[Small bowel overgrowth: a frequent complication after abdominal surgery in newborns]

BACKGROUND/PURPOSE

Surgery for congenital or acquired gastroenterological disorders, and particularly that associated with short bowel, is not infrequently complicated by Small Bowel Bacterial Over growth (SBBO). Aim of this study is to evaluate the clinical course of children undergoing bowel surgery in the newborn period, assessing the development of SBBO and the response to intensive treatment with a "bowel cocktail" of gentamycin, metronidazole and cholestyramine.

METHODS

17 children with various conditions were studied clinically and by Breath Hydrogen Test (fasting and after glucose). 14 children underwent more than one procedure. All children were treated with overall "bowel cocktail" of gentamycin, metronidazole and cholestyramine.

RESULTS

5 children recovered after one course of treatment and 11 children relapsed at least once and required further courses of therapy. One child died from TPN related liver failure and another following a liver and small bowel transplant for short bowel syndrome. A third child required total intestinal tube splinting according to Sauer and another one required a tapering of the preatretic enlarged jejunal loop.

CONCLUSIONS

Our study suggests that children undergoing bowel surgery in the neonatal period and those having more than one procedure are at greater risk of developing small bowel bacterial overgrowth postoperatively. Interestingly, loss of the ileocecal valve was not associated with an increased risk of bacterial overgrowth.

[Chronic idiopathic gastric volvulus in children]

OBJECTIVE

We report clinical, radiograpic and instrumental data about 18 cases of gastric chronic idiopathic volvulus observed since 1997 to june 2000.

METHOD

All cases diagnosed by barium meal, performed for vomiting or after a pHmetric esophageal monitoring, in cases of atipical symptoms of gastroesophageal reflux disease.

RESULTS

All patients underwent a conservative treatment (antireflux position and procinectics): 5 recovered after 1 year of treatment and 13 were operated on because they did not improve during medical therapy or relapsed after the end of conservative treatment.

CONCLUSION

Abnormal position of the stomach is not an absolute indication for surgical treatment. When medical treatment does not obtain improvement in symptoms, surgical option has to be discussed.

Perinatal transmission and manifestation of hepatitis C virus infection in a high risk population

We studied the perinatal transmission of hepatitis C virus (HCV) in 70 high risk mother/infant pairs. Seventy-six percent of the mothers (53 of 70) were coinfected with human immunodeficiency virus (HIV) and 79% (55 of 70) had a history of drug addiction. During the follow-up HCV RNA was detected in 14 of 70 (20%) infants: 12% (2 of 17) in infants born to HIV-negative mothers; and 23% (12 of 53) in infants to HIV-positive mothers. The rate of vertical transmission was significantly higher in vaginally delivered infants than in those delivered by cesarean section (32% vs. 6%; P < 0.05). All 56 uninfected infants lost passively acquired anti-HCV by age 9 +/- 4 months and only 2 of 56 infants (4%) had evidence of HIV infection. Four of 14 HCV RNA-positive infants (29%) had evidence of HIV coinfection. We observed 3 clinical patterns of HCV infection: a transient viremia in 2 infants; an acute pattern in 2 infants; and a chronic pattern in 10 infants. All 4 HIV-coinfected infants had chronic HCV infection. All infants with a chronic pattern, had increased alanine aminotransferase values for more than 6 months and 5 had a liver biopsy that showed signs of chronic persistent hepatitis. HCV perinatal transmission was more frequent in infants born to HIV-coinfected mothers than in infants born to HIV-noninfected women, particularly when delivered vaginally.

Mother-to-infant transmission of hepatitis C virus. Lombardy Study Group on Vertical HCV Transmission

To assess the risk of mother-to-infant transmission of hepatitis C virus (HCV), we followed up 116 babies of anti-HCV positive mothers, of whom 22 were coinfected with HIV and 94 had HCV alone. None of the babies whose mothers had HCV alone acquired HCV, while 8 babies (36%; p < 0.001) of mothers co-infected with HIV acquired HCV (5 babies) or HCV and HIV (3). There was no association between any specific maternal HCV genotype and enhanced risk of neonatal infection. HCV-RNA levels were significantly higher (p < 0.05) in mothers with HIV coinfection than in those with HCV alone. These data indicate that maternal HIV status correlates with enhanced level of viraemia which favours neonatal infection.

Is HCV transmitted by the vertical/perinatal route?

Hepatitis type C is the major aetiological cause of both parenterally transmitted and cryptogenic, sporadic or community acquired nonAnonB hepatitis. The lack of known parenteral risk factors in a consistent number of cases with nonAnonB hepatitis has stimulated the search of other possible modes of viral transmission. The aim of this report is to review the evidence both for and against vertical/perinatal transmission of HCV from anti-HCV positive mothers to infants.

Impaired response to hepatitis B vaccine in HIV infected children

Eighteen human immunodeficiency virus (HIV) vertically infected children (HIV group) and 33 seroreverted children (SR group), who had completed hepatitis B vaccination (Engerix B, 20 micrograms dose) were studied. Four out of 18 (22%) HIV children failed to develop protective antibody levels (anti-HBs titres less than 10 mIU ml-1) compared with 1 out of 33 (3%) SR children (p less than 0.05). Magnitude of response among HIV children was significantly lower than among SR children. In HIV children the probability that anti-HBs titres persist above the protective levels was significantly lower than in the SR group at any time during the 24 month follow-up. These results show that HIV children have a suboptimal response to hepatitis B immunization and the protection is less durable. Further studies are needed to determine the optimal protocol for hepatitis B immunization in HIV children.

Fecal alpha-1-antitrypsin excretion in acute diarrhea: relationship with causative pathogens

Concentrations of alpha-1-antitrypsin (AT) in random fecal samples from 68 infants (92.7% outpatients) with acute diarrhea and 32 healthy controls were determined. The mean +/- s.d. for AT in infants with diarrhea was 2.07 +/- 1.88 mg/g dry stool (mg/g d.s.) compared with 1.29 +/- 0.72 mg/g d.s. (p less than 0.05) in controls. Fecal AT was significantly greater than that of the controls only for diarrhea caused by Rotavirus or Salmonella. Salmonella patients also had significantly higher fecal levels of AT than patients with diarrhea caused by Campylobacter. Fifty percent of the infants with Salmonella infections excreted more than 2.73 mg/g d.s. AT, which is above the control mean + 2 s.d. Fecal excretion of AT was highest in patients with macroscopic intestinal bleeding, but it still depended more on the causative agent than on bleeding per se. This finding of increased intestinal protein loss during acute diarrhea, even in the less severe diseases, emphasizes the necessity to rapidly restart adequate nutritional intake.

Lactose malabsorption and recurrent abdominal pain in Italian children

The role of lactose malabsorption (LM) was investigated in 32 children (mean age 8.13 +/- 2.46 years) with recurrent abdominal pain (RAP). LM was detected in 75% of them by a lactose breath hydrogen test (LBHT) after a 2-g/kg (max 50-g) load. Of the 18 malabsorbers who participated in a 3-month lactose-free diet (LFD), 14 were judged "improved" and reported lower pain frequency (p less than 0.001). The malabsorbers who improved versus the not improved had comparable past lactose ingestion but were distinguishable on the basis of their lactose absorption capacity (0.36 vs. 0.81 g/kg; p less than 0.01), as subsequently determined by multiple LBHTs with 25-, 12.5-, and 6-g loads. The ratio between past lactose ingestion and lactose absorption was 1.89 in the improved and 0.55 in the not improved groups (p less than 0.01), retrospectively indicating lactose as a possible cause of the symptoms in the improved group. The reintroduction of lactose in amounts not exceeding the absorption capacity into the diet of each malabsorber who had improved with LFD caused relapse in none of the 14 subjects monitored for 2-6 months. In conclusion, LM seems an important cause of symptoms in Italian children with RAP. Assessment of the lactose absorption threshold of each subject of LBHTs provides a basis for reintroduction of "calibrated" amounts of lactose-containing foods (e.g., milk) into the diet.

Simple clinical score and laboratory-based method to predict bacterial etiology of acute diarrhea in childhood

We describe a two-step predictive method to assess the probability of bacterial etiology in cases of diarrhea. The patients are divided into three probability groups (high, intermediate, low) according to a clinical score. Thereafter the patients in the intermediate group are further assigned to the high or low probability group according to the presence or absence of fecal leukocytes. We developed the method in an initial series of 157 children with acute diarrhea; the reproducibility of the method was tested in a second series of 180 cases. Eighty-six percent of patients in the first series and 81% in the second were correctly classified by our method. We suggest its use, especially in pediatric practice, to identify children with the highest probability of bacterial diarrhea, thus reserving stool culture to a few selected cases because only a minority of children with diarrhea have a recognized bacterial etiology.