Use of transient elastography to assess hepatic steatosis and fibrosis in patients with juvenile idiopathic arthritis during methotrexate treatment

OBJECTIVES

This study aimed to assess the prevalence and identify predictors of hepatic steatosis and fibrosis in patients with juvenile idiopathic arthritis (JIA) during methotrexate treatment.

METHOD

This cross-sectional study included JIA patients who had received methotrexate for > 1 year. Laboratory data including liver chemistry and lipid profiles were collected. Liver stiffness measurements (LSM) and controlled attenuation parameters (CAP) were determined by transient elastography. Significant hepatic fibrosis was defined as LSM > 7 kilopascal (kPa), and hepatic steatosis was defined as CAP > 225 decibel/meter (dB/m). Logistic regression analysis was performed to identify predictors associated with hepatic steatosis and fibrosis.

RESULTS

Of 60 patients, 66.7% were female, and the median age (IQR) was 12.8 (10.6-15.0) years. The median duration of methotrexate usage (IQR) was 45 (22-85) months, and the median cumulative dose of methotrexate (IQR) was 3768 (1806-6466) mg. The median LSM (IQR) and CAP (IQR) were 4.1 (3.4-4.6) kPa and 191.0 (170.3-223.8) dB/m, respectively. No patients had transient elastography-defined hepatic fibrosis, whereas 21.7% had hepatic steatosis. A body mass index Z-score > 1 (OR 5.71 [95%CI 1.31-24.98], p = 0.021) and higher cumulative dose of methotrexate (OR 1.02 [95%CI 1.00-1.04], p = 0.041) were associated with hepatic steatosis, whereas the cumulative dose of steroids was not (OR 1.00 [95%CI 1.00-1.01], p = 0.097).

CONCLUSIONS

Hepatic steatosis is common among JIA patients receiving methotrexate, but none had transient elastography-defined hepatic fibrosis. Overweight/obese JIA adolescents and patients with a high cumulative dose of methotrexate are at risk for hepatic steatosis. Key Points •Long-term low-dose methotrexate usage and the concomitant use of other DMARDs did not increase the risk of hepatic fibrosis in JIA patients. •The prevalence of hepatic steatosis in JIA patients receiving methotrexate was higher than in a healthy pediatric population. •Overweight/obesity and a higher cumulative dose of methotrexate were predictors of hepatic steatosis.

Polyarteritis Nodosa with Cytomegalovirus Enteritis and Jejunoileal Perforation: Report of a Case with a Literature Review

Polyarteritis nodosa (PAN) is a rare systemic necrotizing vasculitis affecting small- to medium-sized arteries. The most common gastrointestinal manifestation of PAN is postprandial abdominal pain from mesenteric arteritis causing bowel ischemia. When transmural ischemia develops, there may be ischemic necrosis and perforation of the bowel wall, which are life-threatening. Severe, life-threatening gastrointestinal involvement is relatively rare in pediatric PAN and may require different management in adult patients. We report a pediatric PAN case in a patient who presented with acute abdominal pain and superimposed cytomegalovirus enteritis with jejunoileal perforation. The patient improved with emergency small intestinal resection followed by conventional immunosuppressive drugs of a corticosteroid and cyclophosphamide, and anti-viral drugs. Before increasing the immunosuppressive drug dosage, initial screening of infectious cytomegalovirus and comprehensive evaluation for surgical conditions are essential in pediatric PAN with severe gastrointestinal involvement. Early aggressive treatment for acute abdomen is useful in reducing morbidity and mortality in pediatric PAN.

Endoscopic finding and treatment outcome of children with Helicobacter pylori infection in lower northern Thailand

Background

Helicobacter pylori infection is one of the predisposing factors for gastritis, peptic ulcer, and duodenal ulcer. Definite diagnosis of H. pylori infection is important in planning effective medical management. However, confirming the diagnosis through bacterial culture takes a number of days, and thus delays treatment.

Objectives

To examine endoscopic findings in children associated with chronic abdominal pain and H. pylori infection to aid in early diagnosis. We also evaluated treatment outcome of H. pylori infection.

Methods

A retrospective study was performed by reviewing the medical records of children under 15 years of age with chronic abdominal pain who underwent esophagogastroduodenoscopy (EGD) between 2011 and 2017. According to 2016 Joint ESPGHAN/NASPGHAN Guidelines, H. pylori infection was defined by positive tests for both histopathology test and rapid urease test (RUT). The EGD finding, RUT, histopathologic finding, and treatment outcome were recorded.

Results

Forty-eight children presented with chronic abdominal pain (male 47.9%, female 52.1%, mean age was 8.44 ± 2.97 years). Twelve children out of 48 had H. pylori infection (12/48, 25%). Eight among the 12 children had antral nodularity (8/12), wherein there was no antral nodularity in children without H. pylori infection (0/36). This difference was statistically significant (P < 0.001). Sensitivity and specificity of antral nodularity finding for H. pylori infection were 66.7% and 100%, respectively. Eradication of H. pylori infection with standard regimen improved the abdominal pain within 4 weeks.

Conclusion

The occurrence of antral nodularity in endoscopic finding was significantly associated with H. pylori infection. In addition, antral nodularity finding showed a good sensitivity and high specificity for the diagnosis of H. pylori infection.