A significant increase in anthropometric indices during long-term follow-up of pediatric patients with celiac disease, with no endocrine disorders

Celiac disease (CeD) is likely to be associated with growth impairment and poor weight gain. However, long-term growth patterns following diagnosis are poorly characterized. We evaluated long-term anthropometric changes in a large cohort of pediatric patients with CeD. A retrospective chart review of patients diagnosed with CeD between 1999 and 2018 was conducted. Demographic and clinical data were collected, and anthropometrics were analyzed from diagnosis and throughout follow-up. The study included 500 patients (59.8% females, median (IQR) age at diagnosis 5.7 (3.7-8.9) years), with a mean follow-up of 5.5 (range 1.5-16.2) years. Weight, height, and BMI Z-score-for-age (WAZ, HAZ, and BMIZ) increased significantly from a mean (± SD) of - 0.82 (± 1.21), - 0.73 (± 1.16), and - 0.32 (± 1.11) at diagnosis to - 0.41 (± 1.23), - 0.45(± 1.16), and - 0.17 (± 1.14) at last follow-up, respectively (p < 0.001 for WAZ and HAZ and p = 0.002 for BMIZ). The largest improvements were observed in patients diagnosed before 3 years of age (p < 0.01). Patients for whom the final adult height was available (n = 86) improved from HAZ mean (± SD) - 0.89 ± 1.37 at diagnosis to - 0.51 ± 1.28 at adulthood measurement, p < 0.05. Wasting was present in 19.7% and stunting in 16.4% of the cohort at diagnosis and normalized in 77.3% and 64.8%, respectively, within a median (IQR) time of 0.79 (0.42-4.24) and 2.3 (0.72-6.02) years, respectively. Gluten-free diet adherence and frequency of visits were not associated with normalization of wasting or stunting in all age groups.  Conclusion: Over a long-term follow-up, pediatric patients with CeD demonstrate significant increases in weight, height, and BMI-for-age. Younger age at diagnosis is associated with greater improvement in weight and linear growth, emphasizing the importance of early diagnosis of CeD. What is Known: • Celiac disease (СeD) is likely to be associated with growth impairment and poor weight gain. • Long-term changes in anthropometric indices after diagnosis of CeD are not well characterized. What is New: • Over a long-term follow-up, pediatric patients with CeD demonstrate significant increases in weight, height, and BMI-for-age. • Young age at diagnosis is associated with larger improvement in weight and linear growth.

Clinical Presentation of Patients with Eosinophilic Gastrointestinal Diseases beyond Eosinophilic Esophagitis

The clinical presentation of eosinophilic gastrointestinal diseases beyond eosinophilic esophagitis (non-EoE EGIDs) varies depending on the gastrointestinal segments affected by the eosinophilic inflammation, the extent of eosinophilic inflammation within the gastrointestinal tract and its depth through the bowel wall. Non-EoE EGIDs with mucosal involvement tend to present with diarrhea, malabsorption, and sometimes bleeding, those with muscular involvement may present with symptoms of obstruction or pseudo-obstruction, intussusception, and even perforation, whereas those with serosal involvement may present with eosinophilic ascites. Here we describe the differences in symptoms experienced by children with non-EoE EGIDs with varying degrees of eosinophilic inflammation through the bowel wall.

Joint ESPGHAN/NASPGHAN Guidelines on Childhood Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis

INTRODUCTION

Eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis (non-EoE EGIDs) are rare chronic inflammatory disorders of the gastrointestinal (GI) tract. Diagnosis is based on clinical symptoms and histologic findings of eosinophilic inflammation after exclusion of a secondary cause or systemic disease. Currently, no guidelines exist for the evaluation of non-EoE EGIDs. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed a task force group to provide consensus guidelines for childhood non-EoE EGIDs.

METHODS

The working group was composed of pediatric gastroenterologists, adult gastroenterologists, allergists/immunologists, and pathologists. An extensive electronic literature search of the MEDLINE, EMBASE, and Cochrane databases was conducted up to February 2022. General methodology was used in the formulation of recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to meet current standards of evidence assessment.

RESULTS

The guidelines provide information on the current concept of non-EoE EGIDs, disease pathogenesis, epidemiology, clinical manifestations, diagnostic and disease surveillance procedures, and current treatment options. Thirty-four statements based on available evidence and 41 recommendations based on expert opinion and best clinical practices were developed.

CONCLUSION

Non-EoE EGIDs literature is limited in scope and depth, making clear recommendations difficult. These consensus-based clinical practice guidelines are intended to assist clinicians caring for children affected by non-EoE EGIDs and to facilitate high-quality randomized controlled trials of various treatment modalities using standardized, uniform disease definitions.

Gluten Immunogenic Peptides Are Not Correlated With Reported Adherence to Gluten-Free Diet in Children With Celiac Disease

OBJECTIVE

There is no gold standard to assess adherence to gluten-free diet (GFD) among patients with celiac disease (CeD). Gluten immunogenic peptides (GIPs) in urine and stool were suggested as novel markers for evaluating adherence to GFD. Our aim was to assess the presence of GIP in pediatric patients with CeD, and to compare the results with alternative methods for evaluating GFD adherence.

METHODS

Pediatric patients diagnosed with CeD, who were on GFD for at least 1 year, were enrolled and followed prospectively between November 2018 and January 2021. Study visits included clinical assessment, a dietitian interview, Biagi score, food questionnaires, anthropometric and laboratory measurements, and urine and stool samples obtained for laboratory GIP analysis.

RESULTS

The study included 74 patients (63.5% females), with median (interquartile range, IQR) age of 9.9 (7.8-11.7) years, and median (IQR) duration on GFD of 2.5 (2-5.5) years. Good GFD adherence, assessed by Biagi score, was reported in 93.1% of cases. GIP was evaluated during 134 visits, with GIP detected in 27 of 134 (20.1%) of the visits (16.3% of stool samples and 5.3% of urine samples). Positive GIP results were significantly more common in males compared to females (30.6% vs 14.1%, respectively, P < 0.05). Detection of positive GIP was not associated with dietary assessment of GFD adherence, celiac serology results, or reported symptoms.

CONCLUSIONS

Stool and urine GIP can be detected in children with CeD, even when dietary assessment indicate good adherence to GFD. The role of GIP testing in clinical practice should be further explored.

International Consensus Recommendations for Eosinophilic Gastrointestinal Disease Nomenclature

BACKGROUND & AIMS

Substantial heterogeneity in terminology used for eosinophilic gastrointestinal diseases (EGIDs), particularly the catchall term "eosinophilic gastroenteritis," limits clinical and research advances. We aimed to achieve an international consensus for standardized EGID nomenclature.

METHODS

This consensus process utilized Delphi methodology. An initial naming framework was proposed and refined in iterative fashion, then assessed in a first round of Delphi voting. Results were discussed in 2 consensus meetings, and the framework was updated and reassessed in a second Delphi vote, with a 70% threshold set for agreement.

RESULTS

Of 91 experts participating, 85 (93%) completed the first and 82 (90%) completed the second Delphi surveys. Consensus was reached on all but 2 statements. "EGID" was the preferred umbrella term for disorders of gastrointestinal (GI) tract eosinophilic inflammation in the absence of secondary causes (100% agreement). Involved GI tract segments will be named specifically and use an "Eo" abbreviation convention: eosinophilic gastritis (now abbreviated EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC). The term "eosinophilic gastroenteritis" is no longer preferred as the overall name (96% agreement). When >2 GI tract areas are involved, the name should reflect all of the involved areas.

CONCLUSIONS

This international process resulted in consensus for updated EGID nomenclature for both clinical and research use. EGID will be the umbrella term, rather than "eosinophilic gastroenteritis," and specific naming conventions by location of GI tract involvement are recommended. As more data are developed, this framework can be updated to reflect best practices and the underlying science.

Is fundoplication mandatory in children with neurological impairment undergoing gastrostomy?

AIM

Percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy (SG) are common procedures in children with neurological impairment (NI) with swallowing difficulties. Pulmonary aspirations are a major concern and performing concomitant or delayed fundoplication is still controversial, especially among these patients. The aim of our study was to review our experience with fundoplication performed concomitantly with gastrostomy or later and to evaluate patient outcomes.

METHODS

This is a retrospective, cohort study including all paediatric patients who underwent SG or PEG with or without Nissen fundoplication at Schneider Children's Medical Center of Israel between the years 2007 and 2018. Patients' clinical and surgical data were recorded and analysed.

RESULTS

Between 2007 and 2018, 345 patients underwent SG or PEG. Of these, 89 patients underwent fundoplication. Of the patients who underwent PEG/SG, 158 (45.8%) were neurologically impaired. Most of the patients who underwent fundoplication (n = 69, 77.5%) were NI patients (P = 0.0001). NI patients with refractory seizures showed almost no improvement in terms of relief of gastro-oesophageal reflux disease symptoms following fundoplication (P = 0.0001) compared to NI patients without refractory seizures.

CONCLUSION

Our findings suggest that in NI patients a concomitant fundoplication is not mandatory and is not efficacious in preventing gastro-oesophageal reflux disease in patients with refractory seizures.

A Quantitative Assessment of Mucosal Eosinophils in the Gastrointestinal Tract of Children Without Detectable Organic Disease

BACKGROUND

Accurate measurements of mucosal eosinophil concentrations in gastrointestinal tracts of healthy children are necessary to differentiate health and disease states in general, and better define eosinophilic gastrointestinal diseases.

STUDY

We retrospectively reviewed gastrointestinal biopsies from children with macroscopically normal endoscopies, who, after a minimal follow-up of one year, were not diagnosed with any organic disease. Peak eosinophil concentrations and distributions were assessed from each segment of the gastrointestinal tract.

RESULTS

Three centers (Italy, United Kingdom, and Israel) contributed 202 patients (median age 13 years IQR 9.5-15.5, range 1-18 years). Median (IQR, range) eosinophil concentrations (eos/mm²) were: esophagus 0 (0-0, 0-84), stomach 0 (0-4, 0-84), duodenal bulb 20 (13-30, 7-67), second part of duodenum 20 (13-29, 0-105), terminal ileum 29 (14-51, 0-247), cecum 53 (37-89, 10-232), ascending colon 55 (25-84, 0-236), transverse colon 38 (21-67, 4-181), descending colon 29 (17-59, 0-114), sigmoid colon 25 (13-40, 0-215) and rectum 13 (4-28, 0-152). Significant geographical variance was present, however, no differences in eosinophil concentrations were identified between children with resolving symptoms vs. those with functional diagnoses, nor across age groups.

CONCLUSIONS

Standardized eosinophil concentrations from the gastrointestinal tracts of children without organic disease will serve to better define both health and disease states. No differences were found between resolved symptoms vs. functional diagnoses nor between age groups in this pediatric cohort.

Development of a core outcome set for therapeutic studies in eosinophilic esophagitis (COREOS)

BACKGROUND

End points used to determine treatment efficacy in eosinophilic esophagitis (EoE) have evolved over time. With multiple novel therapies in development for EoE, harmonization of outcomes measures will facilitate evidence synthesis and appraisal when comparing different treatments.

OBJECTIVE

We sought to develop a core outcome set (COS) for controlled and observational studies of pharmacologic and diet interventions in adult and pediatric patients with EoE.

METHODS

Candidate outcomes were generated from systematic literature reviews and patient engagement interviews and surveys. Consensus was established using an iterative Delphi process, with items voted on using a 9-point Likert scale and with feedback from other participants to allow score refinement. Consensus meetings were held to ratify the outcome domains of importance and the core outcome measures. Stakeholders were recruited internationally and included adult and pediatric gastroenterologists, allergists, dieticians, pathologists, psychologists, researchers, and methodologists.

RESULTS

The COS consists of 4 outcome domains for controlled and observational studies: histopathology, endoscopy, patient-reported symptoms, and EoE-specific quality of life. A total of 69 stakeholders (response rate 95.8%) prioritized 42 outcomes in a 2-round Delphi process, and the final ratification meeting generated consensus on 33 outcome measures. These included measurement of the peak eosinophil count, Eosinophilic Esophagitis Histology Scoring System, Eosinophilic Esophagitis Endoscopic Reference Score, and patient-reported measures of dysphagia and quality of life.

CONCLUSIONS

This interdisciplinary collaboration involving global stakeholders has produced a COS that can be applied to adult and pediatric studies of pharmacologic and diet therapies for EoE and will facilitate meaningful treatment comparisons and improve the quality of data synthesis.

Age-Dependent Trends in the Celiac Disease: A Tertiary Center Experience

OBJECTIVES

Celiac disease (CD) is a common intestinal autoimmune disorder with diverse presenting features. We aimed to determine age-dependent patterns in CD presentation, diagnosis and management at a large tertiary referral center.

METHODS

A retrospective review of electronic medical records of pediatric patients diagnosed with CD between January 1999 and December 2018 at Schneider Children's Medical Center of Israel. We compared demographics, clinical and laboratory parameters between four age groups at CD presentation.

RESULTS

A cohort of 932 children was divided into four groups by age (in years) at diagnosis: 0-3 (17.9%), 3-6 (31.8%), 6-12 (34.5%), 12-18 (15.8%). The youngest age group presented more frequently with diarrhea, weight loss, abdominal distention, vomiting and lower weight z scores, P < 0.01. Hypoalbuminemia and zinc deficiency were also more frequent in this age group, compared to older patients (P < 0.05, each). Rates of anemia were higher in younger age groups (0-3 and 3-6 years), compared to older age groups, P < 0.05. Patients in the younger age groups (0-3 and 3-6 years) presented more frequently with tissue transglutaminase (TTG) levels above 10 times the upper limit of normal (ULN; P < 0.05), and more often normalized their CD serologies by 24 months of gluten-free diets (GFD) compared to older age groups (P < 0.05).

CONCLUSION

There is an age-dependent variation in CD presentation during childhood. Younger patients present more often with malabsorptive features, and higher TTG levels, yet normalize TTG while on GFD more rapidly than older patients. Clinicians should be aware of the diversity in CD presentation and course at the various presentation age.

Intestinal Fatty Acid Binding Protein Levels in Pediatric Celiac Patients in Transition From Active Disease to Clinical and Serological Remission

Celiac disease (CD) is increasingly diagnosed without endoscopy. As such, the need for accurate serological markers to aid in the diagnosis and follow-up of CD has increased. Intestinal fatty acid binding protein (I-FABP) is a cytosolic protein present in enterocytes, whose blood levels reflect mucosal damage in a reliable and quantifiable way. The aim of this study was to compare I-FABP levels in newly diagnosed patients with CD and to examine changes in levels following 6 months of gluten-free diet (GFD).

Methods

A prospective observational case control study of pediatric patients diagnosed with CD, with measurements of tissue transglutaminase IgA (TTG-IgA) and I-FABP levels at diagnosis and after 6 months of gluten free diet were compared to a control group of nonceliac patients.

Results

This study included 35 patients and 32 controls. The CD group had higher I-FABP levels at diagnosis compared with the control group (median 641.7 pg/mL versus 334 pg/mL; P < 0.05). I-FABP levels significantly differed between patients presenting with TTG-IgA level 3-10 times the upper limit of normal (ULN) compared with those presenting with values >10 times ULN (median 432.2 pg/mL versus 796.2 pg/mL; P < 0.05). Patients with CD had a significant decrease in median I-FABP levels after 6 months of GFD (median 268.2 pg/mL), paralleling a decrease in TTG-IgA and GFD adherence.

Conclusions

I-FABP levels are increased in patients with CD at diagnosis compared with controls and decrease significantly while patients adhere to GFD.

Systemic steroids have a role in treating esophageal strictures in pediatric eosinophilic esophagitis

BACKGROUND

The role of systemic steroids in the treatment of esophageal strictures in children with Eosinophilic Esophagitis (EoE) is poorly defined.

AIMS

To describe a cohort of children with EoE-associated esophageal strictures responding to systemic steroids.

METHODS

Retrospective review of medical records of children with EoE and moderate (<9 mm) to severe (<6 mm) strictures, who responded clinically and endoscopically to systemic steroids.

RESULTS

Twenty children (median age 10.6 ± 4.2 years; 17 males) from nine centers in six countries were included in the analysis; 16 had moderate and four, severe strictures; 18 had dysphagia or bolus impaction; median diagnostic delay was 8 months (IQR 3.5-35). Eighteen patients received oral systemic steroids (mean dose 1.4 mg/kg/day) for a median of 4 weeks, while two initially received IV steroids. All patients showed clinical improvement and 15/20 became asymptomatic. Stricture resolution at endoscopy was found in 19/20, while histological resolution of EoE (<15 eos/hpf) in 13/20. Only minor side effects were reported: hyperphagia (10/20); weight gain (5/20); hyperactivity (2/20) and acne (1/20). Esophageal dilation was required in 3/20 patients during a median follow-up of 48.5 months (IQR 26.7-73.2).

CONCLUSION

Children with EoE and esophageal strictures, may benefit from the use of a short course of systemic steroids, avoiding mechanical dilation.

Knowledge of disease and self-management of adolescents with inflammatory bowel diseases

AIM

To describe factors that might affect successful transition in young adult patients with inflammatory bowel disease (IBD).

METHODS

Questionnaires regarding the personal disease history, treatment and diseases specific knowledge and patients' self-efficacy were completed by teenaged patients with IBD aged 14-18 years, during routine clinic visits. Patient answers were then compared with information obtained from the medical records and information provided by treating physician.

RESULTS

The study included 80 patients with IBD, 54 (67.5%) with Crohn's disease. Patients demonstrated good knowledge in their personal disease history and current treatment. Knowledge gaps were observed in medication dosages, knowledge of potential side effects and effects of smoking on disease, with only 53/80 (66%), 12/80 (15%) and 6/36 (16.7%) of patients providing correct answers. Only 25/36 (69.4%) of the patients aged 16-18 had read about their disease. All patients in 16-18 age group reported needing assistance to schedule a gastroenterologist appointment.

CONCLUSION

Knowledge and self-efficacy skills of IBD teenagers are suboptimal regarding medications, smoking and appointment management. Medical providers should work with parents and teenaged patients with IBD to allow them to attain missing information and promote self-efficacy skills, in order to reinforce readiness towards transition.

Dietary treatment of eosinophilic gastrointestinal disorders in children

PURPOSE OF REVIEW

To provide an overview of recent developments on dietary treatment of eosinophilic gastrointestinal disorders (EGID) in children.

RECENT FINDINGS

Food antigens are the main triggers of eosinophilic esophagitis (EoE); however, currently available allergy tests cannot reliably identify eliciting antigens. Studies evaluating the six-food empiric elimination diet (6FED-milk, wheat/gluten, egg, soy/legumes, nuts and fish/seafood) have shown histological remission rates of 72%. Milk, egg, wheat/gluten, and, to a lesser extent, soy/legumes were the most frequent food triggers with only one or two culprit foods identified for most patients. A 4-food elimination strategy afforded a 64% remission rate. A step-up two-four-six food elimination diet generated a 43% remission rate at the two-food elimination stage, and similar reported rates for 4FED and 6FED. Endoscopic procedures were reduced by a 20% compared with 6FED. In a prospective study including 63 children, exclusive milk elimination has been effective in 44% of them. Controlled elimination and reintroduction with histological assessment is necessary.

SUMMARY

Dietary therapy of EoE has evolved from more restrictive to less restrictive diets to provide better balance between efficacy vs. nutritional deficiencies and quality of life. Data on efficacy of dietary therapy in other EGIDs are very scarce.

Two decades of pediatric celiac disease in a tertiary referral center: What has changed?

BACKGROUND

Celiac disease (CD) is common worldwide with increasing prevalence and changing presentation.

AIMS

To evaluate changes in the presentation and management of CD over the last two decades.

METHODS

Retrospective chart review of pediatric patients with CD between 01.1999 to 12.2018 was performed. Comparisons were made between an early (1999 to 2008) and late (2009 to 2018) decade, regarding clinical and laboratory parameters at presentation and follow-up.

RESULTS

In a cohort of 932 patients (early decade n = 316, late decade n = 616), patients from the late decade presented with lower rates of weight loss and abdominal distention (24.2% vs 34.7% and 6% vs 11%, respectively p < 0.01), and with higher rates of abdominal pain or asymptomatic presentation (41.4% vs 27.4%, p < 0.01, and 18% vs 13%, p < 0.05, respectively). Good adherence to gluten-free diet was reported more often in the late decade (64% vs 50.6%, p < 0.001), and fewer patients were lost to follow-up. During the late decade, significantly higher rates of celiac serology normalization were achieved during the first two years of follow-up.

CONCLUSION

In recent years, children with CD were diagnosed with milder symptoms, showed better adherence and demonstrated earlier normalization of celiac serology.

High rates of serology testing for coeliac disease, and low rates of endoscopy in serologically positive children and adults in Israel: lessons from a large real-world database

BACKGROUND

Although coeliac disease is common worldwide, little is known regarding screening patterns in unselected populations, and on real-life adherence to professional guidelines for coeliac disease diagnosis and management.

OBJECTIVE

To explore current practices in the diagnosis and management of coeliac disease, using data from a large Health Maintenance Organization in Israel that covers 54% of the population.

METHODS

A population-based electronic database of about 4.5 million individuals was reviewed during the period of 1 January 2008 to 31 December 2015. Rates and results of coeliac disease serology testing and endoscopy procedures were examined. Subgroup analysis was performed by age, sex, ethnicity and socioeconomic status.

RESULTS

Coeliac disease serology cumulative testing rate was 17.1% and 8.9% in the paediatric and adult population, respectively. The cumulative incidence of positive coeliac disease serology was 0.45% in children and 0.17% in adults, and was associated with age, sex, ethnicity and socioeconomic status sub-groups (P-value < 0.01). Gastrointestinal endoscopies were not subsequently performed in 44.1% of children and 47.1% of adults with positive coeliac disease serology. Within the study period, 36% of children and 56% of adults never achieved coeliac disease serology normalization.

CONCLUSION

In a large real-life database, screening for coeliac disease was common. However, confirmatory intestinal biopsies were under-utilized, and coeliac disease serology often remained positive over a long period time in both children and adults.

The Yield of Upper Gastrointestinal Endoscopy at a Pediatric Tertiary Care Center

BACKGROUND

The number of investigative esophagogastroduodenoscopies (EGD) in children has increased over several decades, despite their unclear diagnostic yields.

OBJECTIVES

To evaluate the indications for performing EGD, their diagnostic yields, and consequences on pediatric patient management.

METHODS

A retrospective chart review was performed of consecutive pediatric patients aged 0-18 years, who underwent EGD between January and August 2014.

RESULTS

During the study period, 547 EGD were performed on 478 children. The most frequent indications were suspected celiac disease, chronic non-specific abdominal pain, persistent Helicobacter pylori infection, and gastrointestinal hemorrhage. The yield of the diagnostic EGD was 59.2%, and the most common new diagnoses were celiac disease (28%), Helicobacter pylori-positive gastritis (16.5%), and Crohn's disease (5.4%). Of the patients with documented follow-up, 74.1% reported improved symptoms. Procedures performed for chronic unexplained abdominal pain had significantly lower yields (26.2%) and only 39.3% improved at follow-up.

CONCLUSIONS

Our findings suggest a general high diagnostic yield for EGD in pediatric patients, stemming mainly from patients in whom a specific condition was suspected a priori. However, the role of the procedure in the diagnosis and management of non-specific gastrointestinal complaints was minor suggesting that EGD may be superfluous for some of these patients.

Effect of a Gluten Free Diet on Hepatitis B Surface Antibody Concentration in Previously Immunized Pediatric Celiac Patients

PURPOSE

To evaluate the effect of gluten-free diet (GFD) on hepatitis B surface antibody (HBsAb) concentrations among previously immunized pediatric celiac disease (CD) subjects.

METHODS

We retrospectively evaluated pediatric CD subjects in serological remission who were previously immunized for hepatitis B virus as infants. The temporal relationship between HBsAb concentration, the amount of time on a GFD, and age were evaluated.

RESULTS

Overall, 373 CD subjects were analyzed: 156 with HBsAb sampled prior to GFD initiation and 217 after initiation of a GFD and in serological remission. Median age at HBsAb concentration measurement for those before and after GFD initiation was 5.3 years (interquartile range [IQR], 3.1-9.2 years) and 7.6 years (IQR, 5.4-10.9 years), respectively (p<0.001). There was no sex difference between the groups. The median time of HBsAb measurement was 2 months (IQR, 0-5.7 months) before and 12.8 months (IQR, 5.3-30.3 months) after initiation of GFD. The HBsAb concentration was low in 79 (50.6%) and 121 (55.7%) subjects before and after GFD initiation, respectively (p=0.350). Age was inversely associated with low HBsAb concentrations. Neither being on a GFD nor sex was associated with low HBsAb concentrations.

CONCLUSION

Adherence to a GFD does not affect HBsAb concentration in children with CD. Age is inversely associated with HBsAb concentration.

Sustained Remission of Eosinophilic Esophagitis Following Discontinuation of Dietary Elimination in Children

Eosinophilic esophagitis (EoE), when left untreated, may progress from an inflammatory to a fibrostenotic phenotype. Inflammation generally recurs after treatment withdrawal. Thus, long-term treatment has been recommended. Here, we describe a cohort of children with EoE who achieved clinical and histologic remission with elimination diets, and maintained sustained untreated remission (SUR) despite re-introduction of all eliminated food allergens.

Diagnosis and management of children with Blue Rubber Bleb Nevus Syndrome: A multi-center case series

BACKGROUND

Blue Rubber Bleb Nevus Syndrome (BRBNS) is a rare, severe, sporadically occurring disorder characterized by multiple venous malformations.

AIMS

To present and analyze a case series of pediatric patients with BRBNS and to describe diagnostic approaches and management options applied.

PATIENTS AND METHODS

Multicenter, retrospective study, evaluating the diagnosis and management of children with BRBNS.

RESULTS

Eighteen patients diagnosed with BRBNS were included. Cutaneous venous malformations were observed in 78% and gastrointestinal venous malformations in 89%. Lesions were also found in other organs including muscles, joints, central nervous system, eyes, parotid gland, spine, kidneys and lungs. Gastrointestinal lesions were more common in the small intestine than in stomach or colon. The management varied significantly among centers. Endoscopic therapy and surgical therapy alone failed to prevent recurrence of lesions. In younger children and in patients with musculoskeletal or other organ involvement, sirolimus was used with 100% success rate in our series (5 patients treated) although poor compliance with subtherapeutic sirolimus trough levels led to recurrence in a minority.

CONCLUSIONS

Considering the multi-organ involvement in BRBNS, diagnosis and management requires a multidisciplinary approach. The treatment includes conservative, medical, endoscopic and surgical options. Prospective multicenter studies are needed to identify the optimal management of this rare condition.

Endoscopic Findings in Children with Isolated Lower Gastrointestinal Bleeding

BACKGROUND/AIMS

Colorectal polyps are a common cause of lower gastrointestinal bleeding in children. Our aim was to study the causes of isolated lower gastrointestinal bleeding and to analyze the characteristics of the colorectal polyps found in our cohort.

METHODS

We retrospectively reviewed colonoscopic procedures performed between 2007 and 2015. Children with isolated lower gastrointestinal bleeding were included in the study.

RESULTS

A total of 185 colonoscopies were performed for isolated lower gastrointestinal bleeding. The median patient age was 8 years, and 77 patients (41.6%) were found to have colonic polyps. Normal colonoscopy findings were observed and acute colitis was detected in 77 (41.6%) and 14 (7.4%) patients, respectively. Single colonic polyps and 2-3 polyps were detected in 73 (94.8%) and 4 (5.2%) patients with polyps, respectively. Of the single polyps, 69 (94.5%) were juvenile polyps, among which 65 (94.2%) were located in the left colon.

CONCLUSION

Single left-sided juvenile polyps were the most common cause of isolated lower gastrointestinal bleeding in our study. It was rare to find multiple polyps and polyps proximal to the splenic flexure in our cohort. A full colonoscopy is still recommended in all patients in order to properly diagnose the small but significant group of patients with pathologies found proximal to the splenic flexure.

Endoscopic findings and esophageal cancer incidence among Fanconi Anemia patients participating in an endoscopic surveillance program

BACKGROUND AND AIMS

The primary clinical characteristics of Fanconi Anemia (FA) include typical physical features, progressive bone marrow failure, and an increased incidence of neoplasms, including esophageal carcinoma. Currently, there are no data regarding endoscopic findings or the interval time to malignancy in these patients. Data about the contribution of Human Papilloma Virus (HPV) to esophageal carcinoma is conflicting. Our objective is to document the upper gastrointestinal (GI) findings at baseline, document cancer incidence, and evaluate the role of HPV among these cancers.

METHODS

We reviewed endoscopic and clinical data of FA subjects who participated in active surveillance before cancer diagnosis. Incident esophageal cancers were stained for HPV ^p16 protein.

RESULTS

Eight FA patients were included (men 62.5%; median age at first endoscopy 20 years, median endoscopies number: 5.5). At baseline, 8/8 had endoscopic evidence for reflux esophagitis. In 3/8 the reflux esophagitis was mild and in 5/8 it was moderate or severe. During the follow up time (median time 4.5 years 2/8 developed Barrett's esophagus and 2/8 patients had incident esophageal squamous cell carcinoma during follow up, at intervals of eight and eighteen months from the previous upper endoscopy. Both cancers stained negative for HPV ^P16.

CONCLUSIONS

FA subjects have both an extremely high risk for esophageal cancer within short intervals and a very high prevalence of reflux esophagitis with various severities. Active surveillance programs in specialized centers including annual upper endoscopies should be considered in these patients.

Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference

BACKGROUND & AIMS

Over the last decade, clinical experiences and research studies raised concerns regarding use of proton pump inhibitors (PPIs) as part of the diagnostic strategy for eosinophilic esophagitis (EoE). We aimed to clarify the use of PPIs in the evaluation and treatment of children and adults with suspected EoE to develop updated international consensus criteria for EoE diagnosis.

METHODS

A consensus conference was convened to address the issue of PPI use for esophageal eosinophilia using a process consistent with standards described in the Appraisal of Guidelines for Research and Evaluation II. Pediatric and adult physicians and researchers from gastroenterology, allergy, and pathology subspecialties representing 14 countries used online communications, teleconferences, and a face-to-face meeting to review the literature and clinical experiences.

RESULTS

Substantial evidence documented that PPIs reduce esophageal eosinophilia in children, adolescents, and adults, with several mechanisms potentially explaining the treatment effect. Based on these findings, an updated diagnostic algorithm for EoE was developed, with removal of the PPI trial requirement.

CONCLUSIONS

EoE should be diagnosed when there are symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (or approximately 60 eosinophils per mm²) on esophageal biopsy and after a comprehensive assessment of non-EoE disorders that could cause or potentially contribute to esophageal eosinophilia. The evidence suggests that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criterion, and we have developed updated consensus criteria for EoE that reflect this change.

Long-term Extent Change of Pediatric-Onset Ulcerative Colitis

BACKGROUND

Data describing extent change (progression or regression) in pediatric-onset ulcerative colitis (UC) are scarce.

GOAL

We aimed to describe extent change in pediatric-onset UC during long-term follow-up and to assess predictors of extent change.

STUDY

Medical charts of pediatric-onset UC patients with at least 5-year follow-up were analyzed retrospectively. Disease extent was determined using the Paris classification. It was examined at diagnosis and during follow-up at different time points. The impact of possible predictors on extent change including age at diagnosis, gender, clinical manifestations, disease, severity indices, and different therapeutic regimens during disease course was assessed.

RESULTS

Patients (n=134, 55% males) were followed for a median duration of 13.1 (range, 5 to 28) years. Median age at diagnosis was 13.1 (range, 2 to 17.8) years. Of 134 patients, 40.5% had extensive or pancolitis, 33.5% left-sided colitis, and 26% had proctitis at diagnosis. On follow-up (n=117), 45% had unchanged disease extent, 35% experienced extent progression, whereas 20% experienced regression of disease extent. The multivariate Cox models demonstrated that among children with left-sided disease at diagnosis, presence of extraintestinal manifestations (hazard ratio, 5.19; P=0.022), and higher pediatric UC activity index (hazard ratio, 8.77; P=0.008) were associated with extent progression to extensive disease. Predictors of extent regression have not been identified.

CONCLUSIONS

Disease extent changes significantly over time in pediatric-onset UC. In our cohort, presence of extraintestinal manifestation and higher pediatric UC activity index score at diagnosis were associated with progression from limited to extensive disease during follow-up.

Long-Term Outcomes After Primary Bowel Resection in Pediatric-Onset Crohn's Disease

BACKGROUND

There is limited evidence on the long-term outcome of intestinal resection in pediatric-onset Crohn's disease (POCD) with no established predictors of adverse outcomes. We aimed to investigate clinical outcomes and predictors for adverse outcome following intestinal resection in POCD.

METHODS

The medical records of patients with POCD who underwent at least 1 intestinal resection between 1990 and 2014 were reviewed retrospectively. Main outcome measures included time to first flare, hospitalization, second intestinal resection, and response to nonprophylactic biologic therapy.

RESULTS

Overall, 121 patients were included. Median follow-up was 6 years (range 1-23.6). One hundred and seven (88%) patients experienced at least 1 postsurgical exacerbation, 52 (43%) were hospitalized, and 17 (14%) underwent second intestinal resection. Of 91 patients who underwent surgery after the year 2000, 37 (41%) were treated with antitumor necrosis factor ɑ (anti-TNFɑ) (nonprophylactic) following intestinal resection. Time to hospitalization and to second intestinal resection were shorter among patients with extraintestinal manifestations (EIMs) (HR 2.7, P = 0.006 and HR = 3.1, P = 0.03, respectively). Time to initiation of biologic treatment was shorter in patients with granulomas (HR 2.1, P = 0.038), whereas being naïve to anti-TNFɑ treatment before surgery was a protective factor for biologic treatment following surgery (HR 0.3, P = 0.005). Undergoing intestinal resection beyond the year 2000 was associated with shorter time to first flare (HR 1.9, P = 0.019) and hospitalization (HR 2.6, P = 0.028).

CONCLUSION

Long-term risk for flares, hospitalization, or biologic treatment is significant in POCD following bowel resection. EIMs increase the risk for hospitalization and second intestinal resection.

Oesophageal eosinophilia in children with coeliac disease

OBJECTIVES

An association between coeliac disease (CD) and eosinophilic oesophagitis (EoE)/oesophageal eosinophilia (EE) has been suggested. We sought to characterise children with CD+EE in-depth and assess the contribution of each condition to the clinical presentation and treatment response.

STUDY DESIGN

Medical records of children with both CD+EE, or isolated EoE diagnosed between 2000 and 2014, were retrospectively reviewed and compared with patients with isolated CD or epigastric pain. Frequency of EE was calculated from endoscopy results of patients with suspected CD or epigastric pain between 2011 and 2014. Missing data were obtained via a telephone questionnaire.

SETTING

Single large, tertiary paediatric centre.

PATIENTS

17 CD+EE, 46 EoE, 302 isolated CD and 247 epigastric pain.

RESULTS

The patients with CD+EE shared characteristics of both individual conditions. While age at diagnosis, family history of autoimmunity/CD and anaemia were similar to patients with CD, other characteristics such as male gender, personal/family history of atopy, peripheral eosinophilia and oesophageal white papules were more similar to patients with EoE. Combined patients (CD+EE) tended to present with CD-associated symptoms; the majority (63%) later developed typical EoE symptoms. Only a minority (21%) of combined patients had EE that resolved after a gluten-free diet; another 21% had normalisation of EE upon proton pump inhibitor treatment. The remainder required EoE-specific treatment.

CONCLUSION

Patients with CD found to have EE share characteristics with both isolated CD and EoE. It appears that these are two coexisting entities presenting in the same patient rather than eosinophilia associated with CD, and therefore, interventions separately addressing each condition may be considered.

The natural history of pediatric-onset IBD-unclassified and prediction of Crohn's disease reclassification: a 27-year study

OBJECTIVES

A definitive diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) in patients who were initially diagnosed as inflammatory bowel disease-unclassified (IBDU) remains challenging. Our aims were to describe the natural history of pediatric-onset IBDU patients during prolonged period of follow up and to identify associated predictors for CD reclassification among them.

MATERIALS AND METHODS

In this retrospective single center study, out of 723 patients with pediatric onset IBD, we identified 53 patients (7.3%) diagnosed with IBDU at the Schneider Children's Medical Center of Israel between 1986 and 2013. Potential predictors for CD reclassification including age at diagnosis, gender, clinical manifestations, disease extent and laboratory findings were assessed.

RESULTS

The median follow-up was 6.8 (± 6.7) years. Reclassification to CD was observed in 24/53 (45%) of patients. The median interval from diagnosis to CD reclassification was 9.4 years. In 58% of these patients, CD reclassification occurred within 5 years from diagnosis. Multivariate Cox models showed that familial history of CD and hypoalbuminemia at diagnosis were significantly associated with CD reclassification (HR 11.3, p = .02 and HR 5.3, p = .03, respectively). All other assessed clinical, laboratory and endoscopic parameters did not serve as predictors for CD reclassification later on.

CONCLUSIONS

In our cohort, a substantial high proportion of pediatric onset IBDU patients were later re-diagnosed as CD. Only a family history of CD and hypoalbuminemia could predict reclassification among IBDU patients.

Evolution of disease phenotype in pediatric-onset Crohn's disease after more than 10 years follow up-Cohort study

BACKGROUND

Pediatric-onset Crohn's disease (CD) is a heterogeneous disorder which is subjected to progression and complications in a substantial proportion of patients.

AIMS

We aimed to assess the progression in pediatric-onset CD phenotype on long term follow up.

METHODS

Medical charts of pediatric onset CD patients with at least 10 years follow-up were analyzed retrospectively. Disease phenotype was determined at diagnosis and during follow up at different time points. Phenotype was determined according to the Paris classification. The impact of possible predictors on phenotype progression was assessed as well as the association between different therapeutic regimens during disease course and phenotype progression.

RESULTS

Progression of disease location, behavior, and perianal involvement was observed in 20%, 38% and 20% of patients, respectively, after a median follow-up of 16.4 (±4.4) years. Microscopic ileocolonic disease at diagnosis was significant predictors for progression of disease extent. Treatment with anti tumor necrosis factor-ɑ agents and number of flares per years of follow-up were associated with progression of disease extent, behavior and perianal involvement.

CONCLUSION

Disease extent, behavior and prevalence of perianal disease change significantly over time in pediatric-onset CD. In our cohort, most clinical, laboratory and endoscopic parameters do not serve as predictors for long-term disease progression.

Seasonal influenza vaccination rates and reasons for non-vaccination in children with gastrointestinal disorders

OBJECTIVES

Despite advances in the treatment and prevention of influenza, it is still considered an important cause of morbidity and mortality worldwide. Annual vaccination is the safest and most effective mean of prevention. Our study aims were to explore the uptake of influenza vaccination among children with gastrointestinal disorders, and to characterize non-adherent patients.

METHODS

The present cross-sectional study included parents of pediatric patients attending the Gastroenterology Institute at Schneider Children's Medical Center of Israel between September and October 2011. Parents were asked to complete a questionnaire concerning demographic and clinical parameters, influenza vaccination of the child, and reasons for not vaccinating the child, when appropriate.

RESULTS

The study population included 273 patients (50% female), with a median age of 10 years (range, 2-18 years). Overall, the rate of seasonal influenza vaccination was 30.8%. Higher rates were found among immunosuppressed patients (46.1%), and in patients with inflammatory bowel disease (50%). There was no significant effect of patient age, gender, ethnic origin or parental level of education on the vaccination rate. Vaccination rates were significantly associated with parents' information and knowledge of, as well as their personal beliefs regarding the vaccine (P<0.001).

CONCLUSIONS

Influenza vaccination rates are relatively low in the pediatric population attending gastroenterology clinics, in both high- and low-risk groups. The importance of parental knowledge in compliance with influenza vaccination of children should prompt general pediatricians and gastroenterologists to discuss and address the common misconceptions regarding the vaccine.

Duodenal intraepithelial lymphocytosis is common in children without coeliac disease, and is not meaningfully influenced by Helicobacter pylori infection

BACKGROUND

Increased numbers of duodenal intraepithelial lymphocytes (IELs) characterise coeliac disease (CD) but have also been described in noncoeliacs. Controversy exists regarding an association between increased IELs and infection with Helicobacter pylori, which is commonly found in children.

AIM

To assess the relationship between H. pylori infection and duodenal IELs in a large cohort of children, with and without CD.

METHODS

We reviewed gastric and duodenal biopsies of children who underwent esophagogastroduodenoscopy between January 2006 and February 2013 because of either recurrent abdominal pain (RAP) or suspected CD at Schneider Children's Medical Center of Israel, a referral centre for Israel's largest Health Maintenance Organization. The duodenal IEL count and H. pylori presence in antral biopsies were determined for each specimen.

RESULTS

Children with RAP (n = 693) or CD (n = 306) were included. Among children with RAP, H. pylori was present in 33.8%. The mean IEL count in the H. pylori positive RAP group was 17.8(±8.8)/100 enterocytes, vs. 15.8(±8.3) in the H. pylori negative patients (P = 0.004). Increased IEL counts (≥25 IELs/100 enterocytes) were found in 15.7% of H. pylori negative, noncoeliac children. Among children with CD, there was no significant difference in IEL counts according to H. pylori status: 73.1(±26.1) vs. 72.6 (±26.5) in H. pylori positive and negative patients respectively.

CONCLUSIONS

Our study suggests that slightly elevated duodenal intraepithelial lymphocyte counts are common in the paediatric population. Helicobacter pylori infection has no major influence on the intraepithelial lymphocyte counts in children with recurrent abdominal pain or children with coeliac disease.

Cardiovascular disease risk factor profiles in children with celiac disease on gluten-free diets

AIM

To describe the cardiovascular disease (CVD) risk factors in a population of children with celiac disease (CD) on a gluten-free diet (GFD).

METHODS

This cross-sectional multicenter study was performed at Schneider Children's Medical Center of Israel (Petach Tiqva, Israel), and San Paolo Hospital (Milan, Italy). We enrolled 114 CD children in serologic remission, who were on a GFD for at least one year. At enrollment, anthropometric measurements, blood lipids and glucose were assessed, and compared to values at diagnosis. The homeostasis model assessment-estimated insulin resistance was calculated as a measure of insulin resistance.

RESULTS

Three or more concomitant CVD risk factors [body mass index, waist circumference, low density lipoprotein (LDL) cholesterol, triglycerides, blood pressure and insulin resistance] were identified in 14% of CD subjects on a GFD. The most common CVD risk factors were high fasting triglycerides (34.8%), elevated blood pressure (29.4%), and high concentrations of calculated LDL cholesterol (24.1%). On a GFD, four children (3.5%) had insulin resistance. Fasting insulin and HOMA-IR were significantly higher in the Italian cohort compared to the Israeli cohort (P < 0.001). Children on a GFD had an increased prevalence of borderline LDL cholesterol (24%) when compared to values (10%) at diagnosis (P = 0.090). Trends towards increases in overweight (from 8.8% to 11.5%) and obesity (from 5.3% to 8.8%) were seen on a GFD.

CONCLUSION

This report of insulin resistance and CVD risk factors in celiac children highlights the importance of CVD screening, and the need for dietary counseling targeting CVD prevention.

Long-term outcome of tumor necrosis factor alpha antagonist's treatment in pediatric Crohn's disease

BACKGROUND

Anti tumor necrosis factor alpha (TNFα) agents have become widely used in pediatric inflammatory bowel disease (IBD). So far, only few studies examined the long-term results of anti-TNFα treatment in children with IBD.

METHODS

The long-term outcome of pediatric patients with IBD was assessed retrospectively in a multicenter cohort of children treated with anti-TNFα beyond induction treatment. Short- and long-term response rates, predictors for loss of response, data on growth and laboratory parameters were assessed.

RESULTS

120 patients [101 crohn's disease (CD), 19 ulcerative colitis (UC) or indeterminate colitis (IC)] received either infliximab or adalimumab. The mean age at initiation of anti-TNFα was 13.4 ± 3.9 years and the median duration of anti-TNFα treatment was 15 months (range: 2-90). Overall, 89% of the cohort experienced short-term response following induction. Response was associated with improvement in weight and BMI Z-scores (p<0.001) but not with linear growth. Responders experienced a significant decrease in erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) during treatment (p<0.001). Albumin and hemoglobin both improved but only albumin increased significantly (p<0.001). The cumulative probability of losing response to anti-TNFα treatment was 17%, 38%, and 49% after 1, 3, and 5 years, respectively. Responders had a significantly lower weight and BMI Z-scores at initiation of anti-TNFα treatment in compared to non-responders (p=0.04 and 0.02 respectively).

CONCLUSIONS

Our long term cohort supports the current evidence on the effectiveness and safety of anti-TNFα treatment in children with IBD. Response to treatment was interestingly associated with lower weight and BMI.

Concomitant autoantibodies in newly diagnosed diabetic children with transient celiac serology or proven celiac disease

BACKGROUND

We previously demonstrated that children with Type 1 Diabetes Mellitus (T1DM) may have transiently elevated tissue transglutaminase antibodies (TTG) on a gluten-containing diet. This study aimed to examine if the presence of autoantibodies in newly diagnosed T1DM differs between patients with celiac disease and those with transient celiac serology.

METHODS

Forty children were identified who had been diagnosed with T1DM between 2003 and 2009 and who had elevated serum IgA-TTG antibody levels at diagnosis. Blood samples were collected for measurement of insulin (IA-2A) antibodies, islet cell antigen (ICA) antibodies, glutamic acid decarboxylase (GAD) antibodies, thyroglobulin (TgAb) antibodies, and thyroid peroxidase (TPO) antibodies. Children diagnosed with celiac disease (CD; group 1, n=23) and children in whom TTG antibody levels spontaneously normalized over time (group 2, n=17) were compared.

RESULTS

No significant differences in positivity rates between groups 1 and 2 were found for any of the autoantibodies tested. The respective findings were as follows: IA-2A 50% and 47.1% (p=0.855); ICA 77.3% and 76.5% (p=0.953); GAD 27.3% and 52.9% (p=0.102). Thyroid antibodies were found positive in a limited number of patients: TgAb 4.5% and 11.8%; TPO 4.5% and 11.8%. In addition, antibody titer levels did not differ significantly for all autoantibodies. Difference in occurrence of clinical or subclinical thyroid disease did not reach significance (4.3% vs. 29.4%; p=0.07). Age was positively correlated with the presence of thyroglobulin and thyroid peroxidase antibodies, and negatively correlated with the presence of insulin antibody.

CONCLUSION

Neither the number of concomitant autoantibodies nor their titers in newly diagnosed T1DM differed between patients with proven CD and those with transient TTG serology.

Inverse association between Helicobacter pylori and pediatric asthma in a high-prevalence population

BACKGROUND

Helicobacter pylori-associated disease has led to aggressive diagnostic and eradication protocols that are partially responsible for the decrease in prevalence of H. pylori carriage. Recent evidence indicates that in low-prevalence populations, H. pylori may have protective effects on allergic diseases. The aim of this study was to explore the relationship between pediatric asthma and H. pylori infection in a population with high prevalence of H. pylori infection.

MATERIALS AND METHODS

A national referral laboratory was screened for all (13) C urea breath tests performed in children aged 5-18 years between 2007 and 2008, for patient demographics and physician-diagnosed asthma. Data concerning asthma-associated medication usage were extracted from electronic medical records and databases. Data were analyzed using a stepwise logistic regression model.

RESULTS

During the study period, 6959 patients underwent urea breath testing (average age 12.4±3.5years). Of these, 3175/6959 (45.6%) were positive for H. pylori, and 578/6959 (8.3%) had asthma. Rates of asthma in H. pylori-positive and H. pylori-negative children were 7.3 and 9.1%, respectively (odds ratio 0.82; 95% confidence interval (CI) 0.69-0.98; p=.032). We also confirmed that male gender, urban residence, and age are associated with childhood asthma.

CONCLUSIONS

We demonstrate an inverse association between H. pylori and pediatric asthma in a population with a high prevalence of H. pylori.

Follow-up of children with celiac disease - lost in translation?

BACKGROUND

Celiac disease (CD) is a prevalent condition with a broad spectrum of presentations requiring a lifelong gluten-free diet (GFD). Our aims were to examine the presentation and adherence to a GFD as well as the adequacy of follow-up of children diagnosed with CD at a tertiary referral center.

METHODS

A retrospective electronic chart review of pediatric patients suspected of CD (n = 581) who were seen at our institute between January 1999 and December 2008 was performed.

RESULTS

387 children were diagnosed with CD (F/M ratio of 1.54, median age: 6.25 years). Presenting symptoms were iron deficiency anemia (n = 82, 34%), short stature (n = 59, 24.5%) and abdominal pain (n = 59, 24.5%). In 63 patients (16.3%) an associated autoimmune disease was recorded. Only 42.7% of the patients (165/387) had regular out-patient gastroenterologist visits; 22% (86/387) were followed by their primary care physician. Over 35% (136/387) were completely lost to follow-up. Negative serology on follow-up was present in 91% of the CD patients(150/165) followed at our center in comparison to 70% (60/86) in those followed up by their primary physician (p = 0.0002).

CONCLUSIONS

At least in our referral center, follow-up of children diagnosed with CD is far from satisfactory. Initiatives aimed at improving adherence to regular follow-up are needed as this intervention is associated with a significant increase in patient compliance with a long-term GFD.

Age and gender differences in urea breath test results

BACKGROUND

(13) C urea breath test (UBT) results, used for the diagnosis of Helicobacter pylori infection, fluctuate in different age groups. We characterized both the age- and gender-based trends of UBT results, from early childhood through late adulthood.

METHODS

A national H. pylori referral laboratory was screened for all positive UBTs during 2007-2008, determined as a delta over baseline (DOB) ≥ 3·5. Data were analysed with respect to both age and gender.

RESULTS

In the studied period, 61,060 UBTs were performed and 24,237 were positive. After excluding multiple testing for an individual, a total of 21,767 positive results were analysed. The male/female ratio for positive UBTs was 1 : 1·77. DOB results decreased as age increased from a maximum of 38·6 ± 21 at age 3-5 years to 21·1 ± 12 at age 19-30 in females (P < 0·001) and from 30·0 ± 16 at age 6-10 years to 14·7 ± 8 at age 19-30 years in males (P < 0·0001). At this point, the values reached a nadir for both genders. In patients older than 60 years, old test results increased moderately (P < 0·003). In all age groups, except 6-10 years old, females had significantly higher UBT results than males.

CONCLUSIONS

The decrease in mean UBT values already occurs during the first decade of life, and results increase following the sixth decade. Females have significantly higher results than males even in early childhood and throughout old age.

[Eosinophilic esophagitis--the experience in a tertiary pediatric center]

BACKGROUND

Eosinophilic esophagitis (EoE) is an inflammatory disorder with increasing prevalence. It typically presents with swallowing difficulties, heartburn or dyspepsia, and in toddlers, failure to thrive. EoE is characterized by eosinophilic infiltrates of the esophageal mucosa, and endoscopies with tissue diagnosis are mandatory. Hypersensitivity has been implicated in the pathogenesis, therefore, most treatment options include steroids and allergen avoidance.

AIMS

To summarize a tertiary pediatric clinic's experience with EoE in children and adolescents, describe the spectrum of clinical presentations and treatment options, and raise awareness of this disorder among medical personnel.

METHODS

A retrospective, descriptive study of patients diagnosed with EoE at our institute over the past 5 years. Demographic details, presenting symptoms, laboratory studies, endoscopic and pathologic findings were analyzed. Information regarding medical and nutritional therapies and response to treatment were summarized.

RESULTS

Fifteen cases of EoE in children and adolescents are described. Average age at diagnosis was 9 years (range 0.7-161. The most common complaint was dysphagia (60%e. The majority demonstrated food allergies 19/121. Most of the patients were treated with topical ingested steroids, while others had either elemental formula or allergen elimination. Favorable responses were seen in most patients treated with steroids (8/11). Long-term results of nutritional therapy are insufficient to draw conclusions on its efficacy.

CONCLUSIONS

EoE causes major eating difficulties and affects quality of life in children, sometimes accompanied by failure to thrive. There is a clear association with food allergies, and positive responses to steroids are common. A high index of suspicion and referral to a gastroenterologist for definite diagnosis are required. Combining medical with nutritional treatment seems promising but further studies regarding the long-term outcome are needed.

The role of duodenal bulb biopsy in the diagnosis of celiac disease in children

BACKGROUND AND STUDY AIMS

It is suggested that for celiac disease (CD) diagnosis, biopsies should also be taken from the duodenal bulb. Whether bulb biopsies suggestive of CD can be found on upper gastrointestinal endoscopy (EGD) done for reasons other than CD diagnosis is not clear. The aim of our study was to evaluate the contribution of routine bulb biopsies to the diagnosis of CD, when taken regardless of prior suspicion of CD.

METHODS

The study included 96 children who underwent EGD for suspected CD and a control group of 69 children who underwent EGD for reasons other than CD. The mucosal changes were evaluated using the Marsh-Oberhuber classification.

RESULTS

Among the 87 children diagnosed with CD, we identified 6 patients (7%) with typical histologic findings only in the bulb (Marsh 3), but also 1 patient (1.1%) with findings only in the distal duodenum (Marsh 2). In 20 patients (23%) the histological changes were more severe in the bulb. One patient had more prominent findings in the second part of the duodenum. None of the control patients had histological changes compatible with CD in the bulb or the second part of the duodenum.

CONCLUSIONS

Our findings suggest that when CD is suspected, biopsies should be taken from both locations (bulb and second part) as mucosal changes may emerge only at one site. Nevertheless, the presence of characteristic histology on duodenal bulb biopsies might be sufficient for the diagnosis of CD.

Antibiotic resistance of Helicobacter pylori in Israeli children

OBJECTIVES

To determine the antibiotic susceptibility of Helicobacter pylori isolates from Israeli children; assess the role of previous antibiotic use in the development of antibiotic resistance and examine the possibility of simultaneous colonization of strains with different resistance patterns in the same patients.

MATERIAL AND METHODS

A prospective case-series design was used. The study group included 174 patients aged 1-18 years referred to the Schneider Children's Medical Center of Israel for gastroscopy over a 2.5-year period. Antibiotic susceptibility to amoxicillin, clarithromycin, metronidazole, tetracycline, and levofloxacin was determined by E-test on gastric biopsies (2 per patient). Clinical and demographic data were obtained by questionnaire.

RESULTS

Cultures for H. pylori yielded 55 isolates from 53 children. In treatment-naïve children, the prevalence rate of primary resistance to clarithromycin was 25% and to metronidazole, 19%. Respective rates in children previously treated for H. pylori infection were 42% (p = 0.22) and 52% (p = 0.016). Simultaneous resistance to both drugs was found in 13% of isolates (n = 7), all from children with previous treatment failure. No resistance was found to amoxicillin, tetracycline or levofloxacin. Clarithromycin resistance was associated with macrolide use for any indication during the previous year (p = 0.033). In 2 patients (3.8%), a different H. pylori strain was cultured from each biopsy.

CONCLUSIONS

H. pylori resistance to clarithromycin and metronidazole is high in Israeli children, particularly in those previously treated for H. pylori infection, in whom culture-based treatment should be considered. The simultaneous colonization of multiple strains in a minority of patients needs to be further characterized.

Primary meningococcal arthritis in a child: Case report and literature review

We present a case of primary meningococcal arthritis in an 8-month-old immunocompetent female. We also review 18 additional paediatric cases and characterize this unique form of meningococcal disease.

Acute infantile bilateral striatal necrosis: single-photon emission computed tomography (SPECT) imaging and review

Acute infantile bilateral striatal necrosis is a rarely described acute neurological syndrome associated with radiological findings. Its etiology and pathogenic mechanisms are unknown. Clinically, the syndrome usually follows respiratory illnesses and presents with an array of neurological findings, including axial ataxia, grimacing, mutism, head nodding, and high-pitched cry. This study follows a child with acute infantile bilateral striatal necrosis both clinically and radiologically. In addition, for the first time, the authors describe the serial findings of single-photon emission computed tomography (SPECT) from onset of illness through 20 months. Their findings indicate an initial insult apparent on both magnetic resonance imaging and SPECT localized to the basal ganglia, which, although improved over time, does not fully regress. The residual lesion on SPECT was clinically associated with only mild attention deficit disorder and no motor pathology. The authors review the published literature concerning acute infantile bilateral striatal necrosis and suggest possible mechanisms of this poorly understood and probably underreported condition.

Fatty acid cycling in the fasting rat

Adipose tissue lipolysis and fatty acid reesterification by liver and adipose tissue were investigated in rats fasted for 15 h under basal and calorigenic conditions. The fatty acid flux initiated by adipose fat lipolysis in the fasted rat is mostly futile and is characterized by reesterification of 57% of lipolyzed free fatty acid (FFA) back into adipose triglycerides (TG). About two-thirds of FFA reesterification are carried out before FFA release into plasma, whereas the rest consists of plasma FFA extracted by adipose tissue. Thirty-six percent of the fasting lipolytic flux is accounted for by oxidation of plasma FFA, whereas only a minor fraction is channeled into hepatic very low density lipoprotein-triglycerides (VLDL-TG). Total body calorigenesis induced by thyroid hormone treatment and liver-specific calorigenesis induced by treatment with beta, beta'-tetramethylhexadecanedioic acid (Medica 16) are characterized by a 1.7- and 1.3-fold increase in FFA oxidation, respectively, maintained by a 1.5-fold increase in adipose fat lipolysis. Hepatic reesterification of plasma FFA into VLDL-TG is negligible under both calorigenic conditions. Hence, total body fatty acid metabolism is regulated by adipose tissue as both source and sink. The futile nature of fatty acid cycling allows for its fine tuning in response to metabolic demands.

Mapping the Ig superantigen-binding site of HIV-1 gp120

The envelope glycoprotein, gp120, of HIV-1 has recently been identified as a member of the new family of Ig superantigens (Ig-SAg). This classification is based on the selective binding of gp120 to an unusually high proportion of endogenous, nonimmune Ig, and the selective activation of nonimmune B cells by gp120 in vitro. Many, if not all of the nonimmune Ig that bind to gp120 are members of the VH3 Ig gene family. The aim of this study was to determine the epitope on gp120 that was responsible for its Ig-SAg binding activity. To do this, we utilized a panel of 30 peptides derived from gp160 in a competition-binding assay. For five Igs that were tested, as well as for polyclonal serum IgM, two overlapping peptides (each 20 amino acids in length) were identified that were potent inhibitors of gp120 binding. Similarly, the 10 amino acid overlap region of these two peptides had inhibitory activity. Thus, this decamer sequence represented the optimal Ig-SAg epitope or mimotope. The amino acid residue at position 1 of the decamer, and to a lesser extent at position 10, was critical for peptide binding. In addition to this decamer peptide, other peptides that shared modest sequence homology were also selectively inhibitory for specific Ig samples. These findings provide the first definition of an Ig-SAg ligand at the peptide level and will facilitate further structural and biologic characterization of this new class of pathogenic Ags.

Mapping the Ig superantigen-binding site of HIV-1 gp120

The envelope glycoprotein, gp120, of HIV-1 has recently been identified as a member of the new family of Ig superantigens (Ig-SAg). This classification is based on the selective binding of gp120 to an unusually high proportion of endogenous, nonimmune Ig, and the selective activation of nonimmune B cells by gp120 in vitro. Many, if not all of the nonimmune Ig that bind to gp120 are members of the VH3 Ig gene family. The aim of this study was to determine the epitope on gp120 that was responsible for its Ig-SAg binding activity. To do this, we utilized a panel of 30 peptides derived from gp160 in a competition-binding assay. For five Igs that were tested, as well as for polyclonal serum IgM, two overlapping peptides (each 20 amino acids in length) were identified that were potent inhibitors of gp120 binding. Similarly, the 10 amino acid overlap region of these two peptides had inhibitory activity. Thus, this decamer sequence represented the optimal Ig-SAg epitope or mimotope. The amino acid residue at position 1 of the decamer, and to a lesser extent at position 10, was critical for peptide binding. In addition to this decamer peptide, other peptides that shared modest sequence homology were also selectively inhibitory for specific Ig samples. These findings provide the first definition of an Ig-SAg ligand at the peptide level and will facilitate further structural and biologic characterization of this new class of pathogenic Ags.