Duodenal leiomyosarcoma presenting with iron deficiency anemia

Failed iron therapy warrants investigation to rule out disorders of iron absorption or intestinal blood loss. The authors report the third case of duodenal leiomyosarcoma in childhood, which presented with iron deficiency anemia. Endoscopy failed to elicit the cause of this problem. Wide surgical resection, sparing the pancreas, was possible.

Resolution of hepatic abscess after interferon gamma in chronic granulomatous disease

Recombinant interferon gamma has been used prophylactically in children with chronic granulomatous disease, but its role in the treatment of acute infective episodes has not been defined. A 3 year old boy presented with multiple candidal liver abscesses and was given intravenous antifungal treatment and he showed initial improvement. After six weeks his erythrocyte sedimentation rate and C reactive protein remained raised, and a computed tomogram showed a single abscess in the left lobe of the liver from which pus was drained and Staphylococcus aureus isolated. During the next eight months the abscess persisted despite appropriate intravenous antibiotics and percutaneous drainage. Subphrenic extension precluded definitive surgery. Nine months after initial presentation recombinant interferon gamma 0.05 mg/m2 intravenously was commenced three times a week. Complete resolution occurred within two months. It is concluded that interferon gamma is useful in treating infective episodes, and further study of the use of prophylactic antimicrobial treatment and intermittent interferon gamma during acute episodes is now required.

New non-invasive test of gastric acid secretion for use in children

Loss of the gastric acid barrier may lead to recurrent enteric infections, small intestinal bacterial overgrowth, persistent diarrhoea, and thus malnutrition. To investigate this possibility, a new, non-invasive test of gastric acid secretion was developed ideal for field use in the developing world, where chronic diarrhoea and undernutrition are common. The test relies on the capacity of the kidney to retain H+ during gastric acid secretion, leading to a post-prandial urine 'alkaline tide'. Gastric intubation studies of seven healthy adult volunteers showed a direct relation between changes in gastric acid secretion and changes in urine acid output (measured as the H+/creatinine molar ratio in spot urine samples). Subjects who secreted gastric acid in response to stimulation with a sham feed showed a fall in urine acid output > 0.5 mmol H+/mmol creatinine (range -7.4 to -1.52 mean -1.12). The most reproducible decrease in urine acid output in response to normal food was observed around the time breakfast was usually eaten and was abolished by 36 hours of treatment with ranitidine. Breakfast time reductions in postprandial urine acid output in 22 healthy English children were comparable with those in healthy adults, and significantly different from values in achlorhydric adults. They were much more variable, however, in 106 Gambian children in whom values spanned both normochlorhydric and achlorhydric ranges (-12.7 to +1.8). Measuring changes in urine acid output at breakfast time provides a reliable indirect measure of gastric acid secretion that can be used in field conditions, enabling the relation between gastric acid output and the development of diarrhoeal diseases to be investigated.

Prognostic importance of histological and immunopathological assessment of skin and rectal biopsies in patients with GVHD

Skin and rectal biopsies from patients with GVHD were examined histologically and immunopathologically before and after treatment for the disease. The patients were divided into two groups: those showing a good response to treatment and those showing a poor or no response. The aims of the study were to assess the possibility of predicting the response to treatment and to compare good and poor responders after treatment. The results show that there are no features on either skin or rectal biopsy that could identify those patients with early GVHD who would respond to treatment. Following treatment with steroids there was no change histologically in the grading of the skin biopsy whereas the rectal biopsy showed improvement in six of nine good responders and no improvement in the poor responders. There was an increase in infiltrating lymphocytes in both the skin and rectum of patients showing a poor response and this is most likely due to the ongoing immune reaction. The pre-treatment biopsy did not show any features that would predict this development and was therefore of no prognostic value. However, examination of skin and rectal biopsies may aid in determining whether patients are responding to the treatment given for GVHD.

Gut hormones and gastrointestinal motility in children with cystic fibrosis

Intestinal dysmotility may be an important factor contributing to various gastrointestinal complications associated with cystic fibrosis. Motilin, enteroglucagon, neurotensin, and peptide YY may each play a role as endocrine hormones influencing gastrointestinal motor activity. Fasting children with cystic fibrosis (N = 8) and controls (N = 18) received a liquid nutrient test meal (fat 4 g/100 ml, protein 4 g/100 ml, carbohydrate 20 g/100 ml, 125 kcal/100 ml; 200 ml/m2) containing lactulose (5 g/100 ml), and the plasma concentrations of these peptides were studied. Mouth-to-cecum transit time was simultaneously studied using the breath H2 technique. Fasting levels of peptide YY and the postprandial response of all four peptides were significantly increased in those with cystic fibrosis. In repeat studies on those with cystic fibrosis after a period of altered pancreatic enzyme supplementation, no significant changes in peptide concentrations were observed. A rise in breath H2 permitting estimation of mouth-to-cecum transit time was noted in 17 control subjects (70-220 min, median 140). In contrast, a rise occurred in only two with cystic fibrosis after low-dose enzyme (70 and 180 min), and four after high-dose enzyme replacement (120-230 min, median 155). Altered gut hormone secretion may play a role in the pathophysiology of intestinal dysmotility in patients with cystic fibrosis.

Immunopathology of early graft-versus-host disease--a prospective study of skin, rectum, and peripheral blood in allogeneic and autologous bone marrow transplant recipients

The immunopathological appearances of skin and rectum in 64 autologous and allogeneic recipients were determined before and after bone marrow transplantation. Patients who developed acute graft-versus-host disease were biopsied as soon as a clinical diagnosis was made. At the same time peripheral blood samples were collected for comparative analysis. Immunohistological and morphometric techniques were employed using a panel of monoclonal antibodies to T lymphocytes and subsets, B lymphocytes, natural killer cells, macrophages, and Langerhans cells. A reduction in the CD4/CD8 ratio after BMT was seen in skin and rectal biopsies from both autologous and allogeneic recipients with or without GVHD. The same pattern was observed in blood samples taken at the same time. Langerhans cells were reduced in the skin in all patients after BMT, probably by the conditioning regimen. Only a few cells expressing activation or natural killer cell markers were present and there were no changes observed in the macrophage population. This study has provided no evidence to implicate either CD4- or CD8-positive T lymphocytes as the initiators of the cellular damage in acute GVHD. The distribution of lymphocyte subsets in the blood was similar to that in the tissues, suggesting that the tissue changes reflect the pattern of lymphocyte repopulation after BMT and may have little bearing on the pathogenesis of GVHD.

Serodiagnosis of Helicobacter pylori infection in childhood

Sera from 100 children (ages, 6 to 16 years) presenting with upper gastrointestinal symptoms were examined for antibodies to Helicobacter pylori by enzyme-linked immunosorbent assay (ELISA) based on crude, loosely cell-associated antigens and a partially purified urease antigen preparation. All children underwent endoscopy, and 20 children were shown to have H. pylori infection by histology or direct culture. Serum anti-H. pylori immunoglobulin G (IgG) levels (crude antigen) were clearly raised in the infected group, particularly after preabsorption of sera against a Campylobacter jejuni antigen preparation, while IgM and IgA ELISA determinations did not discriminate between infected and H. pylori-negative patients. Only 14 children in the infected group had raised anti-urease IgG levels. Two patients in whom the organism was not demonstrated or cultured had raised specific IgG levels against both crude and urease antigens and pathological features consistent with H. pylori disease. Immunoblotting studies did not reveal any single protein antigen or simple combination of antigens that could be considered as a candidate for a more defined serodiagnostic reagent. Anti-H. pylori antibody determinations (crude antigen) performed on posttreatment samples from children in whom the organism could no longer be demonstrated suggested that sustained IgG levels may not be a reliable index of treatment failure. An IgG ELISA based on crude, loosely cell-associated antigens of H. pylori can be used for the serodiagnosis of H. pylori infection in childhood.

Non-invasive assessment of intraluminal lipolysis using a 13CO2 breath test

Techniques available for the study of lipase activity in the gut are unsatisfactory. Breath tests measuring labelled carbon dioxide (13CO2) may provide a useful means for this assessment. Six subjects with cystic fibrosis and pancreatic insufficiency and 10 controls received a test meal containing [13C] trioctanoin, and breath 13CO2 was measured using a dual inlet, dual detector isotope ratio mass spectrometer. Comparison of postprandial breath 13CO2 enrichment allowed complete separation between children with pancreatic insufficiency and controls. Administration of one capsule of pancreatic enzyme with the test meal resulted in an increase in 13CO2 production in all six patients, and four capsules produced a further increase in five of the six. Serial fat balance studies on four of the patients while receiving comparable doses of oral enzyme failed to demonstrate a progressive improvement in fat absorption. The [13C]trioctanoin breath test may prove a safe, non-invasive technique not only for the detection of pancreatic insufficiency, but also for the quantitative study of intraluminal lipolysis.

Helicobacter pylori in Gambian children with chronic diarrhoea and malnutrition

Infection with Helicobacter pylori (formerly Campylobacter pylori) was studied by measuring antibody titres to H pylori in Gambian children. Serological evidence of infection was found in 12 of 82 (15%) infants aged less than 20 months; this increased to 62 of 135 (46%) in those aged 40-60 months. Positive serology was found in 41 of 77 (53%) infants with chronic diarrhoea and malnutrition (mean age 19 months, range 5-36) compared with 18 of 70 (26%) of age matched healthy controls and nearly a quarter (12/49, 24%) of age matched undernourished (marasmic) subjects. These data show that infection with H pylori is common in the Gambia and that in infancy this infection is associated with chronic diarrhoea and malnutrition.

Achalasia of the cardia associated with hereditary cerebellar ataxia

Achalasia of the cardia, a disorder associated with degenerative loss of esophageal myenteric ganglion cells, is reported in association with a recently described progressive neurological disorder, "early onset cerebellar ataxia with retained reflexes." This form of cerebellar ataxia is thought to be inherited as an autosomal recessive disorder. The occurrence of these two very rare neurodegenerative disorders in a single individual is of interest because of the potential genetic and pathogenetic implications of the association.

Expression of MHC class I and II antigens by keratinocytes and enterocytes in acute graft-versus-host disease. Newcastle Bone Marrow Transplant Group

The expression of MHC class I and subgroups of class II antigens by keratinocytes and enterocytes has been investigated in patients receiving autologous and allogeneic bone marrow transplants. Allogeneic recipients with graft-versus-host disease (GVHD) expressed all the class II antigens HLA DR, DP and DQ more frequently than pretransplant patients, autologous or allogeneic recipients without GVHD post-BMT (p less than 0.01). Staining for DP and DQ was never detected without DR being present. Whenever there was a lymphocytic infiltrate in the epidermis or single cell necrosis in the gut, DR was expressed on the epithelium. There was no difference in class I expression in GVHD. This study further increases the immunopathological characterization of acute GVHD which may improve the understanding of its pathogenesis.

Intestinal permeability in Crohn's disease

Crohn's disease may present insidiously, especially in childhood, and diagnosis may be delayed. In addition, the clinical assessment of the extent of disease activity may be inaccurate. Using mannitol and lactulose as probe molecules we have carried out a cross sectional study of intestinal permeability in patients with active Crohn's disease (n = 17) and control subjects (n = 31). Activity was assessed by an activity index score. The lactulose:mannitol urinary excretion ratio was significantly increased in Crohn's disease. Overall sensitivity was 82%, and 92% when activity was moderate or severe. When permeability was compared with the activity index there was a significant correlation among patients. In five patients studied longitudinally a significant correlation was also present. Measurement of intestinal permeability is non-invasive, and may be useful both as a screening test in patients with non-specific symptoms, and for the assessment of the extent of disease activity in patients with Crohn's disease.

Active and passive sugar absorption in pancreatic insufficiency

Urinary excretion of lactulose, mannitol, and 3-0-methylglucose, following oral administration (5 g, 5 g, and 2 g, respectively, in 100 ml H2O; 80 ml/m2), has been measured in subjects with cystic fibrosis (CF) (22), Shwachman syndrome (3), chronic pancreatitis (3), and normal controls (46). Mean lactulose excretion was increased 10-fold in CF (p less than 0.001), and two-fold in other disorders associated with pancreatic insufficiency (PI) (p less than 0.05). Mean mannitol excretion was 1.6 times greater in CF (p less than 0.001), compared with controls, but was reduced in other forms of PI (p less than 0.03). The mean lactulose/mannitol excretion ratio was increased in all types of PI (p less than 0.001). There were no significant differences in 3-0-methylglucose excretion. This study confirms the large increase in lactulose absorption recently reported in CF and also demonstrates increased absorption of mannitol; these changes are different than those in other forms of PI. This study provides further evidence for a specific abnormality of the mucosal barrier to the absorption of passively absorbed, water soluble molecules in CF.

Reversible renal failure due to the use of captopril in a renal allograft recipient treated with cyclosporin

Angiotensin-converting enzyme (ACE) inhibitors are widely used for the treatment of hypertension, but caution is advised because these drugs may induce reversible acute renal failure. Although this has been ascribed in some cases to nephrotoxicity, hypotension, a hypersensitivity reaction, and interstitial nephritis, most cases have been associated with stenosis of the renal arteries or arterioles occurring in either native or transplanted kidneys. We describe a case of reversible acute renal failure due to the use of captopril in a renal allograft recipient who had no evidence of any of these conditions, but who was also receiving cyclosporin therapy.

Measurement of small intestinal transit time in children

The lactulose hydrogen breath-test provides a non-invasive measure of mouth to caecum transit-time. Its use, particularly in children has not been thoroughly investigated. We have studied the effects on transit time of altering the lactulose concentration of the test solution, and of administering it in a liquid nutrient preparation. Concentration markedly affected transit-time; studies with an isotonic solution may be least affected by delayed gastric emptying, and so may reflect small bowel transit-time. Day-to-day variation was large, and was not reduced by altering lactulose concentration, or by using the liquid nutrient based test solution. There was no correlation between age and transit-time.

Class II antigen expression by keratinocytes and enterocytes--an early feature of graft-versus-host-disease

HLA-DR expression by keratinocytes and enterocytes was studied in 23 patients undergoing BMT (12 autologous; 11 allogeneic). Two monoclonal antibodies were used to detect the HLA-DR antigen. Only in two patients before transplant and in one following autologous BMT was HLA-DR expressed on keratinocytes. Of 11 allogeneic recipients, 7 developed clinical GVHD, and HLA-DR-positive keratinocytes were seen in 6 of these. HLA-DR was expressed by enterocytes in 5 patients with GVHD and 4 of these also showed HLA-DR expression by keratinocytes. HLA-DR expression by keratinocytes correlated well with clinical GVHD. Expression of this antigen by enterocytes was associated with characteristic histological appearances of GVHD, even in the absence of intestinal symptoms. A combination of traditional and immunocytochemical techniques offers a sensitive and accurate method of confirming GVHD before it becomes florid.

Histological features of skin and rectal biopsy specimens after autologous and allogeneic bone marrow transplantation

The histological appearances of skin and rectal biopsy specimens were studied in 31 bone marrow transplant recipients (13 autologous, 18 allogeneic) before transplant, at 28 days, at six months, and as soon as graft versus host disease (GVHD) was clinically suspected. Grades I and II skin changes were commonly seen in patients before transplant and in the autologous group after transplant, as well as in most of the allogeneic recipients with suspected GVHD. Epidermal lymphocytic infiltration was seen only in allogeneic recipients, with clinical GVHD following transplant, but this was not a consistent finding and no other histological features were seen which would distinguish early GVHD from changes caused by cytotoxic agents. Rectal biopsy specimens, however, were normal in patients before transplant and in autologous recipients at 28 days; single cell necrosis of crypt cells was seen only in six of 13 allogeneic recipients studied after transplant with clinical skin GVHD but no gastrointestinal symptoms. Skin changes greater than I and II are required for the histological diagnosis of GVHD. Rectal changes are more specific and may be present despite a lack of intestinal symptoms.

Intestinal permeability during chemotherapy for childhood tumours

The intestinal permeability to mannitol and lactulose was measured in 29 children receiving treatment for solid tumours. At the time of study they had no gastrointestinal symptoms and appeared clinically well. However, there was a significant reduction in the absorption of mannitol when compared to normal children. This small bowel dysfunction may result in malabsorption of nutrients and drugs. There was a significant correlation between decreased mannitol absorption and low nutritional status.

Campylobacter pylori infection in children

Two children with antral nodular hyperplasia and active chronic gastritis associated with Campylobacter pylori are reported. The organism was observed by scanning electron microscopy and cultured from antral biopsies obtained at endoscopy from each patient. Anti-C. pylori IgG was detected in high titre in both patients together with serum IgM in one patient. Treatment with ampicillin and a bismuth preparation resulted in total resolution of symptoms. Repeated endoscopy with antral biopsy and culture, as well as the absence of acute inflammatory changes, confirmed the eradication of the organism. Correlation of positive bacteriological cultures and serological tests with the clinical improvement related to therapy supports a causative role for C. pylori in antral lymphoid hyperplasia and antral gastritis in children.

Peptic ulcer disease in childhood: long-term prognosis

Information concerning the natural history of peptic ulcer disease commencing in childhood is limited. We have followed up 19 individuals in whom this diagnosis had been made in childhood 14-27 years previously. Strict diagnostic criteria were used. A high incidence of morbidity persisting into adult life was found. On investigation 9 (47%) had had a proven ulcer since entering adult life. Ten (53%) were no longer prone to recurring abdominal pain, but four of these had undergone vagotomy and pyloroplasty (three after the age of 21) for intractable symptoms. Thus, only six patients (31%) had made a lasting and spontaneous recovery. Serious complications had occurred at some time in the past in 10 cases (53%). Overt gastrointestinal bleeding had occurred in eight (42%), and this had been after the age of 18 years in three. Duodenal perforation occurred in one subject, and severe pyloric stenosis in another, both of whom were aged 21 years. One subject developed a penetrating duodenal ulcer at the age of 24 years. Seven (37%) had undergone surgery, and in two of these cases more than one operation had been performed. Fifty-eight percent of complications suffered and 89% of surgical operations performed involved patients of 21 years or older. These findings firmly reinforce the opinion that the disorder frequently persists into adult life. The impact of modern means of medical therapy, such as the H2 receptor antagonists, has not yet been fully evaluated.

Duodenal ulceration: review of 110 cases

This paper describes 110 cases of childhood duodenal ulcer, which were diagnosed over 26 years: 63 were diagnosed by barium meal examination; 47 by upper gastrointestinal endoscopy. The mean age at diagnosis was 11.2 years, with symptoms reported in 46% before 10 years and in 15% before 6 years of age. There was often a considerable delay in diagnosis, particularly in the younger age group. Nocturnal pain (61%) and a close family history of duodenal ulcer disease (62%) were the most valuable pointers to the diagnosis. Fifteen children had required surgery for persistent symptoms. Thirty four had received treatment with an H2 receptor antagonist, and all but four had had a satisfactory initial response. Seventy per cent relapsed within six months of discontinuing treatment, and long term maintenance treatment may therefore be necessary.

Herpes oesophagitis in a healthy 8 year-old

An 8 year-old, immunocompetent child developed a severe acute herpetic oesophagitis in the absence of oropharyngeal lesions. Intravenous treatment with the antiviral drug, acyclovir, relieved symptoms within 24 hours.

A review of paediatric admissions to a general intensive therapy unit over a 13-year period

Paediatric admissions to a general ITU are briefly reviewed. Although it may not be an ideal arrangement it is suggested that children can be safely cared for in such a unit. The problems created by the child with acute upper airway obstruction are discussed to demonstrate the way in which the unit is organized to receive acutely ill children.

Small intestinal transit time affects methotrexate absorption in children with acute lymphoblastic leukemia

Serum methotrexate concentrations have been measured in 28 children with acute lymphoblastic leukaemia (ALL) following PO administration under standard conditions. Small-intestinal transit time, measured by the time taken for lactulose to pass from mouth to caecum, has been related with methotrexate absorption parameters. Small intestinal transit times ranged from 30 to 240 min. Children with longer transit times had later times of peak methotrexate concentration and tended to have a more erratic methotrexate absorption profile with two peaks. There appears to be an optimal transit time between 90 and 105 min for methotrexate absorption, with both faster and slower small-intestinal transit times producing lower peak concentrations as a fraction of the dose.

Small bowel function in acute lymphoblastic leukaemia

Small bowel function before, during, and after treatment for acute lymphoblastic leukaemia was studied in 26 children. A significant impairment of D-xylose absorption was found during treatment. Permeability studies showed a significant decrease in mannitol and a significant increase in lactulose concentrations; five of 20 children tested had evidence of lactose malabsorption, three of whom were symptomatic. Intestinal function abnormalities were greater in children whose methotrexate treatments were separated by 7 day than by 16 day intervals. Only five (19%) children had no abnormal tests. Abnormalities of small bowel function may be treatment induced and this has implications for morbidity from gastrointestinal symptoms, impairment of the mucosal barrier, and malabsorption of both nutrients and drugs leading to malnutrition and suboptimal drug concentrations.

Paediatric continuous ambulatory peritoneal dialysis

Ten children in end-stage renal failure were treated by continuous ambulatory peritoneal dialysis (CAPD). This represents a total of 3.4 patient years. Biochemical control was good, and parent and patient acceptability high. Peritonitis was the chief complication, but after the institution of a specific CAPD education and training programme the incidence declined 10-fold. We regard CAPD as an effective short- and medium-term treatment for children with end-stage renal failure as part of an integrated dialysis and transplant programme, but it requires a devoted and enthusiastic trained staff to ensure success.

Intestinal permeability in children with Crohn's disease and coeliac disease

Mannitol and lactulose were used as probe molecules to measure intestinal permeability in children with active small-bowel Crohn's disease and with untreated coeliac disease. Mannitol and lactulose were administered by mouth in a moderately hypertonic solution (580 mmol (mosmol)/l), and results were expressed as the ratio of the molecules excreted in urine over five hours. Patients with Crohn's disease had a sixfold increase in permeability (due to increased lactulose permeability) and those with coeliac disease a fivefold increase (due to decreased mannitol permeability). From these results the test offers potential as a noninvasive investigation in children with small-bowel disease.

Case report. Clindamycin associated pseudomembranous colitis

Pseudomembranous colitis is rare in children. We describe a case associated with clindamycin in which Clostridium difficile and its enterotoxin were isolated from the stool. Treatment with oral vancomycin brought about a prompt and complete recovery.

Chronic nonspecific diarrhea. A complication of dietary fat restriction

Chronic nonspecific diarrhea is a frequent cause of prolonged diarrhea in childhood. Typical diagnostic features include onset by 30 months of age, normal growth and development, and diarrhea lasting longer than two weeks. It usually follows a gastroenteritis or an acute infection and has been associated with a low intake of dietary fat. Five patients experienced this condition following dietary manipulation to prevent the occurrence of atheromatous coronary artery disease. This indicates that diminished dietary fat not only can prolong postinfectious diarrhea but can also induce a state of chronic diarrhea without evidence of malabsorption.

Adverse effects of milk formula ingestion on the gastrointestinal tract. An update

The large-scale use of cow's milk in infant feeding is less than one hundred years old. Much progress has been made by the manufacturers of proprietary formulas during this period to make their products safer. Although the current formulas provide an excellent "substitute" for the majority of infants, problems still remain, and it is necessary for every pediatrician and gastroenterologist to be aware of these. The purposes of this article are to review the adverse effects of nonhuman milk on the gastrointestinal tract, to examine the underlying mechanisms, and hopefully to stimulate further thought and research. Particular emphasis will be placed on hypersensitivity reactions, because there now appears to be a swing back to this diagnosis as a result of more sophisticated immunologic investigations. The arguments in favor of breast-feeding, the systemic biochemical differences resulting from different formulas, and the indications for specialized formula feeding are all beyond the scope of this review.

Antigenicity of infant formulas: role of immature intestine on protein permeability

Preliminary studies of 25 infants fed casein hydrolysate, soy-based or milk-based formulas were undertaken to determine the importance of age with respect to the relative antigenicity of formula proteins. Infants fed casein hydrolysate for the first three months had lower antibody titers (hemagglutinins) to subsequent milk-based or soy-based proteins than those given these formulas since birth. The clinical implications with regard to atopy and gastrointestinal protein intolerance are discussed. Soy protein is at least as antigenic as milk protein and should be used with caution in prophylaxis against possible dietary antigen/antibody-related disease.

Serum ferritin concentration: a reliable guide to iron overload in uremic and hemodialyzed patients

The inter-relationships between serum ferritin, hemoglobin, serum iron and total body iron stores were studied in 20 patients with chronic renal failure treated conservatively and in 20 patients on regular hemodialysis. There was no relationship between serum iron or transferrin and bone marrow iron deposits, but serum ferritin concentration was a good indicator of increased marrow iron stores. All patients with serum ferritin levels above 300 microgram/l had increased iron stores. Serum ferritin assay is a useful non-invasive technique for detecting iron overload in uremic and hemodialyzed patients.

Effect of cow's milk on the gastrointestinal tract: a persistent dilemma for the pediatrician

The confusing area of cow's milk intolerance is explored in an attempt to define the various mechanisms whereby milk affects gastrointestinal function, resulting in clinical symptoms (diarrhea, vomiting, gastrointestinal bleeding, etc.). The adverse reaction of infants to cow's milk ingestion may relate to lactose intolerance (enzymatic), a direct toxic reaction to the mucosal surface resulting in epithelial damage, or it may be immunologically mediated. Factors such as increased intestinal permeability to milk proteins during the newborn period may also contribute to susceptibility of young infants to milk sensitivity. The relative roles of systemic (milk agglutinins) and local immunity (SIgA antibodies) in milk intolerance are discussed and differential immunologic responses (IgE versus IgA/IgM) considered in the pathogenesis. It was concluded that new techniques such as organ culture of intestinal biopsy specimens are needed to establish the diagnosis of hypersensitivity and to begin to provide ways of adequately treating the condition.

Serum ferritin in juvenile chronic polyarthritis

Six children with juvenile chronic polyarthritis were studied and their disease activity correlated with haematological values including serum ferritin. The latter is often raised above reference values, but even when within them appears to fluctuate significantly and correlates more closely with disease activity than any of the other parameters measured. We conclude that the serial measurement of serum ferritin may be a useful guide to the management of such children.

Iron-transport characteristics of vesicles of brush-border and basolateral plasma membrane from the rat enterocyte

Vesicles of brush-border and basolateral plasma membrane were prepared from enterocytes of the rat small intestine. The separateness of these two varieties of plasma membrane was confirmed by appropriate enzyme assays. The uptake of Fe2+ by these membrane vesicles was studied, and the results suggest differences between the two types of membrane in both the amount of Fe2+ taken up and in the rate of uptake. At low (up to 3 micrometer) concentrations of Fe2+, uptake by both membrane types showed evidence of saturation and could be blocked with the thiol inactivator N-ethylmaleimide. The studies suggest that Fe2+ is taken into an osmotically active space by a process of facilitated diffusion at low concentrations, but that at higher concentrations the process appeared to obey first-order kinetics. The data provide further evidence for the existence of functional polarity in the epithelial cell of the small intestine.

Serum ferritin and dysbaric osteonecrosis

Bone and marrow necrosis has been produced in rabbits. Changes in serum ferritin levels have been measured (with appropriate controls). Results suggest that marrow death is followed by a significant rise in serum ferritin levels. The possiblitiy that this may be of value in the early diagnosis of dysbaric osteonecrosis is discussed.

Diagnosis of Giardia lamblia infection as a cause of diarrhoea

Retrospective analysis of the records of 31 patients diagnosed as having Giardia lamblia infection in our hospital over a five-year period suggests that the condition is not considered often or early enough. Adult patients particularly "suffer" more, having to endure more investigations (mean of 16) than do symptomatic children (mean of 6) before a diagnosis is made. The length of time to reach the diagnosis from first referral further supports this view, being almost seven weeks in adults and three weeks in children--both groups having had symptoms for an average of seven months before referral.

Serum ferritin levels in acute hepatocellular damage from paracetamol overdosage

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