Pancreatic family history does not predict disease progression but connotes alcohol consumption in adolescents and young adults with acute pancreatitis: Analysis of an international cohort of 2,335 patients

Background

In pediatric acute pancreatitis (AP), a family history of pancreatic diseases is prognostic for earlier onset of recurrent AP (ARP) and chronic pancreatitis (CP). No evidence supports the same association in adult-onset pancreatitis. Age-specific reasons for familial aggregation are also unclear. We aimed to examine the prognostic role of pancreatic family history for ARP/CP and observe possible underlying mechanisms.

Methods

We conducted a secondary analysis of the Hungarian Pancreatic Study Group’s (HPSG) multicenter, international, prospective registry of patients with AP, both children and adults. We compared the positive family history and the negative family history of pancreatic diseases, in different age groups, and analyzed trends of accompanying factors. Chi-square and Fisher exact tests were used.

Results

We found a higher rate of ARP/CP in the positive pancreatic family history group (33.7 vs. 25.9%, p = 0.018), peaking at 6–17 years. Idiopathic AP peaked in childhood in the positive family history group (75% 0–5 years) and was consistently 20–35% in the negative group. A higher rate of alcohol consumption/smoking was found in the positive groups at 12–17 years (62.5 vs. 15.8%, p = 0.013) and 18–29 years (90.9 vs. 58.1%, p = 0.049). The prevalence of diabetes and hyperlipidemia steadily rose with age in both groups.

Conclusion

Positive family history most likely signifies genetic background in early childhood. During adolescence and early adulthood, alcohol consumption and smoking emerge—clinicians should be aware and turn to intervention in such cases. Contrary to current viewpoints, positive pancreatic family history is not a prognostic factor for ARP and CP in adults, so it should not be regarded that way.

Adherence to the Porto Criteria Based on the Hungarian Nationwide Pediatric Inflammatory Bowel Disease Registry (HUPIR)

Objectives: According to the Porto criteria, upper endoscopy and ileocolonoscopy with histology for patients with pediatric inflammatory bowel disease (pIBD) are recommended with small bowel imaging (SBI). We aimed to evaluate the adherence to the Porto criteria and biopsy sampling practice and to evaluate the diagnostic yield of magnetic resonance enterography (MRE) first time in a nationwide pIBD inception cohort. Methods: Newly diagnosed pIBD cases (ages 0-18 years) are registered in the prospective, nationwide Hungarian Paediatric IBD Registry (HUPIR). We analyzed the diagnostic workup of patients recorded between the 1st of January 2007 and the 31st of December 2016. Results: Data for diagnostic workup was available in 1,523 cases. Forty percent of the cases had complied with the Porto criteria. Adherence to the Porto criteria increased significantly from 20 to 57% (p < 0.0001) between 2007 and 2016. The most frequent reason for the incomplete diagnostic work-up was the lack of small bowel imaging (59%). In 2007, 8% of cases had a biopsy from all segments, and this rate reached 51% by 2016 (p < 0.0001). We analyzed the diagnostic yield of MRE in 113 patients (10.1%), who did not have any characteristic lesion for Crohn's disease. The MRE was positive for the small bowel in 44 cases (39%). Conclusions: Adherence to the Porto criteria increased significantly during the 10-year period. This is the first study that reports multiple biopsy sampling as the less accepted recommendation. The diagnostic yield of MRE in patients without characteristic lesion for Crohn's disease is 39%.

[Not everything is coeliac disease what it seems]

The prevalence of inflammatory bowel disease is ten times more common in patients with celiac disease; however, studies investigating the reverse relation have contradictory findings. Many gene polymorphisms are known to be present in both diseases; furthermore, similarities observed in their pathophysiological mechanism, their family concomitance, results of the serologic analysis and their macroscopic and microscopic symptoms in the gastro-intestinal system suggest a relevant association between the two diseases. The author presents the history of four patients, of whom two had both Crohn's and coeliac diseases. In the two other patients with inflammatory bowel disease the possible diagnosis of coeliac disease was suspected, but after additional examinations coeliac disease was excluded in one patient and seemed to be unlikely in the other patient. The author concludes that the differential diagnosis of the two diseases is not easy and if one of them is diagnosed, the possible presence of the other one should be taken into consideration.

Analysis of infliximab treated pediatric patients with Crohn disease in Hungary

A terápiarezisztens, súlyos Crohn-beteg gyermekek kezelésére új lehetőséget nyújt az antitumornekrózis-faktor-α-terápia (infliximab). Jelen vizsgálat célja az infliximabterápia hatékonyságának, mellékhatásainak felmérése hazánkban, a gyógyszer gyermekgyógyászati alkalmazásának engedélyezésétől a 2008. december 31-ig terjedő időszakban. A vizsgált periódusban országosan 23 gyermek részesült infliximabkezelésben. Az indukciós terápia során a betegek 5 mg/ttkg infliximabot kaptak a 0., a 2. és a 6. héten, ahol meghatároztuk a betegség aktivitását jelző mutatót (pediatric Crohn disease activity index). Az infliximabkezelés során kedvező terápiás választ 18 betegnél (81,8%) tapasztaltunk, teljes remisszióba 13 gyermek került (59,1%). A számításokat 22 beteg adatai alapján végeztük. A kezelés 6. hetére a fistulák 70%-a bezárult. A gyógyszerrel összefüggésbe hozható akut infúziós reakció 2 betegnél jelentkezett, egy másik esetben anaphylaxiás reakció alakult ki. Késői mellékhatás három gyermeknél jelentkezett. A vizsgálatunkban részt vett, hagyományos terápiára rezisztens, súlyos Crohn-betegek döntő többségénél az indukciós infliximabterápia hatásosnak bizonyult.

[Cycle vomiting syndrome as a clinical appearance of eosinophilic gastroenteritis]

The authors report the case study of a 16-year old boy who presented with cyclic vomiting syndrome. His main clinical symptoms had been unpredictable sudden-onset vomiting episodes interrupting long episodes of full health lasting for several months since the patient was a toddler. Histological results of the upper tract endoscopy showed eosinophil gastroenteritis with long-existing, undetected cow milk allergy as the likely underlying reason. The patient became symptomless following the elimination of cow milk from his diet. The symptoms did not recur following a cow milk load test carried out half a year later, and the patient continues to be symptomless after more than one-year of continuous cow milk consumption. In this paper, the authors would like to highlight the importance of EG int the differential diagnosis of any chronic, recidive gastrointestinal symptoms and discuss the likely underlying causes of EG in paediatrics.

[Possibilities of postnatal diagnosis in congenital cytomegalovirus infection]

The authors review two cases of suspected congenital cytomegalovirus (CMV) infections in which modern laboratory approaches were applied to establish the diagnosis postnatally. In the first case, intrauterine infection was suggested by ventriculomegaly, detected by means of a head ultrasonographic scan. The postnatal cranial ultrasonography and computed tomographic scans revealed intracerebral calcifications. CMV was detected in the blood and urine of the newborn. The postnatal serological tests proved that the mother had experienced a primary CMV infection during gestation. Abnormal neurological signs developed in the infant by the age of 9 months. In the second case, the mother had had an active CMV infection at 29 weeks of gestation involving a twin pregnancy. The CMV-specific serological tests demonstrated that this was a recurrent infection. The twins were born without signs or clinical symptoms and CMV was not detected in their urine samples. At 5 months of age, one of the twins excreted CMV in his urine, which must have been a consequence of a postnatal infection. The general screening of young women by CMV serology at the beginning of gestation is recommended. This would establish a CMV serostatus and provide an opportunity for the gynecologist to provide advice concerning the avoidance of infection, especially in cases where the patient is seronegative and therefore at risk of primary CMV infection.

[Non-alcoholic steatohepatitis: a childhood case]

INTRODUCTION

A significant part of cryptogenic cirrhosis among adult patients shows that it can be the result of "burn-out" non-alcoholic steatohepatitis beginning in childhood.

AIM

Describing the case of a 15-year-old boy the aim of the authors is to raise attention to the fact that doctors should think of the possibility of having a fatty liver in presence of certain etiological features.

PATIENT

Although he was asymptomatic, the screening test revealed an elevated serum aspartate aminotransferase level. Abdominal ultrasound examination raised the possibility of a diffuse liver damage. The liver biopsy demonstrated the features of steatosis in the absence of alcohol abuse.

RESULTS

On the basis of these results, NASH was diagnosed. The presence of a severe fatty liver at such an early age is quite unusual. In the background, the authors verified familial combined hyperlipidaemia and heterozygous mutation of the cystic fibrosis gene for delta F508 as genetic predisposing factor. The clinical condition was accelerated and worsened by the fact, that the patient has grown fat since his infancy. It did not prove possible to achieve a weight reduction with a fat- and cholesterol-poor diet, increased physical activity and medical treatment. However, there was significant improvement in the laboratory findings.

CONCLUSIONS

The conclusion drawn from this case, on one hand, is that doctors should think of the possibility of a fatty liver in case of an elevated isolate serum transaminase level in connection with obese or over weight patients. On the other hand the role of other coexisting etiological features must emerge in the background of severe steatohepatitis.

[Unusual manifestations of Bartonella infections]

The authors review the cases of two patients with an atypical form of cat scratch disease. The first case exhibited ileocoecal and hepatoportal lymphadenitis, and the second case the emerging symptoms of a non-specific granulomatous process in the middle third of the right forearm, which caused a differential-diagnostic problem. Establishment of a diagnosis was possible only on the basis of the disease process and the pathological, serological and histopathological pictures of the lymphatic glands after other causes of the lymphadenopathy had been excluded. Following two weeks of antibiotic treatment, the patients were free of complaints- and symptoms. Bartonella antibody tests were performed on 5 cats living in the neighbourhood of the patients with titer determinations too in 3 cases.