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AIM: To review gastrointestinal and liver infections in children undergoing antineoplastic chemotherapy. To look at gut microflora features in oncology children. METHODS: We selected studies published after year 2000, excluding trials on transplanted pediatric patients. We searched English language publications in MEDLINE using the keywords: "gastrointestinal infection AND antineoplastic chemotherapy AND children", "gastrointestinal infection AND oncology AND children", "liver infection AND antineoplastic chemotherapy AND children", "liver abscess AND chemotherapy AND child", "neutropenic enterocolitis AND chemotherapy AND children", "thyphlitis AND chemotherapy AND children", "infectious diarrhea AND children AND oncology", "abdominal pain AND infection AND children AND oncology", "perianal sepsis AND children AND oncology", "colonic pseudo-obstruction AND oncology AND child AND chemotherapy", "microflora AND children AND malignancy", "microbiota AND children AND malignancy", "fungal flora AND children AND malignancy". We also analysed evidence from several articles and book references. RESULTS: Gastrointestinal and liver infections represent a major cause of morbidity and mortality in children undergoing antineoplastic chemotherapy. Antineoplastic drugs cause immunosuppression in addition to direct toxicity, predisposing to infections, although the specific risk is variable according to disease and host features. Common pathogens potentially induce severe diseases whereas opportunistic microorganisms may attack vulnerable hosts. Clinical manifestations can be subtle and not specific. In addition, several conditions are rare and diagnostic process and treatments are not standardized. Diagnosis may be challenging, however early diagnosis is needed for quick and appropriate interventions. Interestingly, the source of infection in those children can be exogenous or endogenous. Indeed, mucosal damage may allow the penetrance of endogenous microbes towards the bowel wall and their translocation into the bloodstream. However, only limited knowledge of intestinal dysbiosis in oncology children is available. CONCLUSION: The diagnostic work-up requires a multimodal approach and should be implemented (also by further studies on new biomarkers) for a prompt and individualized therapy.

history of respiratory distress and ab ingestis bronchial-pneumonia and at 2 years old, he underwent surgical intervention for ultra-short Hirshproung Disease. After the exclusion of neurological and otolaryngological causes, he underwent upper endoscopy, which showed two Mallory-Weiss bleeding tears of about 1.5 cm each. He was immediately admitted and received intravenous treatment with Omeprazole and Ampicillin/Sulbactam. After one week of hospitalization a control upper endoscopy showed superficial erosions till the middle oesophagus, improved over the last. Besides the oesophagus presented a “trachealized” aspect, suspicious for eosinophilic oesophagitis and an hyperaemic gastropathy at the body and at the antrum. However the histological report defined an eosinophilic gastritis. He, also, underwent a ileocolonoscopy that described a linfoid nodular hyperplasia and an severe inflammation of ileo-caecal valve, left-colon and sigmoid-rectum tract to complete the diagnosis. The eosinophilic infiltrate was also significant at the colic level. Finally, chest X-ray, brain RNM and abdominal ultrasound resulted negative while allergic test were positive to many allergens (kiwi, hazelnuts). Faecal research of bacterial and parasites were negative; the peripheral blood smear was negative for blasts. Between biochemical parameters, eosinophils were increased (12.6%) as well as ECP (200 μg/l) and triptase (3 μg/l). According to the allergologist, the child begin a steroid therapy at full dose, a diet restriction and stopped the assumption of Montelukast, because of the possible increasing of eosinophilia. At the moment, his clinical conditions are improved: he no longer vomits, his biochemical parameters are normalizing (eosinophils: 8.2%; ECP: 86 μg/l; triptase: 2.47 μg/l), the last upper endoscopy was showed no lesions and at the histology the eosinophilic infiltrate is decreasing. Discussion: EGIDs are a group of emerging disease, which manifestations can be unspecific and chronic, but also, like in this case, severe and sudden. More studies are needed to evaluate if there were conditions that could trigger the disease (eg. drugs -Montelukast-). Finally, we report this case because of the Mallory-Weiss Syndrome is a rarely complication of EGIDs.

reversed 2 months later. Post-operative follow-up (1-3-6 months) included a clinical, nutritional haematological and biochemical examination. Results: Pre-operatively 1 patient was asymptomatic; 1 patient presented with hematochezia; 1 patient suffered abdominal pain. All patients had hundreds of colonic adenomatous polyps with mild dysplasia; 2 patients had gastric polyps; 1 patient ileal polyps; 1 patient had echo-structural thyroid abnormalities remaining euthyroid. No intra-operative or early post-operative complications occurred. Fifteen days post-operatively, 1 patient had partial small bowel obstruction caused by intestinal infection. After closure of ileostomies, all patients had voluntary bowel movements (mean: 4 movements/day) and no soiling, improving with diet and psyllium. A gradual weight increase was observed in 2 patients. Conclusions: Laparoscopic total colectomy with transanal rectal mucosectomy assures a low rate of complications, good functional outcome and excellent cosmetic results.

Intestinal Failure is a permanent loss of digestive and absorptive functions as a consequence of short bowel syndrome and/or other primary intestinal conditions. Patients with intestinal failure (IF) require long term parenteral nutrition to survive. The only alternative to parenteral nutrition is intestinal transplantation which still entails high mortality. Children with intestinal failure on parenteral nutrition may develop liver failure (LF), as a consequence of central line infections and other conditions. In children with both irreversible IF and LF a combined transplantation is generally considered. Despite low survival rate, combined liver/intestine transplantation is associated to better intestinal graft survival and lower incidence and severity of rejection compared to isolated small bowel transplantation. Recently, isolated liver transplantation was proposed in children with IF and LF. This procedure may have a higher survival probability compared to isolated intestinal transplant, it may allow progressive weaning from PN in children in whom the remnant intestine has the potential for adaptation and offer a timely solution in children for whom intestinal graft is not immediately available. This innovative approach may prove a better option compared to combined transplantation in both the short and long term