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Rybak A, Sethuraman A, Nikaki K, Koeglmeier J, Lindley K, Borrelli O. Gastroesophageal Reflux Disease and Foregut Dysmotility in Children with Intestinal Failure. Nutrients 2020; 12:nu12113536. [PMID: 33217928 PMCID: PMC7698758 DOI: 10.3390/nu12113536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/09/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022] Open
Abstract
Gastrointestinal dysmotility is a common problem in a subgroup of children with intestinal failure (IF), including short bowel syndrome (SBS) and pediatric intestinal pseudo-obstruction (PIPO). It contributes significantly to the increased morbidity and decreased quality of life in this patient population. Impaired gastrointestinal (GI) motility in IF arises from either loss of GI function due to the primary disorder (e.g., neuropathic or myopathic disorder in the PIPO syndrome) and/or a critical reduction in gut mass. Abnormalities of the anatomy, enteric hormone secretion and neural supply in IF can result in rapid transit, ineffective antegrade peristalsis, delayed gastric emptying or gastroesophageal reflux. Understanding the underlying pathophysiologic mechanism(s) of the enteric dysmotility in IF helps us to plan an appropriate diagnostic workup and apply individually tailored nutritional and pharmacological management, which might ultimately lead to an overall improvement in the quality of life and increase in enteral tolerance. In this review, we have focused on the pathogenesis of GI dysmotility in children with IF, as well as the management and treatment options.
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Affiliation(s)
- Anna Rybak
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
- Correspondence:
| | - Aruna Sethuraman
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Kornilia Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London E1 2AJ, UK;
| | - Jutta Koeglmeier
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Keith Lindley
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Osvaldo Borrelli
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
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Kovacic K, Elfar W, Rosen JM, Yacob D, Raynor J, Mostamand S, Punati J, Fortunato JE, Saps M. Update on pediatric gastroparesis: A review of the published literature and recommendations for future research. Neurogastroenterol Motil 2020; 32:e13780. [PMID: 31854057 DOI: 10.1111/nmo.13780] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/11/2019] [Accepted: 11/29/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Due to scarcity of scientific literature on pediatric gastroparesis, there is a need to summarize current evidence and identify areas requiring further research. The aim of this study was to provide an evidence-based review of the available literature on the prevalence, pathogenesis, clinical presentation, diagnosis, treatment, and outcomes of pediatric gastroparesis. METHODS A search of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines with the following databases: PubMed, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Web of Science. Two independent reviewers screened abstracts for eligibility. KEY RESULTS Our search yielded 1085 original publications, 135 of which met inclusion criteria. Most articles were of retrospective study design. Only 12 randomized controlled trials were identified, all of which were in infants. The prevalence of pediatric gastroparesis is unknown. Gastroparesis may be suspected based on clinical symptoms although these are often non-specific. The 4-hour nuclear scintigraphy scan remains gold standard for diagnosis despite lack of pediatric normative comparison data. Therapeutic approaches include dietary modifications, prokinetic drugs, and postpyloric enteral tube feeds. For refractory cases, intrapyloric botulinum toxin and surgical interventions such as gastric electrical stimulation may be warranted. Most interventions still lack rigorous supportive data. CONCLUSIONS Diagnosis and treatment of pediatric gastroparesis are challenging due to paucity of published evidence. Larger and more rigorous clinical trials are necessary to improve outcomes.
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Affiliation(s)
- Katja Kovacic
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Walaa Elfar
- Division of Gastroenterology and Nutrition, Department of Pediatrics, The Pennsylvania State Melton S. Hershey Medical Center, Hershey, PA, USA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Mercy Hospital, Kansas City, MO, USA
| | - Desale Yacob
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Jennifer Raynor
- Edward G. Miner Library, University of Rochester Medical Center, Rochester, NY, USA
| | - Shikib Mostamand
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jaya Punati
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John E Fortunato
- Neurointestinal and Motility Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Miguel Saps
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Holtz Children's Hospital, Miller School of Medicine, University of Miami, Miami, FL, USA
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Rahul SK, Upadhyaya VD, Kumar B. Malrotation and Midgut Volvulus associated with Asymptomatic Duplication Cyst of Jejunum. APSP J Case Rep 2016; 7:33. [PMID: 27672583 PMCID: PMC5027064 DOI: 10.21699/ajcr.v7i4.447] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/21/2016] [Indexed: 11/11/2022] Open
Abstract
Gastrointestinal duplications can affect any part of the alimentary tract and are notorious for their variable presentation. Their association with malrotation and midgut volvulus is rare. We describe an 8-year old boy presented with episodes of abdominal pain. Radiological workup showed whirlpool sign and abnormal relationship of mesenteric vessels. At operation, malrotation with chronic volvulus was found. Incidentally, a jejunal communicating duplication cyst was also noted.
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Affiliation(s)
- Sandip Kumar Rahul
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Vijai Datta Upadhyaya
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Basant Kumar
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Marsaud C, Rossignol S, Tounian P, Netchine I, Dubern B. Prevalence and management of gastrointestinal manifestations in Silver-Russell syndrome. Arch Dis Child 2015; 100:353-8. [PMID: 25700540 DOI: 10.1136/archdischild-2013-305864] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Silver-Russell syndrome (SRS) is an imprinted disorder characterised by intrauterine growth retardation, relative macrocephaly, failure to thrive, typical facial phenotype and frequent body asymmetry. Feeding difficulties are frequently noted, but no study described evolution of gastrointestinal signs during infancy and their management in SRS. The aim of this study was to describe these abnormalities in a large cohort of children with SRS. DESIGN We included 75 patients (median age 24.3 months (5.1-135.2)) in the study. We retrospectively analysed nutritional status before growth hormone therapy, the frequency of gastrointestinal signs, such as gastroesophageal reflux (GER), vomiting, constipation and feeding difficulties, and nutritional management. RESULTS Maternal uniparental disomy for chromosome 7 was found in 10 patients and 11p15 hypomethylation in 65 patients. Malnutrition (defined as a weight/expected weight for height ratio <80%) was detected in 70% of the children. Gastrointestinal signs were found in 77%, including severe vomiting before the age of 1 year in 50% of cases, persistent vomiting from the age of 1 year in 29% of cases and constipation in 20% of cases. Severe GER was diagnosed in 55% of children by 24 h oesophageal pH-metry. Feeding difficulties were described in 65% of cases, with indications for dietary enrichment in 49%. Enteral nutrition by gastrostomy was indicated in 22% of cases. CONCLUSIONS Digestive signs (GER, constipation) and malnutrition are frequent in children with SRS. The systematic exploration and management of these signs are crucial to improve the nutritional status of these children before initiating growth hormone therapy.
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Affiliation(s)
- Céline Marsaud
- Nutrition et Gastroentérologie Pédiatrique, AP-HP, Hôpital Armand-Trousseau, Paris, France
| | - Sylvie Rossignol
- AP-HP, Hôpital Armand-Trousseau, Explorations Fonctionnelles Endocriniennes, INSERM, UMR_S 938, CDR Saint-Antoine, Paris, France Université Pierre et Marie Curie-Paris 6, Institut National de la Sante´́et de la Recherche Médicale U 515, Paris, France
| | - Patrick Tounian
- Nutrition et Gastroentérologie Pédiatrique, AP-HP, Hôpital Armand-Trousseau, Paris, France Institut de Cardiométabolisme et Nutrition (ICAN), INSERM UMRS U872 (Eq7) Nutriomique, Université Pierre et Marie Curie-Paris 6, Centre de Recherche des Cordeliers, Paris, France
| | - Irène Netchine
- AP-HP, Hôpital Armand-Trousseau, Explorations Fonctionnelles Endocriniennes, INSERM, UMR_S 938, CDR Saint-Antoine, Paris, France Université Pierre et Marie Curie-Paris 6, Institut National de la Sante´́et de la Recherche Médicale U 515, Paris, France
| | - Béatrice Dubern
- Nutrition et Gastroentérologie Pédiatrique, AP-HP, Hôpital Armand-Trousseau, Paris, France Institut de Cardiométabolisme et Nutrition (ICAN), INSERM UMRS U872 (Eq7) Nutriomique, Université Pierre et Marie Curie-Paris 6, Centre de Recherche des Cordeliers, Paris, France
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Fragoso AC, Ortiz R, Hernandez F, Olivares P, Martinez L, Tovar JA. Defective upper gastrointestinal function after repair of combined esophageal and duodenal atresia. J Pediatr Surg 2015; 50:531-4. [PMID: 25840057 DOI: 10.1016/j.jpedsurg.2014.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/28/2014] [Accepted: 05/29/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Both esophageal atresia (EA) and duodenal atresia (DA) involve deficient anti-reflux barrier, poor esophageal function and eventually, duodenogastric reflux. This study aims at examining the upper gastrointestinal functional status in a cohort of patients with both EA and DA. METHODS A retrospective survey of patients treated for EA and DA between 1965 and 2012 was conducted. Clinical charts, office visits, imaging, upper gastrointestinal endoscopy and esophageal pH metry/impedance were used to assess the long-term condition of the esophagus, the presence of gastroesophageal reflux disease (GERD) and/or the need for fundoplication. RESULTS Twenty out of 581 patients treated for EA had associated DA. Ten/twenty children survived; 1 had primary esophageal replacement. With a median follow-up of 9 years, 8/9 had complicated outcomes and 5 still suffered digestive ailments: 2 GER; 1 eosinophilic esophagitis; 1 nodular gastritis, and 1 wrap herniation. A total of 10 procedures were performed: 8 fundoplications, 1 esophagogastric dissociation and 1 replacement with colon. DISCUSSION The association of EA with DA involves a poor upper digestive function with high risks of GERD and fundoplication failure. The lifelong synergistic play of esophageal, gastric and duodenal dysfunctions in these patients prompts long-term follow-up, and eventually active treatment.
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Affiliation(s)
- Ana Catarina Fragoso
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain; INGEMM and Idipaz Research Laboratory, Department of Pediatrics, Universidad Autonoma de Madrid; Faculty of Medicine, University of Porto. Porto, Portugal.
| | - Ruben Ortiz
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Francisco Hernandez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Pedro Olivares
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Leopoldo Martinez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain; INGEMM and Idipaz Research Laboratory, Department of Pediatrics, Universidad Autonoma de Madrid
| | - Juan A Tovar
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain; INGEMM and Idipaz Research Laboratory, Department of Pediatrics, Universidad Autonoma de Madrid
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Unusual uptake of radioiodine in the small bowel in a patient with thyroid cancer and bowel malrotation. Clin Nucl Med 2014; 39:936-7. [PMID: 25036018 DOI: 10.1097/rlu.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Whole-body radioiodide scan is an essential procedure in the evaluation of radioiodine-avid metastatic foci in patients with differentiated thyroid carcinoma. Normal physiologic distribution of the radiotracer includes the stomach and colon, but the small intestine is not often seen. Gastrointestinal anatomic variants may be associated with atypical activity on I scan. We report here a case of intestinal malrotation with associated I uptake in the small intestine. Careful correlation of planar imaging with SPECT/CT revealed the likely malrotation as well as small bowel uptake superimposed over normal colonic uptake. This finding was occult on prior I scan.
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Erkan ME, Ozkan A, Yilmaz A, Asik M, Gunes C, Yilmaztekin MZ, Dogan AS. The Scintigraphic Findings of Gastroesophageal Reflux in Children is Related to Body Weight? J Clin Med Res 2014; 6:17-20. [PMID: 24400026 PMCID: PMC3881984 DOI: 10.4021/jocmr1636w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2013] [Indexed: 11/08/2022] Open
Abstract
Background Gastroesophageal reflux disease (GERD) is the most common cause of children admissions to pediatric gastroenterology unit and affects about 30% of pediatric population. Body weight and height percentiles of children with GERD and their relationship between presence and the severity of reflux on scintigraphic images were studied. Methods Patients who underwent reflux scintigraphy between 2005 - 2012 were retrospectively reviewed. Among 200 patients, 49 patients were involved that their ages were ranging from 0 to 18 years old and body weight and height percentiles were recorded. Accurately 37 MBq (1 mCi) 99mTc-MAA in 100 - 150 mL of milk was ingested by the patient. Presence, number, duration and level of reflux were evaluated on the dynamic images. Presences of reflux within last ten minute were also recorded. Region-of-interests were drawn on esophagus and stomach and reflux ratio (RR) was calculated. Results The ratio of the presence of reflux which occurred within the last ten minutes was significantly higher in children with low body weight percentile. High-level reflux frequency was higher in these children than in normal’s. Presence of reflux which occurred within the last ten minutes was related with low body weight percentile. Conclusions If reflux is shown within the last ten minutes and there is high level of reflux, the clinician should be warned about possible low body weight percentile in the future and scintigraphic study should be a guide or a reference for the assessment of more effective treatment methods.
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Affiliation(s)
- Melih Engin Erkan
- Department of Nuclear Medicine, Duzce University School of Medicine, Turkey
| | - Aybars Ozkan
- Department of Pediatric Surgery, Duzce University School of Medicine, Turkey
| | - Ayse Yilmaz
- Department of Nuclear Medicine, Duzce University School of Medicine, Turkey
| | - Muhammet Asik
- Department of Nuclear Medicine, Duzce University School of Medicine, Turkey
| | - Cemalettin Gunes
- Department of Pediatrics, Duzce University School of Medicine, Turkey
| | | | - Ahmet Semih Dogan
- Department of Nuclear Medicine, Duzce University School of Medicine, Turkey
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Macharia EW. Comparison of upper gastrointestinal contrast studies and pH/impedance tests for the diagnosis of childhood gastro-oesophageal reflux. Pediatr Radiol 2012; 42:946-51. [PMID: 22864731 DOI: 10.1007/s00247-012-2405-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Revised: 01/09/2012] [Accepted: 02/12/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND The upper gastrointestinal (UGI) contrast study is used in the assessment of children with gastro-oesophageal reflux (GOR) and for detection of structural anomalies. The pH study is more sensitive than the UGI study for the diagnosis of GOR. The pH study has been replaced by the pH/impedance test, which detects both acid and nonacid reflux. OBJECTIVE To compare the UGI contrast study with the pH/impedance test for the diagnosis of GOR in children. MATERIALS AND METHODS We retrospectively reviewed consecutive records of children investigated for GOR from October 2008 to February 2010, and compared the findings of UGI studies with those of pH/impedance tests. RESULTS The UGI studies revealed GOR in 116 of 579 children (20%). Of the children undergoing a UGI study, 66 also underwent a pH/impedance test. Using the pH/impedance tests as the reference for GOR, UGI had a sensitivity of 42.8% and a negative predictive value of 24%. There was no significant correlation (P > 0.05) between the reflux index and the number of reflux episodes in the pH/impedance tests and height of reflux in the UGI study. There were low incidences of malrotation (0.9%), hiatus hernia (1%) and delayed gastric emptying (0.4%). CONCLUSION The UGI study had low sensitivity for the diagnosis of GOR and low yield for the diagnosis of structural anomalies.
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Affiliation(s)
- Eva W Macharia
- Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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Mooij MG, de Koning BAE, Huijsman ML, de Wildt SN. Ontogeny of oral drug absorption processes in children. Expert Opin Drug Metab Toxicol 2012; 8:1293-303. [PMID: 22686526 DOI: 10.1517/17425255.2012.698261] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION A large proportion of prescribed drugs to children are administered orally. Age-related change in factors affecting oral absorption can have consequences for drug dosing. AREAS COVERED For each process affecting oral drug absorption, a systematic search has been performed using Medline to identify relevant articles (from inception till February 2012) in humans. This review presents the findings on age-related changes of the following processes affecting oral drug absorption: gastric pH, gastrointestinal motility, bile salts, pancreatic function, intestinal pH, intestinal drug-metabolizing enzymes and transporter proteins. EXPERT OPINION Clinicians should bear in mind the ontogeny of oral drug absorption processes when prescribing oral drugs to children. The authors' review shows large information gaps on almost all drug absorption processes. It is important that more knowledge is acquired on intestinal transit time, intestinal pH and the ontogeny of intestinal drug-metabolizing enzymes and drug transporter proteins. Furthermore, the ultimate goal in this field should be to predict more precisely the oral disposition of drugs in children across the entire pediatric age range.
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Affiliation(s)
- Miriam G Mooij
- Erasmus MC-Sophia Children's Hospital, Department of Pediatric Surgery and Intensive Care, Rotterdam, The Netherlands
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Tiboni SG, Patel Y, Lander AD, Parikh DH, Jawaheer G, Arul GS. Management of gastroesophageal reflux associated with malrotation in children. J Pediatr Surg 2011; 46:289-91. [PMID: 21292075 DOI: 10.1016/j.jpedsurg.2010.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 11/04/2010] [Indexed: 02/08/2023]
Abstract
AIM Children being investigated for gastroesophageal reflux (GOR) have a high incidence of malrotation. Current literature suggests these patients should be managed with a combined antireflux and Ladd's procedure. We review our experience, the largest series to date, of performing an elective Ladd's procedure as the first-line intervention. METHOD Retrospective case note review of 20 children with significant symptoms of GOR and an incidental finding of malrotation. Children presenting immediately with bilious vomiting were excluded. All patients underwent a Ladd's procedure as their sole primary operative intervention. RESULTS Median age at operation was 7 months (21 days-12 years). Fifteen patients (75%) had evidence of reflux on barium contrast study. All children were followed up for at least 6 months. Eighteen (90%) had resolution or significant improvement of their symptoms postsurgery. Only 3 have not managed to tolerate a full oral diet, all unrelated to GOR. None of our series required an antireflux procedure. CONCLUSION In children with debilitating vomiting necessitating surgical management, a contrast study is imperative in the work up. The high incidence of GOR and the significant improvement after correction of malrotation show the relationship between delayed gastric emptying and GOR. We suggest that when an abnormally placed duodenojejunal flexure is found, a Ladd's procedure alone is sufficient and may obviate the need for a more invasive antireflux procedure.
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Affiliation(s)
- Sonia G Tiboni
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, United Kingdom
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Vitta L, Raghavan A, Morrell R, Sprigg A. Fluoroscopy-guided insertion of nasojejunal tubes in children - setting local diagnostic reference levels. Pediatr Radiol 2009; 39:1203-8. [PMID: 19789863 DOI: 10.1007/s00247-009-1362-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 05/21/2009] [Accepted: 06/19/2009] [Indexed: 01/15/2023]
Abstract
BACKGROUND Little is known about the radiation burden from fluoroscopy-guided insertions of nasojejunal tubes (NJTs) in children. There are no recommended or published standards of diagnostic reference levels (DRLs) available. OBJECTIVE To establish reference dose area product (DAP) levels for the fluoroscopy-guided insertion of nasojejunal tubes as a basis for setting DRLs for children. In addition, we wanted to assess our local practice and determine the success and complication rates associated with this procedure. MATERIALS AND METHODS Children who had NJT insertion procedures were identified retrospectively from the fluoroscopy database. The age of the child at the time of the procedure, DAP, screening time, outcome of the procedure, and any complications were recorded for each procedure. As the radiation dose depends on the size of the child, the children were assigned to three different age groups. The sample size, mean, median and third-quartile DAPs were calculated for each group. The third-quartile values were used to establish the DRLs. RESULTS Of 186 procedures performed, 172 were successful on the first attempt. These were performed in a total of 43 children with 60% having multiple insertions over time. The third-quartile DAPs were as follows for each age group: 0-12 months, 2.6 cGy cm(2); 1-7 years, 2.45 cGy cm(2); >8 years, 14.6 cGy cm(2). High DAP readings were obtained in the 0-12 months (n = 4) and >8 years (n = 2) age groups. No immediate complications were recorded. CONCLUSION Fluoroscopy-guided insertion of NJTs is a highly successful procedure in a selected population of children and is associated with a low complication rate. The radiation dose per procedure is relatively low.
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Affiliation(s)
- Lavanya Vitta
- Department of Radiology, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.
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Sodhi KS, Khandelwal N. Upper gastrointestinal studies in malrotation. Pediatr Radiol 2008; 38:1034. [PMID: 18607584 DOI: 10.1007/s00247-008-0926-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 06/04/2008] [Indexed: 11/29/2022]
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Abstract
General localization of gastrointestinal bleeding through the use of labeled red blood cells may be performed in children, or (99m)Tc-pertechnetate may be used if a Meckel's diverticulum is suspected. As in adults, cholecystitis and biliary leak may be assessed in children via (99m)Tc-IDA derivatives. Gastroesophageal reflux can be evaluated by oral consumption of the child's usual diet labeled with (99m)Tc sulfur colloid. For the scintigraphic determination of pulmonary aspiration, a relatively high concentration of tracer within a drop of liquid is placed beneath the child's tongue followed by dynamic imaging of the respiratory tract. Colonic transit scintigraphy can aid in the identification and therapeutic decision-making in patients with functional fecal retention, the most common cause of chronic constipation in children. (18)F-DOPA positron emission tomography is useful for classifying pancreatic involvement in infantile hyperinsulinism as focal or diffuse, thereby differentiating between patients who should receive curative focal pancreatic resection versus those who should receive medical management. Assessment of protein-losing enteropathy can be conducted scintigraphically and, compared with fecal alpha-1 antitrypsin collection, the scintigraphic method can detect esophageal and gastric protein loss. Also, scintigraphic quantification of protein loss can be performed without the requirement for fecal collection. Intestinal inflammation in children with inflammatory bowel disease can be evaluated using (99m)Tc white blood cells. The scintigraphic method is safe, accurate, well-tolerated by children and complementary to endoscopy in most patients.
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Abstract
PURPOSE OF REVIEW To summarize and contextualize current concepts in the incidence, diagnosis, management and long-term sequelae of extraesophageal reflux disease in children. RECENT FINDINGS Extraesophageal reflux disease is a different disease entity from gastroesophageal reflux disease. The two diseases have a common etiology, refluxate causing mucosal damage, but the extent and location of the damage varies considerably depending on the underlying mucosal characteristics. Extraesophageal reflux disease in children is characterized by a broad set of symptoms and signs that vary according to age at presentation and severity of disease. Serious long-term effects begin in childhood. The role of pepsin, bile acids, pancreatic enzymes, motility disorders, and food allergies have only recently been recognized. Newer diagnostic modalities include multichannel intraluminal pH/impedance, the 48 h Bravo implantable probe, and hypopharyngeal pH monitoring. While proton pump inhibitors provide superior acid suppression compared with histamine-2 blockers, variability in response and lack of efficacy for alkaline refluxate often require other therapeutic interventions. SUMMARY Pediatric extraesophageal reflux disease has variable presentation and a gold standard test is still lacking. Primary treatment includes lifestyle and feeding changes and medical therapy. Ongoing monitoring for recurrence and agreement as to duration of therapy present significant challenges not yet standardized amongst practitioners.
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Affiliation(s)
- Linda Brodsky
- State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York 14222, USA.
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El-Chammas K, Malcolm W, Gaca AM, Fieselman K, Cotten CM. Intestinal malrotation in neonates with nonbilious emesis. J Perinatol 2006; 26:375-7. [PMID: 16724079 DOI: 10.1038/sj.jp.7211507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intestinal malrotation is a relatively uncommon condition with diverse outcomes. Familiarity with variations in the presentation of malrotation is imperative as early diagnosis and prompt subsequent surgical intervention are essential to optimizing outcome. The most frequent clinical sign in the neonate is bile-stained emesis. We report three cases of unsuspected malrotation that were diagnosed in neonates with a history of nonbilious emesis who were assessed for presumed gastroesophageal reflux or aspiration. Gastroesophageal reflux is a common condition among newborns, and can be a subtle presentation of malrotation. Clinicians should consider malrotation as a possible cause of reflux, particularly in infants with unusually pathologic or persistent symptoms necessitating ongoing treatment for reflux.
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Affiliation(s)
- K El-Chammas
- Department of Pediatrics, American University of Beirut Medical Center, Beirut, Lebanon
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Affiliation(s)
- Bindi Naik-Mathuria
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin CC 650.00, Houston, TX 77030-2399, USA
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Lipscomb K, Schmitt C, Sablyak A, Yoder JA, Nascone-Yoder N. Role for retinoid signaling in left–right asymmetric digestive organ morphogenesis. Dev Dyn 2006; 235:2266-75. [PMID: 16786581 DOI: 10.1002/dvdy.20879] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The looping events that establish left-right asymmetries in the vertebrate gut tube are poorly understood. Retinoic acid signaling is known to impact left-right development in multiple embryonic contexts, although its role in asymmetric digestive organ morphogenesis is unknown. Here, we show that the genes for retinaldehyde dehydrogenase (RALDH2) and a retinoic acid hydroxylase (CYP26A1) are expressed in complementary patterns in the Xenopus gut during looping. A late-stage chemical genetic assessment reveals that agonists and antagonists of retinoid signaling generate abnormal gut looping topologies, digestive organ heterotaxias, and intestinal malrotations. Accessory organ deformities commonly associated with intestinal malrotation in humans, such as annular pancreas, pancreas divisum, and extrahepatic biliary tree malformations, are also induced by distinct retinoid receptor agonists. Thus, late-stage retinoic acid signaling is likely to play a critical role in asymmetric gut tube morphogenesis and may underlie the etiology of several clinically relevant defects in the digestive system.
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Affiliation(s)
- Kristen Lipscomb
- Natural Sciences Collegium, Eckerd College, St. Petersburg, Florida, USA
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Bax KNMA, van der Zee DC. Delayed gastric emptying and malrotation in gastroesophageal reflux disease. Pediatr Surg Int 2005; 21:1027. [PMID: 16273374 DOI: 10.1007/s00383-005-1536-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2005] [Indexed: 12/19/2022]
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