Techniques for the evaluation of dyspepsia in children

Helicobacter pylori infection is high in paediatric nonulcer dyspepsia but not associated with specific gastrointestinal symptoms

AIM

The association between Helicobacter pylori infection and gastrointestinal symptoms is debatable in childhood. We examined the potential relationship between H. pylori infection and gastrointestinal symptoms in Brazilian children with nonulcer dyspepsia.

METHODS

This prospective observational study analysed 240 Brazilian children and adolescents (68.7% girls) with chronic nonulcer dyspepsia, who underwent upper gastrointestinal endoscopy and biopsy. Their mean age was 9.8 years (range 4-17). Upper gastrointestinal symptoms, including abdominal pain, nausea, burning, early satiety, belching and weigh loss, were evaluated by a questionnaire and H. pylori infection was determined by histopathology of gastric biopsies.

RESULTS

H. pylori infection was identified in 123/240 patients (52%). There was no significant association between the H. pylori infection and gastrointestinal symptoms and no relationship between the infection and abdominal pain or pain characteristics. However, nausea was significantly associated with the H. pylori infection, with an odds ratio of 1.76 and 95% confidence interval of 1.1-2.94 p < 0.03. Symptoms lasting longer than 12 months were significantly more frequent in children with pangastritis than in those with antral gastritis (p < 0.05).

CONCLUSION

The prevalence of H. pylori infection was high in Brazilian children with nonulcer dyspepsia, but was not associated with specific signs and symptoms, except for nausea.

Decreased relative diagnostic yield of esophagogastroduodenoscopy in children with gastroparesis

BACKGROUND

Esophagogastroduodenoscopy (EGD) and gastric emptying scintigraphy (GES) are commonly performed in the evaluation of children with upper gastrointestinal symptoms. It has been presumed, but not clarified, that gastroparesis increases the likelihood of identifying abnormalities on EGD. We sought to determine whether the presence of gastroparesis influenced the diagnostic yield of EGD in children.

METHODS

We conducted a retrospective chart review of children who underwent both an EGD and GES within 3 months of each other for evaluation of upper gastrointestinal symptoms (eg, abdominal pain). Clinical history (symptoms, comorbidities, medications, and surgical procedures), GES results, and EGD histology reports were captured.

RESULTS

A total of 125 children (46% female) were included, of whom, 70 (56%) had gastroparesis. Thirty-three (26%) children had liquid meal GES (1.2 ± 1.1 y of age, mean ± SD) and 92 (64%) had solid meal GES (12.4 ± 3.6 y of age). There was an overall trend toward a decreased frequency of biopsy abnormalities in those with gastroparesis (P=0.09). Those with gastroparesis identified through liquid meal GES were less likely to have reflux esophagitis on biopsy (P=0.002). Those with gastroparesis identified on solid meal GES were less likely to have gastritis (P=0.04). Symptoms, comorbidities, or medications were not predictive of GES or EGD results.

CONCLUSIONS

Children with gastroparesis may be less likely to have biopsy abnormalities identified on EGD in comparison to those without gastroparesis. Further prospective, larger, and multicenter studies are needed to validate our findings.

Upper gastrointestinal histopathological findings in children and adolescents with nonulcer dyspepsia with Helicobacter pylori infection

OBJECTIVES

The aim of the study was to investigate the histopathological lesions in the upper gastrointestinal mucosa associated with Helicobacter pylori infection in children with nonulcer dyspepsia.

METHODS

A cross-sectional case-control study was performed on 185 Brazilian children and adolescents (4-17 years, mean 9.5 ± 2.7 years), 63.2% girls, submitted to upper gastrointestinal endoscopy. The histopathological lesions of the esophageal and gastric mucosa were analyzed in biopsy samples.

RESULTS

H pylori infection was identified in 96 children (51.8%). Moderate to severe chronic active gastritis was present in antrum (70.5%) and corpus (45.2%), with higher grading in antrum than in corpus (P < 0.05). The topographic distribution of inflammation was pangastritis (61.9%), followed by antral (32.1%) and corpus (5.9%). H pylori density was higher in antrum than in corpus. Intestinal metaplasia was not found in the H pylori-infected group, nor was significant gastric atrophy. The scores for esophagitis were significantly higher (P < 0.05) in the noninfected group (1.4 ± 0.8) than in the H pylori-infected group (1.07 ± 0.9), with significant negative correlation (r = 0.29; P < 0.05) with the scores of gastric inflammation.

CONCLUSIONS

The prevalence of H pylori infection was high among children with dyspepsia and associated with moderate/severe degrees of gastric inflammation. The high scores of esophagitis in the noninfected group point to 2 distinct groups of pathological conditions sharing similar clinical patterns.

Cortisol diurnal rhythm and stress reactivity in constipation and abdominal pain: the Generation R Study

OBJECTIVES

The aim of this study was to assess whether diurnal cortisol rhythm and cortisol stress reactivity were associated with functional constipation and abdominal pain in infancy.

PATIENTS AND METHODS

This study was embedded in a subset of the Generation R Study, a prospective cohort study from fetal life onward in Rotterdam, the Netherlands. Data of infants between 14 and 24 months of age (N =483) were used. Salivary cortisol diurnal rhythm and salivary cortisol stress reactivity after a Strange Situation Procedure were assessed at age 14 months. Data on functional constipation were available according to the Rome II criteria, and data on abdominal pain on the basis of the Abdominal Pain Index were available from questionnaire data at 24 months.

RESULTS

In the second year of life, 13% of the infants had functional constipation and 17% had abdominal pain. Only 4% had symptoms of both functional constipation and abdominal pain. Diurnal cortisol rhythm did not differ significantly between children with and children without functional constipation and abdominal pain. Cortisol stress reactivity was slightly higher in infants with abdominal pain than in those without it, but this was not statistically significant (odds ratio 1.41; 95% confidence interval 0.46-4.31). No association was found between the cortisol stress reactivity and functional constipation.

CONCLUSIONS

Our results suggest that cortisol as a marker for stress does not play a major role in functional constipation or abdominal pain in infancy.

Indications to upper gastrointestinal endoscopy in children with dyspepsia

OBJECTIVES

The objective of the study was to ascertain the appropriateness of indications for upper gastrointestinal (UGI) endoscopy in children with dyspepsia.

METHODS

We used the RAND/University of California at Los Angeles method to investigate the appropriateness of the opinions of a panel of experts. The panel judged 2304 theoretical patient scenarios defined by a combination of demographic and clinical variables. Descriptive and multivariate logistic regression analyses were performed.

RESULTS

The panel rated UGI endoscopy as appropriate in 27.2% of cases, inappropriate in 14.3%, and dubious in 58.5%. Disagreement emerged for 21% of cases. UGI endoscopy was considered increasingly appropriate in cases with a positive family history of peptic ulcer and/or Helicobacter pylori infection (odds ratio [OR] 8.518, P < 0.0001), when dyspepsia interfered with activities of daily living ("sleep" OR 7.540, P < 0.0001; "normal activities" OR 5.725, P < 0.0001), and when patients were older than 10 years ("<or=10 years" OR 0.310, P < 0.0001) the longer the duration ("0-2 months" OR 0.002, P < 0.0001; "3-5 months" OR 0.059, P < 0.0001; "6-11 months" OR 0.516, P = 0.0005) and the greater the severity ("mild" OR 0.002, P < 0.0001; "moderate" OR 0.013, P < 0.0001) of their dyspeptic symptoms.

CONCLUSIONS

UGI endoscopy is not appropriate for all children with dyspeptic symptoms, but only for cases with a family history of peptic ulcer and/or Helicobacter pylori infection, older than 10 years of age, with symptoms persisting for more than 6 months and severe enough to affect activities of daily living.

Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review

BACKGROUND

Eosinophilic esophagitis (EoE) is an emerging clinicopathologic entity defined by abnormal esophageal eosinophilic infiltration. Our understanding of this disease is hampered by the lack of a uniform diagnostic standard. The aim of this systematic review was to determine the range of diagnostic strategies and histologic criteria in the EoE literature.

METHODS

The MEDLINE-indexed literature from 1950 through December 31, 2006 was independently searched by two investigators. To identify additional relevant studies, bibliographies were hand searched, as were the published proceedings of the 2000-2006 American College of Gastroenterology and American Gastroenterological Association national meetings. Data were extracted from all human EoE case reports, case series, cross-sectional and cohort studies, and clinical trials.

RESULTS

Of 318 publications initially identified, 116 original articles, 39 abstracts, and 69 reviews were included. We found 10 different histologic definitions of EoE, ranging from 5 to 30 eosinophils per high-powered field (hpf), though 41 (35%) of the original articles did not state their diagnostic criteria. In the 13 original articles (11%) reporting an hpf area, the eosinophil density per mm(2) varied 23-fold. There was also variation in esophageal biopsy protocols, but specific protocols were reported in just 45 (39%) original articles.

CONCLUSIONS

Significant variability in diagnostic criteria for eosinophilic esophagitis exists, and in a large proportion of studies, criteria are not reported. Because of this lack of a common disease definition, conclusions drawn from the cumulative EoE literature should be viewed with caution. A consensus research-quality standard for diagnosis of eosinophilic esophagitis is needed.

Neto MC, Pinto EALC. Estudo prospectivo de pacientes pediátricos com dor abdominal crônica

OBJETIVO: Classificar a dor abdominal crônica em crianças e adolescentes por meio dos critérios de Roma II e definir o desfecho diagnóstico em três anos de seguimento. MÉTODOS: Durante um ano, 71 pacientes com dor abdominal crônica foram atendidos como casos novos num ambulatório terciário de gastroenterologia pediátrica. Causas orgânicas foram excluídas por bases clínicas e laboratoriais, e relatos clínicos foram avaliados especificamente quanto à possibilidade de preencherem os Critérios de Roma II para dor abdominal em crianças. Para estabelecer o diagnóstico definitivo, os pacientes foram seguidos por três anos, em média. RESULTADOS: A alocação dos 71 pacientes segundo Roma II foi: doença orgânica (n=12), remissão dos sintomas após a primeira consulta (n=7), ou preencheram os critérios para dor funcional (n=52). Dos 12 pacientes de doença orgânica, nove foram diagnosticados como intolerantes à lactose, mas foram re-alocados para doença funcional no seguimento, visto que a dieta de isenção não aliviou a queixa. Dos 52 pacientes com doença funcional (idade mediana=9,3 anos, 50% meninos), nove, que inicialmente preencheram o critério para dor abdominal funcional, foram re-alocados no diagnóstico de constipação funcional e 43 mantiveram o diagnóstico funcional: 24 com dispepsia funcional, 18 com dor abdominal funcional e um com síndrome do intestino irritável. CONCLUSÕES: Dentre os casos de dor abdominal crônica, a dor do tipo funcional foi mais comum que as causas orgânicas e, dentre os seus subgrupos, a dispepsia funcional foi mais freqüente. O seguimento em longo prazo permitiu estabelecer o diagnóstico definitivo da origem da dor abdominal nessas crianças.