Breakdown of gastric staple line as a complication of the uncut Collis-Nissen fundoplication in children

Uncut Collis-Nissen fundoplication for complicated gastroesophageal reflux was performed in 102 children (46 girls; age 5.6 +/- 4.2 years). Five patients developed intractable emesis postoperatively (average 11 +/- 5 months after surgery) and were found to have two independent luminal openings at the gastroesophageal junction seen on upper endoscopy but not demonstrable on upper GI. The defect was presumed to occur from breakdown of the original staple line on the lesser gastric curve. The condition was successfully repaired in all patients by including a new staple line and rewrapping of the stomach. Practitioners should be aware of this previously unreported complication post uncut Collis-Nissen fundoplication and that this condition may not be excluded by a normal upper GI study.

Whole-bowel irrigation as an adjunct to the treatment of chronic, relapsing Clostridium difficile colitis

We report the successful treatment of two patients with chronic, intractable Clostridium difficile infection using whole-bowel irrigation with a polyethylene glycol solution (Golytely) as adjunctive therapy. Before this treatment, both patients had recurrent symptoms of diarrhea, weight loss, abdominal pain, and documented C. difficile toxin-positive stools despite multiple pharmacologic treatments. Each child was prescribed myriad drug therapies, including vancomycin, metronidazole, bacitracin, and rifampin. Cholestyramine and lactobacillus were also tried alone and in combination with antibiotics. In each case, symptoms recurred shortly after cessation of therapy. Whole-bowel irrigation was subsequently administered until profuse, clear liquid stools were produced. This treatment was followed by a 3-week course of oral vancomycin and lactobacillus. In both cases, the patient became asymptomatic within 3 days of therapy; they have remained symptom-free for 36 and 48 months, respectively. We suggest that whole-bowel irrigation clears active C. difficile organisms, toxins, and spores from the intestine and is effective as an adjunct to routine therapy for chronic, relapsing C. difficile infections.

The influence of age and relative weight on the presentation of familial combined hyperlipidemia in childhood

BACKGROUND

Familial combined hyperlipidemia (FCHL) has been described as the leading cause of familial hyperlipidemia. FCHL is dominantly inherited, occurs in at least 1% of the population, and is responsible for about 10% of premature coronary artery disease (CAD).

OBJECTIVE

Because FCHL in childhood is not well characterized, we evaluated the interrelationships among age, percentage of ideal body weight (%IBW) and plasma lipoprotein levels in FCHL children (age 2-18 years), exploring the possibility that obesity and age may influence the presentation of FCHL in childhood.

METHODS

One hundred and eighty-nine children with FCHL were studied. Significant correlations within this group were further evaluated by examining a subset of 36 FCHL children, each of whom had an unaffected sibling who could serve as a control for comparison.

RESULTS

When the full group was divided into those with TG levels > 90% and those with TG levels < 90%, the correlation with %IBW was stronger in the former (r = 0.45, P < 0.005) as compared with the latter (r = 0.25, P = 0.05). Within the subset of 36 FCHL children and their 36 unaffected siblings (controls), age and sex distributions were similar. Percentage IBW (mean +/- S.D.) (117.3 +/- 29.1 for FCHL and 111.2 +/- 19.4 for controls) was similar and in the overweight range. FCHL children had significantly higher levels of total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), apolipoprotein B (apo B) and triglyceride (TG) levels compared with controls (P < 0.0005 for all comparisons). Of several significant correlations observed in the full group (n = 189), only the correlations of %IBW with plasma TG levels (r = 0.45, P = 0.006), and of age with plasma TG levels (r = 0.48, P = 0.003) persisted with a similar degree of magnitude in the subset of 36 FCHL children. No correlation was significant in the controls. By Fisher's Z-test, the correlation between %IBW and TG in the FCHL children was significantly different from controls.

CONCLUSIONS

These results suggest that TG levels in FCHL children, but not in their unaffected siblings, and sensitive to the presence of obesity, implying an interaction between obesity and the underlying condition, in addition, the association between age and TG level in FCHL children suggests a gradual expression of the hyperlipidermia (i.e. TG) during childhood.

Intestinal malrotation in children: tutorial on radiographic diagnosis in difficult cases

PURPOSE

To analyze difficult diagnostic cases of malrotation to identify features crucial to accurate diagnosis.

MATERIALS AND METHODS

The authors reviewed the radiographs and records of 81 symptomatic children who underwent surgery with a preoperative diagnosis of malrotation. Eleven had subtle rotational abnormalities (potential false-negative examinations), and 12 had false-positive upper gastrointestinal examinations.

RESULTS

Subtle signs of malrotation included unusual redundancy of the duodenum to the right of the spine and location of the duodenojejunal junction (DJJ) medial to the left pedicle. Nevertheless, two children with variations of malrotation had normal upper gastrointestinal examinations. False-positive diagnoses resulted from failure to recognize normal variants: jejunum in the right upper quadrant as the sole finding, DJJ over the left pedicle on the anteroposterior view, "duodenum inversum," and "duodenum mobile." Three children had bowel distention that displaced the DJJ.

CONCLUSION

Diagnosis of difficult cases of malrotation may depend on recognition of anatomic subtleties. False-positive diagnoses may be avoided by appreciation of normal duodenal variants.

A placebo-controlled trial using intravenous atropine as an adjunct to conscious sedation in pediatric esophagogastroduodenoscopy

BACKGROUND

The usefulness of intravenous atropine as an adjunct to conscious sedation in pediatric esophagogastroduodenoscopy remains an unresolved issue.

METHODS

This prospective, double-blind, randomized study examined 101 patients, who were randomized to receive either intravenous atropine 0.02 mg/kg (maximum 0.4 mg) or a placebo of normal saline solution prior to the procedure.

RESULTS

The mean maximum heart rate during the procedure and the percentage of time that the heart rate was more than 1 standard deviation above mean for age was significantly greater in the atropine group as compared to the placebo group (p < 0.0005). There was no significant difference between groups in the amount of secretions noted, gastric motility, retching or vomiting, facial flushing, or dysphoria. There were no causes of significant bradycardia or hypotension in either group. There was a significant number of patients greater than 5 years of age and receiving meperidine and atropine (as compared with meperidine and placebo) whose arterial oxygen saturation dropped below 90% during the procedure (p = 0.0485).

CONCLUSIONS

We found that the use of atropine when used as an adjunct to conscious sedation in children undergoing upper endoscopy did not increase the safety of the procedure or provide significant benefits. We do not recommend the routine use of atropine for upper endoscopy in pediatric patients.

Intravenous sedation in pediatric upper gastrointestinal endoscopy

To assess the safety and efficacy of intravenous sedation in pediatric upper endoscopy, all elective outpatient procedures performed during a 2-year period (January 1, 1991 through December 31, 1992) were retrospectively reviewed. Of 614 children, 553 received intravenous meperidine and midazolam; 61 received fentanyl and midazolam. The mean dose of meperidine was 1.5 +/- 0.7 mg/kg and of fentanyl 0.0031 +/- 0.0014 mg/kg. Less midazolam was needed for children receiving fentanyl than for those receiving meperidine (0.05 +/- 0.03 mg/kg versus 0.08 +/- 0.05 mg/kg, p < 002). Recovery time (minutes) was shorter for those receiving fentanyl (74.7 +/- 22.8 versus 95.1 +/- 23.0, p < .003). Side effects occurred in 117 patients (19.1%), of which the majority were mild (83%); all were transient with no residual sequelae. Inability to complete the procedure occurred in fewer than 1%. We conclude that both combinations of medication are safe and effective for children of all ages. The use of fentanyl/midazolam results in a shorter recovery time and a lower dose of midazolam.

Familial combined hyperlipidemia in children: clinical expression, metabolic defects, and management

The first evidence that elevation of plasma levels of cholesterol is a risk factor for the development of atherosclerosis in children came from the Bogalusa Heart Study in 1986, which reported an association between aortic fatty streaks in 3- to 26-year-old subjects and increased plasma levels of low-density lipoprotein cholesterol (LDL-C). The most compelling evidence of a cause-and-effect relationship has come from the multicenter cooperative study called the Pathobiological Determinants of Atherosclerosis in Youth. When the investigators examined the abdominal aorta and the right coronary artery of adolescents and young adults who had died of trauma, they found a significant relationship between the sum of the very low density lipoprotein (VLDL) plus LDL-C level and both fatty streaks and raised atherosclerotic lesions. They also found an inverse relationship between those lesions and increased high-density lipoprotein cholesterol (HDL-C) levels. In addition, their studies showed that smoking (as assessed by the serum thiocyanate level) promotes atherogenesis in children as young as age 15 years. Thus many pediatricians have now accepted the importance of identifying children with significant hypercholesterolemia so that appropriate dietary and life-style modifications can be recommended. This is especially important because there is often a major genetic component to the hyperlipidemia seen in children.

Familial combined hyperlipidemia in children: clinical expression, metabolic defects, and management

Familial combined hyperlipidemia (FCHL) is a dominantly inherited hyperlipidemia that occurs in at least 1% of the adult population and is responsible for 10% of premature coronary artery disease. In families referred for evaluation because of primary hyperlipidemia in a child, FCHL is expressed three times more commonly than familial hypercholesterolemia and half of the siblings are affected. Several metabolic defects apparently are associated with the FCHL phenotype. Most commonly, excess production of very low density lipoprotein apolipoprotein B can be demonstrated. In other families, reduced lipoprotein lipase activity is associated. One allele at a locus influencing apolipoprotein B levels predicts FCHL in a large proportion of families ascertained through affected children. Whether this allele is responsible for the excess of very low density lipoprotein apolipoprotein B detected in metabolic studies has not been elucidated. Management of FCHL in children begins with dietary modification. A bile acid sequestrant may be considered as well if diet cannot reduce the plasma low-density lipoprotein cholesterol level to less than 4.13 mmol/L (160 mg/dl) after the age of 10 years. Although the hydroxymethylglutaryl-coenzyme A reductase inhibitors are not currently recommended for children younger than 19 years of age, we speculate that they will be increasingly utilized for the management of FCHL in teenage boys who continue to have low density lipoprotein cholesterol levels greater than 4.13 mmol/L (160 mg/dl) after dietary modification.

Use of cholestyramine in the treatment of children with familial combined hyperlipidemia

We studied the effectiveness of and compliance with the use of cholestyramine in children with heterozygous familial hypercholesterolemia (FH) and familial combined hyperlipidemia (FCHL). During a 10-year period, 673 children (aged 10.5 +/- 4.0 years) were referred for evaluation of hyperlipidemia, of whom 87 (36 with FH; 51 with FCHL) were treated with cholestyramine (8 to 24 gm/day). In both groups, total cholesterol, low-density lipoprotein (LDL)-cholesterol, and apolipoprotein B levels were significantly reduced after cholestyramine use. In those with FH, plasma LDL-cholesterol levels decreased from 258 +/- 35 mg/dl (6.67 +/- 0.90 mmol/L) to 190 +/- 31 mg/dl (4.91 +/- 0.80 mmol/L); in those with FCHL, LDL-cholesterol levels dropped from 207 +/- 40 mg/dl (5.35 +/- 1.03 mmol/L) to 141 +/- 35 mg/dl (3.64 +/- 0.90 mmol/L). High-density lipoprotein-cholesterol levels were not significantly changed after cholestyramine use in either group. In the FCHL group, plasma triglyceride levels increased significantly from 81 +/- 35 mg/dl (0.92 +/- 0.40 mmol/L) to 134 +/- 42 mg/dl (1.52 +/- 0.48 mmol/L). Seven patients were lost to follow-up; 18 discontinued the medication within 1 month. Of the remaining 62 children, 59 had a good response to the drug. Of the 62 patients, 52 discontinued the medication after 21.9 +/- 10 months. Adverse effects included foul taste (73%), nausea with bloating (18%), and constipation. Cholestyramine is effective in reducing LDL-cholesterol levels in children with inherited hyperlipidemia, but the majority of children will not comply with its long-term use.

Chronic diarrhea. A practical approach for the pediatrician

Despite the high prevalence of chronic diarrhea there is no universal approach to its diagnosis and treatment. This article summarizes the pathophysiologic processes that result in chronic diarrhea and presents a diagnostic and therapeutic approach to this often distressing problem.