Activity of mitogen-activated protein kinases in the esophageal epithelium of patients with Barrett's esophagus

Barrett's esophagus (BE), a complication of gastroesophageal reflux disease, is associated with an increased risk of esophageal cancer. Mitogen-activated protein kinases may play an important role in the pathogenesis of this process. We aimed to evaluate mitogen-activated protein kinases activity in esophageal mucosa of patients with BE and find possible relationship between reflux type and BE. Twenty-four patients (mean age: 59 years) with gastroesophageal reflux disease symptoms and endoscopically suspected esophageal metaplasia (ESEM) were prospectively enrolled for testing by a multichannel intraluminal impedance monitoring along with a Bilitec 2000. Endoscopic biopsies were taken from methylene blue-positive pit patterns (sites suggesting specialized intestinal metaplasia [SIM]), from 2 cm above the Z-line and from cardial parts of the stomach. The biopsies were analyzed for extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), p38 activity by Western blot. Seventeen ESEMs had histologically proven metaplasia: eight patients had SIM and nine had gastric-type epithelia (GE). Biliary reflux was more evident in SIM (P = 0.019) but not in GE (P = 0.019); non-biliary reflux was typical for GE (P = 0.005) but not for SIM (P = 0.04). Strong activations of ERK and p38 were found predominantly in SIM, but not in normal esophageal mucosa (NE) (P = 0.01 and P < 0.001 respectively). Strong signals for active JNK and p38 were detected in GE, but not in NE (P = 0.006 and P = 0.02 respectively). ERK activity was significantly higher than p38 activity in ESEM patients only with GE (P = 0.02). The strong activation of ERK, but not JNK is indicative of SIM. The presence of bile in gastroesophageal refluxate is predisposing to SIM, but not to GE in esophageal mucosa.

24-hour esophageal pH monitoring in children with pathological acid gastroesophageal reflux: primary and secondary to food allergy. Part II. Intraesophageal pH values in proximal channel; preliminary study and control studies--after 1, 2, 4 and 9 years of clinical observation as well as dietary and pharmacological treatment

PURPOSE

Among 264 children suspected of GERD, acid GER was confirmed in 138 children on the basis of 24-hour pH monitoring.

AIMS OF THE STUDY

Comparative analysis of parameters of 24-hour intraesophageal pH monitoring with dual-channel probe (in proximal channel) in children with acid GER: primary and secondary to cow milk allergy and/or other food allergy (CMA/FA) diagnosed; comparison of examined values of pH monitoring parameters with regard to duration of the disease (preliminary study and prospective studies--after 1, 2, 4 and 9 years of clinical observation and/or conservative treatment).

MATERIAL AND METHODS

264 children suspected of GERD, aged: 1.5-102 months; x = 20.78 +/- 17.23 months, were enrolled in a study. In order to differentiate acid primary GER from GER secondary to CMA/FA in 138 (52.3%) children with GERD immunoallergological tests were performed. Positive result of oral food challenge test confirmed the allergy being the cause of GER. 138 children with pathological acid GER were qualified into two groups: 1 and 2. Group 1--76 patients (55.1%), aged: 4-102 months; x = 25.2 +/- 27.28 months, with pathological primary GER. Group 2--62 patients (44.9%), aged: 4-74 months; x = 21.53 +/- 17.79 months, with pathological GER secondary to CMA/FA.

RESULTS

Significant differentiation of the mean values of these parameters between preliminary study and control studies within groups was shown in the case of: number of episodes of acid GER and duration of the longest episode of acid GER, acid GER index: total and supine (proximal channel). Statistical significance (p < 0.05) was higher in group 1, especially during prospective clinical observation and/or conservative treatment. At the same time significant differentiation of the mean values of: number of episodes of acid GER and episodes of acid GER lasting more than 5 minutes and mean values of acid GER index: total and supine was shown between the groups. Statistical significance (p < 0.05) was higher in group 2.

CONCLUSIONS

The preliminary study of examined children confirmed that values of pH monitoring in proximal channel were comparable to those in distal channel and did not contribute to differentiation of GER into primary and secondary. During prospective clinical observation and/or clinical treatment, on the basis of consecutive measurements, especially the number of episodes of acid GER and episodes of acid GER lasting more than 5 minutes, and also supine acid GER index it was stated that GER secondary to CMA/FA was of wider extent (higher) in comparison with primary GER in these patients.

Is acid gastroesophageal reflux in children with ALTE etiopathogenetic factor of life threatening symptoms?

PURPOSE

Commonly described multiorgan manifestation of acid GER: primary and secondary to cow's milk allergy and/or other food (CMA/FA) sometimes coexists with ALTE (Apparent Life Threatening Events) syndrome symptoms. Among these symptoms are apnea, cyanosis, pallor, hypotonia, non-epileptic seizures, consciousness disorders and bradycardia.

MATERIALS AND METHODS

264 children aged: 4-102 months (x=20.78 +/- 17.23 months) of both sexes, with symptoms suggestive of GER were enrolled into study. 8 children (4.8%) aged up to 2 years (x=10.00 +/- 2.78 months) of both sexes with symptoms suggestive of ALTE were selected from the group. 24-hour esophageal pH monitoring was used for acid GER diagnosis in these children. X-ray of esophagus with barium swallow was performed in order to evaluate the height of GER in infants. Immunoallergologic tests were performed in order to differentiate acid GER: primary and secondary to food allergy in these children.

AIMS

(1) Assessment of the prevalence of acid GER in children with symptoms suggestive of ALTE, (2) Clinical evaluation of symptoms in children with ALTE and acid GER, (3) Assessment of efficacy of conservative treatment in children with reflux and ALTE symptoms, (4) Natural regression of the disease in children with ALTE Results: From among 264 examined children who underwent 24-hour esophageal pH monitoring acid GER was confirmed in 170 (64.4%), and ALTE in 8 (4.8%). The causative role of primary acid GER in children with ALTE regarded to 4 children (50.0%) and GER secondary concerned 4 remaining children (50.0%). Mean number of ALTE episodes that appeared before admission to the hospital was similar in both study groups. The presence of typical reflux symptoms in 5 (62.5%) out of 8 children with ALTE symptoms on the basis of primary or secondary acid GER is significant. Mean value of total acid GER index in a subgroup of children with primary GER constituted x = 11.13 +/- 1.45 and was not statistically significant in comparison with mean value x = 12.13 +/- 1.30 of a parameter measured in a subgroup of children with secondary GER. The most common clinical manifestation was apnea and it was of identical prevalence in both study subgroups. Analysis of clinical differentiation of the course of ALTE in children with primary and secondary acid GER under conservative therapy was performed. Under this therapy, gradual regression of ALTE symptoms was achieved in all (8/100.0%) patients, with a tendency to longer time of improvement in children with secondary GER. Typical and atypical symptoms of GER receded in a subgroup with primary GER and were alleviated in a subgroup with secondary GER. In the second half year of clinical observation aggravation of reflux and ALTE symptoms was observed in subgroups. In the second year of clinical observation various typical and atypical symptoms of GER were observed in both subgroups. All these malaises during this period coexisted with ALTE symptoms. In the third year of clinical observation in both subgroups ALTE symptoms connected with acid GER were not observed.

CONCLUSION

Primary and secondary GER were defined as the causative factors of ALTE in 8 (4.8%) examined infants.

24-hour esophageal pH monitoring in children with pathological acid gastroesophageal reflux: primary and secondary to food allergy. Part I. Intraesophageal pH values in distal channel; preliminary study and control studies--after 1, 2, 4 and 9 years of clinical observation as well as dietary and pharmacological treatment

PURPOSE

Among 264 children suspected of GERD, acid gastroesophageal reflux (GER) was confirmed in 138 children on the basis of 24-hour pH monitoring.

AIMS OF THE STUDY

Comparative analysis of parameters of 24-hour intraesophageal pH monitoring (in distal channel--above cardia) in children with acid GER: primary and secondary to cow milk allergy and/or other food allergy (CMA/FA) diagnosed; comparison of examined values of pH monitoring parameters with regard to duration of the disease (preliminary study and prospective studies--after 1, 2, 4 and 9 years of clinical observation and/or conservative treatment).

MATERIAL AND METHODS

264 children suspected of GERD, of both sexes (140 boys--53.0% and 124 girls--47.0%), aged: 1.5-102 months; x = 20.78 +/- 17.23 months, were enrolled in the study. In order to differentiate acid GER: primary from secondary to CMA/FA in 138 (52.3%) children with GERD immunoallergological tests were performed. Positive result of oral food challenge test confirmed the allergy being the cause of GER. 138 children with pathological acid GER were qualified into two groups: 1 and 2. Group 1--76 patients (55.1%), aged: 4-102 months; x = 25.2 +/- 27.28 months, with pathological primary GER. Group 2--62 patients (44.9%), aged: 4-74 months, mean age x = 21.53+/- 17.79 months, with pathological GER secondary to CMA/FA.

RESULTS

Significant differentiation of the mean values of these parameters between preliminary study and control studies within groups was shown in the case of: number of episodes of acid GER and episodes of acid GER lasting more than 5 minutes, duration of the longest episode of acid GER, acid GER index: total and supine (distal channel). Statistical significance (p < 0.05) was higher in group 1, especially during prospective clinical observation and/or conservative treatment. At the same time significant differentiation of the mean values of: number of episodes of acid GER and episodes of acid GER lasting more than 5 minutes and mean values of acid GER index: total and supine was shown between the groups. Statistical significance (p < 0.05) was higher in group 2.

CONCLUSIONS

The preliminary study of examined children confirmed that values of pH monitoring in distal channel were comparable and did not contribute to differentiation of GER into primary (group 1) and secondary (group 2). During prospective clinical observation and/or clinical treatment the intensity of reflux in these groups was assessed on the basis of the number of episodes of acid GER and episodes of acid GER lasting more than 5 minutes in distal channel. Acid GER index: total and supine appeared to be important diagnostic parameter but only after the first year of dietary and pharmacological treatment.

Gastroesophageal reflux in children and adolescents. clinical aspects with special respect to food hypersensitivity

PURPOSE

Gastroesophageal reflux (acid GER), primary and secondary, has a wide spectrum of clinical symptoms and occurs at developmental age. The study objective was to elaborate the clinical profile of symptoms and to determine whether there are any differences in clinical manifestations between the two acid GER conditions, i.e. primary and secondary to cow milk allergy and/or other food allergy (CMA/FA).

MATERIAL AND METHODS

The study involved 264 children of both genders and at various age, with diverse reflux symptoms from one or many organs and with a positive family history of alimentary tract diseases. Based on preliminary diagnostic tests, the children were divided into groups. In 138 children, pathological acid GER, primary and secondary to CMA/FA, was recognized.

RESULTS

The profile of clinical symptoms observed in 264 children with suspected gastroesophageal reflux disease (GERD) was elaborated according to their frequency. Among differentiating symptoms the most common were: vomiting (12.1%), bronchitis (10.9%) and pneumonia (9.6%). In the group of 138 GER children, 32 (23.2%) had monosystemic symptoms, in the other 106 patients (76.8%) many systems were affected. The most frequent reflux symptoms were: in primary GER (group 2)--alimentary tract disorders (28.6%), pneumonia and bronchitis (20.7%) and neurological symptoms with torticollis (7.4%); in secondary GER (group 3)--alimentary tract disorders: vomiting and anxiety/crying (25.2%); pneumonia and bronchitis (19.4%). In 23 children (37%) with secondary GER, typical allergic symptoms were found to coexist. The 138 GER patients underwent allergologic and immunologic tests to confirm the allergic background of symptoms.

CONCLUSION

Clinical symptoms caused by the presence of secondary acid GER are non-specific, being identical or similar to those observed in primary acid GER. Allergologic and immunologic tests are useful to confirm or exclude the relationship between GER and CMA/FA in the study children.

Gastroesophageal reflux (GER) in children and adolescents with regard to food intolerance

PURPOSE

The hypothesis put forward in the current study was that food intolerance can be a cause of gastroesophageal reflux (GER) affecting children with this pathology at various age. In order to confirm or exclude this hypothesis, the study objective was to determine the frequency of the cause-and-effect relationship between allergy to cow milk proteins and/or other food products and gastroesophageal reflux found in the study group of patients, and to establish diagnostic differentiation guidelines in GER caused by food intolerance, i.e. secondary vs primary GER.

MATERIAL AND METHODS

A total of 735 children (428 boys--58.2% and 307 girls--41.8%; mean age x = 41.12 months +/- 25.03) with symptoms suggesting gastroesophageal reflux disease (GERD) were qualified for the study. The diagnostic procedure included a 24 h pH-metry of the oesophagus, which was performed in all the study children. In 703 patients (411 boys--55.9% and 292 girls--39.7%) upper gastrointestinal endoscopy was carried out. Manometric examination of the oesophagus was performed in 232 children (123 boys--16.7% and 109 girls--14.8%). Allergological and immunological tests were done in 170 children with suspected allergy (91 boys--12.4% and 79 girls--10.7%). Contrast radiography of the upper gastrointestinal tract was performed in 78 children with respiratory symptoms (42 boys--5.7% and 36 girls--4.9%). Oral challenge test was used to differentiate primary GER from GER secondary to cow milk proteins intolerance or other food allergy in 138 children (72 boys--9.8% and 66 girls--8.9%).

RESULTS

Based on the 24 h pH-metry of the oesophagus and endoscopic examination of the upper gastrointestinal tract, gastroesophageal reflux disease and/or reflux oesophagitis were diagnosed in 138 study subjects (18.8%); mean age x = 23.36 months +/- 22.53. Positive oral food challenge test confirmed pathological GER secondary to cow milk protein allergy/other food hypersensitivity in 62 children (8.4%).

CONCLUSION

The current study revealed the existence of the cause-and-effect relationship between allergy to cow milk protein/ /other food products and GER in the study children at various age.

Evaluation of the effect of intravenous l-carnitine on quality of life in chronic hemodialysis patients

AIM

The aim of this study was to determine the effect of l-carnitine on quality of life (QOL) in chronic hemodialysis patients.

PATIENTS AND METHODS

This trial used a randomized, prospective, placebo-controlled, double-blind, crossover design. Inclusion criteria were patients who were older than 18 years, had been on dialysis for a minimum of one year, and had at least two of the following symptoms: intradialytic hypotension, muscle cramping, lack of energy, muscle weakness or myopathy, cardiomyopathy, or lack of responsiveness to erythropoietin (EPO). Patients were excluded if they were mentally incompetent to complete a QOL questionnaire. Sixteen patients were randomized to receive either l-carnitine (20 mg/kg) or placebo (normal saline) after each dialysis session for 12 weeks, followed by a 6-week washout, then the crossover therapy for 12 weeks. The Kidney Dialysis Questionnaire was the assessment tool used to evaluate QOL.

RESULTS

There was no significant effect of l-carnitine on QOL irrespective of treatment order. There were also no differences found in any of the secondary outcomes including incidence of muscle cramping, intradialytic hypotension, EPO requirements or hemoglobin. Adverse effects consisted of gastrointestinal symptoms, with a similar incidence between l-carnitine and placebo.

CONCLUSION

L-carnitine did not have a benefit on QOL in our patient population.

[Congenital megaloblastic anemia in a 22-month-old boy]

A 22-month old boy with the congenital form of megaloblastic anaemia is presented. The child was admitted to hospital with moderate-to-severe hematological and neurological symptoms. Very low serum vitamin B12 concentration and normal gastric secretion were determined. A dramatic recovery after intramuscular injections with vitamin B12 was observed.

[Clinical aspects of gastro-esophageal reflux in children]

In 20 children hospitalized in the age range from 2 months to 7 years the clinical manifestations caused by radiologically demonstrated gastro-oesophageal reflux were analysed. The main symptoms were from the digestive tract and respiratory system. In this group of children this reflux was also the cause of deficient body weight and attacks of apnoea with cyanosis.