Helicobacter pylori infection in recurrent abdominal pain

OBJECTIVE

To study the relationship between Helicobacter pylori (Hp) infection and recurrent abdominal pain (RAP) and to evaluate various modalities to diagnose Hp infection.

DESIGN

Prospective case control study.

SETTING

Teaching hospital.

METHODS

Children between 3-12 years of age with RAP in whom upper gastrointestinal endoscopic examination was indicated were studied. Endoscopic biopsy specimen were collected from duodenum, antrum and esophagus. Apart from histopathological examination of biopsy material, rapid urease test (RUT) of the antral biopsy specimen and blood examination to estimate specific IgG antibodies to Hp by Indirect Solid Phase Enzyme Immunoassay was performed. The results of Hp IgG antibodies was compared with age matched controls.

RESULTS

Thirty one children with RAP were subjected to endoscopic examination and their anti Hp IgG antibodies status compared with 26 controls. Hp colonization was detected in 7 children (23%) with RAP; by RUT in 23% and antral biopsy in 16% of cases. Anti Hp IgG antibodies were also positive in almost equal proportion (19%) of controls (p = 0.757). Endoscopic examination revealed esophagitis in 16% of cases and none had evidence of gastric or duodenal erosion, ulcer or cobblestone appearance of antrum. A significant correlation of Hp was noticed with chronic antral gastritis (p = 0.002), chronic duodenitis (p = 0.02) and age > 10 years (p = 0.02). No significant correlation was noticed between Hp colonization and various socioeconomic risk factors.

CONCLUSION

Hp does not seem to be commonly associated with RAP in our patient population as Hp colonization was detected in only 23% of cases which was not significantly higher than the seroprevalence of anti Hp IgG antibodies in the controls. However, a small sample size of our study limits drawing any firm conclusions. Antral gastritis and chronic duodenitis had a significant correlation with Hp colonization. RUT was found to be a reliable diagnostic test to detect Hp.

Plasticity of the extracranial facial nerve

Although the expansion properties of peripheral nerves have been a matter of considerable study in recent years, investigations of the plasticity of cranial nerves, including the facial nerve, have been lacking. Clinicians, however, have long recognized the tenacity of facial nerve function in patients with slow-growing benign tumors that enormously distort the nerve. An experimental study was designed to assess whether tissue expansion techniques can be applied to the extracranial portion of the facial nerves of cats. In eight cats the frontozygomatic branch of the facial nerve was expanded by stages in seven sessions over a period of 40 days. The length of the nerve increased an average of 95% without significantly impairing nerve function. Pressure changes in the expander averaged 75 mm Hg during each stage of expansion. Electroneurography was performed after each injection of the expander. Statistical analysis of these data did not show consistent evidence of demyelination or denervation, and all but one cat exhibited a normal blink reflex and had normal electromyographic findings at the end of the experiment. Histologic examination of the expanded nerves, however, did show inflammatory changes, intraneural edema, and occasional demyelination.

Nd:YAG laser treatment for laryngeal and hypopharyngeal hemangiomas: a new technique

The treatment of laryngeal and hypopharyngeal hemangiomas is indicated when they are symptomatic, causing dysphagia, recurrent bleeding, or airway obstruction. These tumors are found in the glottis, supraglottic larynx, and hypopharynx. Histologically, they are considered as mixed or cavernous-type hemangiomas. By utilizing a glass slide to compress the lesion, its thickness and blood flow are reduced. The tumor can then be laser-photocoagulated with less energy, with the glass slide used as a laser platform. These conditions optimize the benefits of laser ablation while minimizing the adverse heat sink effects to the surrounding healthy tissue. We present three patients with hemangiomas of the larynx and hypopharynx who were treated with this technique. The details of the technique in each case will be presented with the objective of improving the care of these unusual and challenging tumors.

Positional nystagmus in asymptomatic human subjects

Nystagmus produced by static placement of the head in different orientations is termed positional nystagmus and is known to occur in human subjects who are free of vestibular symptoms. This study provides quantitative data for horizontal positional nystagmus occurrence in 49 normal human subjects, in whom the number of nystagmus beats, the slow-phase velocity of each beat, and distribution statistics were determined. A metric for the possible differentiation of physiologic positional nystagmus from pathologic nystagmus is described.

Positional Nystagmus in Asymptomatic Human Subjects

Nystagmus produced by static placement of the head in different orientations is termed positional nystagmus and is known to occur In human subjects who are free of vestibular sympitoms. This study provides quantitative data for horizontal positional nystagmus occurrence in 49 normal human subjects, in whom the number of nystagmus beats, the slow-phase velocity of each beat, and distribution statistics were determined. A metric for the possible differentiation of physiologic positional nystagmus from pathologic positional nystagmus is described.

Associated infections in persistent diarrhoea--another perspective

Seventy-eight children diagnosed as cases of persistent diarrhoea (PD) from 1 month to 5 years of age (mean age 8.92 months) hospitalized during a 2-year study period were screened for the presence of non-gastrointestinal infections. Clinical screening suggested acute respiratory infection (ARI) in 30 per cent cases, urinary tract infection (UTI) in 19 per cent and acute suppurative otitis media (ASOM) in 10 per cent of cases. Investigations revealed pneumonia on chest X-ray (39 per cent), positive urine culture (32 per cent), leucocytosis (31 per cent) and positive blood culture (22 per cent). Seven cases (9 per cent) of pneumonia and 10 cases (13 per cent) diagnosed to have UTI were not identified on clinical screening and could be detected only after investigations. E. coli was the commonest organism isolated from urine culture (23 per cent) and blood culture (14 per cent); 54 per cent of cases had one or the other associated infection and 28 per cent were suffering from more than one infection. Bacterial pathogens were more frequently isolated from blood in children < 6 months (P < 0.01), with vomiting (P < 0.001), and severe malnutrition (P < 0.05); from urine in association with fever (P < 0.001), duration of diarrhoea > 4 weeks (P < 0.05), and vomiting (P < 0.001). Pneumonia was detected on chest radiograph more frequently in children with severe malnutrition (P < 0.001). Sixty eight per cent of cases were successfully treated with dietary management and appropriate treatment of associated infections and 18 per cent of cases died. Mortality was highest in association with sever oral thrush, severe malnutrition, septicaemia, and ARI. Our results suggest that majority of cases of PD are associated with one or the other non-gastrointestinal infections particularly UTI and ARI which may be missed on clinical examination unless efforts are made to investigate these children. Early detection and appropriate management of these infections can considerably modify hospital course and outcome.

Surgical decisions in the management of cerebrospinal fluid rhinorrhoea

The surgical management of cerebrospinal fluid (CSF) rhinorrhoea has changed significantly after the introduction of functional endoscopic sinus surgery in the management of sinusitis. The clear anatomical exposure of the roof of the nasal and the sinus cavities by the endoscope offers the surgeon an opportunity to identify the area of the CSF leak, which enables one to adequately plan the treatment. The incidence of iatrogenic CSF rhinorrhoea has also increased, especially after the introduction of endoscopic sinus surgery. This study and presentation will analyze the various medical and surgical decisions that can be offered in the management of CSF rhinorrhoea from the authors' combined 10-year experience. The early identification of high-risk patients prior to surgery will be stressed including the various diagnostic options which are currently available in isolating the leak. The technique of endoscopic repair in the surgical management of the various leaks and the timing of the repair will be discussed in detail.

Cranial sonography in bacterial meningitis

Cranial ultrasonography was performed on 61 infants with acute bacterial meningitis (ABM). Thirty nine, infants (64%) had acute meningitis with no clinical evidence of complications (Group-I) and 22 infants (36%) had clinical evidence of complications of ABM (Group-II). Cranial ultrasound was normal in 20 infants (32.8%). The spectrum of sonographic abnormalities included echogenic sulci (60.6%), sulcal separation (49.8%), abnormal parenchymal echoes (42.6%), ventriculomegaly (34.4%), ventriculitis (19.7%), abscess (3.3%), subdural empyema (1.63%) and hemorrhagic infarct (1.63%). Various abnormal findings were seen in all 22 patients of Group II (100%) and in only 19 out of 39 patients in Group I (31.9%). Cranial sonography was comparable to CT scan done in 10 cases of Group II. Our study suggests that ultrasound is a quick, reliable and effective diagnostic tool in diagnosis and management of infants with or without evidence of complications.

Results of intraoral cortical bone screw fixation technique for mandibular fractures

The intraoral cortical bone screw fixation technique carries many advantages over traditional methods of intermaxillary fixation. Simplicity of the technique, reduction of operative time, and reduction of risk of transmission of human immunodeficiency virus and hepatitis make this an important technique in the armamentarium of busy facial trauma surgeons. Since 1992, 45 mandibular fractures in 29 patients treated with the intraoral cortical bone screw technique for intermaxillary fixation were retrospectively analyzed. At our institution, this technique has become the workhorse method of repairing most mandibular fractures and is associated with minimal complications.

Clinical profile of cholera in young children--a hospital based report

Clinical profile of cholera was studied in children attending Diarrhea Training and Treatment Unit from January-December 1993. Out of a total 8714 cases of acute watery diarrhea, 64 children (0.7%) were suspected to have cholera on the basis of acute onset loose water/rice watery stools, high purge rate with or without excessive vomiting and/or severe dehydration. Stool culture was positive for cholera in 33 cases (51.6%). All the isolates were V. cholerae 01 biotype El Tor serotype Ogawa. Sixty four per cent of stool culture positive cases were below 5 years of age. The results assume importance because out of 28 children < 2 years with clinical suspicion of cholera, 11 cases (39.3%) were culture positive for V. cholerae, youngest child being 3 months old. Comparison of various parameters revealed that presence of vomiting > 4 episodes/ day (p < 0.005), frequency of stools >12/24 hours (p <0.002), rice watery stools (p < 0.01) and presence of severe dehydration (p < 0.01) were significant parameters associated with positive stool culture. Beside examination of stool sample by hanging drop method was an excellent diagnostic tool (p < 0.001) with a sensitivity of 51.5%, specificity 100% and positive predictive value of 100%. The isolates of V. cholerae were susceptible to furazolidone, cephelexin, nalidixic acid, norfloxacin and gentamicin. Our observations indicate that cholera is not uncommon in infants and young children. Like children in the older age group, acute onset diarrhea with watery/rice watery stools and high purge rate with or without excessive vomiting and/or rapid development of severe dehydration should arouse suspicion of cholera in younger children also. They should be investigated for cholera even in non-endemic areas and in the absence of cholera outbreaks.

Neuromuscular manifestations of diarrhea related hypokalemia

Twenty-three children from 8-60 months (mean age 21.13 months) admitted with neuromuscular manifestations of diarrhea related hypokalemia were studied. Forty four per cent cases were suffering from diarrhea at the time of admission but in majority of cases (56%), the diarrheal episode had already terminated. Mild hypokalemia was seen in 17.4%, moderate in 43.5% and severe in 39.1%. Neck flop was the commonest (100%) neuromuscular manifestations followed by diminished bowel sounds (82.6%), truncal weakness (52.2%), weakness of limbs (52.2%), lethargy (43. 5%), abdominal distension (43.5%), respiratory involvement (4.3%) and phantom hernia (4.3%). Two cases (8.7%) had flaccid paralysis of both the lower limbs. Severe hypokalemia was more frequently observed in children below 24 months of age and those who had received i.v. fluids or salt sugar solution before reporting in the hospital. A significant correlation was noticed between severity of hypokalemia and frequency of stools (p < 0.05), degree of dehydration (p < 0.01), severity of nutrition (p < 0.01) and extent of neuromuscular involvement (p < 0.01). Our results highlights the importance of diarrhea related hypokalemia particularly in young malnourished children who are rehydrated with solutions inadequate in potassium. Early diagnosis and appropriate treatment can promptly reverse these manifestations within 48-72 hours.

Persistent diarrhea: management in a diarrhea treatment unit

Five hundred ninety two children (6.0%) were diagnosed as persistent diarrhea (PD) out of a total attendance of 9795 cases in the Diarrhea Training and Treatment Unit (DTU) over a period of 1 year. Most of the cases were initially managed as outpatients on dietary advice and treatment of associated infections. Eighty eight per cent of the cases followed as outpatients from the DTU responded to treatment and only 11.5% of them had to be hospitalized. A total of 49/592 cases (8.3%) required to be hospitalized on account of treatment failure from outpatients and other indications. Clinical spectrum of hospitalized children included severe malnutrition (40.8%), pneumonia (40.8%), urinary tract infection (32.7%), lactose intolerance (32.7%), anemia (28.6%), septicemia (16.3%), dysentery (8.2%) and neck flop due to hypokalemia (4.1%). Dietary management included modifications in the diet already offered to hospitalized patients. Thirty eight children were fed on one of these diets. Of these 13/35 children (37.1%) were successfully managed with lactose reduced diet., 18/22 cases (81.8%) with lactose free diet and only in 2 cases carbohydrate free diet was given. In 3 cases, normal feeding was continued. Eleven cases were too sick to be offered any oral feeding. Eleven of forty nine cases (22.4%) expired. Mortality was highest in infants <6 months (31.6%). The causes of death included severe malnutrition (14.3%), septicemia (14.3%) and pneumonia (12.2%). Screening and treating cases of PD for associated infections like septicemia, pneumonia and urinary tract infection seems to be a key factor which determines morbidity and mortality in these cases. Feeding on a hospital food modified as lactose reduced/free diet can benefit majority of cases with PD and a very small proportion of cases may require carbohydrate free diet.

Management of the internal carotid artery during carotid body tumor surgery

Patients with carotid body tumors require accurate preoperative assessment of vessel involvement and the probable impact of interrupting blood flow through the internal carotid artery. Recent developments in imaging, methods of measuring cerebral blood flow, balloon occlusion testing, and techniques to maintain vascular flow when a graft is required have improved the surgeon's ability to completely resect these tumors with reduced complications. We discuss these methods with respect to our review of 20 carotid body tumors in 18 patients. Twenty-five percent of patients were misdiagnosed, and in four patients injury to the vessel wall required appropriate surgical intervention.

Odontogenic keratocysts: a study of 50 patients

The odontogenic keratocyst (OKC) is a locally aggressive neoplasm with rates of recurrence reported as high as 60%. Correlation between histopathology and the likelihood of recurrence remains a subject of controversy. In this review of the authors' experience in treating 50 patients with OKC between 1977 and 1993, 58 specimens were studied to correlate the likelihood of recurrence with the presence of the following histologic features--parakeratosis, orthokeratosis, satellite cysts, epithelial rests, or epithelial proliferation. Orthokeratinized cysts were associated with a higher recurrence rate than in previously reported studies. Disruption of the epithelial lining in the resected specimen was found to be a primary determinant of recurrence.