Quality indicators in pediatric colonoscopy: an Australian tertiary center experience

OBJECTIVES

Quality indicators for colonoscopy in adults are largely driven by colorectal cancer screening, and include cecal intubation rates, with rates of >90% recommended. In contrast, colorectal cancer is rare in childhood, with paucity of data on relevant quality indicators for pediatric colonoscopy. It is also unclear whether high rates of cecal intubation are achievable in small children. Our aim was to audit all colonoscopies performed in a tertiary pediatric center to examine clinical indications for procedure, completeness of examination with cecal and ileal intubation, significant findings, and complications.

METHODS

Retrospective review of colonoscopies performed between November 2011 and October 2015 was undertaken.

RESULTS

Total colonoscopy was performed in 652 patients, 53% male, with median age 13.0 (range 0.4-18.2) years. The most common indications for colonoscopy were assessment of inflammatory bowel disease (IBD) 57.9% (378/652), rectal bleeding 10% (68/652) and abdominal pain 10% (68/652). Trainees performed 69.8% (452/652) of procedures. Quality of bowel preparation was mentioned in 63% (410/652), of which 22% (90/410) were considered inadequate. Cecal intubation rate was 96.3% (628/652) and ileal intubation rate was 92.4% (603/652). Extent of procedure was confirmed in 99.2% of patients with photographs and/or ileal biopsy. Poor quality of bowel preparation (p = .001) and age <5years (p = .007) were inversely related to successful ileal intubation.

CONCLUSIONS

High rates of cecal and ileal intubation are achievable in pediatric colonoscopy. Ileal intubation should be considered a quality indicator since the main indicator for pediatric colonoscopy is to investigate IBD.

Academic potential and cognitive functioning of long-term survivors after childhood liver transplantation

This cross-sectional study assessed intellect, cognition, academic function, behaviour, and emotional health of long-term survivors after childhood liver transplantation. Eligible children were >5 yr post-transplant, still attending school, and resident in Queensland. Hearing and neurocognitive testing were performed on 13 transplanted children and six siblings including two twin pairs where one was transplanted and the other not. Median age at testing was 13.08 (range 6.52-16.99) yr; time elapsed after transplant 10.89 (range 5.16-16.37) yr; and age at transplant 1.15 (range 0.38-10.00) yr. Mean full-scale IQ was 97 (81-117) for transplanted children and 105 (87-130) for siblings. No difficulties were identified in intellect, cognition, academic function, and memory and learning in transplanted children or their siblings, although both groups had reduced mathematical ability compared with normal. Transplanted patients had difficulties in executive functioning, particularly in self-regulation, planning and organization, problem-solving, and visual scanning. Thirty-one percent (4/13) of transplanted patients, and no siblings, scored in the clinical range for ADHD. Emotional difficulties were noted in transplanted patients but were not different from their siblings. Long-term liver transplant survivors exhibit difficulties in executive function and are more likely to have ADHD despite relatively intact intellect and cognition.

Audit of eosinophilic oesophagitis in children post-liver transplant

Pediatric liver transplantation has proven so successful that 10-yr survival post-transplantation is in excess of 70% and following transplantation, emphasis of medical care switches from life saving to promotion of good quality of life. EE is an increasingly recognised phenomenon in the general population. Eosinophilic disorders of the GI tract are increasingly recognised in patient's post-solid organ transplantation but the contribution of EE to morbidity in this population has not been addressed to date. The objective of this study was to identify the incidence of EE in children receiving liver transplantation by the QLTS over the last 15.5 yr. Comprehensive review of medical records of all liver transplant recipients during study period via cross-checking procedural and electronic laboratory results was performed. All oesophageal biopsies reporting mucosal inflammation were reviewed. EE can be diagnosed when oesophageal biopsy reveals > or =5 eosinophils per HPF; however, we used a cut-off of 20 eosinophils per HPF, which is in accordance with current opinion. In the 159 children who received DD OLT, 130 survived and four have been diagnosed with EE (3%). Only 34 are currently followed in Queensland and all four patients diagnosed are in this cohort representing 12% of our follow-up clinic. Many patients are followed elsewhere so occurrence of EE in our total surviving population is an underestimate. EE is clinically important in the post-liver transplant community. Children post-OLT who have upper GI symptoms should be considered for endoscopic evaluation and biopsy to exclude EE.

Resting energy expenditure in children with inflammatory bowel disease

OBJECTIVES

There is controversy in the literature regarding the effect of inflammatory bowel disease (IBD) on resting energy expenditure (REE). In many cases this may have resulted from inappropriate adjustment of REE measurements to account for differences in body composition. This article considers how to appropriately adjust measurements of REE for differences in body composition between individuals with IBD.

PATIENTS AND METHODS

Body composition, assessed via total body potassium to yield a measure of body cell mass (BCM), and REE measurements were performed in 41 children with Crohn disease and ulcerative colitis in the Royal Children's Hospital, Brisbane, Australia. Log-log regression was used to determine the power function to which BCM should be raised to appropriately adjust REE to account for differences in body composition between children.

RESULTS

The appropriate value to "adjust" BCM was found to be 0.49, with a standard error of 0.10.

CONCLUSIONS

Clearly, there is a need to adjust for differences in body composition, or at the very least body weight, in metabolic studies in children with IBD. We suggest that raising BCM to the power of 0.5 is both a numerically convenient and a statistically valid way of achieving this aim. Under circumstances in which the measurement of BCM is not available, raising body weight to the power of 0.5 remains appropriate. The important issue of whether REE is changed in cases of IBD can then be appropriately addressed.

'Free' surfactant in gastric aspirates and bronchoalveolar lavage in children with and without reflux oesophagitis

AIM

Dipalmitoylphosphatidycholine (DPPC) is the characteristic and main constituent of surfactant. Adsorption of surfactant to epithelial surfaces may be important in the masking of receptors. The aims of the study were to (i) compare the quantity of free DPPC in the airways and gastric aspirates of children with gastroesophageal reflux disease (GORD) to those without and (ii) describe the association between free DPPC levels with airway cellular profile and capsaicin cough sensitivity.

METHODS

Children aged <14 years were defined as 'coughers' if a history of cough in association with their GORD symptoms was elicited before gastric aspirates and nonbronchoscopic bronchoalveolar lavage (BAL) were obtained during elective flexible upper gastrointestinal endoscopy. GORD was defined as histological presence of reflux oesophagitis. Spirometry and capsaicin cough-sensitivity test was carried out in children aged >6 years before the endoscopy.

RESULTS

Median age of the 68 children was 9 years (interquartile range (IQR) 7.2). Median DPPC level in BAL of children with cough (72.7 microg/mL) was similar to noncoughers (88.5). There was also no significant difference in DPPC levels in both BAL and gastric aspirates of children classified according to presence of GORD. There was no correlation between DPPC levels and cellular counts or capsaicin cough-sensitivity outcome measures.

CONCLUSION

We conclude that free DPPC levels in the airways and gastric aspirate is not influenced by presence of cough or GORD defined by histological presence of reflux oesophagitis. Whether quantification of adsorbed surfactant differs in these groups remain unknown. Free DPPC is unlikely to have a role in masking of airway receptors.

Airway cellularity, lipid laden macrophages and microbiology of gastric juice and airways in children with reflux oesophagitis

BACKGROUND

Gastroesophageal reflux disease (GORD) can cause respiratory disease in children from recurrent aspiration of gastric contents. GORD can be defined in several ways and one of the most common method is presence of reflux oesophagitis. In children with GORD and respiratory disease, airway neutrophilia has been described. However, there are no prospective studies that have examined airway cellularity in children with GORD but without respiratory disease. The aims of the study were to compare (1) BAL cellularity and lipid laden macrophage index (LLMI) and, (2) microbiology of BAL and gastric juices of children with GORD (G+) to those without (G-).

METHODS

In 150 children aged < 14-years, gastric aspirates and bronchoscopic airway lavage (BAL) were obtained during elective flexible upper endoscopy. GORD was defined as presence of reflux oesophagitis on distal oesophageal biopsies.

RESULTS

BAL neutrophil% in G- group (n = 63) was marginally but significantly higher than that in the G+ group (n = 77), (median of 7.5 and 5 respectively, p = 0.002). Lipid laden macrophage index (LLMI), BAL percentages of lymphocyte, eosinophil and macrophage were similar between groups. Viral studies were negative in all, bacterial cultures positive in 20.7% of BALs and in 5.3% of gastric aspirates. BAL cultures did not reflect gastric aspirate cultures in all but one child.

CONCLUSION

In children without respiratory disease, GORD defined by presence of reflux oesophagitis, is not associated with BAL cellular profile or LLMI abnormality. Abnormal microbiology of the airways, when present, is not related to reflux oesophagitis and does not reflect that of gastric juices.

Acute liver failure in children: A regional experience

OBJECTIVE

To review the outcome of acute liver failure (ALF) and the effect of liver transplantation in children in Australia.

METHODOLOGY

A retrospective review was conducted of all paediatric patients referred with acute liver failure between 1985 and 2000 to the Queensland Liver Transplant Service, a paediatric liver transplant centre based at the Royal Children's Hospital, Brisbane, that is one of three paediatric transplant centres in Australia.

RESULTS

Twenty-six patients were referred with ALF. Four patients did not require transplantation and recovered with medical therapy while two were excluded because of irreversible neurological changes and died. Of the 20 patients considered for transplant, three refused for social and/or religious reasons, with 17 patients listed for transplantation. One patient recovered spontaneously and one died before receiving a transplant. There were 15 transplants of which 40% (6/15) were < 2 years old. Sixty-seven per cent (10/15) survived > 1 month after transplantation. Forty per cent (6/15) survived more than 6 months after transplant. There were only four long-term survivors after transplant for ALF (27%). Overall, 27% (6/22) of patients referred with ALF survived. Of the 16 patients that died, 44% (7/16) were from neurological causes. Most of these were from cerebral oedema but two patients transplanted for valproate hepatotoxicity died from neurological disease despite good graft function.

CONCLUSIONS

Irreversible neurological disease remains a major cause of death in children with ALF. We recommend better patient selection and early referral and transfer to a transplant centre before onset of irreversible neurological disease to optimize outcome of children transplanted for ALF.

Lymphatic absorption of fatty acids and cholesterol in the neonatal rat

High-fat diets are essential in suckling animals to ensure adequate calories for postnatal growth, but their lymphatic transport of dietary lipids has not been characterized. We established a lymph fistula model in suckling rats to quantify intestinal uptake and lymphatic transport of dietary lipids and analyzed lipoprotein fractions. Suckling 19-day-old Sprague-Dawley rats had their mesenteric lymph ducts cannulated and gastroduodenal tubes inserted. After overnight recovery, [(3)H]triolein and [(14)C]cholesterol were infused for 6 h. Of the total dose, only 38% of triolein and 24% of cholesterol were transported in the lymph of suckling rats. Analyses of residual luminal contents and intestinal mucosal homogenate showed neither reduced absorption nor delayed mucosal processing of ingested lipids to be the cause. Thin-layer chromatographic analysis of radioactive mucosal lipids, however, showed a predominance of free fatty acids (60%) and free cholesterol (67%), implying impaired esterification capacity in these animals. We speculate that this reduced esterification allows for portal transport or direct enterocyte metabolism of dietary lipids.

Gastrointestinal infections in children

New pathogens that cause gastroenteritis in children are being recognized. Even well-recognized pathogens, such as Clostridium difficile, may require more extensive testing than was previously thought necessary. Several new tests have emerged that allow for faster identification of these pathogens so that same-day results may be possible. Probiotic therapy has emerged as a novel strategy for the treatment of gastroenteritis. New vaccines against both viral and bacterial causes of gastroenteritis are being developed. The most exciting recent advance in vaccine development may be the creation of edible vaccines.

Nefazodone-induced liver failure: report of three cases

BACKGROUND

Liver failure is a rare but devastating result of drug toxicity.

OBJECTIVE

To describe three cases of subfulminant liver failure that were probably caused by nefazodone, a new antidepressant that is a synthetically derived phenylpiperazine.

DESIGN

Case series.

SETTING

Two university medical centers and a children's hospital.

PATIENTS

Three women 16 to 57 years of age.

INTERVENTION

Two patients underwent liver transplantation; the third was listed for transplantation but subsequently improved.

MEASUREMENT

Liver biopsy.

RESULTS

Nefazodone was administered for 14 to 28 weeks before the onset of symptoms. The duration of jaundice before onset of encephalopathy ranged from 4 to 6 weeks. All cases of liver failure had similar histologic appearance, with prominent necrosis in the centrolobular areas (zone 3). One patient had successful liver transplantation, one underwent transplantation but died, and one improved without transplantation. The temporal onset of disease after the start of nefazodone therapy suggested severe hepatocellular injury caused by the drug.

CONCLUSIONS

Because nefazodone seems to cause severe hepatocellular injury in an idiosyncratic manner, routine liver chemistries should be performed before starting nefazodone therapy and patients should be monitored regularly. Therapy should be discontinued if liver enzyme concentrations become abnormal.