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Serum immunoglobulin A, and G subclasses were measured in patients with ulcerative colitis, Crohn's disease, and in normal controls. Significant differences were noted in elevated total gamma globulin in both disease groups: in elevated IgG1 in ulcerative colitis and elevated IgG2 in patients with Crohn's disease. These differences were not significantly related to disease activity in either disease although higher levels were observed in those with moderate and severe disease.

Before or after their diagnosis, each of three patients with inflammatory bowel disease had an established eating disorder. Two had bulimia and one was presumed to have had anorexia/bulimia. In addition to the usual modes of weight control, such as vomiting and fasting, two of the patients, all of whom were lactose intolerant, used milk ingestion as a purgative.

To determine the incidence of gastric emptying abnormalities in children with inflammatory bowel disease, we performed dual liquid/solid-emptying studies on 25 children with ulcerative colitis (UC) and on 45 with Crohn's disease (CD) over a 6-yr period. Nutritional parameters were evaluated initially and at the time of repeat study in those with abnormal emptying after a period of nutritional rehabilitation. All UC patients and 30 of 45 with CD (67%) had normal emptying of both liquid and solid components of the meal. Fifteen children with CD had delayed emptying of the solid liquid. Fourteen of these had preceding weight loss and one had no weight gain for 3 months prior to the study. Twelve complained of upper gastrointestinal symptoms (nausea, early satiety, postprandial epigastric pain, and anorexia), and five had evidence of growth retardation. The group averaged 4.8 abnormal nutritional parameters, compared with an average of 2.2 in those with CD and normal gastric emptying. Twelve of the 15 with abnormal emptying had abnormal gastric and/or duodenal biopsies: 10 were treated with sulfasalazine and prednisone, whereas five were taking only sulfasalazine. Studies repeated 6-15 months later after establishment of weight gain by caloric supplementation showed significant improvements in gastric emptying, nutritional status, and disease activity for the group, despite persistence of upper gastrointestinal disease documented in eight patients who underwent reexamination.

Primary duodenal ulcer disease occurs in children of all ages, but is most often seen in those over 10 years. As in the adult, it often pursues a chronic course. Primary gastric ulcer is seen in children under 6 years, is more unusual, and does not tend to recur. Stress ulcers are seen most often in infants and in critically ill children and are asymptomatic until the complications of hemorrhage or perforation appear. Drug-related ulcers are being seen more frequently as the use of nonsteroidal anti-inflammatory agents increases. With the use of new therapeutic agents, management has been simplified and surgical intervention has become a rarity. Helicobacter pylori is now a recognized cause of antral gastritis and ulceration in the child.

A retrospective review of children with Clostridium difficile infection and diarrhea identified 43 patients. Fifteen (35%) had immunoglobulins below the normal range for age, and typified those with transient hypogammaglobulinemia of infancy, because all increased their levels over the following 12 months. The age of those with hypogammaglobulinemia was significantly younger (p less than 0.01), averaging 18.8 months, than those with normal immunoglobulins who had a mean age of 4.6 yr. The number with recurrent C. difficile infection was significantly greater (p less than 0.001) in the hypogammaglobulinemic group than in those with normal immunoglobulins (46% vs 18%). Eleven children were identified who had C. difficile toxin in the stool after antibiotic therapy, but who had no diarrhea at the time of study. All had normal immunoglobulins. Control patients (20 without and 40 with diarrhea) had no evidence of C. difficile infection, and all but three had normal immunoglobulins. Three (7%) of those with diarrhea had IgA deficiency, and all had a diagnosis of milk protein allergy. These data suggest that immunoglobulin values be obtained in infants and children who have problematic C. difficile diarrhea in order to identify disorders of immunoglobulin synthesis which may be the underlying cause of repeated upper respiratory disease requiring antibiotic usage.

Seventy-eight patients with inflammatory bowel disease (35 with Crohn's disease and 43 with ulcerative colitis) and a control population of 36 children without organic disease were surveyed to determine the frequency of symptoms compatible with cow's milk-protein sensitivity during infancy. The incidence of a history compatible with cow's milk sensitivity was 8.5% (3/35) in patients with Crohn's disease and 2.8% (1/36) in controls. Patients with ulcerative colitis had a significantly greater prevalence of symptoms, compared with the other patient groups (20.9%, 9/43; p less than 0.03). In addition, patients with a history of cow's milk allergy, who subsequently developed ulcerative colitis, did so at an earlier age (6.68 +/- 2.05 yr vs. 10.62 +/- 0.74 yr: p less than 0.02) than those without a history of cow's milk sensitivity. Thus, there appears to be a potential relationship between early cow's milk sensitivity and the development of ulcerative colitis.

Stools collected from 39 infants and children with chronic nonspecific diarrhea and from 10 age-matched controls were examined for bile acid content with use of gas-liquid chromatography. Values were correlated with stool color. Mean concentration of bile acids in green stools (7.7 +/- 1.52 mg/g dry weight) was significantly higher than that in brown stools (3.76 +/- 0.7 mg/g dry weight) and in control stools (1.42 +/- 0.35 mg/g dry weight). In patients with green diarrhea, treatments with cholestyramine and bismuth subsalicylate (Pepto-Bismol) were equally effective in decreasing stool frequency, with the latter being more effective in decreasing water content. Patients with brown stools had an insignificant response to therapy.

Munchausen syndrome by proxy is a form of abuse in which the child suffers from a factitious illness induced by a parent. A case report of an 18-month-old boy who suffered from intractable diarrhea because of the surreptitious administration of laxatives by his mother is presented. The evolution of this case is discussed, as are the legal and ethical considerations in the diagnosis of Munchausen syndrome by proxy.

The medical and surgical management of the chronic and recurrent esophageal and anal lesions of recessive dystrophic epidermolysis bullosa pose challenging problems for the physician. Various therapeutic approaches are discussed, and the case histories of four problem patients are reviewed.

Esophageal stricture commonly occurs in patients with epidermolysis bullosa dystrophica recessive (EBDR), but esophageal replacement is considered a high risk procedure because of limited exposure of the airway, malnutrition, and postoperative skin bullae to secondary infection. Recent innovations in care, including preoperative parenteral nutrition, topical care for bullae and skin ulceration, fiberoptic tracheal intubation, electrocardiogram monitoring with metallic pacer leads, and an overall concern to protect the fragile intact skin, have improved the results of esophageal replacement. Utilizing these adjunctive measures, ileocolonic substernal interposition has been successfully performed in a 26-yr-old male and a 19-yr-old female at our institution. Despite cervical anastomotic stricture requiring resection in one, and an obstructive cervical esophageal bullous developing acutely 5 yr after operation in the second, both patients now gum or chew a solid diet. The first patient also benefited from total esophagectomy for squamous dysplasia detected at the time of esophageal replacement. Multidisciplinary management by the surgeon, gastroenterologist, anesthesiologist, and dermatologist makes esophageal replacement available for younger patients with epidermolysis bullosa dystrophica recessive and esophageal strictures.

A 29-month-old child with persistent cholangitis and steatorrhea complicating congenital hepatic fibrosis underwent radiographic evaluation of the biliary tree. Communicating intrahepatic cavernous ectasias were demonstrated by percutaneous transhepatic cholangiography, a procedure deemed safe in children of this age group. Unlike most patients with cholangitis, he had documented steatorrhea and growth failure which resolved following successful treatment with trimethoprim-sulfamethoxazole. Bacteriologic diagnosis was made by direct culture of liver tissue combined with duodenal intubation.

The course of 86 children with Crohn's disease was examined during a 10-year period between 1966 and 1976. Patients were classified according to the initial site of disease. Ileocolitis was the most (52%) and colitis the least (9%) common form of disease with diffuse small bowel or ileal disease each comprising nearly 20% of the study group. These figures show a reversal from those of a previous decade when 42% of the patients had only terminal ileal disease and 17% had ileocolitis. Children with ileocolitis had the highest number of extracolonic manifestations and operations and required steroid therapy the longest. Those with only small bowel disease (with the exception of duodenal involvement) had fewer extraintestinal symptoms and operations and showed a consistently good response to medical treatment.

We investigated the capability of Pepto-Bismol and its components (Veegum and bismuth subsalicylate) to sequester bile acids from aqueous solution in vitro and compared it to that of cholestyramine. Through a pH range of 3-9, all substances tested sequestered free and conjugated bile acids in quantities directly related to the concentration of the sequestering agent within the incubation mixture. Veegum was more effective gram for gram than bismuth subsalicylate. Pepto-Bismol, whose sequestering capacity approximated cholestyramine's, absorbed more than either of its components alone. The relationship between Pepto-Bismol's in vitro bile acid binding and its in vivo antidiarrheal properties is unknown.

Acute pancreatitis is being encountered more often in children due to antimetabolite therapy, accidental injury, and traumatic battering. Pancreatitis may occur in the absence of traditionally elevated serum amylase and lipase, and initial diagnosis may depend upon ultrasonography. Traditional therapy of enteric rest with nasogastric suction has been supported by the use of parenteral nutrition. Newer pharmaceutical agents have been ineffective in altering the course of the illness or in preventing complications of pseudocyst or abscess.

Oesophagitis developed in 4 patients, 3 of whom had scoliosis braces and 1 a body cast after surgery for kyphoscoliosis. Symptoms varied from chronic epigastric pain to gastrointestinal haemorrhage. Prophylaxis of oesophageal disease in children undergoing correction of scoliosis may prevent severe oesophagitis.

Twenty-nine infants and children, age 2-70 months with chronic diarrhea, were admitted to a double-blind, parallel clinical trial. The subjects were randomly assigned to receive either a bismuth subsalicylate liquid or a placebo liquid formulation. Treatment was given for 7 days with dosage varied according to age. Analysis of the results showed that the subjects in the bismuth subsalicylate-treated group gained significantly more weight (p less than 0.05), had significantly fewer (p less than 0.01) and firmer (p less than 0.01) stools with less water content (p less than 0.01) during the course of the study than did the placebo-treated group. Response to treatment, as graded by nursing staff, family, and physicians was moderate to excellent in 86% of the treated group while none of the placebo group received such a rating (p less than 0.01). No differences were noted between stool weights or bile acid excretion.

The design of the Boston thoracolumbosacral orthosis for scoliosis treatment may increase intragastric pressure, possibly causing reflux esophagitis. Early recognition and aggressive medical treatment of reflux may avoid esophagitis and the need to either abandon or modify conservative scoliosis management.