacienţi, reprezentând 9,6% din totalul copiilor spitalizaţi. În ceea ce priveşte prevalenţa constipaţiei nu am observat o diferenţă semnifi cativă între sexe, raportul F/M a fost de 1,3/1, dar am remarcat o proporţie semnificativă de pacienţi provenind din mediul urban 68% (676) faţă de 32% (318) din mediul rural. În ceea ce priveşte mediul socio-familial: 34% (338) dintre copii trăiesc cu bunicii, 13,9% (139) provin din familii monoparentale, 6,7% (67) sunt în grija unui asistent maternal şi 2,6% (26) vin din centrele de plasament. În lotul studiat un procent mic de copii au fost alăptaţi, respectiv, 26,2% (261), în prima lună, 10,7% (107) timp de 3 luni în timp ce la 6 luni 98,1% (976) dintre copii au primit o formulă de lapte. Diversificarea a fost făcută incorect în cazul a 41% (408) dintre pacienţi. Doar 14,6% (145) au raportat consumul zilnic de fructe şi legume, în timp ce 51,1% (508) au luat masa cel puţin o dată pe săptămână la restaurante de tip fast-food. 21,6% (214) practică sport cel puţin 2 ore/săptămână, în timp ce 48,7% (484) petrec cel puţin 3 ore/zi la televizor. 12,8% (128) dintre pacienţi sunt supraponderali şi 5,7% (57) obezi. Concluzii. Constipaţia este o boala care afectează copiii de toate vârstele. Nu sunt diferenţe notabile între sexe. Se remarcă o pondere crescută a pacienţilor din mediu urban cu predominanţa unui regim alimentar inadecvat, lipsa activităţii fi zice, precum şi o pondere crescută a pacienţilor supraponderali. Un rol important în modificările psihologice îl deţine mediul socio-familial.

Consideraţii clinico-epidemiologice în legătură cu ulcerul primar la copil – studiu retrospectiv pe 5 ani

Ulcerul peptic primar se menţine frecvent la copiii din ţările în curs de dezvoltare cu o incidenţă crescută a infecţiei cu H. pylori. Autorii au efectuat un studiu retrospectiv pe 84 de copii internaţi în Clinica V-a Pediatrie Gastroenterologie cu diagnosticul de boală ulceroasă între anii 2007-2023. Criteriile de includere în studiu au fost simptomatologia clinică sugestivă şi endoscopia pozitivă. În lotul studiat au existat 79 de copii cu ulcer primar şi 5 copii cu ulcer secundar. Raportând datele la o populaţie pediatrică de 1.400.000 de copii în nordestul României, incidenţa afecţiunii a fost de 5.64/100.000 iar frecvenţa a fost de 2,58% faţă de totalul de 3.052 de endoscopii digestive superioare efectuate în perioada menţionată. Raportul băieţi: fete a fost de 1.46:1 iar 77,41% dintre pacienţi proveneau din mediul urban. Ulcerele au debutat prin sindrom funcţional digestiv în 70,89% dintre cazuri sau printr-o complicaţie în 29,11% dintre cazuri. Prin endoscopie digestivă superioară au fost identificate 62 de ulcere duodenale (UD) şi 10 ulcere gastrice (UG). La 7 copii debutul prin perforaţie a permis identificarea intraoperatorie a leziunilor. În 70,89% dintre cazuri a fost demonstrată prezenţa cu infecţie cu H. pylori. Factorii favorizanţi pentru această boală au fost: dieta necorespunzătoare (63,16%), fumatul (57,89%), consumul de alcool (15,78%), stresul psihologic (27,27%). Am obţinut o corelaţie semnificativă între numărul mare de membri ai unei familii (r = 0,63%; p = 0,002), statusul socioeconomic scăzut (r = 0,87, p = 0,0003) şi infecţia cu H. pylori. Tratamentul antibacterian a utilizat tripla terapie standard la 73,33% pacienţi, cvadrupla terapie bazată pe bismut la 16,66% copii şi terapia secvenţială în 10% dintre cazuri. Rata globală de eradicare moderată obţinută (66,66%) poate fi considerată o dovadă indirectă a rezistenţei mari la claritromicină la copiii din România.

Clinical-epidemiological considerations regarding primary peptic ulcer in children – 5 years retrospective study

Primary peptic ulcer still remains highly quoted in children from developing countries, the infection with H. pylori having a high incidence among this cases. Between 2007 and 2012 a retrospective study was performed, involving 84 children who were hospitalized in our clinic, ulcer disease being the main diagnosis. The study’s inclusion criteria were suggestive clinical symptoms and positive endoscopy. The studied group consisted by 79 children with primary ulcer and 5 with secondary ulcer. Reporting data for 1,400,000 children population in North – Eastern Romania an incidence of 5.64/100.000 of primitive ulcer disease has been found, the frequency being 2.58% compared with the overall 3052 upper digestive endoscopies done in the years mentioned above. Male to female ratio was 1.46:1. 77.41% of the patients originated in urban areas. The onset was by functional digestive syndrome in 70,89% of the cases or by complications in 29.11% of the cases. By upper digestive endoscopy 62 duodenal ulcers (DU) and 10 gastric ulcers (GU) were identified. Perforation allowed intraoperative diagnosis of ulcerative lesions in 7 children. 70.89% were H. pylori infection – related ulcers. The contributing factors for developing this condition were improper diet (63.16%), smoking (57.89), alcohol consumption (15.78), psychological stress (27.27%). We obtained a significant correlation between the high number of a family members, (r = 0.63%; p = 0.002), the low socio-economical status (r = 0.87, p = 0.0003) and H. pylori infection. We used the standard triple therapy on 73.33% of the patients, the quadruple therapy, based on bismuth on 16.66% of the children, and the sequential therapy in 10% of the cases. The global eradication rate was 66.66% therefore we considered this as being an indirect proof for the high clarithromycin resistance in children from our region.

Complicaţii severe în cazul unei ingestii accidentale de baterie (prezentare de caz)

Ingestia anumitor categorii de corpi străini la copii poate provoca complicaţii periculoase şi grave, ducând la morbiditate crescută în rândul acestora. Prezentăm un caz de ingestie de baterie sub formă de disc la o fetiţă în vârstă de 2 ani, cu impactare la nivelul porţiunii superioare a esofagului cervical, extrasă în serviciul ORL, dar complicată ulterior cu fistulă traheoesofagiană şi pneumonie de aspiraţie, iar pe termen lung cu stenoză esofagiană înaltă ce a necesitat dilataţii endoscopice.

Severe complications of a disk battery ingestion (case report)

Certain categories of foreign bodies ingestion in children can cause dangerous and severe complications leading to increased morbidity rates among them. We report a case of disk battery ingestion in a 2 year old girl, with impaction in the upper cervical esophagus, extracted in otolaryngology service but complicated afterwards with tracheo-oesophageal fistula and aspiration pneumonia and by long-term effect with high esophageal stenosis that required endoscopic dilatation.

Multifactorial etiopathogeny of Henöch-Schönlein purpura in pediatric age

Henöch-Schönlein purpura is a small-vessel vasculitis characterized by an abnormal response of the immune system: immunoglobulin A (IgA), C3 and immune complex deposition in arterioles, capillaries and venules. The syndrome is mostly seen in children, but it may affect people of any age. It is more common in boys than in girls. The etiology of Henöch-Schönlein purpura is unknown. Multiple infectious agents as well as drugs, foods, and insect bites may trigger Henöch-Schönlein purpura. Susceptibility to HSP may have a genetic origin. Several reports suggest that deficiency of complement 4 (C4) from deletion of C4 genes predisposes patients to IgA nephropathy and HSP nephritis.

Etiopatogenia multifactorială a purpurei Henöch-Schönlein la vârsta pediatrică

Purpura Henöch-Schönlein (PHS) este o afecţiune a vaselor mici caracterizată printr-un răspuns anormal al sistemului imun: imunoglobulina A (IgA), fracţiunea a 3-a a complementului şi depunerea de complexe imune circulante în pereţii arteriolelor, venulelor şi a capilarelor. Sunt afectaţi predominant copiii, dar simptomatologia poate apărea şi la vârsta adultă. Boala este mai frecventă la pacienţii de sex masculin. Etiologia purpurei nu este deocamdată cunoscută, însă se pare ca există anumiţi factori de risc pentru apariţia acesteia: agenţi infecţioşi (Streptococ, parvovirusuri), înţepături de insecte, alimente sau medicamente (antibiotice, antihistaminice). Susceptibilitatea la PHS poate avea origine genetică. Numeroase rapoarte sugerează că deficienţa complementului (C4) datorată deleţiei genelor ce codează sinteza acestei fracţiuni determină predispoziţia la nefropatie IgA şi la nefrita Henöch-Schönlein.

Consimţământul informat pentru endoscopia gastrointestinală în pediatrie

Consimţământul informat a devenit o componentă majoră, dar şi obligatorie în practica medicală contemporană, numeroase foruri şi publicaţii subliniind comandamentele sale etice şi psihologice, ca şi modalităţile de obţinere şi mai ales implicaţiile de ordin legal. Implicaţiile acestei proceduri în cazul pediatriei sunt complexe, câteodată confuze sau insuficient intelese. Astfel dacă în cazul consultului clinic sau al actelor medicale simple, consimţământul poate fi considerat implicit, în situaţia unor manevre provocatoare de disconfort psihic sau fizic, investigaţii invazive – în care este inclusă şi endoscopia sau acte terapeutice presupunând posibilitatea unor riscuri sau complicaţii, obţinerea unui consimtământ informat din partea parinţilor sau aparţinătorilor legali şi respectiv a unui acord (accept) din partea unui copil evoluat din punct de vedere intelectual, psihologic şi social devine mandatorie. Trebuie totuşi clarificate nuanţele nu numai semantice între consimţământ şi acord, ponderea fiecaruia din acestea în decizia finală, discernământul pacientului minor la diferite grupe de vârstă şi în egală măsură rolul şi locul medicului curant în astfel de circumstanţă.

Informed consent in pediatric gastrointestinal endoscopy

Informed consent has become a major, but also mandatory component in medical praxis nowadays. A great number of forums and publications emphasize its ethical and psychological commands, the most adequate way to obtain it and especially its legal implications. In pediatrics, the implications of this procedure are complex, sometimes confusing or not well understood. Thus, in clinical consultations or simple medical acts, the consent could be seen as implicit; when we talk about maneuvers that lead to psychological or physical discomfort, invasive investigations, including endoscopy or therapeutic acts with possible risks or complications, informed consent from parents or legal tutors, respectively an intellectually, psychologically and socially evolved, educated child’s consent (acceptance) becomes mandatory. We must, however, clarify the nuances between consent and acceptance, not only from the semantic point of view, the proportion of either of the two terms in the final decision, the minor patient’s ability to discern at different age stages and finally the role and the importance of the doctor in such decision makings.