[Capsule endoscopy in children: which are the best indications?]

BACKGROUND AND STUDY AIMS

Capsule endoscopy (CE) is a novel and noninvasive means of investigating the small bowel. In children, the best CE indications have not yet been fully appraised. The aim of this study was to evaluate the diagnostic yield of CE in different pediatric pathologies.

PATIENTS AND METHODS

We retrospectively reviewed every CE performed in children in two French pediatric hospitals between March 2002 and June 2009. Seventy-nine CEs were performed on 70 children (mean age, 10.6 years; range, 2.2-18.0); 52 boys and 18 girls. The indications were iron deficiency anemia (24%), obscure gastrointestinal bleeding (14%), polyposis syndromes (16%), suspected Crohn disease (15%), unresponsive Crohn disease (10%), graft-versus-host disease (10%), and other (10%).

RESULTS

Of the 79 CEs, 69 reached the cecum (87%). Only one occlusion occurred in a case of stenosing Crohn disease, requiring surgical removal. In addition, technical difficulties led to an incomplete small bowel study in 12 cases (16%). The CE showed small bowel lesions in 42 cases (53%). The diagnostic yield was 27% in obscure gastrointestinal bleeding, 37% in iron-deficiency anemia, 42% in suspected Crohn disease, 88% in unresponsive Crohn disease, 62% in polyposis syndromes, and 88% in graft-versus-host disease.

CONCLUSION

In children, CE is well tolerated and can be performed in children as young as 2.2 years of age. Its diagnostic yield is highest in polyposis syndromes, unresponsive Crohn disease, and graft-versus-host disease.

Treatments for pediatric achalasia: Heller myotomy or pneumatic dilatation?

AIM

The treatment of achalasia consists of reducing distal esophageal obstruction by either Heller myotomy surgery or endoscopic pneumatic dilatation. The aim of the present study was to evaluate the short- and middle-term results of these procedures in children.

METHODOLOGY

For technical reasons, children under six years old (n=8) were treated by surgery only, whereas patients over six years old (n=14) were treated by either Heller myotomy or pneumatic dilatation.

RESULTS

Of the children aged under six years, 75% were symptom-free at six months and 83% at 24 months of follow-up. Of the patients aged over six years, complete remission was achieved by Heller myotomy in 44.5% vs. 55.5% by pneumatic dilatation after six months, and in 40% vs. 65%, respectively, after 24 months. Both pneumatic dilatation and Heller myotomy showed significant rates of failure.

CONCLUSION

These results suggest that pneumatic dilatation may be considered a primary treatment in children over six years old. Also, where necessary, Heller myotomy and pneumatic dilatation may be used as complementary treatments.

Double-blind randomized evaluation of clinical and biological tolerance of polyethylene glycol 4000 versus lactulose in constipated children

OBJECTIVES

To assess the safety of a polyethylene glycol (PEG) 4000 laxative without additional salts in pediatric patients.

STUDY DESIGN

This was a 3-month multicenter, randomized, double-blind, double-dummy, lactulose-controlled, parallel study enrolling 96 ambulatory constipated children aged 6 months to 3 years, treated daily with 4-8 g PEG or 3.33 g-6.66 g lactulose. Total protein, albumin, iron, electrolytes, and vitamins B9 (folates), A and D (25OHD3) were measured in blood before and after treatment (day 84) in a central laboratory.

RESULTS

The percentage of children with at least one value out of normal range at day 84 with respect to baseline status (with or without at least one value out of normal range), i.e. the primary endpoint, was 87% and 90% in the PEG and lactulose groups, respectively, without any difference between groups. The whole blood parameters showed no qualitative or quantitative treatment-related changes. Vitamin A values were above normal range in 56% and 41% of children at baseline versus 33% and 36% at day 84 in the PEG and lactulose groups, respectively. Iron values were similarly under normal range in 47% and 51% at baseline versus 42% and 51% at day 84. Clinical tolerance was similar for both treatments except for vomiting and flatulence, which were significantly higher with lactulose. Significantly higher improvements were evidenced with PEG regarding stool consistency, appetite, fecaloma and use of additional laxatives.

CONCLUSION

This 3-month study in 96 constipated children aged 6 months to 3 years confirms the long-term tolerance of PEG 4000 in pediatrics and indicates a PEG efficacy similar to or greater than that of lactulose.

Hématémèse chez un enfant de 11 mois : un mode de révélation rare d'un corps étranger intragastrique

Ingestion of foreign body has often no consequence. We report on a case in an 11-month-old girl who was referred for mild hematemesis and anorexia. Upper digestive tract endoscopy found a small metallic foreign body in the gastric antrum. After its removal, all symptoms disappeared. It is usually recommended to remove foreign bodies by endoscopy when they are in esophageal position, or are more than 3 to 5 cm long, or have a shape that may hurt the gut mucosa. Although rare, a gastric foreign body should be searched for in face of an upper gastrointestinal bleeding in an infant.

Cytokines, chemokine receptors, and homing molecule distribution in the rectum and stomach of pediatric patients with ulcerative colitis

BACKGROUND

Cytokines appear to play a significant role in the pathogenesis of inflammatory bowel disease (IBD) with a predominant Th2 pattern in colonic mucosa of patients with ulcerative colitis (UC). Chemokines and their receptors also regulate the migration of Th1 or Th2 lymphocytes to inflammatory tissues during the immune response. Although adult UC is usually confined to the colon, pediatric UC not uncommonly affects the stomach.

AIMS

The aim of this study was to compare expression of cytokines, chemokine receptors, and homing molecules in the rectal and the histologically characterized gastric mucosa of pediatric patients with UC. SUBJECTS Sixteen patients (11 girls and 5 boys; median age, 9 years) having all the features of UC were included in the study.

METHODS

Rectal and gastric mucosa obtained from UC cases were immunostained with antibodies against L-selectin, beta 7 integrin, CXCR3, CCR3, and CCR5. IL-4 and IL-12 p40 transcript expression was studied by in situ hybridization.

RESULTS

Chronic gastritis was found in 93.7% of cases and Helicobacter pylori (Hp) was found in 2 (13.3%) cases. In the rectal and gastric mucosa, CXCR3 was found in perivascular lymphocytes and CCR5 in a subset of CXCR3+ cells in the lamina propria. CCR3+ lymphocytes and IL-4-positive cells were always found, but there was no evidence of IL-12 production. Most of the lymphocytes infiltrating the gastric mucosa expressed beta 7 but not CD62L. In contrast, beta 7-positive cells were randomly dispersed in the rectal lamina propria, and the fraction of CD3+beta 7+ was low.

CONCLUSIONS

The authors conclude that gastritis is common in pediatric UC. The presence of CCR3+ lymphocytes, IL-4 transcript expression, without IL-12 p40 production in the stomach and in the rectum suggests a Th2 immune response. The presence of CCR3+, CD62L- activated Th2 cells may suggest that these gastric cells are recruited from colorectal primary lesions.

[Pancreatic involvement in inflammatory bowel diseases in children]

Pancreatitis in inflammatory bowel disease (IBD) in children is anecdotal. In adults, symptomatic pancreatitis occurs in 2% and asymptomatic in 8 to 21%.

PATIENTS AND METHODS

The aim of our study was to review retrospectively the frequency of pancreatitis in 124 pediatric patients (54.8% boys, 45.2% girls; 97 with Crohn disease, 16 with ulcerative colitis and 11 with undetermined colitis). Diagnostic criterion of pancreatitis was an increase of amylasemia > or = +2 SD of the normal with or without evocative clinical symptoms.

RESULTS

Symptomatic or asymptomatic pancreatitis was found in 27% (respectively 14.5 and 12.5%). Pancreatitis was significantly more frequent in girls as compared to boys (P = 0.04). Symptomatic pancreatitis was moderate and non complicated, often recurrent. It occurred mainly during active and severe diseases (P = 0.006). The localizations of IBD were not discriminant. Strong relation with drug was found in 25% of pancreatitis mainly due to azathioprine or 5-aminosalicylic acid, and salazopyrin. Duodenal localisation of Crohn disease or hepatobiliary complications were found associated with pancreatitis in 18% and 15% respectively.

CONCLUSION

These data suggest the high incidence of symptomatic and asymptomatic pancreatitis in children with IBD, the importance of its regular monitoring but also its multifactorial causes. Precise diagnosis of pancreatitis in pediatric IBD has to be done in order to avoid inappropriate drug pancreatitis diagnosis.

[Long-term followup of primary intestinal lymphangiectasia in the child. Six case reports]

Primary intestinal lymphangiectasia induce symptoms of protein-losing gastroenteropathy. Only very few studies evaluate the long term follow up of such patients. We reviewed six children diagnosed at 17 +/- 12 months and followed for 11 +/- 4.9 years.

CASE REPORTS

As soon as the diagnosis was made the patients were submitted to a strict low fat diet with added medium chain triglycerides and intermittent liposoluble vitamins perfusions. The diet allowed the disappearance of symptoms for all the patients but laboratory findings indicated continuing chyle leak for most of the children. Only one child who had normal biological parameters tolerates a normal diet since four years. Relaxation of the diet by two patients who had moderate hypoalbuminemia and lymphopenia led to severe clinical relapses 14 and 17 years after the diagnosis period with therapeutic difficulties. Three patients with long term strict low fat diet remain asymptomatic.

CONCLUSION

In most asymptomatic patients, the underlying lymphatic defect remains with permanent biological abnormalities. Clinical relapses may be severe and difficult to treat; thus the need for dietary treatment appears to be permanent.

[Pediatric gastrointestinal endoscopy: which sedation?]

Through an analysis of the French experience of digestive endoscopists in adult patients and of their own 25 years practice of pediatric digestive endoscopy, the authors militate in favour of anesthetic sedation in order to reduce painfulness and to obtain better acceptation of these procedures by children and their parents.

Omeprazole combined with amoxicillin and clarithromycin in the eradication of Helicobacter pylori in children with gastritis: A prospective randomized double-blind trial

OBJECTIVES

The aim of this multicenter prospective, randomized, double-blind study was to assess the efficacy of the combination of omeprazole, amoxicillin, and clarithromycin (OAC) for the treatment of Helicobacter pylori gastritis in children.

STUDY DESIGN

Seventy-three children with dyspeptic symptoms were included in the trial (mean age 10.8 years; range, 3.3 to 15.4). Patients were randomized to receive OAC or amoxicillin and clarithromycin (AC) for 7 days. H pylori status was assessed before and 4 weeks after eradication treatment, by use of the carbon 13-labeled urea breath test.

RESULTS

In intent-to-treat analysis (n = 63), eradication rates were 74.2% (95% CI, 58.7 to 89.6) in the OAC group and 9.4% (95% CI, 0 to 19.5) in the AC group. In per-protocol analysis (n = 53), the eradication rate increased to 80% (95% CI, 64.3 to 95.7), remaining significantly higher than in AC group (10.7%; 95% CI, 0 to 22.2). Resistance of strains to clarithromycin was rare (3/39 = 7.7%) and was not associated with failure of treatment. Adverse events were reported in 24.6% of patients and remained mild.

CONCLUSION

This study shows that 1-week OAC triple therapy results in successful eradication of H pylori in 75% of children with gastritis.

Lansoprazole in children: pharmacokinetics and efficacy in reflux oesophagitis

BACKGROUND

Data on the proton pump inhibitor lansoprazole in paediatric patients are limited.

AIM

To investigate the pharmacokinetics, optimal dosage and efficacy of lansoprazole in paediatric patients.

METHODS

A 24-h gastric pH recording and a pharmacokinetic study were performed after 7 days of lansoprazole, 17 mg/m2, in 23 patients with reflux oesophagitis (median age, 3.5 years). Response was defined as pH > 3 for > 65% of the recording. The dosage was doubled in non-responders. Patients with no response on day 14 were excluded. Responders underwent endoscopy after 4 weeks on the response-inducing dosage; abnormal findings led to a repeat endoscopy after four additional weeks.

RESULTS

Nine patients responded to 17 mg/m2 and six to 30.3 mg/m2. On day 7, time with pH > 3 was significantly correlated with the area under the plasma concentration-time curve (P=0.003). The area under the plasma concentration-time curve was significantly greater in the nine responders to 17 mg/m2 than in the 14 other patients. Pharmacokinetic parameters were similar in responders and non-responders to the higher dose. After 4 weeks, oesophagitis was healed in 80% of responders. Adverse events occurred in three patients and required treatment discontinuation in one.

CONCLUSIONS

Lansoprazole is effective and safe in children. The optimal starting dosage is 30 mg/m2 or 1.4 mg/kg.

Early diagnosis of adenovirus infection and treatment with cidofovir after bone marrow transplantation in children

Adenovirus infection remains an important cause of mortality after bone marrow transplantation (BMT). Currently no efficient antiviral treatment is known. Thus, testing new modalities of early diagnosis and treatment is a crucial objective. Adenovirus infection is defined by the combination of symptoms and the isolation of virus from the source of clinical symptoms. The involvement of two or more organs and the presence of virus in blood cultures define disseminated disease. Seven children with a median age of 7 years received bone marrow transplantation for leukemia. All received an unrelated graft without T cell depletion. Adenovirus was sought in blood, urine and biopsy specimens using PCR and culture. Analysis of biopsy specimens included systematic immunohistochemistry. Cidofovir treatment was initiated as soon as biopsy revealed the histopathological signs of adenovirus. Cidofovir was given at 5 mg/kg once weekly for 3 weeks then every 2 weeks. Six patients had diarrhoea and one patient had cystitis. Adenovirus infection and disseminated disease were diagnosed in four cases and three cases, respectively. In six cases, serotype A31 was isolated from gastrointestinal biopsy and in two cases serotypes B2 and C6 were detected in blood and urine. Cidofovir treatment was associated with clinical improvement of diarrhoea, cystitis and fever in five patients, in whom the virus became undetectable in cultures and PCR analyses despite the persistence of immunodeficiency. The median follow-up was 360 days after BMT (240-570). One child died of invasive aspergillosis and another of disseminated adenovirus after interruption of cidofovir therapy. Further studies in immunocompromised patients will be needed to extend these promising results concerning the role of cidofovir in adenovirus infection.

[Incidence of symptomatic celiac disease in French children]

OBJECTIVE

The study was carried out by the GFHGNP to determine the annual incidence of symptomatic celiac disease in children.

PATIENTS AND METHODS

The diagnostic criteria were: symptomatic patients diagnosed under 15 years of age during 1996, villous atrophy and positivity of antigliadin and/or other antibodies. Cases were collected from referral centers, general hospital pediatric departments and private pediatricians with endoscopic practice.

RESULTS

The study involved roughly half of the French pediatric population in 41 out of the 95 French districts. In all, 124 patients were collected: 76 girls and 48 boys. By geographical areas, in 30 districts where collection of data was complete which counted 186,285 births, the yearly incidence varied from 1/1731 births to 1/3110. (0.57@1000 to 0.32@1000). On the whole there were 77 cases i.e. an annual incidence of 1/2419 or 0.41@1000 (confidence interval 95%: 0.32 to 0.50@1000). Lower incidences were observed in the district of Paris: 1/4865 (0.21@1000) and Lyon: 1/3310 (0.27@1000). Those lower incidences could be explained by the difficulties of collecting the data in the biggest urban areas. The first signs occurred before one year of age in 73% of the cases, during the second year of life in 20.5% and after 3 in only 6.5%. The diagnosis was made before 2 years of age in 77% of the cases and after 3 in only 13%. In order of frequency symptoms were: failure to thrive (80%), diarrhea (59%), anorexia (59%), abdominal distension (57%), weight under 2 standard deviations (43%), short stature (43%).

CONCLUSION

Compared with previous studies in two French districts between 1975 and 1990, the annual incidence of symptomatic celiac disease in children appears to be on the rise. The usual clinical signs continue to be observed.

Selective expansion of intraepithelial lymphocytes expressing the HLA-E-specific natural killer receptor CD94 in celiac disease

BACKGROUND & AIMS

Celiac disease is a gluten-induced enteropathy characterized by the presence of gliadin-specific CD4(+) T cells in the lamina propria and by a prominent intraepithelial T-cell infiltration of unknown mechanism. The aim of this study was to characterize the subset(s) of intraepithelial lymphocytes (IELs) expanding during active celiac disease to provide insights into the mechanisms involved in their expansion.

METHODS

Flow-cytometric analysis of isolated IELs and/or immunohistochemical staining of frozen sections were performed in 51 celiac patients and 50 controls with a panel of monoclonal antibodies against T-cell and natural killer (NK) receptors. In addition, in vitro studies were performed to identify candidate stimuli for NK receptor expression.

RESULTS

In normal intestine, different proportions of IELs, which were mainly T cells, expressed the NK receptors CD94/NKG2, NKR-P1A, KIR2D/3D, NKp46, Pen5, or CD56. During the active phase of celiac disease, the frequency of CD94(+) IELs, which were mostly alphabeta T cells, was conspicuously increased over controls. In contrast, the expression of other NK markers was not modified. Furthermore, expression of CD94 could be selectively induced in vitro by T-cell receptor activation and/or interleukin 15, a cytokine produced by intestinal epithelial cells.

CONCLUSIONS

The gut epithelium favors the development of T cells that express NK receptors. In active celiac disease, there is a specific and selective increase of IELs expressing CD94, the HLA-E-specific NK receptor that may be related to T-cell receptor activation and/or interleukin 15 secretion.

Postoperative outcome of Crohn's disease in 30 children

BACKGROUND

Thirty children operated on for Crohn's disease (CD) were reviewed (1975-1994). The aim of the study was to assess their postoperative outcome.

PATIENTS

19 boys and 11 girls, aged 15.3 (2) years (range 11.3-20) at surgery were studied.

RESULTS

Surgical indications were acute complications of CD and chronic intestinal illness. Six months after surgery, 11 of 12 patients had been weaned off steroids, and 22 of 23 patients were weaned off nutritional support; 17 patients without recurrence had a mean (SD) weight gain of 2.1 (8) kg and a height gain of 3.36 (3) cm. During 3.1 (2.7) years follow up, 12 patients (40%) had a recurrence of the disease after 19.4 (14) months (means (SD)): supra-anastomotic recurrence (six), severe perianal disease (two), and chronic illness (four). Six of 14 patients who were treated with mesalazine (13) or azathioprine (one) had recurrences. The postoperative recurrence rate was 50% at two years.

CONCLUSION

Surgical treatment modifies the immediate outcome of severe or complicated CD, but does not prevent recurrence, despite localised resection or prophylactic postoperative treatment. Extension of the disease before surgery seems to be a major risk factor for postoperative recurrence in children.

CTLA-4 gene polymorphism is associated with predisposition to coeliac disease

BACKGROUND

Susceptibility to coeliac disease is strongly associated with particular HLA class II alleles. However, non-HLA genetic factors are likely to be required for the development of the disease. Among candidate genes is the CTLA-4 (cytotoxic T lymphocyte associated) gene located on chromosome 2q33 in humans, which encodes a cell surface molecule providing a negative signal for T cell activation.

AIMS

To investigate CTLA-4 exon 1 polymorphism (position 49 A/G) in patients with coeliac disease.

PATIENTS

101 patients with coeliac disease and 130 healthy controls.

METHODS

Allele specific hybridisation and restriction enzyme digestion of polymerase chain reaction amplified genomic DNA.

RESULTS

The A allele of the CTLA-4 position 49 polymorphism was found on 82.2% of chromosomes in patients with coeliac disease compared with 65.8% in controls (p < 0.0001), mostly in the homozygous form (68.3% in patients versus 47.7% in controls; odds ratio (OR) 2.36, 95% confidence interval (CI) 1.37 to 4.06, p = 0.002). Four patients only had the G/G genotype compared with 21 controls (OR 0.21, CI 10.07 to 0.64, p = 0.002). These differences were maintained when subjects were stratified according to the HLA class II phenotype, in particular when patients and controls were matched for the presence of the predisposing HLA DQB1*02 (DQ2) allele or HLA-DQA1*0501/DQB1*02 heterodimer.

CONCLUSION

The CTLA-4 gene polymorphism is a non-HLA determinant that predisposes to coeliac disease. Whether it directly contributes to disease susceptibility or represents a marker for a locus in linkage disequilibrium with CTLA-4 needs further investigation.

Collagenous gastritis revealed by severe anemia in a child

Collagenous gastritis is a rare histopathological disorder of unknown origin, characterized by a subepithelial collagen deposit greater than 10 microm thick, associated with an inflammatory infiltrate of the gastric mucosa. This report describes a second pediatric case of collagenous gastritis, revealed by severe anemia caused by gastric bleeding, as was the first case. Unlike the adult cases of collagenous gastritis, lesions were limited to the stomach, and remained unchanged on six series of biopsies taken during a 30 month follow-up, despite treatment with omeprazole, sucralfate and corticosteroids. An immunohistochemical study showed signs of local immune activation on all biopsy specimens, including overexpression of HLA-DR by epithelial cells, increased numbers of CD3+ intraepithelial lymphocytes, and CD25+ cells in the lamina propria. Although the cause of the disease remains unclear, our findings suggest that the histopathological lesions of collagenous gastritis may result from a local immune process.

Endoscopic ultrasonography in the evaluation of pediatric digestive diseases: preliminary results

BACKGROUND AND STUDY AIMS

Endoscopic ultrasonography (EUS) is rarely used in pediatrics. Its feasibility and potential indications have been assessed in this retrospective study.

PATIENTS AND METHODS

Twenty-three EUS examinations were carried out on 18 children (mean age 12 years, ranging from 4 to 16 years) using a mechanically rotating 7.5 and 12 MHz sector scan transducer. Upper digestive tract EUS (n = 17) was performed in children suffering from biliopancreatic diseases, angiomatosis or digestive tumors. They were performed under intravenous sedation. Anorectal EUS (n = 6), carried out after simple lavage in most cases, investigated tumors (adenomas and carcinoid tumor) or proctological diseases.

RESULTS

No technical failures or complications were encountered. EUS proved useful in the diagnosis of pancreatitis and portal hypertension. When included in pretherapeutic examinations, it provided useful information in cases of angiomatosis, biliary lithiasis and polyps. It was also useful in the follow-up of children after endoscopic excision or surgical treatment of adenomas or tumors (carcinoid tumor, neurofibroma).

CONCLUSION

EUS would therefore appear to be a promising technique in pediatric gastroenterology. More work is needed in order to better determine its indications and the need for equipment specific to children.

[Iterative intestinal intussusception and appendiceal mucocele in an infant with mucoviscidosis]

Cystic fibrosis is a common and potentially life-threatening hereditary disease which can affect numerous organs, particularly the digestive tract.

CASE REPORT

A 4.5-year-old boy exhibited two little known clinical manifestations: an appendiceal mucocele and repeated intussusceptions. In spite of an appendectomy, intussusception relapsed and an ileocolic resection was necessary 2 years later.

DISCUSSION

Appendiceal diseases in cystic fibrosis represent a large spectrum, ie, distention on the appendiceal lumen, engorged with sticky mucous matter, which becomes an appendiceal mucocele, peritonitis with an appendiceal perforation due to delayed diagnosis since acute appendicitis is difficult to diagnose in these patients. Intussusception is rarely observed in cystic fibrosis.

CONCLUSION

Appendiceal mucocele could be a cause of intussusception. If an appendectomy is performed, resection of a part of the cecum, around the appendix, could be useful in preventing again mucocele formation.

Interleukin-12 expression is focally enhanced in the gastric mucosa of pediatric patients with Crohn's disease

The stomach is frequently involved in children suffering from Crohn's disease (CD). Diagnosis of specific gastritis may be difficult when granulomas are absent. We have used in situ hybridization to examine the expression of interleukin (IL)-12, a key cytokine in the Th1 response. IL-12 p35 and p40 antisense probes were used to examine ileal specimens from 9 children with CD and gastric biopsies from 24 children (13 with CD, 6 with Helicobacter pylori chronic gastritis, and 5 with a normal gastric mucosa). In all patients with CD, many clusters of IL-12-positive cells were present in the lamina propria. This was the case in the ileal specimens as well as in gastric mucosa showing granulomatous gastritis or nongranulomatous gastritis. The same distribution patterns were found for the IL-12 p35 and p40. In three patients with Helicobacter pylori gastritis, few scattered IL-12-positive cells were found. No positive cells were found in the normal gastric mucosa. The focally enhanced IL-12 expression in the gastric mucosa of pediatric patients with CD, with or without specific lesions, suggests that both are indeed linked to the disease and supports the major part of IL-12 in initiating and maintaining of the cascade resulting in the Th1 responses.

[Perineal lesions in childhood Crohn disease]

BACKGROUND

Perineal lesions (PAL) usually evolve together with bowel disease and often constitute a serious and disabling complication of Crohn's disease.

PATIENTS

Forty-three children (47%) with Crohn's disease developed PAL in a retrospective study of 92 patients ranging in age from 4 to 20 years.

RESULTS

PAL occurred at the mean age of 11.4 +/- 0.7 years, prior to diagnosis in 25% or subsequently in 21%. PAL were severe: complex fistulae (15%), rectovaginal fistulae (2%), anal raggedness (13%); moderate: subcutaneous fistulae (11%), abscesses (19%), cavitating ulcers (9.5%) and stricture formations (5.7%); or mild: eczema (6.7%), fissures (57%) and skin tags (17%). An association with these various features has been observed in 31%. The extent of involvement of the gastrointestinal tract was rectosigmoid (72%), ileal and colonic (41%), ileal with pancolitis (12%). Two PAL course profiles were observed: one with exacerbation and remissions (52%), the other without remission (48%), especially anal raggedness (100%), cavitating ulcers (80%) and skin tags (61%). Medical treatment included steroids (54%), metronidazole (53%), salicylates (51%), nutritional support (44%), azathioprine (17%). PAL healed in 41%. Surgical treatment was performed in 27% with 83% of healing. Relapses occurred in 35% after medical treatment and 86% after surgery.

Increased TIA1-expressing intraepithelial lymphocytes in cow's milk protein intolerance

BACKGROUND

Although a high level of intraepithelial lymphocytes (IELs) has been demonstrated in intestinal biopsies from children with cow's milk protein intolerance (CMPI), the properties of IELs in food-sensitive enteropathies remain unclear. In the present study, we analyzed the cytotoxic potential of IELs in CMPI, using a monoclonal antibody directed against the cytotoxic granule-associated protein TIA1.

METHODS

The study included 18 duodenal biopsies from 10 children previously diagnosed with CMPI and on a cow's milk-free diet of various duration. Six normal duodenal biopsies from children free of food intolerance served as controls. Immunostaining of formalin-fixed tissues was used to determine in the intraepithelial compartment (1) the number of TIA1-expressing cells per 100 epithelial cells, (2) the number of IELs per 100 epithelial cells, (3) the ratio of TIA1-expressing IELs (TIA1/IEL ratio).

RESULTS

In CMPI, the number of IELs and TIA1-positive cells, as well as the TIA1/IEL ratio was significantly increased compared with controls. Moreover, a negative correlation between the TIA1/IEL ratio and the duration of the diet was observed.

CONCLUSIONS

These results suggest that the recruitment of IELs with cytotoxic potential is increased in CMPI, and that IEL-mediated cytotoxicity could be involved in the pathogenesis of the disease.

Histopathology and microbiology of isolated rectal bleeding in neonates: the so-called 'ecchymotic colitis'

Rectal bleeding in neonates is an alarming event which suggests a possible necrotizing enterocolitis (NEC) but is usually the only symptom of an unexplained colitis characterized endoscopically by ecchymotic mucosal lesions, the so-called 'ecchymotic colitis' (EC). We studied histologically and bacteriologically 18 infants (mean age: 18 days) presenting with rectal bleeding by systematic rectosigmoidoscopy and intestinal biopsies. The 18 infants were hospitalized. Prematurity was found in seven cases and an underlying condition in 14 cases (respiratory distress: six cases; infection: six cases; surgery: two cases). Histology showed a mild to moderate inflammation (10/12) of the mucosa with a prevalence of polymorphonuclear cells (8/10), frequent focal haemorrhages (11/12) and foci of pneumatosis (4/12). Numerous bacteria were seen in the mucus layer focally forming large clusters. Cultures of intestinal biopsies yielded exclusively Enterobacteriaceae species: Escherichia coli (seven cases), Klebsiella spp. (seven cases), and Enterobacter cloacae (three cases); four cases were sterile. Our study demonstrates that neonatal bleeding is associated with endoscopic and histological 'ecchymotic colitis' lesions and with a peculiar microbial flora of EBC strains. EC and necrotizing enterocolitis share similar features raising the question of the link between the two syndromes.

Ultrasonographic assessment of inflammatory bowel disease in children: comparison with ileocolonoscopy

OBJECTIVES

To determine the feasibility and value of transabdominal ultrasonography of the terminal ileum and colon of children with inflammatory bowel disease (IBD) and to compare the findings with those of ileocolonoscopy.

STUDY DESIGN

Thirty-eight patients ranging in age from 4 to 18 years who underwent ileocolonoscopy for management of IBD or for diagnosis were studied prospectively. Twenty-one patients had Crohn disease, nine had ulcerative colitis, and eight served as control subjects. Transabdominal ultrasonography was performed on the day before ileocolonoscopy. Ultrasonographic findings were compared with the results of ileocolonoscopy, used as the reference method.

RESULTS

Peristalsis was recorded in all segments of the control subjects; the thickness of the terminal ileum was always less than 2.5 mm, and that of the large bowel, 2 mm or less. In the two patient subgroups, the thickness range of affected ileal and colonic segments was similar, but values were significantly different from those of the control subjects (chi-square test, p <0.0001). The overall sensitivity of the method was 88%, and the specificity, 93%.

CONCLUSION

Transabdominal ultrasonography should prove to be a useful clinical and investigational technique, although further studies are needed to assess its value in the treatment of children with IBD.

[Contribution of endosonography to the diagnosis and follow-up of pediatric gastric neurofibroma revealing von Recklinghausen's disease]

BACKGROUND

Gastrointestinal involvement in von Recklinghausen's disease (RD) is rare during childhood; its symptoms are late and its prognosis is poor, related to local recurrence and risk of malignant transformation.

CASE REPORT

A 13 year-old boy was admitted for hematemesis revealing gastric ulcer. A second episode of hematemesis led to identify a sessile gastric tumor in this patient having numerous skin café-au-lait spots. Recurrent bleeding required laparotomy that showed diffuse infiltration into the anterior gastric wall: histological examination of the excised piece showed characteristic features of neurofibromatosis. The patient was not compliant to the endosonographic survey so that a symptomatic relapse led to total gastrectomy: histological examination did not show malignant transformation.

CONCLUSION

Endoscopy is a major tool for identifying gastrointestinal localization of RD but endosonography is necessary to precise the extent of the tumor.

Intractable diarrhea of infancy with epithelial and basement membrane abnormalities

We describe a form of intractable diarrhea in six children (four girls) with similar clinical histories and identical histopathologic features. The children had watery diarrhea of neonatal onset requiring total parenteral nutrition. Two had siblings who had died of diarrhea in the first year of life; two others are sisters. Repeated duodenal or jejunal biopsies revealed villous atrophy with normal or hyperplastic and regenerative cryptae, normal cellularity of the lamina mesenterii propria, and no signs of T-cell activation. The main histologic features are epithelial dysplasia with focal crowding and disorganization of the surface enterocytes, pseudocystic formation of the glands, and abnormal regenerative cryptae. The basement membrane components were studied with polyclonal antibodies on frozen specimens, and were compared with biopsy specimens from patients with celiac disease or autoimmune enteropathy. Relative to the control subjects, there was faint and irregular deposition of laminin at the epithelium-lamina mesenterii propria interface, whereas deposits of heparan sulfate proteoglycan were large and lamellar. The primary or secondary nature of these modifications of the basement membrane remains to be determined, but the modifications might be related to epithelial abnormalities and to the severity of this neonatal diarrhea, which resisted all treatment and necessitated permanent total parenteral nutrition.

[Adenocarcinoma on villous tumor of the rectum in an adolescent]

CASE REPORT--A 15-year 6-month-old boy suffered from isolated recurrent rectal bleeding. Rectoscopy and colonoscopy allowed to identify and to excise one large size villous polyp, which was the site of dysplasia and liberkühn adenocarcinoma. Transrectal ultrasonography showed thickened mucosa and submucosa and suspect adenopathy. Proctectomy, ganglionic curage and coloanal anastomosis were then performed; one of the excised adenopathies was metastatic. The patient died twelve hours after surgery from an unexplained cardiovascular collapse. CONCLUSIONS--Unspecific symptoms of colorectal cancer explain that its diagnosis is often delayed. Prognosis is poor related to the advanced stages at diagnosis and mucinous adenocarcinomas. Better knowledge of the clinical presentations and of high risk situations as polyposis, ulcerative colitis, hereditary non polyposis colorectal cancer could improve the prognosis.

Reevaluation of the relative risk for susceptibility to celiac disease of HLA-DRB1, -DQA1, -DQB1, -DPB1, and -TAP2 alleles in a French population

In a population of 46 children with CD recruited in the Paris area of France, an excess of DRB1*03 and DRB1*07 alleles and of DR3/DR7, DR3/DR3 and DR11(or 12)/DR7 phenotypes was found (RRs of 6.3, 9.3, 24.6, 15, and 15.1, respectively), which is reminiscent of the markers of susceptibility observed in southern rather than in northern European celiac patients. More importantly, the highest association with CD was not found in individuals expressing the DQA1*0501-DQB1*0201 heterodimer in single dosage (RR = 24.9) or in homozygous state, but in people co-expressing one copy of DQA1*0501-DQB1*0201 on one haplotype and a second copy of DQB1*0201 on the second haplotype (RR = 35.7). This suggests that in our population either DQB1*0201 or a gene closely linked to DQB1*0201 influences the susceptibility to CD conferred by the DQA1*0501-DQB1*0201 heterodimer. Significant positive or negative RRs conferred by some TAP2 or DPB1 alleles were found. However, they were moderate compared to the RR conferred by the expression of a second copy of DQB1*0201. Moreover, they were no longer significant when patients were compared with HLA-DR matched controls. This suggests that associations of CD with TAP2 and DPB1 alleles are secondary to linkage disequilibria and argues against the contribution of these alleles in resistance and/or susceptibility to CD. Thus the "raison d'être" of a "DQB1*0201 second haplotype effect" in susceptibility to CD remains to be elucidated.

[Esophageal dilatation in pediatrics: study of 33 patients]

BACKGROUND

Esophageal dilatation is usually regarded as an effective therapy in a majority of esophageal stenosis in childhood. However, the limited number of pediatric data does not allow definite conclusions on indications and complications of such a procedure.

PATIENTS AND METHODS

The files of 33 children whose esophageal stenosis had been treated by dilatation by the same operator between 1983 and 1992 were retrospectively reviewed. The structure mechanisms were: group 1: repair of esophageal atresia (n = 9), group 2: caustic esophagitis (n = 6), group 3: peptic esophagitis (n = 12), group 4: unclassified structures (congenital esophageal stenosis, achalasia) (n = 6). The dilatations were performed under general anesthesia, and the dilatator guide was introduced under endoscopic control. Two methods were used: Savary esophageal bougies and balloon dilatation. A thoracic X-ray was systematically performed after each dilatation.

RESULTS

One hundred and fourteen dilatations (3.5 dilatations/child) were performed (range: 1-32 dilatations). Twenty-five of the 33 children (76%) were dramatically improved after mechanical dilatation. Esophageal dilatation was unsuccessful in the eight other patients, seven of them requiring a surgical repair. Complications occurred in 3.4% of the dilatations: one esophageal perforation, one pneumomediastinum and two cardiac arrests (one of vagal origin and 1 after accidental extubation). All patients survived. Efficacy, duration of dilatation and complication rates were not similar in the four groups.

CONCLUSIONS

Esophageal dilatation should be considered as a simple and effective procedure when strict security rules are respected by a trained operator.

Prenatal gastrointestinal bleeding caused by esophagitis and gastritis

We report a case of a prenatal esophagitis and gastritis revealed at 33 weeks of gestation by the presence of bloody amniotic fluid and dilated intestinal loops that was confirmed by endoscopy at birth. Complete recovery occurred after treatment with ranitidine.

[A rare cause of rectal hemorrhage in children: rectal angiodysplasia]

BACKGROUND

Parietal vascular malformations of the intestinal tract are rare and their diagnosis is often difficult.

CASE REPORT

A 2 year-old boy had suffered from intermittent rectal bleeding since the age of one year. Endoscopic examination showed unspecific congestive changes and biopsy showed features of chronic inflammatory changes in the rectum. Barium enema was normal. The patient was operated on, but surgery failed to find any cause for these hemorrhages. Rectal bleedings recurred, some of them resulting in severe anemia. Two further endoscopic examination were grossly negative as was inferior mesenteric arteriography. Spontaneous rectal prolapsus occurred when the boy was 4 years old. This allowed resection of all the submucosal veins of the anal canal; it was followed by complete cessation of rectal bleeding with a follow-up of 36 months. Histological examination showed several ectasias of the capillaries and veins in the submucosa and muscular layers.

CONCLUSION

Angiectases can occur in a small part of the intestinal tract, and can escape detection by repeated specialized investigation.

Detection of Mycobacterium paratuberculosis by polymerase chain reaction in children with Crohn's disease

Mycobacterium paratuberculosis, the causative agent of Johne's disease (a chronic enteritis in ruminants), has been suspected to be involved in Crohn's disease. In this study, polymerase chain reaction was used to detect the presence of IS900 DNA sequences specific to M. paratuberculosis genomes in biopsies and surgical resections from 53 children with various gastrointestinal diseases and disorders. IS900 sequences were found in 13 of 18 samples from patients with Crohn's disease (72%; P < .01 vs. samples from patients without Crohn's disease), in 1 of 5 with ulcerative colitis, in 2 of 6 with severe unclassified colitis, and in 7 of 24 with other gastrointestinal illnesses. These results appear to support the hypothesis that M. paratuberculosis is involved in the pathogenesis of Crohn's disease.

[Contribution of genetic typing for the diagnosis of familial adenomatous polyposis in pediatrics]

BACKGROUND

The gene responsible for familial adenomatous polyposis, (APC), has been recently cloned and genetic map with several polymorphic markers has been established.

POPULATION AND METHODS

Blood samples (20 ml) were taken from 34 subjects belonging to four families at risk for familial adenomatous polyposis. Nineteen of these 34, less than 20 years old, had one parent having polyposis or dead because of it. Polyposis was diagnosed, in ten of these 19 by endoscopy. Genomic DNA was extracted from peripheral leukocytes and Southern blot analyses were performed in each family, using RFLPs on both sides of the APC locus.

RESULTS

DNA analysis identified normal and mutant haplotypes at the APC locus in each family. It was thus possible to follow the segregation of mutant alleles. These results were compared with the anamnestic and endoscopic data. Bearing in mind the risk of recombination when using extragenic markers, RFLPs allowed early diagnosis of APC in pre and/or asymptomatic patients.

CONCLUSIONS

Genetic analysis can be used to diagnose APC in affected families, provided the risk of recombination is taken into account. Intragenic microsatellites markers will soon be available. These will provide more information on the APC gene, and hence direct molecular diagnosis of APC.

[Multicenter study of sodium alginate in the treatment of regurgitation in infants]

An open multicenter study was performed to assess the efficacy and safety of alginic acid in two different dosages in 76 pediatric patients with gastroesophageal reflux confirmed by pH monitoring. Among the 69 patients in whom endoscopy was carried out before treatment, 18 had erythematous esophagitis and 5 had erosive esophagitis. Irrespective of the dosage used, the frequency of regurgitation and vomiting decreased significantly (p < 0.00001 and p = 0.01, respectively). Clinical and biochemical tolerance were outstanding and no adverse effects were recorded. On the basis of these data, the recommended dosage is 1 to 2 ml/kg/day in divided doses after meals.

[Severe Crohn's disease in children. Retrospective study of 38 cases]

Thirty-eight children presenting with severe Crohn's disease (CD) were studied retrospectively over a mean period of 6 years. The severity of CD was estimated according to an activity score. This was initially 66 +/- 19 reaching 100 in 16% of cases. Initial involvement included ileon and large intestine only (n = 23), large intestine (n = 11) and ileon only (n = 4), with upper GI tract or perineal involvement in 32 and 75% of cases respectively. The treatments consisted of corticosteroids (n = 34), azathioprine (n = 11), continuous enteral feeding (CEF) (n = 25), parenteral nutrition (PN) (n = 30). Mean recurrence rates per patient and per year were 0.6 in the groups including ileon and large intestine or the large intestine only and 0.3 in the ileal group. A surgical resection was performed in 20 cases with a mean rate of reoperation of 40% at 5 years. Reoperations were necessary only in the group involving the ileon and large intestine. Mean weight catch-up in 3 months and height growth speed were 6 kg and 1.7 to 3.1 cm/year under CED and/or PN. After a 6 year follow-up the activity index was decreased by 70% with a quality of life considered to be good in 60% of cases.

Classification of intractable diarrhea in infancy using clinical and immunohistological criteria

Several experimental studies have demonstrated that activated intestinal T cells can induce villous atrophy. This observation led us to examine the possible role of activated T cells in the pathogenesis of intestinal lesions in a group of 13 children with intractable diarrhea and villous atrophy of unknown origin. Immunohistochemical study showed signs of intestinal mononuclear cell activation in seven patients. These signs included a marked increase in the number of mucosal T cells, mainly TCR alpha beta+, the appearance of lamina propria interleukin-2-receptor-bearing cells, and an increased expression of HLA-DR antigens by enterocytes. No local cause of intestinal T-cell activation was found. However, four out of seven patients had extradigestive symptoms of autoimmunity, suggesting that the intestine might also be the site of an autoimmune reaction responsible for the epithelial lesions. In these patients, presence of crypt necrosis and colic extension of the lesions suggested poor prognosis. In contrast, in six other patients, no immunohistochemical evidence of mucosal T-cell activation was obtained. In the latter cases, analysis of clinical data favored the hypothesis of a primary inborn defect of enterocyte differentiation.

Microscopic colitis: a new cause of chronic diarrhea in children?

From a retrospective study on children who underwent colonoscopy or rectosigmoidoscopy with multiple level biopsies, we selected five patients whose rectocolonic endoscopic aspect was normal and contrasting with the presence of a microscopic colitis on biopsies. These five children had chronic diarrhea (mean duration of 14 months), associated with vomiting (three cases), abdominal pain (two cases), anorexia (two cases), abdominal distension (two cases), and weight loss (four cases). Symptomatic treatment was used in all children: loperamide (one case), trimebutine (three cases), and aluminium and magnesium silicate (two cases). One child received sulfasalazine for 2 months. After 1 year, all patients had normal stools. Rectosigmoidoscopy was performed in four patients and was normal. Biopsies obtained in three cases were normal in two cases and showed a persistent microscopic colitis in one case. Microscopic colitis may be a distinct cause of chronic diarrhea in children.

[Pharmacologic efficacy of sodium alginate suspension on gastro-esophageal reflux in infants and children]

Eighty-three children presenting with symptomatic gastro-esophageal reflux (GER) (48 males, 35 females, aged 15 days to 57 months (mean = 7 months) were assessed by pH monitoring. All showed acid pathological GER on the 3 hours post-prandial esophageal pH measurement (% of time at pH less than 4 greater than 4.2) and all had a second pH measurement within the following 3 hours after intake of a single (5 ml) dose of sodium alginate (AGS). AGS administration was followed by a highly significant reduction (p less than 0.00001) of all pH measurement variables: a) Percentage of time spent at pH less than 4 returned to normal with a mean 11.7% to 4.8%; that is a 52.5% improvement (median); b) Total number of reflux reduced on average from 8.9 to 5.0: that is a 35% improvement (median); c) Mean duration of reflux reduced on average for 4 to 2 min; that is a 60% improvement (median). In 76 patients hourly monitoring of % of time spent at pH less than 4 shows that hourly improvement persists.

Crohn's disease lesions in the upper gastrointestinal tract: correlation between clinical, radiological, endoscopic, and histological features in adolescents and children

The incidence of Crohn's disease (CD) lesions in the upper gastrointestinal (GI) tract of both adults and children is frequently underestimated. In this prospective study, a total of 31 children suspected of having Crohn's disease were systematically examined to identify upper digestive tract lesions. They all underwent barium transit endoscopy with multiple-level biopsies. Typical clinical symptoms suggestive of upper GI tract involvement were found in 5 children (16%), radiological signs in only one child (3%), endoscopic lesions in 13 children (42%), and specific granulomas in 12 children (39%). In eight of these 12 children, the biopsies were taken from macroscopically normal areas of the esophagogastroduodenal mucosa. One of the 31 children had no abnormal radiological and endoscopic features suggestive of CD on the distal small bowel and the colon. There was no correlation between the clinical, radiological, and histological data. Endoscopy plus biopsy provided a positive diagnosis in 39% of cases and a confirmation of the diagnosis in 87% of cases. Endoscopic and histological evidence of CD of the upper GI tract is often present despite an absence of clinical symptoms or radiological changes. Upper GI tract endoscopy with multiple biopsies may be important in the evaluation of this condition and even in some cases for the establishment of the diagnosis.

[Recto-colic polyps in the child. Analysis of 183 cases]

Between January 1974 and April 1988, 1,533 colonoscopy were carried out in children less than 15 years old. Two hundred and seventy-four polyps were demonstrated in 183 children (106 boys, 77 girls, mean age: 6 years). The main symptom in most cases was rectal bleeding during defecation. A family history of polyps or digestive cancer was found in 6% of all patients. Two hundred and thirty-nine polyps were removed by endoscopic resection, 232 of them by the diathermic snare and 7 by William's hot biopsy technique. Histological examination of 129 polyps revealed a juvenile polyp in 125 cases, an hyperplastic polyp in 2 cases, a lymphoid polyp in 1 case and an adenoma in 1 case. No complications were observed except for one case each of hemorrhage and perforation following endoscopic polypectomy.