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Aim The BLEED criterion is a triaging model for lower gastrointestinal bleeding (LGIB), which was developed and validated in the USA. We assessed the BLEED criteria in a UK population and aimed to elucidate factors that can be implemented for early risk stratification. Method Patients were identified from a prospectively maintained surgical admission database at a central London teaching hospital. Data were collected on 26 clinical factors available on initial presentation. The primary-outcome end-points included severe bleeding (persistent bleeding within the first 24 h, blood transfusion, a decrease in haematocrit of ≥ 20% or recurrent bleeding after ≥ 24 hours of stability) and adverse outcome (emergency surgery to control bleeding, intensive care unit [ITU] admission or death). Results One hundred and eighty-four clinical episodes were identified, representing 3% of all surgical referrals. Twelve patients with upper gastrointestinal bleeding were excluded. Severe bleeding occurred in 110 (64%) patients. An adverse outcome was recorded in 20 (11.6%) patients, and 10 (5.4%) patients died during admission. The commonest aetiologies were diverticular disease, haemorrhoids and malignancy. Four prognosticators of adverse outcome were identified, these being: creatinine > 150μm (P = 0.002); age > 60 years (P = 0.001); abnormal haemodynamic parameters on presentation (P = 0.05); persistent bleeding within the first 24 h (P = 0.05); and area under the receiver–operating characteristics curve (AUC) = 0.79. The BLEED criteria were shown to be nonpredictive (AUC = 0.60). Conclusion The BLEED criterion was not shown to have any predictive value in this patient cohort. Our study has determined an independent set of prognostic factors that could be incorporated into initial triaging of patients presenting with LGIB. This may facilitate the early identification of patients requiring more aggressive resuscitation, admission to a monitored bed and consideration for early radiological or surgical intervention.

Background and aims Eosinophilic esophagitis (EE) continues to present clinical challenges, including a need for noninvasive tools to manage the disease. To identify a marker able to assess disease status in lieu of repeated endoscopies, we examined 3 noninvasive biomarkers, serum interleukin (IL)-5, serum eosinophil-derived neurotoxin (EDN), and stool EDN, and examined possible correlations of these with disease phenotype and activity (symptoms and histology) in a longitudinal study of children with EE. Subjects and methods Children with EE were studied for up to 24 weeks (12 weeks on 1 of 2 corticosteroid therapies and 12 weeks off therapy). Twenty children with normal esophagogastroduodenoscopies with biopsies were enrolled as controls. Serum IL-5, serum EDN, and stool EDN were measured at weeks 0, 4, 12, 18, and 24 in children with EE, and at baseline alone for controls. Primary and secondary statistical analyses (excluding and including outlier values of the biomarkers, respectively) were performed. Results Sixty subjects with EE (46 [75%] boys, mean age 7.5 ± 4.4 years) and 20 normal controls (10 [50%] boys, mean age 6.7 ± 4.1 years) were included. Significant changes in serum EDN (significant decrease from baseline to week 4, and then rebound from week 4 to week 12) occurred. Serum EDN levels were stable after week 12. Serum IL-5 and stool EDN levels in subjects with EE were not statistically different from those of the control subjects when each time point for the cases was compared with the controls' 1-time measurement. Conclusions Serum EDN levels were significantly higher in subjects with EE than in controls, and the results suggest a possible role, after additional future studies, for serum EDN in establishing EE diagnosis, assessing response to therapy, and/or monitoring for relapse or quiescence.

Improvements in insulin resistance after anti-TNF-alpha therapy have been reported in inflammatory conditions, although no changes were noted in adult patients with Crohn's disease. There is no information concerning insulin resistance and substrate metabolism in children with Crohn's disease after anti-TNF-alpha therapy. Our aim was to describe changes in carbohydrate and lipid metabolism in children with active Crohn's disease after their initial dose of infliximab. Children with active Crohn's disease underwent measurement of plasma insulin and glucose just before and 2 wk after their initial infusion of infliximab, an anti-TNF-alpha antibody. In addition, resting energy expenditure, with determination of both carbohydrate and lipid oxidation rates, was determined. Measurements were conducted in both fasting and parenterally fed states. Despite no changes in resting energy expenditure, a significant reduction (p0.05) in RQ (5%) and carbohydrate oxidation rate (24%), with a corresponding increase in lipid oxidation rate (42%) was found during parenteral nutrition infusion. No differences in plasma insulin, glucose, and insulin resistance were noted when comparing pre- and postinfliximab measurements.

OBJECTIVES Tumor necrosis factor-alpha (TNF-alpha) may play a significant role in growth disturbance in pediatric Crohn disease. The aim of this study was to determine the effects of anti-TNF-alpha therapy on albumin and fibrinogen synthesis during both fasting and parenteral nutrition infusion in pediatric patients with active Crohn disease. PATIENTS AND METHODS Children with active Crohn disease scheduled for their initial dose of infliximab underwent assessment immediately before and 2 weeks following infliximab infusion. Using the stable isotope [d5] phenylalanine, rates of fractional and absolute albumin and fibrinogen synthesis were calculated. Measurements were made in both the fasting and parenterally fed states. RESULTS Fifteen children (mean age 14.9 +/- 0.3) completed the study. The mean serum albumin changed from 3.59 +/- 0.08 to 3.66 +/- 0.04 g/dL, and the mean fibrinogen level decreased from 230 +/- 17 to 187 +/- 8 mg/dL (P < 0.05) following infliximab therapy. During fasting, there were no changes in albumin and fibrinogen synthesis rates following infliximab. During parenteral nutrition infusion, the fractional albumin synthesis rate changed from 11.8% to 15.1%/day (P = 0.06), and the absolute albumin synthesis rate increased from 192 to 248 mg x kg(-1) x day(-1) (P < 0.05), whereas no changes in fibrinogen synthesis rates were observed. Synthesis rates of albumin and fibrinogen were increased during parenteral nutrition infusion compared with the fasting state. CONCLUSIONS Following infliximab therapy, during parenteral nutrition infusion, albumin synthesis increased significantly. Conversely, serum fibrinogen levels decreased following infliximab therapy in the absence of significant change in synthesis rates.

Background & Aims: Although eosinophilic esophagitis is recognized increasingly, outcome data guiding therapy are limited. We conducted a prospective randomized trial comparing oral prednisone (P) and swallowed fluticasone (F) for histologic and clinical response. Methods: Patients were randomized to receive P or F for 4 weeks, followed by an 8-week weaning protocol. Esophageal histology was evaluated at baseline and after 4 weeks of therapy. Clinical assessments were performed at weeks 0, 4, 12, 18, and 24. Results: Eighty patients with eosinophilic esophagitis were enrolled: 40 in the P arm and 40 in the F arm. Histologic improvement was seen in 30 of 32 P and 34 of 36 F patients, with a greater degree of histologic improvement in the P group. All P and 35 of 36 F patients were free of presenting symptom(s) at week 4. Symptom relapse was seen in 45% of patients by week 24. Kaplan–Meier analysis showed no difference between P and F with regard to relapse rate (P = .7399). No significant difference in time to relapse was found between groups (P = .2529). Systemic adverse effects were noted in 40% of the P arm, whereas esophageal candidal overgrowth was seen in 15% of the F arm. Conclusions: Systemic and topical corticosteroids were effective in achieving initial histologic and clinical improvement. P resulted in a greater degree of histologic improvement, without evidence of an associated clinical advantage over F in terms of symptom resolution, relapse rates, or time to relapse. Symptom relapse was common to both groups upon therapy discontinuation, highlighting the need for maintenance treatment protocols.

The aim of this study was to determine if the Bravo pH capsule is comparable to the nasally placed pH catheter in terms of pH-metry, safety, and tolerability in children.Ten patients each in the age ranges of 4 to 6 years, 7 to 10 years, and10 years were tested simultaneously with the catheter and the capsule. Six each were tested with the catheter alone or the capsule alone. Subjects recorded adverse events and graded tolerance (in terms of activity, appetite, and satisfaction) on a scale of 1 to 5, with a score of 5 indicating that the device was well tolerated. A 24-hour reflux index and 24- and 48-hour reflux indices were generated from the catheter and capsule, respectively. Student t test, Mann-Whitney U test, and Fisher exact test were used to compare reflux index, tolerability, and adverse events between the catheter and capsule.Sixty-six patients 4 to 16 years of age (mean, 9.4 years) were enrolled. There was no statistically significant difference between the mean reflux indices (RIs) obtained simultaneously with the catheter and capsule in all patients combined on day 1 (P = 0.0665). There was a significant difference between day 2 and days 1 and 2 combined with the capsule versus the catheter (P = 0.007 and P = 0.0107); however, a discordant result of normal RI on day 1 and pathological RI on day 2 was seen in only 1 patient. The capsule was better tolerated than the catheter in terms of appetite (P = 0.029), activity (P = 0.001), and satisfaction (P = 0.003). There were no significant complications.The Bravo pH capsule was as accurate and safe and better tolerated than the conventional pH catheter in children 4 years of age and older.

The objective of this study was to determine at what age suction rectal biopsy is less likely to provide adequate tissue to detect submucosal ganglion cells in a child being evaluated for Hirschsprung disease.Childrenor =1 year of age undergoing a rectal biopsy at a single children's hospital had 1 biopsy each obtained simultaneously with a suction biopsy device and a grasp biopsy forceps. The biopsies were examined by 2 pathologists for adequacy of the submucosa (none, scant, adequate, or ample) and the presence of ganglion cells. The 2 specimens were compared with each other.One hundred fifty-two children 1 to 17 years of age were included. Fifty-three were female. Subjects were grouped into 4 age categories: 1 to 3 years (group A), 4 to 6 years (group B), 7 to 9 years (group C), andor =10 years (group D). Similar numbers of patients were recruited for each group. Ganglion cells were identified in 73% and 90% by the suction and grasp devices, respectively, in group A. In groups B through D, ganglion cells were identified in 50% to 53% vs 92% to 97% of the suction and grasp biopsies, respectively (P0.001). Submucosa was present in 88% (suction) vs 98% (grasp) in group A, 70% vs 95% in group B, 69% vs 94% in group C, and 45% vs 92% in group D.The suction rectal biopsy is less likely to provide adequate submucosa for identification of ganglion cells after 3 years of age.

Objectives: We studied the expression of cytokines and inflammatory cells in normal and inflamed esophageal mucosa of children with the aim of furthering our understanding of the pathophysiology of allergic eosinophilic esophagitis (AEE). Methods: Controls and AEE patients (≥15 eosinophils/highpower field on esophageal mucosal biopsies) between the ages of 1 and 18 years were recruited. Esophageal biopsies were obtained for histologic examination, immunohistochemical studies, and cytokine analysis. Results: Eight controls (4 males; mean age 9.99 years) and 11 AEE patients (8 males; mean age 7.15 years) were studied. mRNA expression ofinterferon (IFN)-γ, interleukin (IL)-4, IL-5. IL-13, eotaxin-1, eotaxin-2, eotaxin-3, and RANTES was studied. IFN-γ and IL-5 expressions were significantly up-regulated in AEE patients compared with controls. Expressions of IL-4 and IL-13 were similar between AEE patients and controls. Eotaxin-1 expression was significantly up-regulated in AEE patients, whereas eotaxin-2 was up-regulated in controls. Expression of RANTES and eotaxin-3 was similar between the two groups. There was increased staining for mast cells in AEE patients compared with controls. Conclusions: Our data suggests that AEE is primarily an IL-5 selective TH2 response, with a possible TH1 component, and a differential role of eosinophilic chemoattractants. The role of mast cells in the pathogenesis of AEE needs additional study.

Interest in the gastrointestinal (GI) factors of autistic disorder (autism) has developed from descriptions of symptoms such as constipation and diarrhea in autistic children and advanced towards more detailed studies of GI histopathology and treatment modalities. This review attempts to critically and comprehensively analyze the literature as it applies to all aspects of GI factors in autism, including discussion of symptoms, pathology, nutrition, and treatment. While much literature is available on this topic, a dearth of rigorous study was found to validate GI factors specific to children with autism.

The presence of eosinophils on esophageal biopsy is a marker of esophagitis in children. Eosinophilic inflammation without evidence of gastroesophageal reflux has led to the new diagnosis of eosinophilic, or allergic, esophagitis. The aim of this study was to correlate the number of eosinophils with the reflux index on same day esophageal biopsy and 24 h esophageal pH monitoring.A retrospective analysis of data collected from children who underwent same day endoscopy with esophageal biopsies and 24 h esophageal pH monitoring over a 3-yr period was performed. The patients were divided into five groups: Group 1: 0 eosinophils/hpf and no histologic change, Group 2: 0 eosinophils/hpf but histologic changes, Group 3: 1-5 eosinophils/hpf, Group 4: 6-20 eosinophils/hpf, and Group 5:20 eosinophils/hpf. Reflux indices were analyzed within each group.A total of 305 patients met the inclusion criteria. The mean reflux indices +/- standard error within each group were Group 1 (n = 171): 2.14 +/- 0.18%, Group 2 (n = 40): 3.93 +/- 1.24%, Group 3 (n = 42): 5.96 +/- 1.53%, Group 4 (n = 21): 4.18 +/- 1.27%, and Group 5 (n = 31): 2.02 +/- 0.53%. The mean reflux index in Group 3 was significantly greater than Groups 1 and 5.The presence of denser infiltrates of eosinophils does not correlate with increased gastroesophageal reflux. The finding of more than 20 eosinophils/hpf is likely associated with a normal reflux index and a nonacid-related cause of esophagitis.

Objective: The study objective was to determine whether the rectoanal inhibitory reflex (RAIR) can be elicited during limited anorectal manometry (ARM) performed under general anesthesia (GA). Methods: In this retrospective study, patients with intractable constipation who underwent ARM under GA from November 1999 to March 2002 were evaluated. Rectal biopsy specimens were examined for the presence of ganglion cells. Results: Eighty consecutive patients aged 5 months to 16 years were evaluated. Three patients with Hirschsprung disease were excluded from analysis. Ganglion cells were found in rectal biopsy specimens from 76 patients. RAIR was positive in 69 (90%) and negative in 8 (10%). Forty-five patients received preoperative medications: midazolam (n = 36), midazolam + atropine (n = 3), atropine (n = 1), midazolam + glycopyrrolate (n = 3), and glycopyrrolate (n = 2). Different combinations of general anesthetic medications were used. Ten patients received neuromuscular blockers. The use of preoperative midazolam or atropine did not affect the presence or absence of RAIR; however, the proportion of patients with negative RAIR was higher in those receiving glycopyrrolate (P = 0.007) than in those receiving other medications. There was no significant difference in the effect of the general anesthetic agents or neuromuscular blockers used on the presence or absence of RAIR. Conclusions: The rectoanal inhibitory reflex in children can be elicited even when anorectal manometry is performed under general anesthesia. Glycopyrrolate, an anticholinergic, appears to inhibit the demonstration of the RAIR.

Objectives Upper GI endoscopy (UGE) is a common procedure performed for evaluation and treatment of various upper GI tract disorders in children. Limited comprehensive data are available on the complications of UGE in adults and particularly in children. The goals of this study were to identify complications and adverse events reported by patients and their parents after outpatient UGE under general anesthesia (GA). Methods Pediatric patients who underwent outpatient UGE under GA between April, 2000 and April, 2001 at the James Whitcomb Hospital for Children were identified. The interviewer obtained verbal consent and performed standardized telephone interviews 30 days after the outpatient UGE. Results A total of 393 patients participated in this survey. Of the patients, 165 (42%) had one or more complications or adverse events. The most common ones reported by patients or parents 30 days after the UGE under GA were sore throat or hoarseness (34.6%), fatigue (6.6%), cough (4.1%), headache (3.3%), excessive gas or burping (2.8%), nausea (2.5%), emesis (2.3%), abdominal pain (2%), fever (2%), behavior problems (1.8%), upper respiratory symptoms (1.3%), excessive drowsiness (0.5%), nosebleed (0.3%), perioral rash (0.3%), and chest pain (0.3%). Ten of 165 patients with complications or adverse events after UGE sought medical assistance. Conclusions Approximately one third of pediatric patients complained of sore throat or hoarseness after UGE under GA. All other reported complications or adverse events were infrequent. We conclude that UGE under GA is safe and well tolerated in pediatric patients.

We conducted a retrospective analysis to determine if both alpha1-antitrypsin serum level and phenotype need be studied when evaluating children for alpha1-AT deficiency. We collected data from patients less than 19 years old who had both serum alpha1-AT level and phenotype determined over a 9-year period (January 1992-December 2000). Eighty-eight patients were identified and 15 had the PiZZ phenotype. The serum alpha1-AT level was below normal (normal 85-215 mg/dl) in all 15 PiZZ patients. Seventy-two of 73 non-PiZZ patients had normal or above normal serum levels. The sensitivity of the serum alpha1-AT level was 100%, and the specificity was 99%. The serum alpha1-AT level had a positive predictive value of 94% and a negative predictive value of 100%. We conclude that serum alpha1-AT levels are highly predictive of the PiZZ phenotype. Determination of the serum alpha1-AT level alone should be the initial test when evaluating for alpha1-AT deficiency.

Asymptomatic infants and infants with gastroesophageal reflux have been noted to have peak reflux in the midafternoon. The aim of this study was to examine circadian variation of gastroesophageal reflux in children with both normal and abnormal 24-hr esophageal pH probe studies. Eighty-seven patients were studied and 15 of these patients were found to have a reflux index >4% for the duration of the study. These 15 patients were found to have significant circadian variation. Peak reflux indices (mean 12.60%) were detected in the mid-afternoon, with a smaller peak at night (mean 8.07%). Trough indices (mean 2.60%) occurred in the early morning. The 72 patients with normal studies were found to have less circadian variation, although peak reflux indices (mean 1.76%) occurred in the early morning. Clinicians should target their antireflux therapy to periods of peak gastroesophageal reflux.

To assess the role of esophagogastroduodenoscopy in the evaluation of children with suspected inflammatory bowel disease.All children with inflammatory bowel disease who underwent esophagogastroduodenoscopy during their initial evaluation at our institution during a 7-year period (December 1993 to November 2000) were included in the study.The study included 115 patients: 81 with Crohn disease (mean age, 11.34 years; 42 males) and 34 with ulcerative colitis (mean age, 11.79 years; 20 males). Abnormal findings on esophagogastroduodenoscopy were noted in 64% of patients with Crohn disease and 50% of children with ulcerative colitis; histologic abnormalities were found in 81.6% and 70.6% of the patients, respectively. Granulomas were found in the upper gastrointestinal tracts of 23 of 81 patients (28.4%), with the most common site being the gastric mucosa. Nine of these 23 patients had granulomas solely in the upper gastrointestinal tract. Additional unsuspected pathology noted included: candidiasis, hiatal hernia, Helicobacter pylori infection, and giardiasis.Endoscopic and histologic abnormalities were found in the upper gastrointestinal tracts of a significant number of children with inflammatory bowel disease. While the mechanism(s) underlying these abnormalities in patients with ulcerative colitis is unclear, the pathology can contribute to the patient's clinical condition. Pathology in the upper gastrointestinal tract should not exclude a diagnosis of ulcerative colitis. Granulomas, confirming the diagnosis of Crohn disease, were found in the upper gastrointestinal tracts of 28% of our patients with Crohn disease. In some cases, granulomas were found solely in the upper gastrointestinal tracts. Based on our data, esophagogastroduodenoscopy with biopsy should be performed in all pediatric patients with suspected inflammatory bowel disease.

Lactase deficiency is commonly found in adults with inflammatory bowel disease (IBD). Our aim was to determine its prevalence in children with IBD.We conducted a retrospective and descriptive analysis of patients with symptomatic IBD whose mucosal lactase activity was measured on duodenal biopsies obtained during gastrointestinal endoscopic evaluations. Age- and gender-matched controls were chosen randomly from a group with chronic abdominal pain.One hundred twelve patients with IBD were identified from January 1994 to December 2000. Seventy-nine (71%) had Crohn disease, and 33 (29%) had ulcerative colitis. Forty-five (40%) of all IBD patients (29 with Crohn disease and 16 with ulcerative colitis) had low lactase activity levels (15 microM/min/gm). The prevalence of lactase deficiency in patients with IBD was 37% (38 of 103) in white patients and 78% (7 of 9) in blacks. Thirty-four of 112 controls (30%) had lactase deficiency. IBD patients were more likely to be lactase deficient than the controls, but the difference was not statistically significant ( = 0.162). Normal duodenal histology was found in 67% of lactase-deficient IBD patients compared with 82% in lactase-sufficient IBD patients. The frequency of duodenal inflammation did not differ significantly between lactase-deficient and -sufficient patients with IBD ( = 0.068).More than one third of pediatric patients with IBD have lactase deficiency, which is not significantly different from non-IBD patients with chronic abdominal pain. The majority of lactase-deficient patients with IBD have normal duodenal biopsy results. Lactase activity from small bowel biopsy specimens can be measured at the time of initial endoscopy. Reevaluation, either by small bowel biopsy or the breath hydrogen test, may then be considered during follow-up of symptomatic patients.

Objective. A variety of methods are used to assess the length of infants at hospital admission. A tape-measure technique is commonly used; however, this measure is potentially inaccurate. We aimed to assess accuracy of tape measurement of infant lengths by comparison with the more accurate length-board technique. Methods. During a 1-year period, 25 infants who were younger than 36 months were seen for a nutrition consultation. The length obtained at admission was compared with that obtained with a length-board by a trained dietitian. Results. Overall, the lengths varied enough both positively and negatively that no overall statistical difference was seen; however, the average difference between the tape measure and the length-board was 2.23 cm. The change in length resulted in a change in the weight-for-length percentile range in 13 of 25 patients. Conclusion. The more accurate length-board measurement should be applied at the time of admission of an infant.

Direct measurement of pancreatic enzymes is the gold standard in the evaluation of exocrine pancreatic function. The purpose of our study was to evaluate the use of cholecystokinin as a single-agent secretagogue for pancreatic drainage studies. Twenty pediatric patients received cholecystokinin (group 1) and 40 patients received either secretin plus placebo (group 2) or secretin plus cholecystokinin (group 3). Duodenal fluid was collected for measurement of lipase, amylase, trypsin, chymotrypsin. The mean lipase and amylase activities were higher in group 3 and the mean trypsin and chymotrypsin activities were higher in group 1, but none of these observations were statistically significant. Group 3 had more patients with all four enzymes being normal (75%) compared to groups 1 (60%) and 2 (50%) (P = 0.262). Patients in all three groups had at least one normal enzyme. Cholecystokinin is useful as a single agent for direct pancreatic enzyme measurements in the absence of commercially available secretin.

Background Percutaneous endoscopic placement of a gastrostomy tube is a common procedure to provide feeding access in children. The practice has been to withhold the initial feeding for a prescribed length of time because of safety concerns. The shortest reported time to feeding in pediatric patients is 6 hours. Patients and methods A prospective randomized trial was devised to compare the tolerance of feedings at 3 and 6 hours after percutaneous endoscopic gastrostomy placement. The change in abdominal girth before and 1 hour after the initial feeding, any vomiting, and the gastric residual volume before the next feeding were recorded. The length of stay was also documented. Results Forty successive patients who met the entry criteria were enrolled, with 20 in each group. There were no statistical differences between the groups for age or sex distribution. There were no significant differences in the recorded episodes of emesis from either group (median value 0 in both groups, P = 0.82). The changes in abdominal girths were also similar and statistically not significantly different (median values 0 for 3 hours vs 0.5 cm for 6 hours, P = 0.29). Gastric residual volumes were low overall and not different depending on the time that feedings were started (median value 0 in both groups, P = 0.47). The length of stay was statistically the same between the 3- and 6-hour feeding groups (median values 30.7 hours for 3 hours vs 30.0 hours for 6 hours, P = 0.92). Conclusions Feedings after percutaneous endoscopic gastrostomy placement can be started as soon as 3 hours after the procedure is completed with no increase in complications.

BACKGROUND Direct measurement of pancreatic enzymes after administration of pancreatic secretagogues is the gold standard in the assessment of exocrine pancreatic function. Recent experience at the authors' institution showed that endoscopic collection of pancreatic secretions 5, 10, and 15 minutes after intravenous administration of secretin is useful in screening for pancreatic insufficiency. Concomitant administration of intravenous cholecystokinin has been a subject of debate. The purpose of this study was to compare pancreatic enzyme levels after administration of secretin versus secretin plus cholecystokinin and to validate the timing of collection of duodenal fluid. METHODS A prospective, randomized, double-blind study was conducted from September 1997 through September 1998. Patients scheduled for pancreatic enzyme sampling were randomly assigned to receive intravenous secretin (2 U/kg) plus placebo (group 1) or intravenous secretin (2 U/kg) plus cholecystokinin (0.02 microg/kg [Group 2]). Duodenal fluid was collected 5, 10, and 15 minutes later and placed in dry ice. Samples were measured for the levels of trypsin, amylase, lipase, and chymotrypsin. RESULTS Twenty patients were assigned to each group. The age range was similar in both groups: 12 months to 16 years, 8 months in group 1 (median, 2.1 years) and 15 months to 13 years, 7 months in group 2 (median, 2.5 years). Group 2 had a greater number of patients with all four enzymes at normal levels during at least one of the time points, 75% versus 50% (P = 0.102). The difference in enzyme levels at the 5-, 10-, and 15-minute collections was statistically significant. For all four enzymes in both groups, values varied from highest to lowest with time (P = 0.0001). The enzyme levels at 10 minutes were close to the enzyme levels at 5 minutes; the lowest values occurred at 15 minutes. CONCLUSIONS Higher pancreatic enzyme levels were obtained after administration of secretin plus cholecystokinin, although the trend did not reach statistical significance. Pancreatic enzyme levels are highest at 5 and 10 minutes, indicating that collections of duodenal fluid should be completed within 10 minutes of the administration of the secretagogues.

The relationship between symptoms, intestinal mucosal histology, and disaccharidase activities is not well defined. An analysis of disaccharidase activities was performed in children grouped by age, symptoms, and intestinal mucosal histology and normal values established.Disaccharidase activities and histology of 246 endoscopically obtained duodenal biopsies in 232 patients (121 girls; age range, 0.08-17 years; mean, 5.9 years) in a 3-year period were reviewed. Patients were divided into two groups based on absence (group 1; n = 142) or presence (group 2; n = 90) of diarrhea and were subdivided by age into, less than 24 months of age and 24 months of age or more. Histologic changes within groups were classified as (A) normal, (B) mild, or (C) moderate to severe based on villus height abnormalities. A questionnaire was sent to 34 patients with hypolactasia to assess the efficacy of lactose avoidance and/or lactase supplementation.All group 1 patients had normal findings in analysis of mucosal specimens, and their disaccharidase activities showed normal values because they had no diarrhea. The geometric means (95% confidence interval) in children aged less than 24 months are (in micromoles of substrate hydrolyzed per minute at 37 degrees C per gram protein) (units [U]) lactase, 36.7 (13.4-100.4); maltase, 178.5 (88.9-356.3); palatinase, 12.7 (3.8-41.5); and sucrase 60.0 (24.0-148.1). In children 24 months of age or more, the values are 23.2 (3.9-108.1), 167.6 (78.8-355.9), 12.7 (4.9-32.9), and 51.0 (20.5-126.0), respectively. Only lactase activity decreased with age (p0.05). No differences in disaccharidase activities were noted in patients with and without diarrhea if the mucosal histology was normal (group 1A vs. 2A). In patients with diarrhea, values were commensurate with the degree of mucosal injury, especially in the older group. Twenty-two of 27 patients (81%) who responded to the questionnaire had benefited from lactase supplementation and/or lactose avoidance.We have established normal values for disaccharidase activities in the pediatric population. Although the disaccharidase activities correlate more with degree of intestinal mucosal injury than with symptoms, their activities are difficult to predict accurately based on these criteria. If required, disaccharidase activities should be measured biochemically.

Background: Labeled leukocyte imaging is a helpful diagnostic tool in the detection of inflammation and sepsis. The technetium TC 99m hexamethyl propylene amine oxime ( 99m Tc HMPAO)-labeled leukocyte scan has been found to be more sensitive than the Indium- 11 labeled leukocyte scan in detecting inflammatory bowel disease, with reported sensitivities of 95% to 100%. Experience with the 99m Tc HMPAO-labeled leukocyte scan was examined and its clinical applications evaluated in the immediate treatment of patients with inflammatory bowel disease. Methods: A retrospective chart review was undertaken that included pediatric patients who underwent Tc HMPAO-labeled leukocyte scan at the James Whitcomb Riley Hospital for Children. The disease activity of patients with inflammatory bowel disease was assessed. The leukocyte scan was performed according to the manufacturer's specifications, and images were obtained 30 minutes and 2 hours after administration of the radiopharmaceutical. Results: During the period of July 1996 through November 1997, 41 scans were performed in 35 patients. Twenty-nine patients had histologically proven inflammatory bowel disease: 24 with Crohn's disease, 4 with ulcerative colitis, and I with indeterminate colitis. Active inflammatory bowel disease was suspected in 24 patients when the leukocyte scan was performed. Twenty of the 24 patients (83% sensitivity) had abnormal findings in leukocyte scans that prompted more aggressive management in 15 (75%). Six of the 15 who were receiving maximum medical therapy underwent surgical resection of severely affected bowel segments, and medical treatment was intensified in the other 9. The remaining 5 patients were receiving optimal medical therapy, instituted at their recent visit, and did not require further medication adjustments. Four of the 24 patients with active inflammatory bowel disease had normal leukocyte scans (17% false-negative rate), 3 of whom were receiving corticosteroid therapy at the time the scans were performed. All of the 11 patients in whom inflammatory bowel disease was in remission and 6 patients who did not have inflammatory bowel disease had normal findings in leukocyte scans (100% specificity). Conclusions: Although a tissue diagnosis is still recommended, obtained during upper and lower gastrointestinal endoscopic examinations, and contrast radiography of the small bowel for the initial work-up of patients with suspected inflammatory bowel disease, the 99m Tc HMPAO-labeled leukocyte scan is a safe and useful diagnostic adjunct for subsequent evaluation of patients known to have inflammatory bowel disease. The results of 99m Tc HMPAO-labeled leukocyte scans directly influenced treatment of 75% of the study patients with active inflammatory bowel disease, which included the decision to refer patients for surgical intervention.

Introduction Allergic eosinophilic esophagitis (AEE) is thought to be an allergic reaction that is characterized by inflammation caused by predominant accumulation of eosinophils in esophageal mucosa (> or =15 eosinophils per high power field). Aims To examine the seasonal distribution of newly diagnosed AEE children. Methods Retrospective analysis of all patients diagnosed with AEE at our institution over a nearly 6-year period (December 1998 to October 2004). Results Two hundred thirty-four children (mean age 7.3 y, median age 7.0 y, age range 0.2 to 19.5 y) were diagnosed with AEE during the study period. Significantly fewer patients were diagnosed with AEE in Winter as compared with Spring, Summer, and Fall. Although all the patients had severe eosinophilic esophagitis, the intensity of esophageal eosinophilia was less in Winter than in Summer or Fall, but not Spring, seasons. Conclusions A seasonal variation was noted with Winter, a season of low outdoor allergens, having the fewest number of newly diagnosed AEE patients.

Background: The finding of characteristic small intestinal mucosal abnormalities on histologic examination of a biopsy specimen remains the first requirement for the diagnosis of celiac disease. A reliable and noninvasive test would be ideal for the patient's convenience and for reducing health-care costs. The sensitivity and specificity of anti-gliadin antibodies (AGA-immunoglobulin [Ig] G, AGA-IgA) have been variable; anti-endomysium IgA (EmA-IgA) is more helpful. In an earlier study conducted at the authors' institution, celiac disease was present in 19 patients examined from 1992 to 1995. Anti-endomysium titers were higher than normal in all 19 patients (100%). Total villous atrophy was seen in 14 of 17 biopsy specimens (82%) and subtotal atrophy in 3 (18%). The purpose of the current study was to evaluate further the accuracy of EmA-IgA in diagnosing celiac disease. Methods: One hundred seven patients were screened for celiac disease between March 1996 and July 1997. The level of EmA-IgA was measured in all patients, and AGA-IgG and AGA-IgA were measured in 104 patients. Forty-six patients underwent endoscopic biopsy of the small bowel, with measurement of disaccharidase enzymes in 45 patients. Results: Five of 46 patients had celiac disease (three boys and two girls; mean age, 5.3 years; 2-9.5 years); one also had cystic fibrosis and another had insulin-dependent diabetes mellitus. All five had marked to complete villous atrophy with crypt hyperplasia and increased serum EmA-lgA (100% sensitivity). None of the remaining patients had increased EmA-IgA (100% specificity). Serum levels of AGA-IgG and AGA-IgA were increased in all four celiac disease patients (100% sensitivity), but they were also high in patients without celiac disease (38% and 92% specificity, respectively), which compromises their diagnostic value. None of the patients confirmed to have celiac disease had IgA deficiency. Abnormal disaccharidase enzyme activities were documented in all five celiac disease patients: severe generalized deficiency (n = 2), moderately severe generalized deficiency (n = 2), and alactasia with moderate deficiency of the α-glucosidases (n = I). Conclusions: This study confirmed the reliability and accuracy of EmA-IgA in the diagnosis of celiac disease. Small bowel biopsy may be unnecessary in EmA-positive patients in whom celiac disease is suspected.

Adjunctive drugs play an important role in the management of chronic pain states. Recent analysis of previous studies has confirmed the efficacy of both anticonvulsant and antidepressant medications in the treatment of a variety of chronic pain conditions. There are few trials investigating the use of antiarrhythmic drugs in chronic pain. The studies that exist do suggest that antiarrhythmics may be of use in some cases. There are serious toxicities associated with all of these agents. Many of these are so troublesome as to require cessation of the drug. There are also some alarming idiosyncratic reactions associated with their use. Recent advances have included the introduction of gabapentin and lamotrigine. Both of these have significantly fewer side effects and are better tolerated. Currently there is little clinical data regarding their efficacy in chronic pain states. Newer antidepressants do not appear to be significantly better than placebo in treating pain. Their faster onset and fewer side effects may make them better tolerated in the treatment of associated depression. Antiarrhythmic agents, due to potentially lethal side effects, are best reserved for resistant pain unresponsive to more conventional drugs.

Objective: Increasing evidence suggests that nitric oxide participates in the pathophysiology of intestinal barrier function/dysfunction and inflammation. Increases in inducible nitric oxide synthase (iNOS) mRNA and protein expression have been observed in colonic mucosal biopsies of adults with inflammatory bowel disease (IBD). It is unclear whether iNOS induction is specific for IBD or a reflection of nonspecific mucosal inflammation. Furthermore, the characteristics of iNOS mRNA expression in pediatric patients with gastrointestinal disorders remains ill-defined. Our objective was to examine the relationship between iNOS mRNA expression and gastrointestinal mucosal inflammation in a pediatric population. Methods: Esophageal and colonic mucosal biopsies were obtained during endoscopy. Total RNA was isolated from these biopsies and reverse transcription-polymerase chain reaction (RT-PCR) performed (35 PCR cycles) using two 20-bp primers that amplified a predicted 372-bp conserved iNOS mRNA fragment. Results: Biopsies were obtained from 29 children (22 boys; mean age 10.6 yr [range 1.7–16.5 yr]). Endoscopic and histological findings included normal esophageal mucosa (n = 3), esophagitis (n = 10), normal rectal mucosa (n = 2), ulcerative colitis (n = 10), and Crohn disease (n = 4). Evidence of iNOS mRNA was detected by PCR amplification in six of 10 patients with ulcerative colitis and in two of four patients with Crohn disease. However, iNOS mRNA was not amplified in any esophageal biopsy or in rectal mucosa biopsies with normal histology. Conclusions: These data indicate that upregulation of iNOS mRNA expression in colonic mucosa is a feature of IBD in children. iNOS mRNA expression is not upregulated in esophageal mucosa or in the absence of colonic inflammation. Further studies designed to determine the site- and cell-specificity of iNOS mRNA upregulation in mucosal biopsies from children with IBD may further illuminate the pathophysiology of these disorders.

We report three boys, ages 8 to 14 years, who experienced dysphagia or chest pain while eating. In each patient, contrast esophagrams or esophagogastroduodenoscopy (EGD) demonstrated mid-esophageal traction diverticula, and serologic findings were compatible with acute or recent histoplasmosis. Diverticula appear to result from esophageal traction induced by inflammatory changes in adjacent infected lymph nodes. Antifungal and anti-inflammatory therapies were individualized in each case; all patients recovered fully.

Nineteen patients, aged 2½ years or younger, underwent liver transplantation at the Indiana University Medical Center. Three required a second graft and one required a third. The transfusion requirements of these children were compared with the needs of adults receiving liver allografts at the same institution. When expressed as units of blood components transfused per kilogram of patient weight, the intraoperative use for the two groups was similar. After surgery, pediatric patients required the greatest hemotherapy support and received considerably larger doses of fresh frozen plasma than did adults. Thus, in contrast to adults, who require greater hemotherapy support during surgery, these pediatric patients required the greatest amount of blood components posttransplantation. Ten of the 19 pediatric patients were cytomegalovirus (CMV)-seronegative before transplantation. Three of the 10 seroconverted after transplantation. Two had received organ grafts from CMV-seropositive donors, but the third received a liver graft and cellular blood components from only CMVseronegative donors. The cause of this patient’s seroconversion was unknown.

Objective. To determine the role of Helicobacter pylori infection in children with recurrent abdominal pain and the usefulness of serologic tests in screening H pylori infection and monitoring treatment of H pylori-associated gastritis. Methods. During a 3 year period, we investigated the presence of serum immunoglobulin G (IgG) antibody to H pylori in 456 children using the high-molecular-weight cell-associated protein H pylori enzyme immunoassay kit. Among the 456 children studied, 218 (age range, 3 to 18 years; mean age, 9.5 years) had symptoms of recurrent abdominal pain (RAP syndrome) with or without vomiting, and the remaining 238 (age range, 3 to 18 years; mean age, 9.8 years) had no RAP (non-RAP syndrome). We performed upper gastrointestinal endoscopy on 111 consecutive children of the 218 with RAP syndrome and obtained mucosal biopsies for culture, histologic analysis, CLO test (Delta West, Perth, Australia), and H pylori detection by polymerase chain reaction. Results. Thirty-eight (17.4%) of 218 children in the RAP group and 25 (10.5%) of 238 children in the non-RAP group were seropositive for H pylori. Of the 111 children endoscoped, 95 were found to be negative, and 12 were positive by all five assays. Specimens from 2 children were negative by culture and the CLO test but positive by the other three assays. Specimens from 1 child were negative by histologic analysis but positive by all other tests. The remaining child was positive for anti-H pylori IgG but negative by all of the other four assays. Upper gastrointestinal endoscopy detected 14 children with peptic ulcer disease (9 duodenal ulcer and 5 gastric ulcer) and 12 with antral nodular gastritis. Only 4 of the 14 diagnosed with peptic ulcer were H pylori positive by all five assays, whereas all 12 children with antral nodular gastritis were H pylori positive. Nine of the 12 H pylori-positive children were treated with a combination of bismuth subsalicylate, amoxicillin, and metronidazole for 2 weeks. Sera obtained at 2, 4, and 6 months after treatment from all 9 children showed a decrease in anti-H pylori IgG titer. Three H pylori-infected children who did not receive any treatment served as control children, and their IgG levels remained elevated or increased over time. Conclusion. The results from our study indicate that screening for the serum IgG antibody to H pylori is a practical method for diagnosing H pylori infection in children, and that serial measurements of the H pylori IgG antibody are useful for monitoring treatment of H pylori because of its high sensitivity and ease of performance. Only 4 of the 14 children diagnosed with peptic ulcer disease were confirmed to be infected with H pylori, whereas all 12 children with antral nodular gastritis were found to be infected by H pylori. These observations suggest that H pylori infection is more frequently associated with gastritis than with peptic ulcer disease in children, and that H pylori gastritis is a cause of RAP syndrome in children.

Our objective was to examine the diagnostic yield of duodenal aspirates for Giardia in children and compare it to results of duodenal mucosal biopsies. The results of all duodenal aspirates submitted for direct parasite examinations over a 31-month period were reviewed, as were the histological results of duodenal mucosal biopsies from these patients. In all, 161 children (89 boys; age range 0.33-18 years) were included in the study. Giardia was identified in the duodenal aspirate of 5.6% (9/161) patients and on duodenal mucosal biopsies from all nine patients. In conclusion, the 5.6% diagnostic yield of duodenal aspirates for Giardia is higher than reported in a previous study of adult patients from a similar geographical region (0.7%). The detection of Giardia on duodenal mucosal biopsies from all patients with positive duodenal aspirates brings into question the utility and cost of the latter test. Duodenal aspirates for Giardia may be unnecessary if duodenal mucosal biopsies are obtained for histological examination.

The neurologic complications of 24 children, ages 5 months to 18 years, following orthotopic liver transplantation at the Indiana University hospitals are reported. Biliary atresia (14 patients) was the most common cause for orthotopic liver transplantation. Three children died. Seventeen children (70%) had no neurologic deficit on follow-up 6 months or longer after transplantation. Eleven children (46%), including 4 of 16 patients (25%) who had received OKT3, had neurologic complications. Seven children (29%) had newonset seizures; 4 of these patients had status epilepticus. Two children had intracranial hemorrhage. Seizures occurred later in children than in adults following orthotopic liver transplantation and were not associated with poor prognosis. Longer term follow-up is indicated to assess subtle, cognitive deficits following liver transplantation in children.

Emulsion stability of total nutrient admixtures containing TrophAmine amino acid injection admixed with Intralipid, Nutrilipid, and Liposyn II was studied. High and low electrolyte concentrations were added to each total nutrient admixture before storage at 4 degrees C for 48 hours then at 20-22 degrees C for 24 hours. Stability studies were also performed on total nutrient admixtures containing higher concentrations of fat emulsion and total nutrient admixtures with added cysteine hydrochloride and carnitine. High electrolyte concentrations only were added to these total nutrient admixtures before being stored refrigerated for 24 hours then at room temperature for 24 hours. Visual assessment, pH determination, and particle size analysis were performed immediately after compounding and after refrigerated and room temperature storage. Particle size was assessed by measuring the mean diameter of the fat emulsion and the percent of oil volume in particles greater than 5 microns. Repeated-measures analyses of variance were used to determine significance of type or concentration of fat emulsion, electrolyte concentrations, or time on mean diameter or percent particles greater than 5 microns. There were minimal changes in pH values over time. Creaming was observed in all total nutrient admixtures at all sampling times except time zero. This was reversible upon agitation. Results of particle size analysis over time indicated little change in mean diameter or percent particles greater than 5 microns. These minimal changes did not seem to be clinically significant. It is concluded that total nutrient admixtures prepared with this pediatric amino acid formulation are stable when prepared and stored as reported.

Records of 20 consecutive pediatric patients receiving total parenteral nutrition over a 1-month period were reviewed for appropriateness of nutritional assessment and management. Each patient was monitored until total parenteral nutrition was discontinued or for a maximum of 2 weeks. A total of 124 therapy days were reviewed. Results demonstrated that only 35% of these patients had a nutritional assessment performed prior to initiation of therapy, and only 65% had nutritional goals determined. Nutritional goals were defined as patient-specific goals for fluid volume (FV), calories, protein, and fat emulsion. Analysis of data demonstrated that goals for FV were met on 62% of therapy days. Of the days on which FV goals were met, goals for calories, protein, and fat emulsion were met on 54%, 59%, and 51% of therapy days, respectively. Baseline serum triglyceride levels were measured in one of 20 patients. Serial laboratory monitoring was adequate, with the exception of hepatic enzymes and serum triglycerides, which were measured in 14 and 9 patients, respectively. Recommendations for pediatric parenteral nutrition therapy are discussed, as well as methods to implement these recommendations.

Background: Tumor necrosis factor-α (TNF-α) may contribute to the alterations in protein and energy metabolism present in children with Crohn's disease (CD), who frequently suffer from growth disturbance. We hypothesized that anti-TNF-α therapy would reduce protein losses, due to decreased proteolysis and increased protein synthesis, and that anti-TNF-α therapy would decrease resting energy expenditure. Methods: Children with active CD underwent metabolic assessment immediately before and 2 weeks following initial infliximab infusion. Using the stable isotopes [d5] phenylalanine and [1–13C] leucine, 2 independent measures of protein metabolism were determined during fasting and in response to parenteral nutrition. Energy expenditure, determined by indirect calorimetry, was measured in fasting and parenterally fed states. Results: Fifteen children completed the study. Following infliximab therapy, significant reductions in proteolysis (P < 0.05) were noted in the fasting state (8%–11%) and during parenteral nutrition infusion (10%–12%). Phenylalanine utilization for protein synthesis decreased significantly (8%–13%) following infliximab (P < 0.05). Protein balance was not significantly altered. No significant changes in energy expenditure were observed following infliximab in fasting or parenterally fed states. Supplementation with parenteral nutrition resulted in significantly decreased proteolysis (8%–21%; P < 0.05), increased protein synthesis (37%–45%; P < 0.01), and improved protein balance (P < 0.01) compared to the fasting state. Conclusions: Following the initial infliximab infusion in children with CD, proteolysis and protein synthesis were significantly reduced in the fasting and parenterally fed states. Supplementation with parenteral nutrition resulted in significant improvements in protein metabolism compared to the fasting state both before and after infliximab therapy. (Inflamm Bowel Dis 2007)

Objectives: Endoscopic examination of the colon is indicated in children with diarrhea, hematochezia and suspected inflammatory bowel disease. The aim of this study was to determine the rate of patient-reported symptoms after colonoscopy and flexible sigmoidoscopy under general anesthesia in children. Patients and Methods: This prospective study included patients 18 years of age and younger who underwent colonoscopy or flexible sigmoidoscopy during a 1-year period. At least 30 days after the endoscopy, an interview was conducted regarding symptoms after colonoscopy or flexible sigmoidoscopy. Results: Eighty-eight children were eligible, and 68 (77%) were available for follow-up. Ten (15%) reported symptoms after their endoscopy. The most common symptoms reported were diarrhea, excessive gas and sore throat. The frequency of reported symptoms was similar between colonoscopy and flexible sigmoidoscopy. The frequency of symptoms was not affected by intubation of terminal ileum, polypectomy or the number of prior colonoscopies or flexible sigmoidoscopies. Conclusions: Outpatient colonoscopy and flexible sigmoidoscopy under general anesthesia are well tolerated by children. A minority of children reports mild symptoms that spontaneously resolve.

Allergic eosinophilic esophagitis (AEE) is characterized by intense eosinophilic inflammation of the esophageal mucosa. Cysteinyl leukotrienes (CysLT) are eosinophil chemoattractants. We studied CysLT levels in esophageal mucosa of children with AEE and controls.CysLT levels (pg CysLT/microg protein) were quantified by Enzyme-linked Immunosorbent Assay (ELISA) on endoscopically obtained esophageal mucosal biopsies.Twelve children with AEE (eight boys, mean age 6.6 yr, range 1.0-14.5 yr) and 10 controls (six boys, mean age 9.56 yr, range 1.08-15.08 yr) were enrolled. None were on anti-LT or corticosteroid therapy. All controls had histologically normal mucosal biopsies of the esophagus, stomach, and duodenum. Patients with AEE had intense eosinophilic inflammation of the esophageal mucosa (mean 39 eosinophils/hpf, range 15-70 eosinophils/hpf) and a normal 24-h pH probe study. CysLT levels were similar between the two groups: mean levels were 12.44 (median 10.87, range 2.54-28.29) in AEE patients and 9.52 (median 9.26, range 1.71-21.64) in controls. CysLT levels did not correlate with the degree of esophageal eosinophilic inflammation. Incidentally, five patients with eosinophilic gastroduodenitis, in addition to esophagitis, were enrolled; their CysLT levels were statistically higher than those of controls.This is the first study to examine CysLT levels in esophageal mucosal biopsies of children with AEE and normal children. CysLT levels in AEE patients are similar to those in controls, and independent of the severity of inflammation. While this would argue against the use of CysLT antagonists in the treatment of AEE, further studies into the expression of the CysLT receptor itself are needed.

Objectives We aimed to determine if nocturnal acid breakthrough occurs in children receiving proton pump inhibitors for reflux esophagitis, and to compare the healing of esophagitis in children with nocturnal acid breakthrough receiving proton pump inhibitors +/- ranitidine. Methods This is a prospective, double-blind study. Endoscopic and histologic esophagitis were scored 0-4 and 0-3, respectively. Patients were treated with a proton pump inhibitor twice daily and esophagogastric pH monitoring was performed at week 3. Patients with nocturnal acid breakthrough were randomized. One group received ranitidine and the other received placebo at bedtime in addition to proton pump inhibitor therapy. Endoscopy was performed on all patients (with pH monitoring on patients with nocturnal acid breakthrough) during the 17th week of therapy. Results We enrolled 18 patients, ages 1 to 13 years (mean = 10.3 years). Mean baseline endoscopic and histologic scores were 3.1 +/- 1.4 and 1.8 +/- 0.7, respectively. Mean dose of proton pump inhibitor was 1.3 mg/kg +/- 0.6. Nocturnal acid breakthrough was documented in 16/18 (89%) patients. Seven patients received ranitidine and 9 received placebo. The reflux index improved: mean of 14.3 at baseline, 2.0 at week 3 (P = 0.0001), and 5.1 at week 17 (P = 0.09). Nocturnal acid breakthrough persisted in 9/12 (75%) patients, 3 of whom received ranitidine at bedtime. Esophagitis improved in all patients following therapy: mean endoscopy and histology scores were 1.6 +/- 1.8 (P = 0.0020) and 0.8 +/- 0.9 (P = 0.0013), respectively. Symptoms significantly improved from a mean score of 2.0 at baseline to 0.4 at week 17 (P = 0.0001). Conclusions Nocturnal acid breakthrough is common in pediatric patients treated with proton pump inhibitors. Reflux index remains normal in spite of nocturnal acid breakthrough. Symptoms and esophagitis continued to improve during therapy in spite of nocturnal acid breakthrough. There appears to be no additional benefit to supplementation with ranitidine at bedtime.

Background Allergic eosinophilic esophagitis (AEE) is defined by a dense infiltrate of eosinophils within the esophageal mucosa and the absence of pathological gastroesophageal reflux. Objective To characterize a pediatric population with AEE to determine if AEE can be diagnosed based on history; to compare patients with varying degrees of esophageal eosinophilic inflammation to determine if moderate esophageal inflammation is part of a continuum of AEE. Design Medical records of 112 patients with eosinophils on esophageal biopsy specimens were reviewed. Patients were grouped according to eosinophils per high power field (eos/hpf): group 1 (1-5 eos/hpf, n=31), group 2 (6-14 eos/hpf, n=13), and group 3 (≥15 eos/hpf, n=68) and compared. Setting University Children's Hospital. Patients Children and adolescents with eosinophils on esophageal mucosal biopsy specimens. Interventions Analysis of clinical information. Main Outcome Measurements Clinical characterization of patients with esophageal eosinophilia. Results There was no significant difference in patient demographics. Patients in groups 2 and 3 had multiple food allergens identified. Patients in group 3 with a positive type I allergic response were significantly younger than those with a negative response (mean, 4.6 years old vs mean, 8.5 years old; P = .0065). In group 2, 3 of 13 patients responded histologically to acid-suppressive therapy, whereas 6 patients had improved histology with corticosteroids; 4 of these 6 patients had not responded histologically to acid-suppression. Limitations Retrospective study. Conclusions History and clinical presentation were not useful in predicting the severity of histologic esophageal inflammation in this cohort. Patients with moderate esophageal eosinophilia (group 2) exhibited a variable response to medical therapy.

The purpose of this study was to determine whether biofeedback benefits children with dyssynergic defecation and constipation/encopresis, and whether home biofeedback improves long-term outcomes. Thirty-six patients with chronic constipation who had failed at least 6 months of conventional treatment and demonstrated dyssynergic defecation at anorectal manometry were randomized to biofeedback in the laboratory alone (group 1, n=24) or in the laboratory and at home (group 2, n=12) and followed up at 2, 4, and a mean of 44 months. Thirty patients were available for long-term follow-up. Bowel movements increased in all from a mean of 1.4/week to 5.1, 5.8, and 5.1 per week at 2 months, 4 months, and long-term, respectively (p ≤0.001). Soiling decreased in all from a mean of 5.5/week to 0.6, 0.1, and 1 per week at 2 months, 4 months, and long-term, respectively (p ≤0.001). Laxative use decreased from a mean of 4.1 days/week to 0.6, 0.3, and 0.7 per week at 2 months, 4 months, and long-term, respectively (p ≤0.001). Twenty-seven of 30 parents ranked their satisfaction a mean of 2.2 (range 1-excellent to 3-good). There were no significant differences in outcomes between the laboratory alone group and the laboratory plus home group. Biofeedback is beneficial for some children with chronic constipation and dyssynergic defecation. Supplemental home biofeedback does not improve long-term outcomes.

The PCR primer set Hp1-Hp2, which amplifies a 109-bp fragment of the 16S rRNA gene of Helicobacter pylori, has been widely used for the detection of H. pylori in clinical specimens. We have examined 34 stool samples and 50 human tissue samples from H. pylori-infected and uninfected patients, five human leukocyte samples, and one human cell line by this PCR method. All of these specimens produced a 109-bp PCR product. When Escherichia coli DNA was used as the template, several nonspecific bands, but not the 109-bp band, were observed. No PCR products were generated when DNA samples from five different fungi were used as templates. These results indicate that this 109-bp PCR product was amplified from the human genome. The 109-bp PCR product generated from various clinical specimens also hybridized with the probe pHp, corresponding to a region internal to the PCR product of Hp1-Hp2. We conclude that the 16S rRNA gene PCR with the primer set Hp1-Hp2 is not specific and cannot be used to detect H. pylori in clinical specimens.

Background: Our purpose was to study the concordance of serological tests for inflammatory bowel disease with clinical diagnosis established by traditional testing in children. Methods: All children seen in our division who had IBD Diagnostic System (ie, pANCA, ASCA IgA, and ASCA IgG) performed over a 21-month period (June 1998 to February 2000) were identified. Their medical records were reviewed for basic demographics, test results (endoscopy, histology, and radiology), IBD Diagnostic System results, and patient symptoms/medications. Results of the IBD Diagnostic System were compared with several patient characteristics including age, sex, absence/presence of symptoms, medication use, disease activity and duration. Results: One hundred seven patients were divided into 6 groups based on clinical diagnosis and IBD Diagnostic System results. The sensitivity, specificity and +/− predictive values of the IBD Diagnostic System for ulcerative colitis were 69.2, 95.1, 90.0, and 87.1%, respectively, and for Crohn's disease were 54.1, 96.8, 90.9, and 80.8%, respectively. Overall, the results of the IBD Diagnostic System were concordant with the clinical diagnosis in 76 of the 107 (71%) patients. Conclusions: In our experience, the specificity of IBD Diagnostic System is better than the sensitivity; the sensitivity is better for ulcerative colitis than Crohn's disease (69.2% vs 54.1%). The low sensitivity, especially for Crohn's disease, precludes the possibility that the IBD Diagnostic System can replace traditional studies when evaluating for inflammatory bowel disease. Though we do not exclude inflammatory bowel disease solely by IBD Diagnostic System results, it is reassuring to note that all patients without clinical evidence of inflammatory bowel disease also had negative IBD Diagnostic System results.