Association between tracheal pepsin, a reliable marker of gastric aspiration, and head of bed elevation among ventilated neonates

OBJECTIVES

To determine the frequency of tracheal pepsin in ventilated neonates and whether the angle of head elevation was associated with tracheal pepsin.

STUDY DESIGN

Serial trachael samples (at 3, 7, 14, 21 and 28 days of ventilation) were obtained from intubated, ventilated very low birth weight infants. Presence of tracheal pepsin was determined by Western blot analysis using a specific anti-human pepsin antibody.

RESULTS

Tracheal pepsin was detected in 35/66 (53%) of the ventilated neonates (birthweight: 798 ± 268 grams [mean ± standard deviation]). Neonates whose head elevation was in the upper quartile (≥14 degrees) during the first sampling time (day 3) were less likely (4/16 vs 9/10, P = 0.0013) to have tracheal pepsin when compared to neonates whose head elevation was in the lowest quartile (≤8 degrees).

CONCLUSIONS

Pepsin, a marker for gastric secretion aspiration, was detected in 53% of ventilated low birth weight neonates; early elevation of the head of the bed was associated with a lower rate of tracheal pepsin.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

The prevalence and clinical characteristics of celiac disease in juvenile diabetes in Wisconsin

BACKGROUND

The relationship between celiac disease and juvenile diabetes has long been known. Only a single study in the United States, from Buffalo, New York, has reported the prevalence of celiac disease in a pediatric diabetic population. This study was conducted to determine the prevalence and clinical presentation of celiac disease in children and adolescents with juvenile diabetes in Wisconsin, USA, using serum antiendomysial antibody as a screening test.

METHODS

Two hundred eighteen patients with diabetes (113 males; age range, 4-21 years) and 117 age-and gender-matched control participants were tested for immunoglobulin A endomysial antibody. Patients with positive results were offered a small bowel biopsy. A questionnaire regarding abdominal pain, diarrhea, and growth failure was completed by the parents.

RESULTS

Seventeen of 218 diabetic patients (7.7%) had positive endomysial antibody. All control participants had negative results for the endomysial antibody. Small bowel biopsy was performed in 14 patients. Ten patients had villous atrophy. In one patient without villous atrophy, a repeat biopsy 2 years later showed villous atrophy, and two patients had increased intraepithelial lymphocytes without villous atrophy. Seventy percent of the patients with celiac disease were asymptomatic. The reported symptoms were abdominal pain and diarrhea (n = 1) and growth failure (n = 2). Two patients with celiac disease had Down syndrome.

CONCLUSIONS

The prevalence of celiac disease in children with juvenile diabetes in Wisconsin is at least 4.6%, which is comparable with European and Canadian studies. Because patients without villous atrophy may have latent celiac disease, the prevalence may be even higher. All children with juvenile diabetes should be screened for celiac disease.

Percutaneous colonoscopic cecostomy for management of chronic constipation in children

BACKGROUND

Chronic constipation and encopresis are common problems in children with spina bifida and anorectal anomalies. Commonly used therapies include complicated bowel regimens and antegrade continence enemas delivered via surgically placed appendicostomies and radiologically placed cecostomies.

METHODS

A technique is described for percutaneous placement of cecostomies for the delivery of continence enemas or venting.

RESULTS

Percutaneous cecostomies were placed in 12 patients. Improvement in bowel management occurred in all patients.

CONCLUSIONS

Percutaneous endoscopic cecostomy is a safe and effective method for the treatment of intractable constipation.

Oral tacrolimus treatment of severe colitis in children

OBJECTIVE

To evaluate the efficacy of oral tacrolimus as an induction agent in steroid-refractory severe colitis.

STUDY DESIGN

Open-label, multicenter trial of oral tacrolimus in patients with severe colitis. Patients not responding to conventional therapy received tacrolimus, 0.1 mg/kg/dose given twice a day, and the dosage was adjusted to achieve blood levels between 10 and 15 ng/mL. Response was defined as improvement in a number of clinical parameters (including abdominal pain, diarrhea, rectal bleeding, and cessation of transfusions). Patients who responded by 14 days continued to receive tacrolimus, and 6-mercaptopurine or azathioprine was added as a steroid-sparing agent 4 to 6 weeks after the tacrolimus was instituted.

RESULTS

Fourteen patients were enrolled in the study. One patient elected to withdraw after 48 hours. Of the 13 remaining, 9 (69%) responded and were discharged. Tacrolimus was continued for 2 to 3 months in the responders, except for 1 patient who was given tacrolimus for 11 months. After 1 year of follow-up, only 5 (38%) patients were receiving maintenance therapy; the other 4 responders had undergone colectomy.

CONCLUSION

Although tacrolimus is effective induction therapy for severe ulcerative or Crohn's colitis, fewer than 50% of patients treated will successfully achieve a long-term remission.

Prolonged duration of response to infliximab in early but not late pediatric Crohn's disease

OBJECTIVES

Tumor necrosis factor-alpha plays a central role in chronic intestinal inflammation of Crohn's disease. Targeting this cytokine with the chimeric monoclonal antibody infliximab has emerged as an effective form of therapy in adult Crohn's disease patients. We sought to determine whether infliximab treatment would benefit pediatric patients with medically refractory Crohn's disease. We also assessed the duration of response, comparing children with early disease to children with long-standing (late) Crohn's disease.

METHODS

Fifteen consecutive children (mean age 12.8 +/- 3.2 yr) with medically refractory Crohn's disease were enrolled in a prospective, open-label trial of a single, 5-mg/kg infliximab intravenous infusion. Medically refractory disease was defined as an inability to taper steroids, lack of response to immunomodulator therapy over 4 months, and active disease as measured by the Pediatric Crohn's Disease Activity Index (PCDAI). Primary endpoints included measurements of disease activity (PCDAI), steroid use, and duration of clinical response.

RESULTS

In all, 14/15 children (94%) improved after infliximab infusion, with a significant decrease of both PCDAI and daily steroid use by 4 wk. Ten patients (67%) achieved complete remission by 10 wk. Among the 14 patients who responded, three of six children (50%) with early disease maintained clinical response through the 12-month trial period, compared to none of eight children with late disease. There were no serious complications associated with the use of infliximab in any of the patients.

CONCLUSIONS

Infliximab is safe and effective in the short-term treatment of medically refractory pediatric Crohn's disease. More importantly, there is a remarkably prolonged duration of response after infliximab therapy in children with early compared to late Crohn's disease.

Esophageal biopsy does not predict clinical outcome after percutaneous endoscopic gastrostomy in children

Clinically symptomatic gastroesophageal reflux may occur after percutaneous endoscopic gastrostomy (PEG). Preoperative evaluation for gastroesophageal reflux does not reliably predict those individuals who will develop reflux unresponsive to medical management after PEG. Esophageal histology at the time of PEG might be used to identify patients at risk for developing intractable gastroesophageal reflux. The study aim was to correlate the clinical outcome after PEG with esophageal histology at the time of PEG insertion. A retrospective review of 68 consecutive children who had an esophageal biopsy obtained at the time of PEG insertion was undertaken. Preoperative evaluation, esophageal histology, and clinical outcomes were compared. Preoperative gastroesophageal reflux was present in 23% of upper gastrointestinal series performed, in 10% of pH probe studies, and in 29% of reflux scans. Histology was normal in 57% of esophageal biopsies obtained at the time of PEG insertion. Symptomatic gastroesophageal reflux requiring antireflux surgery or conversion to gastrojejunostomy developed in 10% of patients after PEG placement. Only one of these patients had esophagitis on biopsy. In conclusion, preoperative esophageal histology does not reliably predict the development of symptomatic gastroesophageal reflux after PEG placement.

Presenting symptoms and diagnostic lag in children with inflammatory bowel disease

Presenting symptoms and their duration may affect the time that elapses prior to definitive diagnosis of inflammatory bowel disease (IBD). This study was undertaken to determine the mean duration of presenting symptoms and diagnostic lag in children with IBD. The medical records of all patients less than 19 years of age diagnosed with IBD at the pediatric gastroenterology clinic of Children's Hospital of Wisconsin between 1990-1995 were reviewed. The age at diagnosis, gender, presenting symptoms and duration, disease location, and diagnostic lag were analyzed. There were 91 children (49 male) diagnosed with IBD. Crohn's disease (CD) was diagnosed in 58, ulcerative colitis (UC) in 24, and indeterminate colitis in 9. The mean ages at diagnosis were 11.4 years for CD, 9.7 years for UC, and 7.8 years for indeterminate colitis. The most frequent presenting symptoms were abdominal pain, diarrhea, hematochezia, and weight loss. The average lag in diagnosis of CD was 7.1 months, which varied by disease location: small intestine 10.5 months, ileocolonic 7.5 months, and colonic 6.4 months. The average lag in diagnosis was 6.7 months for UC and 14 months for indeterminate colitis. Children presenting with growth failure had the longest diagnostic lag. (a) The elapsed time between symptom onset and the diagnosis of CD has decreased. (b) The diagnostic lag in CD decreases with distal colonic involvement. (c) Following onset of symptoms UC was diagnosed only slightly more rapidly than CD.

Colonic motility in children with repaired imperforate anus

Following surgical correction of imperforate anus, voluntary bowel control is frequently poor because of abnormal anorectal function. Using colonic manometry we investigated the role of colonic motility in the pathogenesis of fecal soiling in children following imperforate anus repair. Thirteen children with repaired imperforate anus and fecal soiling underwent motility testing 2-12 years after anoplasty. All had fecal incontinence unresponsive to conventional medical treatment. Colonic manometry was performed using water-perfused catheters. Anorectal manometry was undertaken in 10 patients. Motility study results, treatment and outcomes were compared. All patients had high-amplitude propagating contractions (HAPCs) with an average of 80% propagation into the neorectum. There was no correlation between HAPC number or morphology and any variable. Internal anal sphincter resting pressure was low in 6/10 patients. Relaxation of the internal anal sphincter was present in 6/10 children. Only 1 of 5 patients able to cooperate was capable of generating a normal maximal squeeze pressure. Therapeutic regimens were changed in 11 patients with clinical improvement in five. Fecal soiling in patients with repaired imperforate anus is a multifactorial problem including propagation of excessive numbers of HAPCs into the neorectum as well as internal anal sphincter dysfunction. Colonic manometry in conjunction with anorectal manometry aids in the understanding of the pathophysiology of fecal soiling and guides clinical management in children with repaired imperforate anus.

Electrogastrography in gastrostomy-tube-fed children

Following gastrostomy tube placement some children develop gagging, retching, vomiting, pain, or irritability during feedings. Conventional medical management is not always successful. It is possible that intolerance of gastrostomy tube feedings reflects an underlying motility disorder of the foregut. The study aim was to determine whether children with gastrostomy tube feeding difficulties demonstrate abnormal gastric electrical control activity as measured by electrogastrography. Cutaneous electrogastrography of interpretable quality was performed in 25 feeding-tolerant and 23 feeding-intolerant children less than 10 years of age. Dominant frequencies, rhythm indices, and postprandial power measurements were recorded during the fasting and postprandial periods. Differences between groups were compared using the Student's t test. The groups were similar in method of gastrostomy tube placement, antireflux surgery, neurological impairment, duration of gastrostomy feeding dependence, formula type, volume, and administration. The feeding-tolerant group was significantly older (P<0.01). There were no significant differences between groups in the mean dominant frequencies or rhythm indices. The feeding-intolerant children had a mean postprandial power change that was significantly lower than that of the feeding tolerant group (P<0.003), although overlap was present. Children who are intolerant of gastrostomy tube feeding have an abnormal postprandial power decrease. EGG dominant frequency and rhythm indices are not predictive of gastrostomy feeding tolerance in predominantly neurologically impaired children.

Disorders of the pancreas in children

In the past year, major advances in understanding pancreatic disease have been made through the tools of molecular biology. Genes responsible for both hereditary pancreatitis and pancreatic agenesis have been identified. The first description of magnetic resonance cholangiopancreatography, a new noninvasive imaging study of the pancreatobiliary tree, was reported in children. Reviews of autoimmune pancreatitis, a newly described condition, pancreatitis in inflammatory bowel disease, tropical pancreatitis, and pancreatitis following liver transplantation were also published, as well as surgical and endoscopic therapy of pancreatitis.

Hyperammonemic encephalopathy after chemotherapy. Survival after treatment with sodium benzoate and sodium phenylacetate

A 16-year-old boy had hyperammonemia and encephalopathy develop after high-dose chemotherapy for acute lymphoblastic leukemia. He was treated successfully with the ammonia-trapping agents sodium benzoate and sodium phenylacetate.

Hepatocellular injury in Streptococcus pneumoniae-associated hemolytic uremic syndrome in children

Streptococcus pneumoniae is an uncommon etiological organism in hemolytic uremic syndrome (HUS). Production of neuraminidase by S. pneumoniae results in exposure of red blood cell T-antigen, resulting in hemolysis, thrombocytopenia, and acute renal failure. Hepatic involvement in this form of HUS has not been described in the literature. We report in three children with S. pneumoniae-associated HUS the presence of severely elevated transaminases and conjugated hyperbilirubinemia. Increases in asparagine transaminase ranged from 11 to 46 times normal values and an increase in alanine transaminase ranged from 1.6 to 8 times normal. In all patients the rise in total bilirubin was 7-15 times normal. Biliary tree obstruction and viral causes for liver dysfunction were absent. Hepatocellular injury in S. pneumoniae-associated HUS likely results from mechanisms involved in sepsis and pneumonia-induced jaundice, combined with severely increased bilirubin production following massive hemolysis. The hepatic injury in all three patients resolved within 9, 5, and 10 days. Our experience suggests that an extensive evaluation including liver biopsy is not indicated.

The induction of hepatic cytochrome P450 3A in rats: effects of age

Liver microsomal cytochrome P450 3A (CYP3A) concentrations were evaluated by Western blots using specific antisera. Low levels of CYP3A protein were found in untreated animals. Dexamethasone (DX) treatment resulted in a significant induction of CYP3A. The induction was dose and time dependent. Addition of U486 (a specific type II glucocorticoid receptor antagonist), but not spironolactone (a specific type I receptor antagonist) blocked the induction of CYP3A proteins by dexamethasone, suggesting a receptor-mediated mechanism. Concomitant administration of either actinomycin D or cyclohexamide, together with dexamethasone completely abolished the induction of CYP3A protein by dexamethasone, suggesting the requirement of both protein and RNA synthesis. A comparison of the inducibility of CYP3A protein by dexamethasone in rats from different age groups showed that the degree of increase was higher in the younger than in the older groups (e.g., 5 days versus adult). Thus, there is an attenuation in the responsiveness to dexamethasone induction of CYP3A proteins with age. Evaluation of the steady-state levels of CYP3A mRNA by Northern blots showed increases in mRNA following DX treatment in both young and old rats. The final level of CYP3A mRNA reached after DX treatment was higher in the pups than that found in similarly treated older rats. This decrease in responsiveness in older animals appeared to manifest at least in part of the pretranslational level.

Proximal pH-metry for diagnosis of upper airway complications of gastroesophageal reflux

Otolaryngologic complications of gastroesophageal reflux (GER) are well described in adults, but this relationship has not been as carefully studied in children. We reviewed 26 dual pH-probe studies performed on 22 children with upper airway symptoms. The proximal probe was placed in the nasopharynx or hypopharynx. The distal probe was placed in the mid-proximal oesophagus. The proximal recording was considered normal if no episodes of pH < 4 were recorded. Indications for the studies were upper airway obstruction (UAO) and congenital choanal atresia (CCA). The age range was from 2 weeks to 47 months. The distal pH probe study was normal in 13 of 22 patients overall. Seventeen UAO patients had abnormal proximal pH probe studies. After treatment, 16 of 17 had improved airways. Twelve with UAO (67%) were premature and/or had developmental delay. Three CCA patients had abnormal proximal pH-probe studies and all improved after treatment. Four follow-up pH studies were normal or improved. GER-induced UAO is more frequent in infants or children with a history of prematurity or developmental delay. Proximal pH-metry is a useful technique to document the relationship between upper airway symptoms and GER. Patients with GER-induced UAO should undergo endoscopy to rule out simultaneous airway lesions.

Treatment of central venous catheter occlusions with ethanol and hydrochloric acid

BACKGROUND

Occluded central venous lines (CVLs) is a major problem in pediatric patients.

METHODS

To relieve obstructed catheters, infusions of ethanol (up to 3 mL of a 70% solution) for presumed lipid occlusions and hydrochloric acid (HCl, 0.1 N, up to 3 mL) for presumed mineral and drug precipitates were given in an attempt to relieve obstructed catheters.

RESULTS

Patency was restored in 34 of 39 occluded catheters over an 18-month period.

CONCLUSIONS

Clearing occluded CVLs with ethanol and HCl is not only beneficial to the patient but also offers considerable cost savings compared to CVL replacement.

Serious bacterial illnesses in recently hospitalized young infants

We undertook a retrospective chart review of 27 patients less than 60 days of age, hospitalized for possible serious bacterial illness (SBI), but who were culture negative, and then readmitted within seven days for the same reason. Upon repeat evaluation for sepsis, five of these infants had significant illnesses; two (7.4%) had SBIs (one had pneumococcal bacteremia and the other a urinary tract infection), and three (11.1%) had aseptic meningitis. Our results suggest that young infants, despite recent hospitalization for possible SBI, may be at risk for a serious infectious process and need reevaluation if symptoms recur.

Pancreatitis associated with brain tumor therapy

PURPOSE

Four children with prolonged emesis during brain tumor therapy were diagnosed with pancreatitis.

PATIENTS AND METHODS

All were exposed to medications or radiotherapy that potentially contributed to pancreatitis.

CONCLUSIONS

Because recognition of pancreatitis may necessitate changes in supportive care, pancreatitis should be included in the differential diagnosis of vomiting in this population.

Age and gender effect on the inducibility of steroid metabolizing cytochrome P450 in rat liver

Liver microsomal steroid hydroxylases and 5 alpha reductase activities were evaluated by quantitation of specific metabolites from 4-C14 progesterone after TLC separation. Each enzyme showed a different developmental profile depending on the gender of the rat. Dexamethasone induced both 6 beta and 16 alpha progesterone hydroxylase, being more potent for 6 beta (3 to 4 folds) than 16 alpha (1.2 to 1.6 folds). A comparison of the inducibility of 6 beta and 16 alpha hydroxylase by dexamethasone in rats from different age groups showed that for both enzymes, the degree of increase was higher in the younger than older groups. Thus there is a blunting in the responsiveness to dexamethasone induction of both 6 beta and 16 alpha hydroxylase with age particularly in female animals. This decrease in responsiveness in older females could potentially affect their capacity to metabolize endogenous and exogenous agents.

Pancreatitis associated with remote traumatic brain injury in children

Vomiting, abdominal distension, and feeding intolerance are common findings following brain injury in children, and are usually attributed to the brain injury or to delayed gastric emptying: a specific cause is usually not sought. We report six children who developed mild to moderate pancreatitis at least 7 days following apparently isolated brain injury, a previously unreported association. Five of the six patients received drugs that are known or suspected pancreatotoxins; all recovered without changes in the medications. When children develop feeding intolerance or upper gastrointestinal symptoms following traumatic brain injury pancreatitis should be suspected.

Effect of abrupt discontinuation of high glucose infusion rates during parenteral nutrition

We measured serum glucose and insulin levels in 15 children older than 2 years of age for 30 minutes after abrupt discontinuation of total parenteral nutrition. Initially high insulin levels rapidly became normal, and glucose levels were stable after 15 minutes. No patient had biochemical or symptomatic hypoglycemia. Glucose infusion rate, age, or use of steroid therapy had no apparent influence. Abrupt discontinuation of total parenteral nutrition is safe in most children older than 2 years of age.

Endoscopic retrograde cholangiopancreatography in children

Endoscopic retrograde cholangiopancreatography (ERCP) is playing an increasingly important role in the evaluation and treatment of children with disorders of the pancreas and biliary tree. In this article the technique, indications, and complications of diagnostic and therapeutic ERCP in children are reviewed. ERCP, when used properly, improves the ability of the clinician to diagnose and treat. Therapeutic ERCP reduces the need for surgery, and preoperative ERCP provides surgeons with a "road map" when surgery is required.

Control and variability of gastric pH in critically ill children

OBJECTIVES

To determine the effect of illness severity and acute central nervous system injury on the control and variability of gastric pH in pediatric intensive care unit (ICU) patients receiving ranitidine.

DESIGN

Prospective, descriptive study.

SETTING

Pediatric ICU of a children's hospital.

PATIENTS

Fourteen pediatric ICU patients.

INTERVENTIONS

Ranitidine (4 mg/kg/day) was administered to all patients.

MEASUREMENTS AND MAIN RESULTS

Patients enrolled in the study were divided into two groups based on illness type and severity. Illness severity was measured by the Pediatric Risk of Mortality (PRISM) score, with a PRISM score of > or = 20 defining severe illness. Illness type was designated as central nervous system or noncentral nervous system. Gastric pH was continuously monitored in all patients using an intragastric, pH-sensitive electrode. Poor control of gastric pH was defined as a pH of < 4.0 for > 20% of the time monitored. The statistical significance of the differences between groups was measured using the Wilcoxon two-sample test or Fisher's exact test. Patients with severe illness or acute central nervous system injury had a lower mean gastric pH than all other patients (4.6 vs. 6.4; p = .008) and spent more time with a gastric pH of < 4.0 than other patients (47.5% of time monitored vs. 12.5% of time monitored; p = .003). Poor control of gastric pH occurred in 100% of patients with severe illness or acute central nervous system injury, while only 20% of the remaining patients had poor control of gastric pH (p = .01). Using power-spectrum analysis to evaluate gastric pH variability, gastric pH in patients receiving bolus ranitidine was more variable than gastric pH in patients receiving ranitidine continuously (p = .045). Illness severity or type had no effect on gastric pH variability (p = .78).

CONCLUSIONS

a) Continuous infusion of ranitidine decreases variability of gastric pH in pediatric ICU patients; b) gastric pH variability may make intermittent monitoring of gastric pH inaccurate; c) children with acute central nervous system injury or PRISM scores of > or = 20 have poor control of gastric pH; d) type of injury and PRISM scores predict response to ranitidine therapy.

Development of lipolytic activity in gastric aspirates from premature infants

Neonates, having little or no pancreatic lipase, would have a compromised ability to digest lipids if not for lingual and gastric lipases. To document the postnatal developmental profile of preduodenal lipase activity, 350 premature infants who were at various gestational ages and who had an orogastric tube had their gastric aspirates collected. Two hundred one infants had their gastric aspirates collected within 12 h after delivery. Serial collections were performed in 25 infants at various postnatal ages. Gastric aspirates collected from premature infants had a pH activity profile similar to that of lingual and gastric lipase but different from that of pancreatic lipase, indicating that their origin was from the tongue and/or stomach. Lipolytic activity and pH of these aspirates were quite variable, but no correlation was found between pH and enzyme activity. At birth, lipase activity was lower in the younger infants (< or = 26 weeks, n = 13). It increased to a peak at 30-32 weeks of gestational age and then declined to a lower level at term (> or = 40 weeks, n = 40). Postnatally, a composite plot of the serially collected aspirates also showed a predominant peak at 28-33 weeks of age. Comparison among siblings in twins (n = 12 pairs) and triplets (n = 3) showed great variations in their lipolytic activities, suggesting that the hereditary factor is not a major determinant. Various combinations of antibiotic medications (ampicillin, cefotaxime, gentamicin, and vancomycin) and drugs (dexamethasone, heparin, furosemide, phenobarbital, albumin, and vitamin K) apparently had no effect on the level and development of gastric lipolytic activities.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography in children

We performed 121 endoscopic retrograde cholangiopancreatographies (ERCPs) in 92 patients (60 girls and 32 boys), aged 4 months to 19 years, as part of diagnostic evaluation for suspected pancreatic or biliary tract disease or as therapeutic intervention. ERCP was successful in 116 attempts. The most common indications were recurrent pancreatitis (35 children), nonresolving acute pancreatitis (20), unexplained elevated amylase or lipase (19), postcholecystectomy syndrome (14), and elevated biliary tract enzymes (12). One hundred and one ERCPs were performed for more than one indication. The most common findings included chronic pancreatitis (26 cases), pancreas divisum (14), dilated pancreatic duct (10), gallstones or sludge (8), and abnormal common bile duct (8). Complications were uncommon and usually minor. ERCP is a safe and helpful procedure in the evaluation of suspected pancreatic and biliary tract disease in children and frequently allows for nonoperative treatment of these disorders.

Thyroidal regulation of lingual lipase development in suckling rats

Rat lingual lipase undergoes maturational increases during postnatal development. The role of thyroxine (T4) in the control of lingual lipase during development was evaluated. T4 given at an early suckling stage (starting day 4 or 5) moderately increased lingual lipase (20-30%) compared to age-matched controls. A similar dose of T4 given later (age > 2 weeks) was ineffective. The T4-sensitive period coincides with a time of low circulating T4, suggesting a role of T4 in modulating the development of lingual lipase in rat pups. Since simultaneous treatment with U486, a type II glucocorticoid receptor antagonist only partially blocked the T4 induction of lingual lipase, T4 appeared to have a direct action on the lingual gland. Pups of propylthiouracil (PTU)-treated dams (previously found to be hypothyroid) showed a delay in the maturation of lingual lipase compared to age-matched pups whose dam was not given PTU. Pups were most sensitive to PTU in the early suckling stage. PTU-induced delayed maturation of lingual lipase was a result of hypothyroidism, since T4 replacement when given early (at the age of 5 days) abolished most of the effect of PTU. When T4 was given later (at the age of 10 days), recovery was much less. This suggests the presence of an early period that is critically dependent on T4 for the full expression of lingual lipase in the rat tongue serous glands.(ABSTRACT TRUNCATED AT 250 WORDS)

Crohn's disease presenting as unilateral labial hypertrophy

We describe a child who had unilateral hypertrophy of the vulva, a rare extraintestinal manifestation of Crohn's disease. A biopsy specimen revealed a noncaseating granuloma. Flexible sigmoidoscopic examination revealed punctate 1 mm lesions with surrounding erythema in the rectum and sigmoid colon. Response to treatment with sulfasalazine was excellent. Gastrointestinal symptoms developed 1 year later when sulfasalazine was discontinued.

Pancreatitis associated with bone marrow transplantation in children

Vomiting, abdominal pain and distension, common findings in children who receive bone marrow transplants (BMT), are usually attributed to chemo-irradiation and mucositis, universally found in these patients. We report seven children, 3.5% of BMT patients at our institutions, with these symptoms who were found to have mild to severe pancreatitis during conditioning for or after receiving BMT. All patients were receiving drugs known to cause pancreatitis, such as adrenocorticosteroids and sulfonamides as well as numerous putative pancreatotoxins such as cyclosporin A and cytosine arabinoside. Five of the seven patients had suffered from graft-versus-host disease. In patients who have received BMT, upper gastrointestinal symptoms should not be attributed to mucositis or chemo-irradiation without first testing for pancreatitis.

Developmental delay of lingual lipase expression after guanethidine-induced sympathectomy

Rat lingual lipase increases during postnatal development. To evaluate the role of the sympathetic nervous system in the control of lingual lipase during development, suckling rats were chemically sympathectomized by chronic treatment with guanethidine. This treatment was found to be effective in suppressing the developmental increase of lingual lipase. The effect was age dependent and also related to the dose of guanethidine given (i.e., the higher the dose, the more effective the suppression is, up to 40 micrograms/g body wt). The effect of guanethidine on lingual lipase suppression was not a result of induced stress, since simultaneous treatment with RU-38486, a known glucocorticoid receptor antagonist, did not prevent the decrease in lingual lipase activity. Ephedrine, a known sympathomimetic agent, restored the lingual lipase to a near normal level in guanethidine-treated animals, confirming that guanethidine acts through the sympathetic nerves. Furthermore, histochemical studies showed that guanethidine-treatment resulted in the reduction or elimination of catecholaminergic fibers in the von Ebner's glands. The effect of guanethidine was found to be transient, in that the lingual lipase activity showed complete recovery upon withdrawal of the treatment for 1 week. Together, the results indicated that sympathetic nerves have an important regulatory role in lingual lipase in rat pups during development.

Herpetic esophagitis in an immunocompetent boy

An immunocompetent 12-year-old boy had epigastric pain, odynophagia, fever, and hematemesis. Esophagoscopy demonstrated ulceration of his proximal and distal esophagus. Although histopathologic analysis of biopsies obtained from the lesions was nondiagnostic, herpes simplex virus type 1 was isolated from these samples. The patient responded rapidly to acyclovir therapy. Only a handful of cases of herpes esophagitis have been reported previously in immunocompetent children. This infection must be considered in children having odynophagia and fever, even if they are not immune compromised.

Modulation of lingual lipase development by glucocorticoid in the rat

Lingual lipase in the rat is present in the neonatal period and undergoes developmental increase during postnatal life. To evaluate the role of glucocorticoid in the control of lingual lipase during development, suckling rats were adrenalectomized at d 10 and various hormone replacements were performed. Adrenalectomy abolished the developmental increase of lingual lipase. Low doses of dexamethasone (0.2 and 0.5 microgram/100 g body wt) restored the lingual lipase to near normal level in adrenalectomized animals. High doses of dexamethasone (20 micrograms/100 g body wt), when given to similarly adrenalectomized animals, however, led to a reduction of lingual lipase levels. Inhibition by dexamethasone is through the action of the hormone inasmuch as the coadministration of RU38486, a glucocorticoid type II receptor antagonist, completely abolished the inhibitory action. Inhibition is also steroid specific, with dexamethasone and triamcinolone acetonide being more effective. The results suggest a unique bimodal regulation of lingual lipase by dexamethasone in the rat serous glands. Because of the possible importance of lingual lipase as an alternative enzyme for fat digestion in neonates, the inhibitory action of high doses of glucocorticoid on lingual lipase development may have important implications. The use of steroidal compounds in the hastening of lung maturation and treatment of inflammatory disease might conceivably compromise their lingual lipase development, hence their capacities of fat digestion and malabsorption in the same period.

Gastrointestinal myoelectric activity in an infant with congenital idiopathic motility disorder

We investigated myoelectric activity in an 8-month-old male who presented with a perinatal bowel obstruction, duodenal band, congenital short small intestine, and persistent feeding intolerance. Serosal electrodes were surgically implanted on stomach, duodenum, and jejunum during Nissen fundoplication and ileostomy. A 5-cm ileal specimen was taken for in vitro studies. Spontaneous migrating myoelectric complexes (MMC) were present in stomach and small intestine. Bethanechol increased electrical response activity (ERA) in stomach and duodenum. Morphine induced intense ERA and distinct phase III activity. Pentagastrin infusion did not disrupt MMC cycling. Feeding disrupted MMC complex cycling 30-40 min after the meal. Metoclopramide before feeding delayed disruption of the MMC cycling after the feeding. Intermittent gastric arrhythmias were present after the fifth postoperative day. In vitro muscle strips showed spontaneous contractions and electrical control activity (ECA). Bethanechol, McNeil A-343, motilin, and cholecystokinin induced contractions, but pentagastrin had no effect. We conclude that in spite of a major clinical motility dysfunction, several of our findings were normal. The abnormalities include short MMC period, absence of disruption of MMC by pentagastrin, and gastric arrhythmias.

Ischemic hepatitis in children: diagnosis and clinical course

Hepatic hypoperfusion can result in ischemic hepatitis, a clinical syndrome characterized by a sudden rise in serum transaminases followed by resolution to near normal levels within 7 to 10 days. Although described in adults, this syndrome has not been well defined in pediatric patients. We report 22 children who developed ischemic hepatitis during an acute illness. Fifteen of 22 patients had a documented hypotensive episode or no cardiac output before the onset of the ischemic hepatitis episode. Four of the seven patients without documented hypotension required pressor therapy to maintain their BP. SGOT showed a marked rise (mean 2294 IU/L, range 438 to 6652) from admission to 96 h (mean 34) with a rapid decline to near normal levels within 9 days (mean 5.1). Serum bilirubin levels also rose transiently, but generally not to the extent of transaminase levels. A clinically significant coagulopathy occurred in six patients. Although nine patients expired, none died as a direct result of the hepatic damage. Ischemic hepatitis can occur during illnesses associated with diminished hepatic blood flow and follows a characteristic course that usually can be differentiated from viral or drug-induced hepatitis on clinical and biochemical criteria.

Cholecystectomy and cholelithiasis in sickle cell anemia

Elective cholecystectomy was performed on 12 children (eight male and four female; age range, 4 to 19 years; and mean age, 11.2 years) with abdominal pain that was related to gallstones. Seven patients had jaundice, six had nausea, five had fat intolerance, and three had biliary colic. Two simple transfusions (10 mL/kg of packed red blood cells), designed to decrease the hemoglobin S content to less than 30% and to increase the total hemoglobin level to greater than 100 g/L, were given preoperatively two to three weeks apart. A third transfusion was given on the day before surgery if the total hemoglobin level was less than 100 g/L. The preoperative mean hemoglobin S content was decreased from 88% to 31%, and the mean total hemoglobin level was raised to 122 g/L. There were no preoperative or intraoperative complications. Post-operatively, no patients developed complications that were related to sickle cell anemia. Hospitalization averaged 6.3 days. Recurrent abdominal pain resolved shortly after surgery in all patients. With proper preoperative transfusions, elective cholecystectomy is safe in children with sickle cell anemia. Elective cholecystectomy should be recommended at the time of diagnosis of cholelithiasis.

Effects of cholecystokinin and hydrocortisone on DNA and protein synthesis in immature rat pancreas

To define the developmental pattern of the trophic effects of cholecystokinin octapeptide (CCK-8) and hydrocortisone on immature rat pancreas, we injected newborn rats, rats aged 4, 7, 11, 18, and 25 days and 3 months, and adult rats with CCK (5 and 10 micrograms/kg) in gelatin and hydrocortisone (10 mg/kg) for 3 days. Animals were killed, the pancreata were removed, and the concentrations of DNA and protein were measured and DNA and protein synthesis rates determined by incorporation of [3H]thymidine and [14C]leucine, respectively. These values were compared with those of saline-injected controls. DNA concentration was significantly increased over control at ages 2 days to adult by hydrocortisone and by CCK (10 micrograms/kg) in the adult. Protein concentration was increased on days 3-14 by hydrocortisone. DNA synthesis was increased by CCK and decreased by hydrocortisone at 3 months and adult. Protein synthesis was decreased by hydrocortisone at ages 3-14 days. Thus, each agent has its own developmental pattern with age on the rat pancreas.

DNA and protein synthesis in developing rat pancreas

To define developmental patterns, we determined the rate of protein and DNA synthesis in rat pancreas at birth, 1, 2, 3, 7, 10, 14, 21, 28 days, 2 months, 3 months, and in adults. Fragments of freshly minced pancreas were incubated with [3H]-thymidine and [14C]-leucine and the DNA and protein synthesis rates were measured. We found that DNA content was lowest at birth, rose through day 3, plateaued at about 8 mg/g wet weight through day 14, then slowly decreased to the adult value of about 5 mg/g at 2 months; protein content, although high at birth, decreased rapidly to a value of 80 mg/g at day 3 and slowly rose to the adult value of 160 mg/g; protein synthesis, low at birth, rapidly increased to about five times the adult value by day 3, and remained elevated for the 1st month; DNA synthesis was 15 times the adult rate at birth, increased to 30 times at 3 days of age, then declined slowly in an exponential fashion to the adult value. We conclude that the pancreas at birth is poised biosynthetically to undergo a rapid hyperplastic and hypertrophic response, and this process reaches a maximal rate at about 3 days of age.

Ontogeny of secretory function and cholecystokinin binding capacity in immature rat pancreas

Isolated acini were prepared from the pancreas of immature rats (age less than 1 hr. - 48 hrs) in order to study the development of the secretory process. The ultrastructural integrity of the acinar cells was maintained after digestion and stimulation with secretagogues. Acini prepared from rats aged 24 - 48 hours responded to both CCK-8 and carbachol with significant increases in amylase release. Although typical biphasic dose response curves were obtained, the curves were shifted to the right by 1 - 2 log units, compared to the responses of adult acini. At ages younger than 24 hours, acini were insensitive to secretagogues but were sensitive to the calcium ionophore A23187. CCK receptors were virtually absent from membranes prepared from newborn pancreases, but binding of CCK, although small, was measurable at 12 hours and slowly increased up to 48 hours. A greater amount of binding was seen at 72 hours, which appeared constant up to 14 days. At 21 days, adult levels of binding were found. These results confirm previous studies that the rat pancreas is insensitive to secretagogues in the first 24 hours of life. After age 24 hours the secretory process is intact but less sensitive to secretory agents than the more mature pancreas. In the case of CCK, this may be due to lesser numbers of CCK receptors and/or affinity of CCK for its receptor.

Cholelithiasis in an infant with polycythemia

An 11-week-old infant with polycythemia presented with cholestasis secondary to cholelithiasis. It is likely that hemolysis secondary to polycythemia predisposed our patient to cholelithiasis. We suggest that polycythemia may be a new cause of cholelithiasis in infancy.

Endoscopic retrograde cholangiopancreatography in children

Endoscopic retrograde cholangiopancreatography (ERCP) is a universally used diagnostic and therapeutic modality in adults with pancreaticobiliary tract disease; its use in children with similar problems has been limited. We have performed ERCP procedures in 39 children and adolescents (aged 6 months to 18 years; mean 12.5 years), using the standard adult and pediatric side-viewing endoscopes. In selected cases, ERCP manometric study of the sphincter of Oddi, endoscopic sphincterotomy, or balloon extraction of common bile duct stones was performed. Nineteen patients had significant or abnormal structural findings, including pancreas divisum (four patients); sclerosing cholangitis (three); and choledochal cyst, chronic pancreatitis, choledochocele, pancreatic pseudocyst, common bile duct stone, and sphincter of Oddi motor dysfunction (two each). In all instances in which patients required operation, ERCP examination provided specific anatomic detail that was useful for planning appropriate intervention. The only significant complication after ERCP was mild pancreatitis, which occurred in four patients and responded to supportive, short-term measures.

Intrahepatic biliary tract abnormalities in children with corrected extrahepatic biliary atresia

Three children with surgically corrected extrahepatic biliary atresia developed recurrent cholangitis associated with bile lakes that failed to drain via the hepatoportoenterostomy. Surgical or percutaneous drainage of these cysts was followed by both resolution of the infection and spontaneous internal drainage. We postulate that the ongoing inflammatory process resulted in intrahepatic biliary obstruction, which caused cholangitis and bile cysts. Successful treatment required not only antibiotics but drainage of the bile lakes. Development of bile cysts is a new cause of recurrent cholangitis seen in extrahepatic biliary atresia.

Aeromonas hydrophila colitis in a child

A 5-year-old girl presented with chronic bloody diarrhea. Evaluation including sigmoidoscopy, rectal biopsy, and barium enema was consistent with the diagnosis of ulcerative colitis. Culture of the stool grew Aeromonas hydrophila. A. hydrophila colitis may be more common than presently realized.