Enhancement of Circulating and Intestinal T Regulatory Cells and Their Expression of Helios and Neuropilin-1 in Children with Inflammatory Bowel Disease

Background/Aims

The proportions of intestinal and peripheral regulatory T cells (Tregs) in pediatric inflammatory bowel disease (IBD) were poorly investigated, as well as different subsets of these cells. Helios and Neuropilin-1 were proposed as markers differentiating between thymic and peripheral Tregs. Therefore, the aim of current work was to investigate the proportions of Tregs and expression of Helios and Neuropilin-1 in Tregs in peripheral blood and intestinal mucosa of children with inflammatory bowel disease.

Materials and methods

Fifteen patients newly diagnosed with inflammatory bowel disease: ulcerative colitis (n=7) and Crohn's disease (n=8) were included in the study. Nine children who presented with no abnormalities in colonoscopy served as a control group. Quantification of regulatory T cells of the CD4⁺CD25^highFOXP3⁺ phenotype, as well as Helios⁺ and Neuropilin-1⁺ in peripheral blood and bowel mucosa was based on multicolor flow cytometry.

Results

The rates of circulating and intestinal Tregs were significantly higher in the studied group than in the control group. The rate of intestinal T regulatory lymphocytes was significantly higher than circulating Tregs in patients with IBD, but not in the control group. The median proportion of circulating FOXP3⁺Helios⁺ cells amounted to 24.83% in IBD patients and 15.93% in the controls. The median proportion of circulating FOXP3⁺Nrp-1⁺ cells was 34.23% in IBD and 21.01% in the control group. No statistically significant differences were noted for the circulating FOXP3⁺Helios⁺ cells and FOXP3⁺Nrp-1⁺ cells between the studied and the control group.

Conclusion

The rates of circulating and intestinal T regulatory cells are increased in naïve pediatric patients with IBD. The rate of Tregs is higher in intestinal mucosa than in peripheral blood in patients with IBD. Flow cytometry is a valuable method assessing the composition of infiltrates in inflamed tissue. Helios and Neuropilin-1 likely cannot serve as markers to differentiate between natural and adaptive Tregs.

Indoleamine 2,3-dioxygenase and regulatory t cells in intestinal mucosa in children with inflammatory bowel disease

Impaired immune regulation has been suggested as an underlying mechanism of inflammatory bowel disease. Indoleamine 2,3-dioxygenase (IDO) and regulatory T cells expressing FOXP3 are crucial elements of immune regulation. Conversion of FOXP3- lymphocytes to Tregs is one of the functions of IDO. The aim of this study was to evaluate the number of cells expressing FOXP3 and IDO in the lamina propria of intestinal mucosa and to evaluate correlations between these parameters and disease activity. Sixty-six children newly diagnosed with inflammatory bowel disease (41 patients with ulcerative colitis and 25 patients with Crohn’s disease) were included in the study. Clinical activity of the disease was assessed by the Pediatric Ulcerative Colitis Activity Index and the Pediatric Crohn’s Disease Activity Index. Histopathological activity was scored according to the system described by Geboes. The infiltration of FOXP3+ and IDO+ cells was evaluated by immunohistochemistry. Sixteen patients with a diagnosis of irritable bowel syndrome (IBS) served as a control group. Lamina propria demonstrated a significantly higher infiltration of FOXP3+ and IDO+ cells in inflammatory bowel disease compared to the control group (p=0.001, p=0.004, respectively). The number of IDO+ and FOXP3+ cells correlated with clinical and histopathologic activity of Crohn’s disease. A positive correlation between the number of IDO+ and FOXP3+ cells was found in both types of inflammatory disease but not in patients with IBS. We conclude that indoleamine dioxygenase and FOXP3+ cells are upregulated in the intestinal mucosa of children with inflammatory bowel disease. IDO mediated conversion of FOXP3 -T cells to Tregs predominantly occurs in inflammation.

Peripheral and Intestinal T-regulatory Cells are Upregulated in Children with Inflammatory Bowel Disease at Onset of Disease

BACKGROUND/AIMS

To determine the proportion of T-regulatory cells (CD4⁺CD25^highFOXP3⁺ cells) in peripheral blood and the number of FOXP3⁺ cells in intestinal mucosa of children with inflammatory bowel disease (IBD), and to verify whether these parameters correlate with the activity of the disease.

MATERIAL AND METHODS

24 patients newly diagnosed for IBD were included in the study: ulcerative colitis (UC; n = 13) and Crohn's disease (CD; n = 11). Seventeen healthy controls (HC) and 16 patients with irritable bowel syndrome (IBS) served as a control group for peripheral and intestinal Tregs assessment, respectively. The disease activity was assessed by Pediatric Ulcerative Colitis Activity Index (PUCAI) and Pediatric Crohn's Disease Activity Index (PCDAI). Quantification of regulatory T cells of CD4⁺CD25^highFOXP3⁺ phenotype in peripheral blood was based on three-color flow cytometry. Mucosal Tregs represented by FOXP3⁺ cells were evaluated using immunohistochemistry.

RESULTS

Median proportion of CD4⁺CD25^highFOXP3⁺ cells among CD4⁺ T cells in peripheral blood (5.1%, range 1.7-84% vs. 4.3%, range 2-8.1%, p = 0.023) and median number of intestinal FOXP3+ cells (115.33 per high-power field, hpf, range 39.33-375.67 vs. 10.16 per hpf, range 5-30, p = 0.0001) were significantly higher in children with IBD than in the controls. The proportion of circulating Tregs and the number of intestinal FOXP3+ cells did not correlate with clinical activity of the disease, as well as with endoscopic and histopathologic scoring. No significant correlation was found between the percentage of peripheral CD4+CD25^highFOXP3+ cells and the number of intestinal FOXP3+cells.

CONCLUSIONS

Children with IBD likely do not present with a quantitative deficiency of circulating and intestinal Tregs at the moment of diagnosis.

Expression of death receptor 3 on peripheral blood mononuclear cells differes in adult IBD patients and children with newly diagnosed IBD

BACKGROUND

Interaction between TL1A and death receptor 3 (DR3) is associated with the pathogenesis of inflammatory bowel disease (IBD), although their role in the development of this disease remains not fully explained. Some studies showed elevated expression of TL1A and DR3 in inflamed intestinal tissue but currently there are no reports concerning expression of DR3 on peripheral blood mononuclear cells (PBMCs) of IBD patients which was the subject of our study.

METHODS

We performed flow cytometry analysis of DR3 expression on CD4(+), CD8(+), CD11c(+), CD14(+) or CD20(+) PBMCs of adults and children with IBD and healthy volunteers with respect to C-reactive protein (CRP) levels in blood. Blood samples were collected from pediatric patients before the beginning of therapy, whereas adults patients were undergoing anti-inflammatory IBD treatment and had much lower CRP levels.

RESULTS

With regard to appropriate healthy volunteers, children with IBD had elevated percentage of DR3-expressing CD4(+), CD8(+), CD11c(+) and CD20(+) PBMCs which, with the exception of DR3(+) CD11c(+) cells in children with ulcerative colitis, was correlated with CRP level in blood. Adult patients had increased frequency of DR3(+) CD8(+) and CD20(+) PBMCs and their CRP levels correlated only with DR3(+) CD8(+) cells.

CONCLUSIONS

In comparison to healthy volunteers, untreated children with IBD have higher percentage of DR3(+) PBMCs than adults with IBD undergoing anti-inflammatory treatment. In most of the investigated PBMCs populations, the frequency of DR3(+) cells is correlated with the level of CRP. We suggest anti-inflammatory treatment may lead to reduction in the frequency of DR3(+) PBMCs. © 2016 International Clinical Cytometry Society.

Assessment of induction therapy with infliximab in children with moderate to severe ulcerative colitis: a multi-center study

THE AIM OF THE STUDY

Assessment of clinical and endoscopic efficacy of induction therapy with infliximab in children with ulcerative colitis.

MATERIAL AND METHODS

This is a retrospective analysis of medical records of pediatric patients with moderate to severe UC who had received at least one infusion of infliximab in Polish pediatric academic clinical centers from 2003 to 2013. The primary endpoint was clinical remission rate at week 10, (PUCAI score <10 points) while the secondary endpoints were: clinical response rate (>19-points decrease in PUCAI), mucosal response rate (defined as an improvement of the Baron score), and mucosal healing rate (Baron score 0 or 1).

RESULTS

44 patients, at mean age of 14±3.9 years, were included into the study. 38 (86%) patients completed induction therapy regimen with infliximab and were finally included into the analysis. Clinical response and remission rates at week 10 there were 36% and 25% respectively. There was significant drop of PUCAI (58.31±15.5 vs. 24.23±23.83) and Baron score (2.63±0.49 vs. 1.44±0.99) at this time point. Mucosal response and mucosal healing rate were 57% and 48% respectively. Infliximab failure defined as non-clinical and non-mucosal response at week 10, occurred in 16 patients. Infliximab-associated adverse events occurred in 3 patients, with all severe hypersensitivity reactions to infliximab.

CONCLUSIONS

Infliximab induction therapy was safe and effective in Polish moderate to severe UC pediatric patients with 50% rate of mucosal improvement. However, clinical response rate was lower than previously reported.

Immunohistochemical evidence of the co-localisation of cocaine and amphetamine regulatory peptide with neuronal isoform of nitric oxide synthase, vasoactive intestinal peptide and galanin within the circular muscle layer of the human caecum

The enteric nervous system consists of about one hundred million of neurons. In big mammals (including humans) intestinal enteric neuronal cells are grouped into three types of intramural ganglia located within myenteric, as well as outer and inner submucosal plexuses, which are connected by numerous nerve fibres. Both nerve fibres and cell bodies located in the gastrointestinal tract utilise a broad spectrum of active substances. One of them is cocaine- and amphetamine-regulated transcript peptide (CART). The goal of the current study was to determinate the distribution and degree of co-localisation of CART with substances taking part in intestinal motor activity by double labelling immunofluorescence technique. During the study CART-, neuronal isoform of nitric oxide synthase (nNOS)-, vasoactive intestinal peptide (VIP)- and/or galanin (GAL) - like immunoreactive (LI) nerve fibres in the circular muscle layer of the human caecum were observed in all patients studied. The degree of co-localisation of particular substances with CART depended on their type. The majority of CART-LI fibres contained simultaneously nNOS, slightly lower degree of co-localisation was observed in the case of the VIP, while simultaneously CART- and GAL-positive nerve fibres were observed less often.

Small Bowel Bacterial Overgrowth Associated with Persistence of Abdominal Symptoms in Children Treated with a Proton Pump Inhibitor

Small bowel bacterial overgrowth (SBBO) was diagnosed in 22.5% of 40 children treated for 3 months with a proton pump inhibitor (PPI). Compared with those without SBBO, children with SBBO had higher frequency of abdominal pain, bloating, eructation, and flatulence. Patients with gastrointestinal symptoms after PPI treatment should be evaluated for SBBO rather than empirically prolonging PPI therapy.

Evaluation of clinical usefulness of serum neopterin determination in children with bacterial infections

Neopterin (NPT) (6-D-erythro-trihydroxypropyl pteridin) is one of the indicators of the immune system activity. Elevated neopterin concentration occurs in diseases mostly involving stimulation of cellular immunity. The determination of neopterin concentration, usually in blood serum and urine but also in many other bodily fluids, has already been applied in many areas of medicine, such as transfusiology, transplantology, oncology, infectious diseases and autoimmunological diseases.

OBJECTIVE

The aim of this work is to evaluate clinical usefulness of serum neopterin determination in children with urinary tract infections of confirmed bacterial etiology.

MATERIAL

The study involved 56 children with bacterial urinary tract infections - patients of the Clinic of Paediatrics, Paediatric Gastroenterology, Hepatology & Paediatric Nutrition of Medical University of Gdańsk in the years 2012-2013. The control group included 105 healthy children.

RESULTS

The values of NPT concentration in blood serum obtained in the group of children with urinary tract infections did not significantly differ from the values obtained in the control group.

CONCLUSIONS

The determination of neopterin concentration in children with bacterial urinary tract infections is not a clinically useful parameter.

Evaluation of CD40 and CD80 receptors in the colonic mucosal membrane of children with inflammatory bowel disease

INTRODUCTION

The most prevalent inflammatory bowel diseases (IBD) include ulcerative colitis (UC) and Crohn's disease (CD). Immune processes play a vital role in the etiopathogenesis of these conditions, involving both cellular and humoral response mechanisms. The aim of this study was to quantify CD40- and CD80-positive cells in the biopsy specimens of large intestinal mucosa from children with IBD.

MATERIALS AND METHOD

The study comprised 38 children aged between 3-17 years (mean 11.5±3.7 years) - 20 boys (52.6 %) and 18 girls (47.4%). Eighteen patients were diagnosed with UC on the basis of clinical manifestation, endoscopic and histopathological findings. Mean age of this subgroup was 11.55±4.07 years. A group of 10 children (mean age 12.30±2.83) diagnosed with CD was also included. The control group comprised 10 IBD-free children (mean age 10.28±4.07 years). The surface expressions of CD40 and CD80 were analyzed in large intestine mucosa biopsy specimens, fixed in formaldehyde, embedded in paraffin, and cut with a microtome into 4 µm slices.

RESULTS

The number of CD40- and CD80-positive cells in the large intestinal mucosa of children with Crohn's disease and ulcerative colitis was significantly higher than in the controls. The highest number of CD40+ and CD80+ cells was observed in the caecal mucosal membrane of Crohn's disease patients and in the rectal mucosa of individuals with ulcerative colitis.

CONCLUSION

IBD is characterized by elevated, segment-specific, expression of CD40 and CD80.

Immunohistochemical distribution of cocaine and amphetamine regulatory peptide-like immunoreactive (CART-LI) nerve fibers in the circular muscle layer and their relationship to other peptides in the human caecum

Motor activity of the gastrointestinal tract is extensively controlled by the enteric nervous system (ENS). Numerous neurotransmitters and neuromodulators are responsible for this regulation. One of them is cocaine- and amphetamine-regulated transcript peptide (CART). So far, there are few reports available concerning the distribution, functions, and co-localization of CART in the human gastrointestinal tract. The aim of the present investigation was to study the distribution and degree of co-localization of CART with substances taking part in conducting sensory stimuli, such as: substance P (SP), neurokinin A (NKA), calcitonin gene related peptide (CGRP) and Leu 5 enkephalin (L-ENK) in the circular muscle layer of the human caecum. CART-like immunoreactive (CART-LI) nerve fibers formed a very dense meshwork in the circular muscle layer of the caecum in all patients studied. Moreover, all neuronal substances tested during the present investigation were observed in CART-LI processes, but the degree of co-localization depended on the type of substance. The highest number of CART-positive nerves also contained L-ENK. A slightly lower level of co-localization was observed in the case of CART and SP or NKA, while only single nerve fibers were simultaneously CART- and CGRP-positive.

[Biological treatment of inflammatory bowel diseases in children in the years 2004-2013 in Poland]

In the last years an increase in Crohn's disease morbidity in children is observed together with constant morbidity of ulcerative colitis. The course of these diseases is severe, younger children are affected and the diseases are resistant to conventional treatment. Biological drugs are a chance for a longer remission and healing of the intestinal mucosa. OBJECTIVE OF THE WORK: Assessment of the use of biological drugs in treatment of inflammatory bowel disease in Poland was the objective of the work.

MATERIAL AND METHODS

Gastroenterological centers treating inflammatory bowel disease during the years 2004-2013 were invited to a questionnaire retrospective study.

RESULTS

The questionnaires of biological treatment of Crohn's disease and ulcerative colitis in children were received from 12 centers. In the years 2004-2013 the number of children aged 4 months to 18 years with Crohn's disease treated with biological drugs was 424. In the years 2004-2008--69 children were treated with infliximab and in the years 2009-2013--299 children, which was a four-fold increase. 56 children were treated with adalimumab in the years 2008-2013. In the years 2005-2013--72 children with ulcerative colitis were treated with infliximab and 11 with adalimumab. The age of the children ranged from 2 years to 18 years. The higher number of children treated was in the years 2009-2013: 59 with infliximab and 10 with adalimumab.

CONCLUSIONS

In the last decade a significant increase on the number of children with Crohn's disease and ulcerative colitis treated with biological drugs was observed. It is connected not only to greater morbidity but above all to the introduction of a treatment program by the National Health Insurance Fund for children with Crohn's disease. There is an expectation that the introduction of biological treatment in inflammatory bowel disease will prolong clinical and endoscopic remission and diminish the number of surgeries.

Prevalence and correlates of vitamin K deficiency in children with inflammatory bowel disease

Although vitamin K deficiency has been implicated in adult inflammatory bowel disease (IBD), its prevalence in pediatric IBD remains unknown. We carried out a cross-sectional study in 63 children with Crohn's disease (CD) and 48 with ulcerative colitis (UC) to assess the prevalence of vitamin K deficiency and to search for potential correlation between vitamin K status and pediatric IBD activity. Vitamin K status was assessed using protein induced by vitamin K absence-II (PIVKA-II; ELISA). Prevalence of vitamin K deficiency was 54.0% in CD and 43.7% in UC. Vitamin K deficiency was more common in patients with higher CD activity, in CD patients with higher mass Z-scores, and less common among children with CD treated with infliximab. Relation of vitamin K deficiency to pediatric IBD clinical course and treatment demand further research.

Comparison of fecal pyruvate kinase isoform M2 and calprotectin in assessment of pediatric inflammatory bowel disease severity and activity

Accurate assessment of inflammatory bowel disease (IBD) activity is the cornerstone of effective therapy. Fecal M2 isoform of pyruvate kinase (M2-PK) and fecal calprotectin (FC) are noninvasive markers of mucosal inflammation in IBD. The aim of this study was to compare performance of M2-PK and FC in assessment of pediatric ulcerative colitis (UC) and Crohn's disease (CD) severity and activity. 121 patients with IBD, including 75 with UC and 46 with CD were recruited. Control group consisted of 35 healthy children (HS). Patients were assigned to groups depending on disease severity and activity. M2-PK and calprotectin concentration were determined in stool samples using ELISA. Areas under receiver operating characteristic curves (AUC) for FC and M2-PK with cut-off level at which M2-PK specificity was matching FC specificity were calculated and compared. Performance of M2-PK at identifying patients with IBD, UC and CD among HS was inferior to FC. The differences in AUC were respectively: -0.10 (95% confidence interval [CI] [-0.13-(-0.06)], p

Comparison of fecal pyruvate kinase isoform M2 and calprotectin in assessment of pediatric inflammatory bowel disease severity and activity

AIMS

Accurate assessment of inflammatory bowel disease (IBD) activity is the cornerstone of effective therapy. Fecal M2 isoform of pyruvate kinase (M2-PK) and fecal calprotectin (FC) are noninvasive markers of mucosal inflammation in IBD. The aim of this study was to compare performance of M2-PK and FC in assessment of pediatric ulcerative colitis (UC) and Crohn's disease (CD) severity and activity.

MATERIALS AND METHODS

121 patients with IBD, including 75 with UC and 46 with CD were recruited. Control group consisted of 35 healthy children (HS). Patients were assigned to groups depending on disease severity and activity. M2-PK and calprotectin concentration were determined in stool samples using ELISA. Areas under receiver operating characteristic curves (AUC) for FC and M2-PK with cut-off level at which M2-PK specificity was matching FC specificity were calculated and compared.

RESULTS

Performance of M2-PK at identifying patients with IBD, UC and CD among HS was inferior to FC. The differences in AUC were respectively: -0.10 (95% confidence interval [CI] [-0.13-(-0.06)], p<0.0001), -0.14 (95% CI [-0.19-(-0.09)], p<0.0001) and -0.03 (95% CI [-0.05-(-0.001)], p<0.02). M2-PK was inferior to FC in discriminating patients with mild UC from those with HS (AUC difference -0.23, 95% CI [-0.31-(-0.15)], p<0.0001).

CONCLUSIONS

FC reflects pediatric IBD severity and activity better than M2-PK. This difference is particularly pronounced when identifying patients with mild UC and UC in remission.

The Foker technique (FT) and Kimura advancement (KA) for the treatment of children with long-gap esophageal atresia (LGEA): lessons learned at two European centers

INTRODUCTION

We present the experiences from two European centers performing the Foker technique (FT) of esophageal lengthening by axial traction and the Kimura advancement (KA) method of lengthening the upper pouch by extrathoracic resiting a spit fistula (SF) in children with long-gap esophageal atresia (LGEA, gap length > 5 cm).

MATERIALS AND METHODS

A total of 15 children were treated (8 pure EA, 6 lower tracheoesophageal fistula [TEF], and 1 upper TEF). Gaps ranged from 5 to 14 cm. Nine children already had a SF. Patients were grouped according to the presence of a SF and the subsequent surgical strategy: Group A (no SF, n = 6) received FT on both pouches. Group B (with SF, n = 6) received KA of SF and FT of the lower pouch. Group C (with SF, n = 3) received closure of the SF and subsequent Foker traction (CSFT) on both pouches.

RESULTS

Group A: Primary repairs for all six children (mean age 3 months, gap length 6.5 cm) after a mean traction time of 3 weeks and a mean of 2.1 thoracotomies (range 2 to 3). Dilations were required in three out of six for anastomotic strictures with one perforation during the second dilation. Group B: All six children (mean age 16.4 months, gap length 9.5 cm) had a primary anastomosis, although for two it was significantly delayed (48 and 143 weeks traction time) because of infections. The number of thoracotomies ranged from 2 to 8 (mean 3.6). Leaks occurred in five out of six anastomoses (responsive to conservative management). Two children developed severe strictures, which required the anastomosis to be redone. In group C (mean age 10.6 months, gap length 6.5 cm), several major complications occurred. The three SF closures leaked (one iatrogenic) causing severe mediastinitis. CSFT was successful in only one case and the other two children had an esophageal replacement (stomach, jejunum). No deaths occurred in the series.

CONCLUSION

FT of both pouches (group A) resulted in primary repairs of all six LGEA patients. The combination of KA and FT (group B) resulted in an equivalent rate of primary repairs, but with an increased number of thoracotomies and rate of complications compared with group A. CSFT (group C) resulted in a high failure rate. More data are needed (we propose a multicenter registry) to elucidate the safety and efficacy of each elongation technique and to establish an algorithm with clearer inclusion and exclusion criteria.

The mRNA level of the transforming growth factor β1 gene, but not the amount of the gene product, can be considered as a potential prognostic parameter in inflammatory bowel diseases in children

PURPOSE

Transforming growth factor β1 (TGF-β1) plays a role in cell proliferation and differentiation, and it can modulate immune response. In this work, we asked whether levels of either TGF-β1 or mRNA of the corresponding gene in plasma or tissue can be useful in diagnosing and/or monitoring of the clinical course of inflammatory bowel diseases (IBD).

METHODS

The study group consisted of 104 pediatric patients with IBD: 36 with Crohn's disease (CD) and 68 with ulcerative colitis (UC); 42 children represented the control group. TGF-β1 levels in plasma and intestinal mucosa were estimated by ELISA and immunohistochemistry (IHC), respectively. Levels of TGF-β1 mRNA were determined by reverse transcription and real-time PCR.

RESULTS

In patients with IBD, and in subgroups with CD and UC, no significant differences in the TGF-β1 level in plasma and tissue were found relative to the control group. These variables were not dependent on the stage of the disease, its activity or severity of endoscopic and histopathological findings. TGF-β1 mRNA levels were significantly higher in tissue samples withdrawn during the relapse of the disease than in those taken during the remission or in the control group. However, no correlation between TGF-β1 plasma levels and TGF-β1 mRNA amount in the intestinal mucosa was observed.

CONCLUSIONS

The TGF-β1 mRNA level, but not the amount of the gene product, was significantly increased in the pathologically changed tissue during the relapse of IBD. We suggest that this parameter might be considered as a potential prognostic value when assessing IBD in children.

Immunohistochemical distribution of cocaine- and amphetamine-regulated transcript peptide - like immunoreactive (CART-LI) nerve fibers and various degree of co-localization with other neuronal factors in the circular muscle layer of human descending colon

Cocaine- and amphetamine-regulated transcript peptide (CART) is a neuromediator and/or neuromodulator in nerve structures within the gastrointestinal tract, but knowledge about its distribution, functions and co-localisation with other neuronal factors, especially in humans, is very scarce. During the present investigation the distribution and immunohistochemical reaction (IR) of CART - like immunoreactive (CART-LI) nerve fibers in the circular muscle layer of human descending colon were studied. Fragments of human colon were processed for double labelling immunofluorescence using a mixture of anti-CART antibodies with antibodies against vesicular acetylocholine transporter (VAChT), vasoactive intestinal polypeptide (VIP), pituitary adenylate cyclase - activating peptide (PACAP), substance P (SP), galanin (GAL) and nitric oxide synthase (NOS). Thick CART-LI nerve fibers formed a very dense meshwork within the colonic circular muscle layer in all patients studied. The highest number of CART - positive nerves also contained VAChT and/or VIP. A slightly lower level of co-localisation was observed in the case of CART and PACAP or CART and NOS. Only single nerve fibers were concurrently immunoreactive to CART and SP or CART and GAL. The present study reports for the first time a detailed description of the IR of CART-LI nerve fibers in the circular muscle layer within adult human descending colon.

Modern approach for determination of lactulose, mannitol and sucrose in human urine using HPLC-MS/MS for the studies of intestinal and upper digestive tract permeability

A new analytical procedure was described for the simultaneous determination of lactulose, mannitol and sucrose in urine, in which HILIC chromatography and tandem mass spectrometry detection are used. Sugars are orally administered for the estimation of intestinal permeability in children digestive tract. Samples were purified by dispersive solid phase extraction (d-SPE) using Amberlite MB150 resin. Raffinose was selected as an internal standard. The chosen chromatographic separation was carried out on ZIC(®)-HILIC column in 10 min at a flow rate of 0.3 mL/min, using mixture of acetonitrile (ACN) and ammonium acetate (NH(4)Ac) in water (H(2)O) as the mobile phase. Within-run precision (CV) measured at three concentrations was 1.08%, 0.32% and 0.49% for lactulose; 1.88%, 0.47% and 0.75% for mannitol, 2.95%, 1.31% and 0.6% for sucrose. Between-run CVs were 0.75%, 1.1% and 1.2% for lactulose; 1.1%, 1.02% and 1.01% for mannitol; 1.17%, 1.4% and 1.05% for sucrose. Analytical recovery of all three sugar probes was 95.06-99.92%. The detection limits were: 15.94 ng/mL for lactulose, 17.10 ng/mL for sucrose and 11.48 ng/mL for mannitol. The proposed method is rapid, simple, sensitive and suitable for the determination of intestinal permeability of the sugar derivatives in children.

Diagnosis and treatment difficulties in 18-year-old male patient with hereditary hemochromatosis, chronic hepatitis B, Gilbert syndrome and ulcerative colitis

Among possible causes of chronic hepatitis in adolescents most common are infections, autoimmune disorders and metabolic diseases. Thus, diagnostic procedures should be multidirectional. This study reports diagnosis and treatment difficulties in an 18-year-old male patient with hereditary hemochromatosis (HH), ulcerative colitis (UC), chronic hepatitis B (CHB) and Gilbert syndrome. The presented case illustrates problems in diagnostics related to the presence of numerous disease conditions in one patient. It should be taken into consideration that these diseases coexisting in one patient can mutually affect their symptoms creating specific diagnostic difficulties.

Diagnosis and treatment difficulties in 18-year-old male patient with hereditary hemochromatosis, chronic hepatitis B, Gilbert syndrome and ulcerative colitis

Among possible causes of chronic hepatitis in adolescents most common are infections, autoimmune disorders and metabolic diseases. Thus, diagnostic procedures should be multidirectional. This study reports diagnosis and treatment difficulties in an 18-year-old male patient with hereditary hemochromatosis (HH), ulcerative colitis (UC), chronic hepatitis B (CHB) and Gilbert syndrome. The presented case illustrates problems in diagnostics related to the presence of numerous disease conditions in one patient. It should be taken into consideration that these diseases coexisting in one patient can mutually affect their symptoms creating specific diagnostic difficulties.

Epidemiology of inflammatory bowel disease among children in Poland. A prospective, population-based, 2-year study, 2002-2004

BACKGROUND/AIMS

The incidence of pediatric inflammatory bowel disease (IBD) in Western countries is on the rise. No prospective studies have been conducted on the epidemiology of pediatric IBD in Poland. The aim of the study was to define the characteristics of new pediatric IBD and assess the incidence of new IBD among children in Poland between 2002 and 2004.

METHODS

Patient records from 24 pediatric gastroenterology centers servicing the whole population of Poland were collected. IBD diagnosis was based on clinical, radiological, endoscopic and histological features.

RESULTS

There were 491 new IBD patients, representing an overall incidence of IBD of 2.7 cases/100,000 children/year. The incidence of Crohn's disease (CD) was 0.6, ulcerative colitis (UC) 1.3, and indeterminate colitis (IC) 0.8. The age-related incidence of IBD was 1.8 in the 0- to 10-year-old age group, rising to 3.7 for the 11- to 18-year age group.

CONCLUSIONS

The overall incidence of IBD (as well as CD, UC and IC) in Poland is lower than that in Western countries. The relative contribution of UC and IC to the overall IBD incidence is higher in Poland than in most Western countries. These findings may suggest a tendency towards under- or misdiagnosis.

Helicobacter pylori increases expression of proapoptotic markers Fas and FasL on CD4 lymphocytes in children

The pathomechanism of Helicobacter pylori action upon gastric mucosa and its role in the pathogenesis of gastritis have not been fully elucidated. The aim of this study was to evaluate the most prevalent lymphocyte subpopulations of the gastric mucosa in gastritis in children, as well as to evaluate the expression of Fas and Fas ligand receptors (FasL), periapoptotic markers of gastric mucosa lymphocytes before and after H. pylori eradication. Forty nine patients aged 6 to 17 years, investigated due to chronic abdominal pain, were studied. The obtained tissue samples were analysed by immunohistochemistry. Different lymphocyte subsets were quantified on the basis of surface antigen expression (CD3, CD4, CD8, CD20), secreted cytokines (IL-4, IL-6, IFNgamma) and Fas and FasL proteins in the gastric mucosa. B and T helper lymphocytes were found to play a major role in the inflammatory infiltration in the gastric mucosa in children during H. pylori infection. Their expression was found to decrease after eradication. The enhanced expression of Fas receptor on lymphocytes before treatment and a decrease of this expression after eradication of H. pylori were shown. It was demonstrated that there is a correlation between CD4 and Fas receptor expression that may induce apoptosis of the helper lymphocytes in infected children.

Helicobacter pylori increases expression of proapoptotic markers Fas and FasL on CD4 lymphocytes in children

The pathomechanism of Helicobacter pylori action upon gastric mucosa and its role in the pathogenesis of gastritis have not been fully elucidated. The aim of this study was to evaluate the most prevalent lymphocyte subpopulations of the gastric mucosa in gastritis in children, as well as to evaluate the expression of Fas and Fas ligand receptors (FasL), periapoptotic markers of gastric mucosa lymphocytes before and after H. pylori eradication. Forty nine patients aged 6 to 17 years, investigated due to chronic abdominal pain, were studied. The obtained tissue samples were analysed by immunohistochemistry. Different lymphocyte subsets were quantified on the basis of surface antigen expression (CD3, CD4, CD8, CD20), secreted cytokines (IL-4, IL-6, IFNgamma) and Fas and FasL proteins in the gastric mucosa. B and T helper lymphocytes were found to play a major role in the inflammatory infiltration in the gastric mucosa in children during H. pylori infection. Their expression was found to decrease after eradication. The enhanced expression of Fas receptor on lymphocytes before treatment and a decrease of this expression after eradication of H. pylori were shown. It was demonstrated that there is a correlation between CD4 and Fas receptor expression that may induce apoptosis of the helper lymphocytes in infected children.

[Posterior gastric wall ulceration as a complication of percutaneous endoscopic gastrostomy. A report of 2 cases]

Two cases of posterior gastric wall ulceration are presented as a rare complication of percutaneous endoscopic gastrostomy (PEG). Percutaneous endoscopic gastrostomy (Flocare, Nutricia) was performed in two boys (aged 2 and 19 months), who were unable to take necessary nutrients by mouth due to neurological disorders concerning swallowing and deficiency of body mass. This status does not allow to cover liquid and caloric requirement. In one case bleeding occurred 12 days after PEG insertion, in the second--6 weeks after PEG insertion. Both patients were treated with parenteral nutrition and omeprazol intravenously, with good result. The described complications are rare, however, the proton pomp inhibitors application in prevention should be considered.

[Dysphagia and gastroesophageal reflux in children with oesophageal atresia with tracheo-oesophageal fistula after succesful surgery treatment. Own observations]

BACKGROUND

current succesful surgery of oesophageal atresia with tracheo-oesophageal fistula leads to increased survival of the affected newborns Hence late complications of the defect itself or those due to surgical methods occur more often.

AIM OF THE STUDY

was to establish on the base of own observations, the frequency of swallowing problems, gastro-esophageal reflux and oesophagitis after successful surgery of oesophageal atresia.

MATERIAL AND METHODS

we investigated 17 patients after successful surgery of oesophageal atresia and tracheo-oesophageal fistula, performed during the first days of life, in the Department of Paediatric Surgery, Medical University of Gdańsk (chief prof Czesław Stoba). These patients were diagnosed and treated in the Department of Paediatrics, Paediatric Gastroenterology and Oncology, Medical University of Gdańsk, during 2005-2006. There were 10 boys and 7 girls, aged from 4 to 14 years (in the - years 2005-2006). In all children, besides obtaining the detailed history concerning dyspeptic symptoms and dysphagia, upper alimentary tract endoscopy, oesophagography and pH-metric examinations were performed

RESULTS

gastroesopghageal reflux (GER) was diagnosed in 41.2%, and oesophagitis, by endoscopic examination, in. 17.7% of patients. Disturbed oesophageal motility on radiography was observed in 88.2% of children.

CONCLUSIONS

despite the high frequency of gastroesopghageal reflux among this group of patients, their health condition was good, dysphagia and the intensity of the oesophagitis were mild. But it should be remembered that prolonged gastroesopghageal reflux may cause serious complications.

[Inflammatory bowel disease in children--an analysis of the clinical symptoms and selected biochemical parameters]

AIM OF THE STUDY

an analysis of clinical symptoms and laboratory tests in children with inflammatory bowel disease (IBD).

PATIENTS AND METHODS

eighty-nine children with IBD (58 with ulcerative colitis (UC) and 31 with Crohn's disease (CD) diagnosed on the basis of clinical symptoms, endoscopic and histopathological examination, were qualified into the studied group. Disease activity was evaluated by using Truelowe-Witts scale for UC and PCDA9 scale for CD cases. Forty-two children without acute or chronic inflammatory diseases constituted the control group.

RESULTS

the frequency of such clinical symptoms as: diarrhea, fever, weight loss, abdominal pain, weakness, constipations, anemia, joints pain, vomits, and jaundice was comparable in children with UC and CD while intestinal bleeding was significantly more frequently observed in patients with UC than with CD (P<0.05). There was no statistically significant difference in BMI between patients with UC and CD. Cole's index was significantly higher in children with UC than with CD (P<0.05). Hemoglobin level and serum iron level were statistically significantly lower in patients with CD than in the control group (P<0.05). Mean leukocyte count in children with CD was significantly higher than in the control group (P<0.05). Neutrophils percentage in patients with UC and CD was significantly higher than in the control group (P<0.05). Platelet count was significantly higher in all children with IBD than in the control group (P<0.05). Mean serum CRP level was significantly higher only in children with CD while ESR was significantly higher in both groups of IBD patients. Mean serum gamma-globulin level was statistically significantly higher in children with UC and with CD but no significant differences were observed in serum IgA, IgG, and IgM levels among the analyzed groups. Serum GT level was higher in children with CD than in the control group while serum ALT and AST level did not differ significantly among the analyzed groups of patients.

CONCLUSIONS

1. Serum C-reactive protein level is one of the most valuable markers for monitoring the course of IBD, especially CD, in children. 2. In patients with IBD systematic monitoring of liver function parameters (especially parameters of cholestasis) is necessary as severe hepatic complications may occur. 3. Further search for new sensitive and specific markers monitoring the course of inflammatory bowel diseases is needed.

[The role of sulphate reducing bacteria in inflammatory bowel disease. A review]

The aetiology of inflammatory bowel disease is still unkown. Sulphate reducing bacteria are a probable factor. Researchers are concerned with complicated relations between the colonic flora species and colonocytes, also with influence of pharmacotherapy and of the diet. The aim of those efforts is to get to know the pathomechanism and to improve the treatment of inflammatory bowel disease.

[Analysis of enteral nervous system in children with drug resistant ulcerative colitis]

INTRODUCTION

pathogenesis of inflammatory bowel diseases has been intensively investigated for many years. The role of enteric nervous system (ENS) and neuroprotective transmitters such as galanine (GAL), vasoactive intestinal peptide (VIP) and pituitary adenosine cyclase activating peptide (PACAP) has been underlined recently. Neuroprotective transmitters play a role in the regulation of intestinal contractions, ion transport in the intestinal epithelium and modulation of the proinflammatory cytokine production, which may result in diminuation of inflammation.

AIM OF THE STUDY

was to investigate activity of ENS in children with drug resistant ulcerative colitis measured by the density of GAL, VIP and/or PACAP containing nervous fibres in mucosal membrane in course of pharmacological treatment and 12 months after colectomy.

MATERIAL AND METHODS

16 children were included in the study. Group I consisted of 7 children with drug resistant ulcerative colitis. Mucosal biopsy specimen was taken twice: colonoscopy before colectomy during (12 months earlier on average) and from resected colon. Group II (reference group) consisted of 9 children with excluded inflammatory bowel diseases based on colonoscopy and biopsy mucosal specimen assessment. Histology and immunochemistry of mucosal samples were analysed.

RESULTS

decreased density of GAL, VIP and/or PACAP containing nervous fibres in colon mucosal membrane of children with ulcerative colitis was found: GAL-IR (3.5 +/- 3.15), VIP-IR (19.7 +/- 2.7), PACAP-IR (6.3+/-2.52) as compared to the reference group: GAL-IR (11.2+/-5.58), VIP-IR (36.1 +/- 16.0) and PACAP-IR (15.7 +/- 9.95). Significant diminuation of the density of GAL, VIP and/or PACAP containing nervous fibres was found in the study.

CONCLUSION

1. The density of VIP, PACAP and GAL containing nerve fibres diminishes in the course of ulcerative colitis, which may be a result of progressive degradation of colon mucosal membrane. 2. The hypothesis that absence of chemotaxis inhibition by low levels of neuroprotective transmitters might be a reason for drug resistance in ulcerative colitis.

[Tryptase activity in colon mucosal samples of children with inflammatory bowel disease]

INTRODUCTION

mast cells are dispersed in many tissues, especially in the digestive and respiratory system mucosal membranes. Tryptase is the most important proteinase released from mast cells after degranulation. It influences strongly the cells and tissues by activating the inflammatory process.

THE AIM OF THE STUDY

was to assess the activity of tryptase in colon mucosa samples in children with inflammatory bowel diseases (IBD) and in children with bleedings from lower part of gastrointestinal tract (GTB), without inflammation.

MATERIAL AND METHODS

a group of 30 children with IBD was analyzed in the study. IBD is formed by three disease entities: ulcerative colitis (UC) - 14 patients, Crohn's disease (CD) - 9 patients and non-specific colitis (NSC) - 7 patients. Moreover, a group of 18 children with bleeding from lower part of gastrointestinal tract was studied. The activity of tryptase in homogenates of colon mucosal samples was estimated fluoroimmunoenzymatically.

RESULTS

the results of our analysis showed no statistically important difference between the mean activity of tryptase in groups of children with IBD and GTB (31442 +/- 1304 vs 31868 +/- 775 ug/l). The study of tryptase activities in different disease entities of IBD group showed, that its value in ulcerative colitis group was 31382 +/- 1170 ug/l, in Crohn's disease group it was 31536 +/- 1120 ug/l; in non-specific colitis group the tryptase activity was 32277 +/- 498 ug/l. The analysis with Kruskal-Wallis Anova test revealed that the differences are statistically significant (p = 0.034). In post hoc test the outstanding value is the tryptase activity in children with NSC. Activity of tryptase in colon in much higher than its activity in plasma (normal range 1-19 ug/l).

CONCLUSIONS

the activity of tryptase in mucosal membrane samples is much higher than in blood. The extent of mast cells degranulation may be dependent on the form of IBD.

[Changes in the number of neuroprotective transmitter containing mucosal nerve fibres in children with ulcerative colitis]

INTRODUCTION

Ulcerative colitis and Crohn's disease are two main disease entities that belong to the group of inflammatory bowel diseases (IBD). Chronic inflammatory process concerning intestinal mucosal membrane causes structural and functional changes of intestinal nervous system. This phenomenon is called the plasticity of the nervous system and is due to the ability of nerve cells to adapt to changing environmental conditions. The resulting alterations of intestinal neurons' chemical code are augmentation, inhibition or initiation of the neurotransmitters' synthesis (synthesis "de novo"). The role of neuroprotective transmitters - galanine (GAL), vasoactive intestinal peptide (VIP) and pituitary adenosine cyclase activating peptide (PACAP) seems to be important in the pathogenesis of inflammatory bowel diseases. They are responsible for the regulation of intestinal contraction and modification of ions' transport in the intestinal epithelium. They also diminuate the inflammation by modulation of the proinflammatory chemokines and cytokines production.

THE AIM

of the study was to analyse the changes in the nerve fibres' containing GAL, VIP and/or PACAP, density in the mucosal membrane of children with ulcerative colitis (UC) with different Clinical activity index.

MATERIAL AND METHODS

the study included 33 children hospitalised due to UC with different activity and 9 children in the control group, after exclusion of IBD. All the studied patients underwent colonoscopic examination with colon mucosa biopsies. Histology and immunochemistry of mucosal samples were analysed. Those studies helped to assess the changes in the number of nerve fibres containing analysed transmitter substances in the mucosal membrane of the colon.

RESULTS

the results showed a statistically significant diminuation of nerve fibres containing analysed neurotransmitters number in colon mucosa samples of children with UC. There were no statistically significant changes in number of nerve fibres dependent on the clinical activity index of UC.

CONCLUSIONS

the process of degradation present in UC is accompanied by the important diminuation on neurotransmitter containing fibres number. However, their density is not dependent of the clinical activity of the disease.

[The case of gastric and ileal bezoar in a 3 year old boy]

The authors report a case of a 3-year-old boy with a gastric and ileal bezoar, in whom severe anaemia and tumor in the epigastrium were the main symptoms. Bezoars are rare foreign bodies of the gut. They contain swallowed hair, different fibres, seeds, nutshells, sweets or drugs. The group of risk factors for bezoar formation includes anatomical defects, motoric disorders of the digestive tract, type of prescribed drugs and other coexisting chronic diseases. Most cases need surgical treatment.

[Bone mineral density in inflammatory bowel diseases in children]

OBJECTIVE

determination of bone mineral density in children treated because of inflammatory bowel diseases.

MATERIAL AND METHODS

42 patients were included: 21 with ulcerative colitis and 21 with Crohn's disease. The duration of illness was from 2.0-24.0 months. Glucocorticoid therapy was applied in 92.9% of patients with the duration from 4-1680 days. The cumulative doses of glucocorticoids were from 160 to 25900 mg. Bone mineral density (BMD) and z-score of L1-L4 were assessed by dual-energy X-ray absorptiometry (DEXA). The mean BMD of L1-L4 were measured in g/cm2 and compared with referential values for gender and age. Osteopenia (ope) mean z-score from -1 to -2 SD, osteoporosis (opo) < -2 SD were accepted.

RESULTS

BMD values varied from 0.531 to 1.301 g/cm. Z-score values varied from 0.9 to -5.6 SD. Bone mineral disturbances occurred in 57.2% of cases and it was equally both in 28.6% of cases osteoporosis and osteopenia. In ulcerative colitis osteopenia was predominant (23.8%), while in Crohn's disease osteoporosis occurred more often (23.8%). There was no significance in the duration time of the disease and BMD and z-score. The significant difference was found in the duration of steroid therapy and z-score. No association was found among cumulative dose of steroids and z-score. No significant differences were found in BMD and z-score of lumbar spine in ulcerative colitis and Crohn's disease.

CONCLUSIONS

1. Bone mineral disturbances often complicate inflammatory bowel diseases in children. 2. The association among the duration time of steroid therapy and bone mineral density was confirmed. 3. No significant differences were found in bone mineral density among colitis ulcerasa and Crohn's disease cases.

[Undernutrition in hospitalised children. Part I]

THE AIM OF THE STUDY

Determination of the incidence of undernutrition among children on admission to hospital.

MATERIAL AND METHODS

In 818 patients aged l week to 20 years admitted to Paediatric Department from January to May 2004, the height and body mass was recorded and body mass index (BMI) was calculated. The incidence of undernutrition in this population was calculated.

RESULTS

Body mass below 10th percentile was found in 158 children (19.3%). including 96 with body mass <3 percentile. Undernutrition was more frequent in children below 5 year of age (22.16%) than in the older ones (16.74%).

CONCLUSIONS

Undernutrition among children admitted to hospital is relatively frequent and can make treatment more difficult and expensive.

[Environmental factors in the etiopathology of inflammatory bowel syndrome]

Inflammatory bowel syndrome (IBS) mainly includes ulcerative colitis (UC) and Crohn's disease (CD). UC and CD are chronic and recurrent conditions, with a tendency to exacerbations and remissions. The incidence of diseases worldwide has increased over the last years. Although the etiology of inflammatory bowel syndrome has been studied intensively it still remains unclear. The development and persistence of inflammation is an effect of numerous factors: proinflammatory (aggressive), regulating bowel mucosa homeostasis and protective factors. Proinflammatory factors include intestinal bacteria, bile acids, digestive enzymes, lipopolysaccharides and peptidoglycans. Protective mechanisms are impermeability of mucosa barrier, presence of intestinal mucus, activity of secretive immunoglobulins, some prostaglandins and interleukins, glutamine, somatostatin, cortisol and short-chain fatty acids. Factors modifying intestinal mucosa homeostasis consist of genetically determined immunoregulators and activity of intestinal mucosa barrier and some environmental factors (diet, smoking, infections, stress, antibiotics and others). Environmental factors are jointly responsible for IBS occurrence in case of genetically determined dysregulation leading to proinflammatory cytokines overproduction or disturbances in synthesis of cytokines regulating intestinal mucosa homeostasis.

The influence of experimental Bacteroides fragilis infection on substance P and somatostatin-immunoreactive neural elements in the porcine ascending colon - a preliminary report

The present study was aimed at disclosing the influence of Bacteroides fragilis (one of the most important bacterial agents causing colitis in children) experimental infection on the expression of substance P (SP) and somatostatin (SOM) in neurons and nerve fibres within the porcine ascending colon. Distinct differences in the distribution pattern of neural elements immunoreactive to the substances studied were observed between the experimental (Inflam) and control (Contr) pigs. In general, the number of SP-IR neurons and nerve terminals increased, while the expression of SOM decreased after Bacteroides fragilis-induced colitis (BFIC). However, distinct differences in the intensity of these alterations were observed between particular compartments of the bowel segment studied. Thus, the present results suggest that SP- and SOM-immunoreactive (SOM-IR) elements of the enteric nervous system play a part in the control of colonic activity during BFIC.

Relations between Leu(5)-enkephalin- (LENK) and VIP-immunoreactive nerve fibres during human drug-resistant colitis. A case study

The double immunofluorescence technique was used to examine the distribution and interrelationship between LENK- and VIP-immunoreactive nerve fibres within the muscle layer and myenteric plexus of the large intestine in a young female patient (aged 17 years) suffering from colitis ulcerosa activa (CUA). As the CUA was found to be totally drug-resistant, a pancolotomy was performed by means of the Soave technique. Varicose nerve fibres, immunoreactive either to LENK or VIP, but not to both substances simultaneously, were found in all fragments of the bowel studied. A striking feature was their distribution pattern within the studied layers. In all cases LENK-IR fibres were closely accompanied by VIP-IR terminals. The density of the examined fibres depended on the bowel fragment studied, and was the greatest in the sigmoid colon, descending colon and rectum, while the lowest number was found in the caecum. The results of the present study may thus be indicative for the involvement of LENK- and VIPIR nerve fibres in the control of bowel functions during CUA, possibly on the basis of a "cross-talk" between terminals running in close vicinity to each other.

[Adhesion lysis and removal of an intraperitoneal contraceptive device by celioscopy]

The intra-peritoneal location of an I.U.D. immediately after its insertion is not an unusual situation. In the context of a case of immediate migration followed by intra-uterine pregnancy, which was dealt with by diagnostic coelio-surgery and therapeutic coelio-surgery, we suggest a diagnostic and therapeutic sequence. The incidence of uterine perforation decreases with the experience of the operator. The diagnosis is clinical, ultrasonic, radiological and coelioscopic. Coelioscopic diagnosis makes it possible to choose the method of treatment. Coeliosurgery is feasible in virtually all cases. In experienced hands, this method is rapid, the hospitalization required short and the sequelae simple.