Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia

Allergic Proctocolitis: Literature Review and Proposal of a Diagnostic-Therapeutic Algorithm

Allergic proctocolitis (AP) is a benign condition, frequent in childhood, that is classified as a non-IgE-mediated food allergy. The prevalence is unknown; however, its frequency appears to be increasing, especially in exclusively breastfed infants. Clinical manifestations typically begin in the first few months of life with the appearance of bright red blood (hematochezia), with or without mucus, in the stool of apparently healthy, thriving infants. Most cases of AP are caused by cow's milk proteins; however, other allergens, such as soy, egg, corn, and wheat, may be potential triggers. Diagnosis is based on the patient's clinical history and on the resolution of signs and symptoms with the elimination of the suspected food antigen from the diet and their reappearance when the food is reintroduced into the diet. The treatment of AP is based on an elimination diet of the trigger food, with resolution of the symptoms within 72-96 h from the beginning of the diet. The prognosis of AP is good; it is a self-limiting condition, because most children can tolerate the trigger food within one year of life, with an excellent long-term prognosis. The purpose of this review is to provide an update on the current knowledge and recommendations in epidemiological, diagnostic, and therapeutic terms to the pediatricians, allergists, and gastroenterologists who may find themselves managing a patient with AP.

Consensus on the diagnosis and treatment of cow's milk protein allergy of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Cow's milk protein allergy (CMPA) is the most frequent cause of food allergy in the first months of life. Despite the fact that there are different guidelines and recommendations on the management of children with CMPA, there continues to be great variability in diagnostic and therapeutic criteria in Latin America. The Food Allergy Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition summoned a group of Latin American experts to reach a consensus and formulate a document to unify diagnostic and therapeutic criteria for CMPA. Three teams were formed, each with a coordinator, and the members of each team developed a series of statements for their corresponding module: a) clinical manifestations and diagnosis; b) diagnostic tools, and c) treatment. A search of the medical literature was carried out to support the information presented in each module and 28 statements were then selected. The statements were discussed, after which they were evaluated by all the experts, utilizing the Delphi method. Their opinions on statement agreement or disagreement were anonymously issued. The final statements selected were those with above 75% agreement and their corresponding recommendations were formulated, resulting in the document presented herein.

Food protein-induced allergic proctocolitis in infants: Literature review and proposal of a management protocol

Food protein-induced allergic proctocolitis (FPIAP) is a condition characterized by inflammatory changes in the distal colon in response to one or more foreign food proteins because of immune-mediated reactions.

FPIAP prevalence estimates range widely from 0.16% in healthy children and 64% in patients with blood in stools.

In clinical practice, FPIAP is diagnosed when patients respond positively to the elimination of a suspected triggering food allergen. Nevertheless, significant proportions of infants get misdiagnosed with IgE mediated allergy and undergo unnecessary dietary changes.

Diagnosis is based on clinical symptoms, a good response to an allergen-free diet and the recurrence of symptoms during the “allergy challenge test”. Sometimes clinical features may be non-specific and the etiology of rectal bleeding in childhood may be heterogeneous. Therefore, it is crucial to exclude a variety of other possible causes of rectal bleeding in the pediatric age group, including infection, anal fissure, intestinal intussusception and, in infants, necrotizing enterocolitis and very early onset inflammatory bowel disease. The diagnostic workup includes in those cases invasive procedures such as sigmoidoscopy and colonoscopy with biopsies.

The high prevalence of FPIAP contrasts with the lack of known information about the pathogenesis of this condition. For this reason and due to the absence of a review of the evidence, a literature review appears necessary to clarify some aspects of allergic colitis.

The aim of the review is to fill this gap and to lay the foundations for a subsequent evidence-based approach to the condition.

Abdominal ultrasonography of the pediatric gastrointestinal tract

Ultrasound is an invaluable imaging modality in the evaluation of pediatric gastrointestinal pathology; it can provide real-time evaluation of the bowel without the need for sedation or intravenous contrast. Recent improvements in ultrasound technique can be utilized to improve detection of bowel pathology in children: Higher resolution probes, color Doppler, harmonic and panoramic imaging are excellent tools in this setting. Graded compression and cine clips provide dynamic information and oral and intravenous contrast agents aid in detection of bowel wall pathology. Ultrasound of the bowel in children is typically a targeted exam; common indications include evaluation for appendicitis, pyloric stenosis and intussusception. Bowel abnormalities that are detected prenatally can be evaluated after birth with ultrasound. Likewise, acquired conditions such as bowel hematoma, bowel infections and hernias can be detected with ultrasound. Rare bowel neoplasms, vascular disorders and foreign bodies may first be detected with sonography, as well. At some centers, comprehensive exams of the gastrointestinal tract are performed on children with inflammatory bowel disease and celiac disease to evaluate for disease activity or to confirm the diagnosis. The goal of this article is to review up-to-date imaging techniques, normal sonographic anatomy, and characteristic sonographic features of common and uncommon disorders affecting the gastrointestinal tract in children.