Is routine dilatation after repair of esophageal atresia with distal fistula better than dilatation when symptoms arise? Comparison of results of two European pediatric surgical centers

BACKGROUND/PURPOSE

The aim of this study was to determine whether routine dilatation of the anastomosis after repair of an esophageal atresia with distal fistula (EADF) is superior to a wait-and-see policy with dilatation only when symptoms arise.

METHODS

The records of 100 consecutive patients operated on for EADF in 2 European pediatric surgical centers (A [n = 63], B [n = 37]) were reviewed. In center A, dilatation of the anastomosis was carried out in symptomatic cases only, whereas in center B dilatation was begun 3 weeks postoperatively and repeated every 1-3 weeks until a stable diameter of 10 mm was reached. Particular attention was paid to the number of dilatations per patient, dilatation-related complications, and differences in results after 2 years.

RESULTS

The patient materials of both centers did not differ with respect to the incidence of prematurity, tracheomalacia, gastroesophageal reflux (GER), and major postoperative complications. The incidence of associated anomalies was higher in center B (P < .05). In center A, 26 of 63 patients underwent dilatation; in center B, all 37 patients were dilated (P < .05). Median number of dilatations per patient was 4 in center A and 7 in center B (P < .05). In center A, 23 of 26 and in center B, 20 of 37 of the patients received medical treatment for GER at the time of the dilatations. Dilatation-related complications developed in 7 of 26 patients of center A and in 3 of 37 patients in the center B (P value, not significant). The median primary hospital stay was 24 days in center A and 33 days in center B (P < .05), median secondary hospital stay for dilatation was 6 days in center A and 13 days in center B (P < .05). After 2 years of follow-up, the incidence of dysphagia, respiratory problems, or bolus obstruction did not differ significantly between the 2 centers.

CONCLUSIONS

A wait-and-see policy and dilatations based on clinical indications for patients with repaired EADF is superior to routine dilatations. It appears that more than half of the patients do not require dilatations at all.

A genetic test which can be used to diagnose adult-type hypolactasia in children

BACKGROUND/AIMS

Adult-type hypolactasia (primary lactose malabsorption) affects most of world's human population and limits the use of fresh milk due to lactose intolerance. The diagnosis of adult-type hypolactasia has been difficult to establish because of unsatisfactory diagnostic methods. C/T(-13910) single nucleotide polymorphism residing 13910 base pairs from the 5' end of the lactase gene has been shown to be associated with lactase persistence. The aim of the study was to assess the applicability of the C/T(-13910) variant as a diagnostic test for adult-type hypolactasia during childhood.

METHODS

Intestinal biopsies were obtained from 329 children and adolescents of African, Finnish, and other White origins aged 0.1-20 years undergoing upper gastrointestinal endoscopy because of abdominal complaints. The biopsies were assayed for lactase, sucrase, and maltase activity and genotyped for the C/T(-13910) variant using polymerase chain reaction minisequencing.

RESULTS

The frequency of the C/C(-13910) genotype defining lactase non-persistence was well in agreement in this study with published figures for the prevalences of adult-type hypolactasia in Africans and Whites. The C/C(-13910) genotype was associated with very low lactase activity (<10 U/g protein) in the majority of children tested at 8 years of age and in every child older than 12 years of age giving a specificity of 100% and sensitivity of 93% for the genetic test. The decline of lactase activity was somewhat earlier in African compared with Finnish children with C/C(-13910) genotype (p<0.03).

CONCLUSIONS

Genetic test of C/T(-13910) polymorphism can be used as a first stage screening test for adult-type hypolactasia.

The Santulli enterostomy in necrotising enterocolitis

An ideal operation for necrotising enterocolitis (NEC) would be quick and reliable, remove all nonviable bowel, minimise the loss of intestinal length, permit early restoration of intestinal continuity, and minimise the need for secondary operations. No operation currently meets all these needs. In this study we review our experience with the Santulli enterostomy in NEC. From 1992 to 1998, 19 patients (16 males, three females) underwent a Santulli enterostomy for Bell grade III NEC. The median gestational age at birth (GA) was 26 weeks (range 23-30), and the median birth weight 755 g (range 600-1095). The median patient age at operation was 10 days (range 3-59), and the median operative time was 55 min (range 25-90). Sixteen (84%) patients survived. Complications included leakage of the Santulli anastomosis in four cases, stomal necrosis in two cases, additional intestinal necrosis in two cases, leakage of a concurrent intra-abdominal anastomosis in two cases, and intestinal obstruction in four cases. Twelve patients underwent relaparotomy. Enteral feeding was started at a median of 5 days postoperatively (range 2-9), with full oral feeding possible at a median of 21 days (range 10-128). The median time until closure of the enterostomy was 48 days and the median hospital stay 87 days (range 19-197). After stomal closure, obstructive symptoms necessitated a new Santulli enterostomy in two patients and a revision of the anastomosis in one patient. Santulli enterostomy can be used to treat NEC even in very small premature babies. It enables rapid recovery of intestinal continuity and early stomal closure. However, the operation is technically demanding and carries significant morbidity.

Does postoperative pH monitoring predict complicated gastroesophageal reflux in patients with esophageal atresia?

Gastroesophageal reflux (GER) is common after repair of esophageal atresia with a distal tracheoesophageal fistula (EATOF). In a retrospective study we assessed whether early 18-h pH monitoring can predict the development of EATOF-associated gastroesophageal reflux. During 1980-1997, 90 consecutive patients had primary repair for EATOF. Development of GER was classified as favorable if the patient developed no esophagitis or mild esophagitis and needed no antireflux medication, and as unfavorable if the patient developed moderate or secondary esophagitis or required an antireflux procedure. Patients who developed unfavorable GER outcome before pH monitoring or needed secondary reconstruction or those whose endoscopic follow-up data were insufficient were excluded. Eighteen-hour pH monitoring was considered pathologic if esophageal pH was <4 more than 10% of the recorded time or 5% of the recorded time minus 2 h after each meal, or if there were more than three preprandial reflux periods lasting longer than 5 min. A total of fifty patients were included into the study. pH monitoring was performed at the median age of 9.2 (range 2.5-95.0) months and classified as pathologic in 10 and normal in 40 patients. After a median follow-up of 59 (0.3-217.6) months, nine of 10 (90%) patients with pathologic pH monitoring and five of 40 (12.5%) patients with normal pH monitoring developed unfavorable outcomes ( p<.05). We conclude that early pH monitoring predicts the development of significant GER, but because 12.5% of patients with normal early pH monitoring also developed significant GER, early pH monitoring alone does not rule out the development of significant GER.

Increased cell turnover, but no signs of increased T-cell infiltration or inflammatory cytokines in the duodenum of pediatric patients after allogeneic stem cell transplantation

Intestinal immunopathology was studied after allogeneic stem cell transplantation (SCT) in a common clinical setup in 20 children with malignant (n=17) or nonmalignant diseases (n=3) receiving grafts from siblings (7) and unrelated donors (13). In all, 19 had total body irradiation. Duodenal biopsies at 6 and 12 weeks post transplant were evaluated by histology, immunohistochemistry, and ISEL for the detection of T-lymphocytes, inflammatory cytokines, proliferation, and apoptosis. The controls were 12 healthy children and three patients with proven intestinal graft-versus-host disease. An increased rate of apoptosis and proliferation with upregulated expression of HLA-DR antigen was detected up to 3 months post transplant in the SCT patients, even in those with a histologically normal small intestine. A low level of IFNgamma and TNFalpha was observed in the lamina propria. The initial low density of gammadelta-positive T cells had recovered to normal by the time of the second endoscopy at 12 weeks post transplant. We conclude that inflammatory activity and T cell infiltration detected by immunohistochemistry may not belong to the 'normal' recovery of the small intestine after SCT. Increased cell turnover in the intestinal crypts continues until 3 months after SCT, suggesting either an unexpectedly long-lasting effect of transplant-related toxicity or, preferably, an ongoing subclinical alloreactive process, also present in the patients without intestinal symptoms.

Endoscopic follow-up in esophageal atresia-for how long is it necessary?

PURPOSE

The aim of this study was to find out how long it is necessary to follow-up esophageal atresia patients endoscopically to prevent irreversible mucosal changes.

METHODS

Seventy-four of 79 long-term survivors with esophageal atresia and primary anastomosis underwent a total of 322 esophagogastroduodenoscopies during a follow-up period of 0.5 to 19 years (mean, 10.3) after the primary operation. For analysis, the biopsy findings were divided into 2 groups: good, histologically normal or only mildly inflamed mucosa; unfavorable, moderate or severe esophagitis or gastric metaplasia. Fundoplication irrespective of indications was considered unfavorable. The results were analyzed using actuarial survival analysis; the changing point was when a "good" turned into "unfavorable."

RESULTS

Forty-five patients (61%) remained in the "good" group throughout the study period; 15 of those (20%) had completely normal findings. Nine patients (12%) had moderate, one (1%) had severe esophagitis, and 13 patients (18%) had gastric metaplasia. Fundoplication was performed on 21 patients (28%).

CONCLUSIONS

About 40% of esophageal atresia patients eventually have significant esophageal mucosal pathology or need to have a fundoplication. The majority of these changes appear before the age of 3 years. Routine endoscopic follow-up of esophageal atresia patients is recommended at least to the age of 3 years.

Helicobacter pylori serology at diagnosis and follow-up of biopsy-verified infection in children

Data on the use of Helicobacter pylori serology in children are limited. We studied the serum antibodies of 105 H. pylori-infected children (median age 9.1 y, range 1.5-17.5 y) using an in-house enzyme immunoassay. At diagnosis of the biopsy-verified infection, IgG antibodies to H. pylori were elevated in 98/105 children (93%) but were at a normal level in 7 children, 5 of whom were < 5 y of age. Serum IgA antibodies to H. pylori were elevated in 40/105 children (38%). The levels of IgG and IgA antibody titers to H. pylori correlated with age (p < 0.001 and p < 0.02, respectively). IgG titers were reduced by > or = 50% in 85% (83/98; median follow-up 0.6 y) of children after therapy. In 56 such children eradication was verified by negative histology or urea breath test but I such child showed Helicobacters on histologic examination. Of the 15 children whose IgG titers dropped by < 50%, 7 were considered positive and 4 negative on the basis of histology or urea breath test. In 3 children, IgG titers returned to pretreatment levels 1 y after a 50% drop was seen. Serology is 1 alternative for monitoring H. pylori infection in children, although its sensitivity is lower in very young children. The length of follow-up needed after eradication, however, is unclear.

Intraluminal casein model of necrotizing enterocolitis for assessment of mucosal destruction, bacterial translocation, and the effects of allopurinol and N-acetylcysteine

An intraluminal casein model (ICM) of necrotizing enterocolitis (NEC) is able to produce small-bowel changes reminiscent of human NEC in neonatal animals. We studied bacterial translocation (BT) in NEC induced by using the ICM in neonatal piglets. We also studied whether allopurinol (AL) and N-acetylcysteine (NAC) have an effect on BT and mucosal changes in the ICM of NEC. Twenty-eight neonatal piglets were randomized into four groups. NEC was induced in 21 by injecting casein-d-gluconate into a loop of terminal ileum: group Cas (n = 7) had no premedication, in group Cas/AL (n = 7) intravenous (i.v.) Al (100 mg/kg), and in group Cas/NAC (n = 7) i.v. NAC (200 mg/kg) was given. Group Sham (n = 7) had the ileum injected with 0.9% saline with no premedication. Immediately after the injection a mesenteric lymph node (MLN) adjacent to the loop was harvested for quantitative aerobic bacterial culture; 4 h after the injection another MLN and samples of spleen, liver, kidney, and lung were harvested and cultured. Comparison of the incidence of samples with positive bacterial cultures and the number of colony-forming units (CFU) in samples was made between groups. The severity of NEC in the ileum was graded from 0 to 3 according to macroscopic and histologic findings. NEC changes in the bowel were most severe in Cas piglets, less severe in Cas/NAC piglets ( P < 0.5), and sham piglets had the least severe changes ( P < 0.05). piglets with NEC changes in the ileum had a higher incidence of BT into the MLN than piglets without NEC changes ( P < 0.05), but the difference in CFU was not significant ( P > 0.05). In Cas and Cas/NAC piglets a high incidence of BT into the MLN was noted as early at -5 min after casein injection. The incidence of BT into the MLN was significantly higher in Cas and Cas/NAC piglets than in Sham piglets ( P < 0.05), the difference in CFU being not significant ( P > 0.05). BT in Cas/Al piglets was not significantly different from that of Cas piglets ( P > 0.05), but less than in Cas/NAC piglets ( P < 0.05). Four hours after casein injection into the ileum there was significant BT into the MLN. Premedication with NAC was associated with less severe NEC changes, but neither NAC nor AL significantly affected BT.

Morbidity and quality of life in adult patients with a congenital abdominal wall defect: a questionnaire survey

BACKGROUND

In children with congenital abdominal wall defects (CAWD), surgical treatment of the abdominal defect and the associated anomalies cause considerable morbidity in the first years of life. Afterward, most of the CAWD patients with correctable anomalies develop as other children. The morbidity and quality of life (QoL) of CAWD patients who have reached their adulthood is less well known and the subject of this study.

METHODS

A 3-part questionnaire was sent to 75 former patients with CAWD, aged 17 years or more. The first part included questions about health, symptoms, and education; the second part consisted of 3 tests of psychosocial functioning; and the third part was a SF-36 questionnaire measuring the QoL.

RESULTS

Of the 75 patients, 57 (76%) answered: (25 males, 32 females); omphalocele (n = 16) gastroschisis (n = 11); median age, 27 (range, 17 to 48) years. With the exception of rheumatoid arthritis (in 7% of patients), the prevalence of acquired diseases in CAWD patients was comparable with that of the general population; 50 of 57 (88%) considered their health good. The most frequent causes of morbidity were disorders in the abdominal scar in 21 (37%) patients, and functional gastrointestinal disorders in 29 (51%) of patients. Low self-esteem was found in 12% of patients, but the QoL and educational level of CAWD patients were not different from that of the general population.

CONCLUSIONS

In CAWD patients the morbidity from acquired disorders is similar to morbidity in the general population. Disorders with the abdominal scar and various functional gastrointestinal disorders are common, but they rarely cause serious problems. The majority of CAWD patients have a quality of life not different from the general population.

Dental caries is common in Finnish children infected with Helicobacter pylori

Childhood factors such as low socioeconomic status are risk factors for Helicobacter pylori infection and Streptococcus mutans-related dental caries. We examined whether H. pylori infection and dental caries are present today in the same group of children examined previously. We reviewed the public dental health service files of 21 H. pylori-positive children (upper gastrointestinal endoscopy at a median age of 13.5 y) and 27 H. pylori-negative children (endoscopy at a median age of 12.5 y) examined during 1995-98 at the Helsinki University Central Hospital, Finland. All H. pylori-positive children had experienced dental caries in their primary or permanent teeth or in both whereas among H. pylori-negative children the respective proportion was 70% (p < 0.01). At the age of 7 y, 18% (3/17) of the H. pylori-positive children had experienced caries in permanent teeth as compared to 0% among H. pylori-negative children (0/24; p < 0.05). At the age of 12 y, H. pylori-positive children had more decayed, missing or filled permanent teeth than H. pylori-negative children (80% vs. 38%; p < 0.05). Although a causal relationship between H. pylori and dental caries is unlikely, it is possible that H. pylori-infected children have an increased risk of other health problems, such as dental caries, for which proper treatment is needed.

Anti-alpha-fetoprotein imaging is useful for staging hepatoblastoma

BACKGROUND

Liver transplantation (Tx) has become an alternative treatment of malignant childhood liver tumors, and the importance of careful pretransplantation evaluation has been emphasized. Anti-alpha-fetoprotein (AFP) imaging has been suggested for evaluation of adult patients with AFP-positive tumors.

METHODS

Antibody imaging utilizing Tc-99 m-labeled monoclonal anti-AFP Fab' fragments was used to demonstrate pathologic uptake in hepatoblastoma (HB).

RESULTS

Radical operation or liver Tx was not possible after four cycles of chemotherapy in a child with HB because of a single extrahepatic metastasis. Chemotherapy was continued, and reevaluation with anti-AFP imaging demonstrated a pathologic uptake only in the liver. Subsequently, a right liver lobe resection was performed. Along with a new rise in serum AFP, repeated anti-AFP imaging revealed active liver tumor but no metastases. A liver Tx was performed, and the child is well with a normal serum AFP level 18 months after the operation.

CONCLUSION

This is the first case of pediatric HB in which anti-AFP imaging has been successfully used for patient management.

Sodium cromoglycate in the management of chronic or recurrent enterocolitis in patients with Hirschsprung's disease

BACKGROUND/PURPOSE

Chronic or recurring enterocolitis is a rare but perplexing complication of Hirschsprung's disease affecting especially patients with altered immune defense such as those with Down's syndrome. Sodium cromoglycate (SCG) is a nonabsorbable mast cell stabilizing agent that has been documented to be effective in the treatment of inflammatory bowel disease. The authors studied the effect of SCG in Hirschsprung patients with refractory chronic or recurrent enterocolitis.

METHODS

Eight patients (4 with Down's syndrome, 2 with other chromosomal aberrations, 2 otherwise healthy; age range from 4 to 22 years) with chronic (5 patients) or recurrent (>6 episodes/year, 3 patients) enterocolitis received 100 to 200 mg of SCG 4 times a day depending on the age of the patient. The chronic diarrhea or recurrent bouts of enterocolitis in the patients were refractory to dietary management and enteral antibiotics. Before the treatment all patients had ileocolonoscopy, the results of which showed macroscopic and histological chronic inflammation in all cases. No neuronal abnormalities were detected in biopsy results. None of the patients had colonic dilatation or increased anorectal resting pressures suggesting outlet obstruction.

RESULTS

The follow-up of the patients ranges from 8 months to 26 months. Three of the 5 patients with chronic enterocolitis responded favorably. In these 3 patients the median number of daily bowel movements decreased from 6 to 3, and none experienced bouts of abdominal distension. Diarrhea-related soiling decreased also significantly. Two of the 3 patients with recurrent enterocolitis have remained asymptomatic, and none has required antibiotics after the onset of SCG treatment; one patient had an episode of enterocolitis after 12 months treatment. Two patients with chronic enterocolitis did not respond to SCG. No side effects of SCG were encountered.

CONCLUSIONS

This preliminary and nonrandomized study suggests that SCG is an effective treatment modality for chronic or recurrent enterocolitis in patients with Hirschsprung's disease. Because SCG is not absorbed From the intestinal tract there are no systemic side effects.

Rectosigmoid pHi monitoring during experimental necrotizing enterocolitis

BACKGROUND/PURPOSE

Gastric or rectosigmoid intramural pH (pHi) is considered a reliable indicator of splanchnic perfusion. The aim of this study was to evaluate whether rectosigmoid pHi reflects the severity of bowel damage in experimental necrotizing enterocolitis (NEC).

METHODS

A total of 36 neonatal piglets, (median age, 3; range, 1 to 11 days; median weight, 2.5; range, 1.2 to 3.8 kg), were anesthetized, ventilated mechanically, and had invasive monitoring of hemodynamics. A sigmoid tonometer was inserted into the rectosigmoid colon. Enterocolitis was induced in 27 piglets by intraluminal injection of casein-d-gluconate (16.0 mL/kg) into terminal 100 cm of the ileum. Nine control piglets received an equal amount of intraluminal saline. NEC was graded macroscopically as follows: 0, no changes; 1, mild; 2, moderate; and 3, severe. Histology was evaluated according to Chiu scale from 0 to 5.

RESULTS

The macroscopical bowel injury in caseine-injected piglets was as follows: grade 3 (n = 6), grade 2 (n = 9), grade 1 (n = 12). All control piglets showed macroscopically normal bowel (grade 0). All affected bowels showed histologic changes (Chiu's scale 2 to 4). All study animals had an initial drop of pHi after injection of casein or saline. In control piglets and those with mild NEC (grade 1) pHi tended to return to preinjection level. In animals with moderate or severe NEC (grade 2 to 3) the initial drop was deeper and the pHi continued to decrease significantly throughout the experiment (P < .05). In the arterial pH and mean blood pressure there were no statistically significant differences between piglets with no NEC and mild NEC, and these with moderate or severe NEC.

CONCLUSION

Drop in rectosigmoid pHi was the most sensitive and earliest sign of severe mucosal necrosis of ileum in this experimental NEC model.

cagA, vacA and iceA virulence genes of Helicobacter pylori isolates of children in Finland

cagA, vacA s and m genotypes and iceA alleles were analyzed from Helicobacter pylori strains isolated from 17 Finnish children and 32 children of non-Finnish origin living in Finland. Twelve children in the latter group were eastern European and 15 were of African origin. Only three children of non-Finnish origin were born in Finland. The vacA sla subtype was more prevalent in the isolates from Finnish children than African children (76% vs. 7%, P<0.001); vacA s1b frequencies were 5% and 67%, respectively (P<0.001). The iceA1 allele was significantly more prevalent in African than Finnish isolates (93% vs. 35%, P< 0.01). Considerable variation was noted in the frequency of vacA s1 subtypes and iceA alleles in children originating from different geographic regions, but the geographic variation of s1 subtypes resembled that described in other reports.

Transanal endorectal coloanal surgery for Hirschsprung's disease: experience in two centers

BACKGROUND/PURPOSE

Transanal mucosal proctectomy with low coloanal anastomosis has been used widely in the treatment of rectal malignancies, ulcerative colitis, and familial polyposis. The use of this technique for Hirschsprung's disease is a relatively new concept. The aim of this study was to evaluate and compare the results of transanal endorectal coloanal anastomosis (TECA) for Hirschsprung's disease from 2 centers.

METHODS

All children who underwent TECA for Hirschsprung's disease at Alder Hey Children's Hospital, Liverpool, England from January 1995 to December 1998 (n = 41) and the Children's Hospital, Helsinki, Finland from June 1988 to December 1998 (n = 95) were evaluated. Patient demographics, age at diagnosis, initial management, length of aganglionic segment, and age at operation were documented. Postoperative complications and functional outcome were analyzed.

RESULTS

Patient demographics were similar in the 2 centers. Age at diagnosis was less than 1 month in 71% of children at Liverpool, compared with 53% at Helsinki. Sixteen (39%) patients in Liverpool and 75 (79%) patients in Helsinki underwent primary TECA without colostomy. Postoperative enterocolitis occurred in 14 of 136 patients (10%). An ischemic stricture of the colon was documented in 4 children in the Liverpool series, 2 of whom had TECA as a salvage procedure after a previously failed Duhamel pull-through operation. Frequency of bowel movements, seen in the immediate postoperative period in most patients gradually improved with time from a median of 5 (range, 2 to 12) bowel movements a day at 3 months after TECA to 2 (range, 1 to 6) bowel movements a day at 2 years' follow-up. Assessment of continence was possible in 51 of 136 patients (37%) over the age of 4 years. Thirty-nine children had normal bowel function giving an overall success rate of 76%.

CONCLUSIONS

Transanal endorectal coloanal anastomosis is a good technique for treatment of Hirschsprung's disease with few operation-related complications. Based on the data emerging from these 2 centers the functional outcome is highly satisfactory and comparable with other established procedures.

Gastroesophageal reflux in children with a congenital abdominal wall defect

BACKGROUND/PURPOSE

Gastroesophageal reflux (GER) is considered common in patients with congenital abdominal wall defects (CAWD). The aim of this study was to find out the frequency of GER in children with CAWD and, in particular, whether there is difference between patients with omphalocele and gastroschisis.

METHODS

Forty-two children, 19 with gastroschisis and 23 with omphalocele were examined for GER at the median age of 12.0 months (range, 1 to 132). Esophagoduodenoscopy with biopsies was performed on all patients. Eighteen patients underwent 18-hour esophageal pH-monitoring.

RESULTS

GER was detected in 13 patients. All but one patient of the 13 had either macroscopic or microscopic esophagitis. One patient had pathological pH monitoring only. In children with omphalocele, the incidence of GER was 43% (10 of 23), whereas in gastroschisis patients the incidence was 16% (3 of 19), (P value, not significant). The median age of omphalocele patients with GER was significantly lower (7 months) than the median age of those without GER (72 months; P = .01). In patients with gastroschisis age made no difference. Six of 32 patients (19%) with primary fascial closure (small defects) had GER, whereas 7 of 10 patients (70%) in which primary fascial closure was impossible (large defects) had GER (P < .01).

CONCLUSION

CAWD patients, especially those with omphalocele and a large defect have a high incidence of GER complicated by esophagitis during the first few years of life.

Gastric inflammation is enhanced in children with CagA-positive Helicobacter pylori infection

BACKGROUND

Helicobacter pylori infection is likely to be acquired at an early age. The factors leading to active inflammation in childhood, however, are largely unknown.

SUBJECTS AND METHODS

We determined the CagA status, the best characterized virulence factor of H. pylori, and serum antibodies of IgG and IgA classes to H. pylori in 39 infected children.

RESULTS

Mononuclear cell infiltration in the antrum but not in the gastric body was more intense in CagA-positive children than in CagA-negative children. The degree of polymorphonuclear cell infiltration on the other hand was independent of the CagA status. The antibody titers of IgG and IgA classes to H. pylori were higher in CagA-positive than in CagA-negative infections (P<0.001 and P<0.01, respectively). IgG antibody titers to H. pylori correlated directly with the density of mononuclear and polymorphonuclear cell infiltration in the gastric antrum but not in the gastric body.

CONCLUSION

H. pylori-infected children with CagA antibodies seem to have a more severe inflammation in the gastric antrum than CagA-negative children as shown by an increase in the density of antral mononuclear cells. A finding of higher serum antibody titers to H. pylori in CagA-positive children may be related to this enhancement of inflammation.

Helicobacter pylori-positive gastritis in pediatric patients with chronic inflammatory bowel disease

BACKGROUND

Gastritis is a common finding in patients with inflammatory bowel disease. However, the association of gastritis with Helicobacter pylori is unclear in these patients.

METHODS

The prevalence of antibodies for H. pylori in serum was determined in 47 pediatric patients with inflammatory bowel disease (19 with Crohn's disease, 21 with ulcerative colitis, and 7 with unclassified disease). H. pylori antibodies of the IgG and IgA classes were measured by enzyme immunoassay in 24 patients at the time of diagnosis of inflammatory bowel disease and in 23 more patients during the follow-up of inflammatory bowel disease (mean follow-up, 3.5 years; range 1-10 years). Esophagogastroduodenoscopy was performed on 40 patients during the examination for inflammatory bowel disease.

RESULTS

In contrast to earlier findings, no patient was determined to be positive for H. pylori, either in serologic or histologic examination. This negative finding was unexpected, because it is known that approximately 10% of asymptomatic Finnish children have antibodies for H. pylori in serum and approximately 10% of analyses of specimens obtained in gastric antral biopsies obtained at the Hospital for Children and Adolescents, Helsinki, Finland, are positive for H. pylori.

CONCLUSIONS

Permanent colonization of the stomach with H. pylori is unusual in children with inflammatory bowel disease.

Segmental colonic motility in patients with anorectal malformations

BACKGROUND

Constipation is one of the most important functional sequelae in patients with anorectal malformations. The cause of this motility disorder is unknown.

AIM

The purpose of this study was to assess total colonic transit time (TCT) and segmental colonic transit time (SCT) in patients with anorectal malformations.

METHOD

Ninety patients with anorectal malformations (40 low and 50 high; median age, 7 years; range, 3 to 13) and twenty-five healthy children (median age, 8 years; range, 3 to 14 years) underwent measurement of TCT and SCT by the saturation technique. Ten radiopaque markers were ingested daily for 6 days followed by administration of a single abdominal x-ray on day 7. TCT in days was calculated by dividing the number of retained markers in the whole colon by the daily intake. SCT in four colonic segments (right, transverse, left, rectosigmoid) was described as a percentage of TCT (markers in one segment versus total number of retained markers). In high anomalies the degree of rectosigmoid dilatation was assessed by contrast enemas taken before closure of the stoma and later during follow-up.

RESULTS

TCT was significantly (P < .03) prolonged in patients with anorectal anomalies (median high, 2.1 days; low, 1.9 days versus 1.3 in healthy subjects). In patients with high anomalies right SCT was prolonged when compared with low anomalies and healthy subjects (median high, 24% versus low, 10% and normal subjects, 10%; P < .01). The impairment was more severe in patients with very high anomalies (P < .005). Patients with a low anomaly had prolonged rectosigmoid SCT (median low, 65% versus high, 43% and normal subjects, 49%; P < .05). Prolonged right colonic SCT and TCT correlated with symptomatic constipation in patients with high anomalies (P < .05) but not with those who had low anomalies. Impaired overall functional outcome correlated with prolonged right colonic SCT in patients with high anomalies and with prolonged rectosigmoid SCT in patients with low anomalies. There was no correlation between the degree of rectosigmoid dilatation and SCT or TCT.

CONCLUSION

Patients with anorectal malformations have abnormal colonic motility. The type of motility disorder in low anomalies is rectosigmoid hypomotility. In patients with high anomalies the motility disturbance is more generalized. The overall functional outcome was strongly related to the degree of these motility disorders.

Long-term pulmonary sequelae in survivors of congenital diaphragmatic defects

Between 1948 and 1980, 107 of 164 patients survived after repair of a congenital diaphragmatic defect. Sixty of the survivors (mean age, 29.6 years; SD, 9.0 years) underwent clinical examination, chest radiography, spirometry, and diffusing capacity measurement 11 to 41 years after the diaphragmatic repair. Twenty-seven of the 60 had body plethysmography, xenon 133 radiospirometry, and a test of bronchial hyperreactivity. Subjective physical performance was below average for eight patients (13%), seven patients (12%) had asthma, and four patients (7%) reported increased susceptibility to respiratory infections. Thirty-one patients (52%) had ventilatory impairment, which was obstructive in nine (15%), restrictive in seven (12%), and obstructive and restrictive in 15 patients (25%). Nine (35%) of the 26 patients tested had bronchial hyperreactivity. The presence of ventilatory impairment and bronchial hyperreactivity correlated with the initial clinical severity of the affliction. Chest asymmetry (29 patients; 48%) and scoliosis (16 patients; 27%) were more common among patients with ventilatory impairment than among those with normal spirometric findings. Ventilatory impairment and thoracic deformities are common in adults with repaired diaphragmatic defects. Surveillance should begin in infancy and continue into adulthood.

Chest wall and spinal deformities in adults with congenital diaphragmatic defects

Between 1948 and 1980, 107 of 164 patients survived after repair of congenital diaphragmatic defects. To study chest wall and spinal deformities among these patients, 60 survivors (mean age, 29.6 +/- 9.0 years) underwent clinical examination, chest and spinal radiography, spirometry, and diffusing capacity measurements. Twenty-seven of these patients also had body pletysmography, xenon 133 radiospirometry, and a test for bronchial hyperreactivity. Chest asymmetry was present in 29 patients (48%). Eleven patients (18%) had pectus excavatum, and one had a pectus carinatum deformity. Anterior asymmetry, pectus deformities, and a flat chest were more common among the patients who initially had a large diaphragmatic defect. Two patients underwent anterior thoracoplasty because of their deformities. Sixteen patients (27%) had significant scoliosis (Cobb angle > or = 10 degrees). Scoliosis was more common in patients with ventilatory impairment than in those with normal lung function. One patient required spinal stabilization, one with severe kyphoscoliosis remains under observation, and a patient with moderate scoliosis was treated with a spinal brace. The results of this study indicate that chest wall deformities and scoliosis are common among adults with repaired congenital diaphragmatic defects. In most patients the deformity is mild, but some will require surgery. Surveillance until adulthood is appropriate.

Long-term gastrointestinal morbidity in patients with congenital diaphragmatic defects

Recent reports indicate a significant incidence of gastroesophageal reflux (GER) and other nonpulmonary problems after the repair of congenital diaphragmatic defects. Reports of follow-up through adulthood are few and based on a small number of patients. From 1948 to 1982, 107 of 164 patients (65%) treated at the authors' institution survived after repair of congenital diaphragmatic hernia or eventration. Sixty of the 107 survivors (56%) (mean age, 29.6 years; SD, 9.0 years) were interviewed and examined clinically. Forty-one of the sixty (68%) underwent upper gastrointestinal endoscopy. Early postoperative GER was recorded for 11 of the 60 patients (18%). Two of them underwent fundoplication because of an esophageal stricture. At the time of the follow-up study, 38 of the 60 (63%) reported symptoms suggestive of GER. Endoscopic or histological GER (esophagitis, Barrett's esophagus) was present in 22 of 41 patients (54%). No significant correlation between the initial severity of the diaphragmatic defect or neonatal postoperative problems and the late GER could be verified. Intestinal obstruction requiring hospital admission occurred in 12 of the 60 patients (20%), eight of whom had surgical treatment between 1 month and 20 years after repair of the diaphragmatic defect. GER and intestinal obstruction are common among patients who have undergone repair of a congenital diaphragmatic defect. Investigations for GER should be performed routinely during the follow-up of these patients.