Endoscopic examination of the colon in infancy and childhood

Intestinal lymphoid nodular hyperplasia in children: the relationship to food allergy

BACKGROUND

Lymphoid nodular hyperplasia (LNH) of the lower gastrointestinal tract is a common finding during paediatric colonoscopies, and its clinical significance has not yet been clearly established.

OBJECTIVE

The purpose of this prospective, parallel multi-arm, randomized clinical trial was to study relationship between food allergy and LNH.

METHODS

We recruited 268 children who had undergone a diagnostic colonoscopy between 1 January 2009 and 30 September 2011. The inclusion criteria were the following: (i) demonstration of LNH; (ii) no concomitant inflammatory or immune disease; (iii) no treatment since the clinical onset. The patients were assigned 1:1:1 to elimination diet (Group A), mesalamine (Group B) or symptomatic treatment with antispasmodics or antidiarrhoeal drugs (Group C) for an 8-wk period. Patients were followed for 24 months.

RESULTS

We enrolled 72 of 97 children with intestinal LNH who were referred for haematochezia (76%), recurrent abdominal pain (68%) and/or chronic diarrhoea (32%). Clinical improvement was observed in 75%, 83% and 79% of the patients in Groups A, B and C, respectively. The difference in the response to treatment among the groups and the association to the clinical, endoscopic and allergic features of the patients were not statistically significant.

CONCLUSIONS

Intestinal LNH should be considered a benign finding in children without red flags, because the symptoms are largely self-limiting. The use of mesalamine or elimination diet does not modify the clinical outcome compared to symptomatic therapy. The presence of food allergy was not predicted by allergy skin testing and was found in a minority of patients.

Gastrointestinal food allergy in infants

Food allergies are classified into three types, "IgE-mediated," "combined IgE- and cell-mediated" and "cell-mediated/non-IgE-mediated," depending on the involvement of IgE in their pathogenesis. Patients who develop predominantly cutaneous and/or respiratory symptoms belong to the IgE-mediated food allergy type. On the other hand, patients with gastrointestinal food allergy (GI allergy) usually develop gastrointestinal symptoms several hours after ingestion of offending foods; they belong to the cell-mediated/non-IgE-mediated or combined IgE- and cell-mediated food allergy types. GI allergies are also classified into a number of different clinical entities: food protein-induced enterocolitis syndrome (FPIES), food protein-induced proctocolitis (FPIP), food protein-induced enteropathy (Enteropathy) and eosinophilic gastrointestinal disorders (EGID). In the case of IgE-mediated food allergy, the diagnostic approaches and pathogenic mechanisms are well characterized. In contrast, the diagnostic approaches and pathogenic mechanisms of GI allergy remain mostly unclear. In this review, we summarized each type of GI allergy in regard to its historical background and updated clinical features, offending foods, etiology, diagnosis, examinations, treatment and pathogenesis. There are still many problems, especially in regard to the diagnostic approaches for GI allergy, that are closely associated with the definition of each disease. In addition, there are a number of unresolved issues regarding the pathogenic mechanisms of GI allergy that need further study and elucidation. Therefore, we discussed some of the diagnostic and research issues for GI allergy that need further investigation.

Ileal lymphonodular hyperplasia is not associated with NOD2/CARD15 mutations

INTRODUCTION

Lymphonodular hyperplasia (LNH) is a mass of lymphoid tissue that has been described in the terminal ileum, colon and duodenum mainly in children. Controversy exists regarding the benign nature of LNH. The combination of chronic abdominal pain and hematochezia leads many of these patients to undergo investigations for inflammatory bowel diseases. NOD2/CARD15 on chromosome 16 has been identified as a susceptibility gene for Crohn disease (CD). No study has yet examined the possible association of NOD2/CARD15 mutations with patients with LNH. The purpose of this study was to investigate the presence of NOD2/CARD15 mutations in patients with clinically proven LNH.

METHODS

Children and young adults with gastrointestinal symptoms diagnosed as having terminal ileum LNH were eligible for the study.

RESULTS

The study group consisted of 32 patients (15 males and 17 females), age range 3-23 years, mean 13.1 +/- 5 years. Twenty-seven (84%) had abdominal pain, 3 (9%) had rectal bleeding. The duration of symptoms ranged from 1-60 months (17.9 +/- 14.5). Only 2 patients (6.2%) were found to be heterozygote for the NOD2/CARD15 mutation (1007 fs), whereas all of the others did not carry any of the 3 common mutant alleles. This number is significantly lower (P < 0.001) than the mutation prevalence demonstrated in both pediatric and adult Israeli CD patients.

CONCLUSIONS

NOD2/CARD15 mutations are not associated with LNH. This may strengthen the lack of association between CD and LNH that has been previously reported. We suggest that genotyping NOD2/CARD15 may help to distinguish LNH from inflammatory bowel diseases in selected patients.

Lymphoid nodular hyperplasia and cow's milk hypersensitivity in children with chronic constipation

OBJECTIVE

To investigate the incidence of cow's milk allergy as evidenced by milk challenge and the findings of endoscopic and immunohistochemical examinations in children with chronic and refractory constipation.

STUDY DESIGN

Thirty-five study subjects (mean age, 8.3 +/- 3.3 years; range, 3-15 years; 17 girls) and 15 control subjects (mean age, 11.7 +/- 3.2 years; range, 2-15 years; 9 girls) were studied by colonoscopy and a 4-week cow's milk elimination and challenge.

RESULTS

Lymphoid nodular hyperplasia was the most prominent endoscopic finding in half of the subjects (46%), mostly occurring patchily in the transverse colon. Histologic findings other than lymphoid accumulation and mildly increased density of eosinophils were few. During the milk elimination and with supportive medication, 83% of subjects remitted. Constipation and/or other gastrointestinal or skin symptoms relapsed only in one third (34%) during the cow's milk challenge, these having significantly higher densities of intraepithelial gammadelta + T cells ( P <.001) in the biopsy samples of the terminal ileum as compared with the control subjects.

CONCLUSIONS

We were able to find formal evidence for the presence of cow's milk allergy in children with chronic constipation.

Lymphonodular hyperplasia on the mucosa of the lower gastrointestinal tract in children: an indication of enhanced immune response?

BACKGROUND

To discover the prevalence and significance of lymphonodular hyperplasia (LNH) of the lower gastrointestinal tract, the authors did a retrospective analysis of a consecutive series of children using colonoscopy to evaluate persistent and severe gastrointestinal symptoms. The authors also sought to discover in more detail how often subjects with LNH of the terminal ileum (TI) or colon show an association with food allergy (FA).

METHODS

The analysis included a consecutive series of 140 children evaluated at the Oulu University Hospital using colonoscopy, which extended to the TI in 74 of these children. A total of 102 patients underwent gastroduodenoscopy. The disease category was assessed using endoscopic, histopathologic, and clinical information. To diagnose FA, a masked or an open food challenge was administered to all patients who aroused any suspicion of food-related exacerbation of symptoms.

RESULTS

Of 140 patients, LNH of the colon was diagnosed in 46 subjects, 9 of 38 patients had colitis, 1 of 8 patients had Crohn disease, and 36 of the remaining 94 subjects did not have colitis. Twelve patients of the 22 with LNH of the colon (55%) showed concomitant LNH on the bulb of the duodenum. Lymphonodular hyperplasia of the TI was diagnosed in 53 of the 74 subjects in whom TI could be visualized. It was seen in most patients without colitis (80%), in one half the subjects with colitis (48%), and in one quarter of those with Crohn disease (25%). Among the whole study group 37 (26%) could be defined as having FA. It was more prevalent in patients with (52%) than in those without (13%) LNH of the colon ( P < 0.001). The presence of LNH in the TI also showed some association with FA ( P < 0.05), but less than did LNH of the colon.

CONCLUSION

We consider LNH on the mucosa of the colon or TI common but not an innocent bystander. Significantly related to a diagnosis of gastrointestinal FA in this study, it is an expression of mucosal immune response. If detected on the colon, FA should be considered, whereas if present in TI, it may be related to FA but also to a variety of other immunologically active disease states.

A randomized, prospective study to evaluate the efficacy and acceptance of three bowel preparations for colonoscopy in children

OBJECTIVE

We performed a prospective, randomized, single-blind study in children undergoing colonoscopy to evaluate the acceptance and efficacy of three different bowel preparations.

METHODS

Seventy patients (ages 3-20 yr, 38 males) were randomly assigned to one of the three study preparations: Magnesium citrate with X-prep and clear liquid diet for 2 days (group A); Dulcolax for 2 days and Fleet enema without dietary restriction (group B); and Golytely 20 ml/kg (up to 1 L) per hour for 4 h with clear liquid diet for 1 day (group C). Endoscopists blinded to bowel preparation graded the adequacy of colon cleansing. The preparations were rated by patients for tolerance, willingness to retake them, adverse effects, and compliance.

RESULTS

Data analysis using Fisher exact test and trend test showed that colon cleansing in groups A and C was superior to that in group B (p < 0.0001) and better in group C than A (p < 0.075). Overall tolerance and compliance were significantly better for groups A and B than group C (p < 0.003), but not different between A and B. More of group B patients were willing to retake the preparation than in group C (p < 0.002) and group A (p < 0.05), but this was not different between groups A and C. Adverse effects were reported more frequently by patients in group C than in groups A and B (p < 0.01).

CONCLUSIONS

Although the least well tolerated, Golytely provided the best cleansing. Dulcolax without dietary restriction provided unsatisfactory colon cleansing. Magnesium citrate with X-prep was acceptable and provided good cleansing.

Colonoscopy under general anesthesia in children

OBJECTIVE

In children, colonoscopy is usually performed using deep sedation that may be associated with significant risks. The purpose of this study was to evaluate the safety of colonoscopy performed under general anesthesia.

METHODS

All patients undergoing colonoscopy during a 3-year period were reviewed for the study. One hundred and thirty-six procedures were performed. Colonoscopies were performed by a pediatric gastroenterologist. Anesthesia was administered by a pediatric anesthetist in a gastroenterology procedure room, adjacent to the operating recovery area.

RESULTS

Three patients had significant abdominal pain and tenderness after the procedure, 1 of whom suffered a perforation of the sigmoid colon. This patient had severe ulcerative colitis. The gastrointestinal complication rate was no higher than reported in adult patients undergoing colonoscopy under sedation. No significant complications relating to the administration of anesthesia were encountered.

CONCLUSION

We conclude that colonoscopy performed under general anesthesia in children is a very safe procedure. It is superior to the use of sedation because the child is not placed at risk of respiratory compromise. Furthermore, the procedure is less worrisome for children when performed under a general anesthetic.

Ulcerative colitis in children

Chronic nonspecific ulcerative colitis remains a disease of unknown etiology, although much new information continues to be gleaned from basic research and clinical trials. In most instances, ulcerative colitis responds to medical therapy. Selecting appropriate drug therapy for a specific child depends on the extent and severity of the colitis. This article summarizes the clinical information, diagnostic studies, and approaches to management that should be considered when evaluating a child for ulcerative colitis.

Preparing the bowel for colonoscopy

Bowel preparation methods for total colonoscopy in children generally involve whole gut irrigation with electrolyte lavage solutions, which in most children will require hospitalisation for nasogastric tube administration. The aim of the study was to determine the efficacy of oral bisacodyl combined with a single phosphate enema as a bowel preparation regimen in children. In an open prospective trial, 30 children (aged 18 months-15 years) were given oral bisacodyl on each morning of the two days before colonoscopy. The children were maintained on a normal diet. A phosphate enema was administered on the morning of the procedure. The adequacy of bowel preparation was graded as grade I if no faecal material was encountered, grade II if small amounts of faecal material were present in scattered locations, and grade III if there was poor preparation with faecal material precluding satisfactory visualisation of the bowel mucosa. Eight children (26.6%) had minor abdominal cramps when taking bisacodyl, but all had a previous history of similar pain. Five children (16.6%), all under 5 years of age, cried during the administration of phosphate enema. Bowel preparation was considered excellent (grade I) in 26 (86.6%) and good (grade II) in four (13.3%). In all patients adequate visualisation of the bowel mucosa was obtained. Oral bisacodyl combined with a single phosphate enema provides an ideal method of preparing the bowel for total colonoscopy. This preparation allows colonoscopy to be carried out as a day case procedure in children while maintaining them on a normal diet.