Augmentation of mucosal adaptation following massive small-bowel resection by 16,16-dimethyl-prostaglandin E2 in the rat

Survival following massive resection of the small intestine is often possible due to substantial hyperplasia of the mucosal surface in the remaining small intestine. While nutrients provide the major stimulus for hyperplasia in the clinical setting, the availability of drugs to augment this process would have obvious therapeutic implications. We evaluated the ability of 16,16-dimethyl-prostaglandin E2 (PGE2 to augment mucosal hyperplasia following massive small bowel resection in the rat. Three groups of 7 Sprague-Dawley rats, 160 g body weight, were subjected to 70% jejunoileal resection. One group was given 150 micrograms/kg of 16,16-dimethyl-PGE2 intragastrically twice daily, a second group 75 micrograms/kg subcutaneously, and a third group was untreated. After 17 days, segmental evaluation of mucosal mass in the remaining small intestine was determined by measuring mucosal protein, DNA, and disaccharidase levels. A significantly greater increase in mucosal mass was developed in the duodenum proximal to the anastomosis in both treatment groups, but neither the proximal nor distal ileum demonstrated significantly more adaptation. Histological examination in the duodenum confirmed the presence of a greater adaptive response in both the intragastrically and subcutaneously treated animals. 16,16-dimethyl-PGE2 appears to augment mucosal adaptation following massive small bowel resection in the rat, primarily in the very proximal small intestine.

Lack of effect of arbaprostil on the human non-pregnant uterus

Arbaprostil ((15R)-15-methyl Prostaglandin E2) is being studied for the treatment of gastrointestinal illness. To determine its effect on the human uterus, eight sterilized pre-menopausal women were studied during the proliferative phase of their menstrual cycle. Using a microtransducer catheter, intra-uterine pressures were recorded for at least 30 minutes prior to and 2 hours after arbaprostil administration. Each subject was studied four times, at 48-hour intervals, receiving in a double-blind manner; 0, 10, 25, and 50 micrograms. Arbaprostil at does up to 50 micrograms was found not to have any clinically significant effects on the non-pregnant human uterus.

Transient hypergastrinemia of 2 years' duration in a young pediatric patient

A 24-month-old female child experienced watery diarrhea, growth failure, and abdominal pain from age 3 months. Hypergastrinemia, hypochlorhydria, and fundic gastritis were documented. A secretin stimulation test was normal but protein meal stimulation revealed an abnormal serum gastrin response. Antral biopsies revealed G cell hyperplasia. Chronic treatment with antacids and an anticholinergic agent was unsuccessful. Spontaneous recovery occurred at age 29 months. Gastrin stimulation tests, gastric acid secretory tests, antral mucosal biopsies, and multiple basal serum gastrin levels were repeated. All were normal. Follow-up of greater than 3 years has documented a completely normal clinical and laboratory course.

Gastric emptying times of water in infants and children: comparison of those with and without gastroesophageal reflux

Thirty children without and 15 with gastroesophageal reflux had 1-h gastric emptying rates of water determined by a double dilutional method. The rates were similar in each group at all time intervals. No correlation between age, weight, or surface area and emptying rates was found.

Gastric emptying in children: unusual patterns detected by scintigraphy

The time-activity curve of gastric emptying of milk was evaluated in 49 infants and children who were also being evaluated for gastrointestinal reflux. After oral ingestion of technetium-99m sulfur colloid in a milk formula, the normal 1 hr time-activity curve and normal values for percentage of gastric emptying in 1 hr were determined. Normal gastric emptying in infants was 48% (+/- 16%) and in children 51% (+/- 7%). Unusual emptying patterns were observed when an overlying duodenum was present, making accurate estimation of gastric emptying difficult. Three children with gastric outlet obstruction showed similar delayed plateau emptying patterns.

Gastroesophageal reflux--the acid test: scintigraphy or the pH probe?

The best established technique for diagnosing gastroesophageal reflux in children is the 24 hr esophageal pH probe test. No simultaneous comparison of this technique with radionuclide scans has been reported. Therefore, simultaneous 1 hr pH monitoring and gastroesophageal scintigraphy were performed in 49 infants and children with suspected gastroesophageal reflux. Forty-seven of these patients also were later monitored by the 24 hr pH probe test. Upper gastrointestinal series were performed on all patients. All patients with a positive 1 hr pH monitoring also had positive simultaneous scintigraphy. All patients with positive scintigraphy and pH probe monitoring also had a positive upper gastrointestinal series for reflux. The sensitivity of gastroesophageal scintigraphy, when compared to the 24 hr probe as a standard, was 79%; its specificity was 93%. The sensitivity of the upper gastrointestinal series was 86%, when compared to the 24 hr pH probe test. However, it specificity was only 21%.

Achalasia: diagnosis, management, and clinical course in 16 children

Clinical features, radiographic and esophageal manometry findings, and treatment results in 16 patients less than 15 years old with achalasia are described. Esophageal manometry performed in 15 patients showed results similar to those found in adults: (1) increased resting lower esophageal sphincter pressure, (2) incomplete or failure of relaxation of the lower esophageal sphincter on swallowing, and (3) ineffective or absence of peristalsis in all. The most common symptoms in the 16 patients were: dysphagia in 15, postprandial vomiting in 13, and retrosternal pain in five. The average duration from onset of symptoms to diagnosis was 28 months. The esophagram was diagnostic in all patients. Pneumatic dilation was the initial treatment in eight and was successful for more than 1 year in five. Two patients required two dilations and were then symptom-free for more than 1 year, but required a Heller myotomy. The remaining patients underwent Heller myotomy following failure of the second dilation. Three patients underwent myotomy and two patients had myotomy with fundoplication as initial treatment; only one remained symptomatic. Esophageal dilation using a pneumatic dilator should be the initial treatment of choice in school-aged children. However, if more than two dilations are required within 1 year, surgical management is recommended.

A diagnostic approach to vomiting in severely retarded patients

Vomiting is a considerable problem among severely retarded individuals. The majority have gastroesophageal reflux (GER). The incidence is increased in those who are nonambulatory or have scoliosis and/or spastic quadriplegia. In the absence of other symptoms, these persons should be kept in the upright position as much as possible. Persistent vomiting warrants a roentgenographic examination of the upper gastrointestinal tract. If GER is the only finding, upright positioning should be continued. The occurrence of complications attributable to GER is an indication for further diagnostic evaluation.

Effect of enteral feeding on the maintenance of gastric acid secretory function

The effects of enteral feeding on the maintenance of gastrointestinal function in human infants are unknown. The effects of enteral feeding on gastric acid secretory function were studied by investigating three groups of infants: infants fed normally, infants with gastrointestinal disease fed by a combination of enteral and parenteral means, and infants fed by total parenteral nutrition. In 14 infants with gastrointestinal disease fed with total parenteral nutrition for a mean of 7 mo (range 1.5-24 mo), basal gastric acid secretion and pentagastrin-stimulated maximal gastric acid secretion were significantly less than in 26 normal infants (p less than 0.01) and in 11 infants with gastrointestinal disease nourished with a combination of enteral and parenteral feeding (p less than 0.01). In each of seven infants fed with total parenteral nutrition for a mean of 5 mo (range 1.5-10 mo), basal and maximal gastric acid secretion increased after a 6-8-wk trial of enteral feeding, a highly significant difference. In one infant, the ability to secrete normal amounts of acid in response to pentagastrin (achieved after an initial trial of enteral feeding) was lost after a 4-mo enteral fast, but returned after a second trial of enteral feeding. These results demonstrate that, in human infants, enteral feedings are necessary for normal oxyntic mucosal secretory function.

Bacteremia in children following upper gastrointestinal endoscopy or colonoscopy

Fifty children undergoing upper gastrointestinal endoscopy and 25 undergoing colonoscopy were studied prospectively with aerobic and anaerobic blood cultures for the development of bacteremia. Twenty-six of the endoscopies and all the colonoscopies were done under general anesthesia. Cultures were obtained before, at 5 min, and at 30 min after the procedure. Only a single positive blood culture was obtained in an upper endoscopy patient. All cultures from the colonoscopy patients were negative. Biopsy or polypectomy were not important variables in the development of bacteremia. It is concluded that the risk of bacteremia in children following upper endoscopy or colonoscopy is minimal and should not be considered a contraindication to their performance.

Gastrointestinal symptoms in Rocky Mountain Spotted Fever. Histopathologic finding of ulcerative enteritis with vascular

Gastrointestinal symptoms are often in patients with Rocky Mountain Spotted Fever (RMSF), particularly early in the course of the illness. However, changes in the gastrointestinal tract have not been reported in a child who has survived. We document vasculitis in the terminal ileum of a child with RMSF who also had radiographic findings consistent with involvement of the entire small bowel. An appreciation for the gastrointestinal manifestations should facilitate a rational approach to their management and prevent a delay in diagnosis.

Body position and esophageal sphincter pressure in infants

Lower esophageal sphincter pressure was measured in infants in the supine, prone, right lateral, left lateral, and upright positions; 14 had gastroesophageal reflux and 16 did not. Position had no significant effect on pressure in either group. However, patients with reflux had significantly lower pressures in each position. The rationale for postural therapy in infants with reflux cannot be based on alterations in sphincter pressure but is more likely related to the effect of gravity on the gastric pool. Compared with roentgenograms of the upper gastrointestinal tract or esophageal manometry the one- and 24-hour pH probe tests best identified reflux in those patients who were first seen with symptoms compatible with this diagnosis.

Lymphoid polyps (focal lymphoid hyperplasia) of the colon in children

Lymphoid polyps (focal lymphoid hyperplasia) of the colon are rare in children. These lesions are benign, but must be differentiated from malignant lymphomas. Grasp biopsies of the lesion are inadequate for this purpose and the polyp should be submitted in toto for pathologic examination. No treatment other than local excision is warranted. Two cases are presented and the literature is reviewed.

Gastroesophageal reflux in the severely retarded who vomit: criteria for and results of surgical intervention in twenty-two patients

Forty-two severely retarded patients, ranging in age from 2 to 26 years, were referred for diagnostic evaluation because of chronic vomiting. The diagnosis of gastroesophageal reflux (GER) was made in 28 of the basis of reflux (grade III) on upper gastrointestinal series and the presence of esophagitis either grossly at endoscopy or on esophageal biopsy. Nissen fundoplication was performed in 22 because of the frequent occurrence of complications such as pneumonia, gastrointestinal blood loss, and malnutrition attributable to GER. The incidence of postoperative complications was 59%. However, during a mean follow-up period of 14.1 months, no further vomiting or gastrointestinal blood loss was encountered, and only one patient had a single episode of pneumonia. Weight gain in those who were malnourished was impressive. In addition, the already difficult care of the patients was greatly facilitated. Severely retarded patients with GER who suffer recurrent complications should be considered for Nissen fundoplication.

Pharyngoesophageal pulsion diverticulum (Zenker) in a ten-year-old boy

Posterior pharyngoesophageal pulsion diverticula are rare during the pediatric years. We present the third case (a 10-yr-old). Proper diagnosis was made during fiberoptic esophagoscopy.

The role of sigmoidoscopy, radiographs, and colonoscopy in the diagnostic evaluation of pediatric age patients with suspected juvenile polyps

Juvenile polyps are the most common cause of painless hematochezia in pediatric Age patients after the first year of life. This study evaluated the role of rigid proctosigmoidoscopy, air contrast barium enema examinations, and colonoscopy in the diagnostic approach to 43 such patients. During sigmoidoscopy, polyps were removed from 31 children. On subsequent barium enema examination, more proximal lesions were found in only 4 of these 31 patients, but were seen in 7 of the 12 children who had negative sigmoidoscopic evaluations. Fourteen children had colonoscopy performed. This group included the latter 12 patients plus 2 of the former 4 who again developed hematochezia. Polypectomies were done during 11 of these procedures. Eight of these 11 children had proximal lesions seen during radiographic studies. The diagnostic approach to pediatric age patients with painless hematochezia should include an initial rigid sigmoidoscopic examination. Barium enema evaluation should be reserved for those patients requiring colonoscopy. The latter examination should be performed in all children who have had negative sigmoidoscopic examinations plus those who have had polyps removed from the rectum and then again develop hematochezia.

Depressed neutrophil chemotaxis in infants with cow's milk and/or soy protein intolerance

Neutrophil chemotaxis and random migration were studied in 11 infants with active cow's milk and/or soy protein intolerance and in an additional four infants following clinical recovery. Results were compared to 15 age-matched control subjects. Infants with active intolerance exhibited depressed chemotaxis and enhanced random migration. The four recovered infants had values similar to those of control subjects.

Use of bethanechol for the treatment of gastroesophageal reflux

A double-blind crossover study utilizing bethanechol was performed among 45 pediatric-aged patients with gastroesophageal reflux. Thirty young children (age = less than 1 year) were studied. These infants did significantly better while taking bethanecol than when they were receiving placebo. Fifteen children (age greater than 1 year) were also studied. These patients also had significant clinical improvement while on the drug when compared to the period when they were receiving placebo. Esophageal pH probe testing after the oral administration of bethanecol showed a significant decrease in frequency and duration of episodes of gastroesophageal reflux. This improvement may be secondary to the increases in lower esophageal sphincter pressure and persistaltic activity seen during esophageal manometrics. Bethanechol should be considered for pediatric-aged patients who are not benefited by conventional medical therapeutic regimens.

Basal and pentagastrin-stimulated acid secretion in newborn human infants

Basal and pentagastrin-stimulated gastric acid secretion was measured in 26 healthy newborn infants on the 1st and 2nd days of life. Basal acid outputs (BAO) on day 1 (0.378 mEq/hr) and day 2 (0.388 mEq/hr) were similar and not significantly different from the maximal acid outputs (MAO) on day 1 (0.413 mEq/hr) and day 2 (0.452 mEq/hr). When calculated on a mEq/kg/hr basis, BAO on day 1 was 0.110 with an MAO of 0.122. The BAO on day 2 was 0.114 with an MAO of 0.133. Fasting serum gastrin levels obtained before the acid studies on each day were elevated (mean, day 1 = 100 pg/ml; mean, day 2 = 108 pg/ml). These findings suggest that either gastric acid secretion in the newborn is maximal under basal condition or that newborn parietal cells are unresponsive to pentagastrin on day 1 and 2 of life.