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Benninga MA, Hussain SZ, Sood MR, Nurko S, Hyman P, Clifford RA, O'Gorman M, Losch-Beridon T, Mareya S, Lichtlen P, Di Lorenzo C. Lubiprostone for Pediatric Functional Constipation: Randomized, Controlled, Double-Blind Study With Long-term Extension. Clin Gastroenterol Hepatol 2022; 20:602-610.e5. [PMID: 33838349 DOI: 10.1016/j.cgh.2021.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/26/2021] [Accepted: 04/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pediatric functional constipation (PFC) is a common problem in children that causes distress and presents treatment challenges to health care professionals. We conducted a randomized, placebo-controlled trial (study 1) in patients with PFC (6-17 years of age) to evaluate the efficacy and safety of lubiprostone, followed by an open-label extension for those who completed the placebo-controlled phase (study 2). METHODS Study 1 (NCT02042183) was a phase 3, multicenter, randomized, double-blind, placebo-controlled, 12-week study evaluating the efficacy and safety of lubiprostone 12 μg twice daily (BID) and 24 μg BID. Study 2 (NCT02138136) was a phase 3, long-term, open-label extension of study 1. In both studies, lubiprostone doses were based on patients' weight. Efficacy was assessed solely based on study 1, with a primary endpoint of overall spontaneous bowel movement (SBM) response (increase of ≥1 SBM/wk vs baseline and ≥3 SBMs/wk for ≥9 weeks, including 3 of the final 4 weeks). RESULTS 606 patients were randomized to treatment (placebo: n = 202; lubiprostone: n = 404) in study 1. No statistically significant difference in overall SBM response rate was observed between the lubiprostone and placebo groups (18.5% vs 14.4%; P = .2245). Both the 12-μg BID and 24-μg BID doses of lubiprostone were well tolerated in the double-blind and extension phases, with a safety profile consistent with that seen in adult studies. CONCLUSIONS Lubiprostone did not demonstrate statistically significant effectiveness over placebo in children and adolescents with PFC but did demonstrate a safety profile similar to that in adults. (ClinicalTrials.gov: Number: NCT02042183; Number: NCT02138136).
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Affiliation(s)
- Marc A Benninga
- Department of Paediatric Gastroenterology & Nutrition, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Sunny Z Hussain
- Willis-Knighton Pediatric Gastroenterology and Research, Shreveport, Louisiana
| | - Manu R Sood
- Division of Pediatric Gastroenterology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, Massachusetts
| | - Paul Hyman
- Gastroenterology Department, Children's Hospital, New Orleans, Louisiana
| | | | - Molly O'Gorman
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | | | - Shadreck Mareya
- Clinical Program Management, Sucampo Pharmaceuticals, Rockville, Maryland
| | | | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio.
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Kovacic K, Kern M, Pawela L, Shaker R, Sood MR. Characteristics of high-resolution esophageal manometry in children without dysphagia. Neurogastroenterol Motil 2022; 34:e14184. [PMID: 34089288 PMCID: PMC10128867 DOI: 10.1111/nmo.14184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The absence of high-resolution esophageal manometry (HREM) norms in pediatrics limits the assessment of children with dysphagia. This study aimed to describe HREM parameters in a cohort of children without dysphagia. METHODS Children ages 9-16 years with a negative Mayo Dysphagia Questionnaire screen and normal histologic findings underwent HREM after completion of esophagogastroduodenoscopy. Ten swallows of 5 ml 0.45% saline boluses per subject were captured in supine position. Analyzed data included resting and integrated relaxation pressures (IRP) of lower (LES) and upper (UES) esophageal sphincters, peristaltic contractile integrals, transition zone (TZ) breaks, velocities, and lengths associated with proximal and distal esophagus. KEY RESULTS 33 subjects (15 female) with mean (range) age 12.9 (9-16) years completed the study. Two of 330 analyzed swallows failed. The UES mean resting pressure, and its 0.2 s and 0.8 s IRPs were 48.3 (95% CI 12.9) mmHg, 2.9 (95% CI 1.9) mmHg, and 12.1 (95% CI 2.5) mmHg, respectively. The LES mean resting pressure and its 4 s IRP were 29.0 (95% CI 4.0) mmHg and 9.2 (95% CI 1.3) mmHg. The mean proximal (PCI) and distal (DCI) esophageal contractile integrals were 231 (95% CI 54.8) mmHg-s-cm and 1789.3 (95% CI 323.5) mmHg-s-cm, with mean TZ break 0.5 (95% CI 0.3) cm. CONCLUSIONS & INFERENCES This is the first study to describe HREM parameters in children without dysphagia. Most of the reported measurements were significantly different and less variable from reported adult norms. This emphasizes the need for child-specific catheters, norms, and protocols to define pediatric esophageal motility disorders.
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Affiliation(s)
- Karlo Kovacic
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mark Kern
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Louis Pawela
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Reza Shaker
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Manu R Sood
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
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Kolacz J, Kovacic K, Lewis GF, Sood MR, Aziz Q, Roath OR, Porges SW. Cardiac autonomic regulation and joint hypermobility in adolescents with functional abdominal pain disorders. Neurogastroenterol Motil 2021; 33:e14165. [PMID: 33991431 DOI: 10.1111/nmo.14165] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 04/01/2021] [Accepted: 04/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Joint hypermobility (JH) is associated with autonomic nervous system dysregulation and functional abdominal pain disorders (FAPDs). Understanding the neurophysiological processes linking these conditions can inform clinical interventions. Autonomic activity regulates gastrointestinal (GI) sensorimotor function and may be a key mechanism. The aims of this study were to examine the relation of JH with dynamic autonomic activity and parasympathetic regulation in adolescents with FAPDs and identify optimal JH cutoff scores that best index autonomic regulation in FAPDs. METHODS A total of 92 adolescents with FAPDs and 27 healthy controls (age 8-18 years; 80% female) were prospectively enrolled. JH was assessed by Beighton scores. ECG recordings were conducted during supine, sitting, and standing posture challenges. ECG-derived variables-heart period (HP), respiratory sinus arrhythmia (RSA), and vagal efficiency (VE)-were analyzed using linear regression and mixed effects modeling. KEY RESULTS Beighton scores of ≥4 optimally distinguished autonomic function. Adolescents with FAPD and JH had reduced VE compared to adolescents with FAPDs without JH (B = 18.88, SE = 6.25, p = 0.003) and healthy controls (B = 17.56, SE = 8.63, p = 0.044). These subjects also had lower and less dynamic RSA and HP values during posture shifts, with strongest differences in supine position and using the VE metric. CONCLUSIONS & INFERENCES Suboptimal autonomic regulation indexed by reduced vagal efficiency may be a mechanism of symptoms in hypermobile FAPD patients with Beighton score ≥ 4. Autonomic disturbance may serve as potential intervention target for patients with JH and functional GI disorders.
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Affiliation(s)
- Jacek Kolacz
- Socioneural Physiology Laboratory, Kinsey Institute, Indiana University, Bloomington, IN, USA.,Traumatic Stress Research Consortium, Kinsey Institute, Indiana University, Bloomington, IN, USA
| | - Katja Kovacic
- Department of Pediatrics, University of Illinois College of Medicine, Chicago, IL, USA
| | - Gregory F Lewis
- Socioneural Physiology Laboratory, Kinsey Institute, Indiana University, Bloomington, IN, USA.,Intelligent Systems Engineering, Indiana University, Bloomington, IN, USA
| | - Manu R Sood
- Department of Pediatrics, University of Illinois College of Medicine, Chicago, IL, USA
| | - Qasim Aziz
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Olivia R Roath
- Socioneural Physiology Laboratory, Kinsey Institute, Indiana University, Bloomington, IN, USA
| | - Stephen W Porges
- Traumatic Stress Research Consortium, Kinsey Institute, Indiana University, Bloomington, IN, USA.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Kovacic K, Zhang L, Nugent Liegl M, Pawela L, Simpson P, Sood MR. Gastric emptying in healthy children using the Spirulina breath test: The impact of gender, body size, and pubertal development. Neurogastroenterol Motil 2021; 33:e14063. [PMID: 33300658 DOI: 10.1111/nmo.14063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/10/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are no pediatric norms for gastric emptying (GE) measured by nuclear scintigraphy. The 13 C-labeled, stable isotope GE breath test (GEBT) is a non-radioactive alternative. We aimed to determine normative GEBT ranges in a cohort of healthy children and examine the influence of age, gender, puberty, and body surface area (BSA). METHODS Healthy children ages 8-18 years completed the [13 C]-Spirulina platensis GEBT after an overnight fast. Breath samples were collected at baseline, every 15 min × 1 h, then every 30 min for 4 h total. The 13 CO2 excretion rate was determined by the change in 13 CO2 /12 CO2 over time in each breath sample, expressed as kPCD (Percent 13 C Dose excreted/min). A mixed model with random time was used for multivariable analysis and outcome fit into a quadratic model. KEY RESULTS The 100 subjects completed the test meal within allotted time. Median (IQR) age was 13.5 (11.3-15.5) years; 51% were female. Females had lower 13 CO2 excretion rates (slower GE) than males across time (p < 0.001) while decreased excretion rates correlated with higher BSA (p = 0.015). Gender differences were also noted within pubertal stages with females showing slower GE. Multivariable analysis suggested that pre-pubertal children have faster GE than both peri- and post-pubertal groups (p < 0.0001). CONCLUSIONS & INFERENCES Gender, puberty, and BSA influence GE rates in healthy children more than age. Although further data are needed, pubertal stage and hormonal influences may be unique factors to consider when assessing GE in children.
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Affiliation(s)
- Katja Kovacic
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Liyun Zhang
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Melodee Nugent Liegl
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Louis Pawela
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Pippa Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Manu R Sood
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
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Krasaelap A, Sood MR, Li BUK, Unteutsch R, Yan K, Nugent M, Simpson P, Kovacic K. Efficacy of Auricular Neurostimulation in Adolescents With Irritable Bowel Syndrome in a Randomized, Double-Blind Trial. Clin Gastroenterol Hepatol 2020; 18:1987-1994.e2. [PMID: 31622740 DOI: 10.1016/j.cgh.2019.10.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/25/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Auricular neurostimulation therapy, in which a noninvasive device delivers percutaneous electrical nerve field stimulation (PENFS) to the external ear, is effective in pediatric patients with functional abdominal pain disorders. Preclinical studies showed that PENFS modulates central pain pathways and attenuates visceral hyperalgesia. We evaluated the efficacy of PENFS in adolescents with irritable bowel syndrome (IBS). METHODS We analyzed data from pediatric patients with IBS who participated in a double-blind trial at a tertiary care gastroenterology clinic from June 2015 through November 2016. Patients were randomly assigned to groups that received PENFS (n = 27; median age, 15.3 y; 24 female) or a sham stimulation (n = 23; median age, 15.6 y; 21 female), 5 days/week for 4 weeks. The primary endpoint was number of patients with a reduction of 30% or more in worst abdominal pain severity after 3 weeks. Secondary endpoints were reduction in composite abdominal pain severity score, reduction in usual abdominal pain severity, and improvement in global symptom based on a symptom response scale (-7 to +7; 0 = no change) after 3 weeks. RESULTS Reductions of 30% or more in worst abdominal pain were observed in 59% of patients who received PENFS vs 26% of patients who received the sham stimulation (P = .024). The patients who received PENFS had a composite pain median score of 7.5 (interquartile range [IQR], 3.6-14.4) vs 14.4 for the sham group (IQR, 4.5-39.2) (P = .026) and a usual pain median score of 3.0 (IQR, 3.0-5.0) vs 5.0 in the sham group (IQR, 3.0-7.0) (P = .029). A symptom response scale score of 2 or more was observed in 82% of patients who received PENFS vs 26% of patients in the sham group (P ≤ .001). No significant side effects were reported. CONCLUSIONS Auricular neurostimulation reduces abdominal pain scores and improves overall wellbeing in adolescents with IBS. PENFS is a noninvasive treatment option for pediatric patients with functional bowel disorders. ClinicalTrials.gov no: NCT02367729.
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Affiliation(s)
- Amornluck Krasaelap
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Manu R Sood
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - B U K Li
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rachel Unteutsch
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ke Yan
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Melodee Nugent
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Katja Kovacic
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Kovacic K, Kapavarapu PK, Sood MR, Li BUK, Nugent M, Simpson P, Miranda A. Nausea exacerbates symptom burden, quality of life, and functioning in adolescents with functional abdominal pain disorders. Neurogastroenterol Motil 2019; 31:e13595. [PMID: 30957319 DOI: 10.1111/nmo.13595] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/05/2019] [Accepted: 03/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Nausea frequently co-exists with functional abdominal pain disorders (FAPDs) and may be linked to a higher disease burden. This study aimed to prospectively compare multisystem symptoms, quality of life, and functioning in FAPDs with and without nausea. METHODS Adolescents ages 11-18 years fulfilling Rome III criteria for a FAPD were grouped by the presence or absence of chronic nausea. Subjects completed validated instruments assessing nausea (Nausea Profile Questionnaire = NPQ), quality of life (Patient-Reported Outcome Measurement Information System), functioning (Functional Disability Inventory), and anxiety (State-Trait Anxiety Inventory for Children). Group comparisons were performed for instruments, multisystem symptoms, school absences, and clinical diagnoses. KEY RESULTS A total of 112 subjects were included; 71% reported chronic nausea. Patients with Nausea compared to No Nausea had higher NPQ scores (P ≤ 0.001), worse quality of life (P = 0.004), and greater disability (P = 0.02). State and trait anxiety scores were similar (P = 0.57, P = 0.25). A higher NPQ score correlated with poorer quality of life, more disability, and higher anxiety. Specific comorbidities were more common in Nausea vs No Nausea group: dizziness (81% vs 41%; P ≤ 0.001), concentrating difficulties (68% vs 27%; P ≤ 0.001), chronic fatigue (58% vs 20%; P = 0.01), and sleep disturbances (73% vs 48%; P = 0.02). The Nausea group reported more school absences (P = 0.001) and more commonly met criteria for functional dyspepsia (P = 0.034). CONCLUSION AND INFERENCES Nausea co-existing with FAPDs is associated with a higher extra-intestinal symptom burden, worse quality of life, and impaired functioning in children. Assessing and targeting nausea therapeutically is essential to improve outcomes in FAPDs.
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Affiliation(s)
- Katja Kovacic
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Prasanna K Kapavarapu
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Manu R Sood
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - B U K Li
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Melodee Nugent
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Adrian Miranda
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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Kovacic K, Matta SR, Kovacic K, Calkins C, Yan K, Sood MR. Healthcare Utilization and Comorbidities Associated with Anorectal Malformations in the United States. J Pediatr 2018; 194:142-146. [PMID: 29198537 DOI: 10.1016/j.jpeds.2017.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/25/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine nationwide prevalence and healthcare utilization in children with anorectal malformations and associated anomalies over a 6-year period. STUDY DESIGN We used the Kids' Inpatient Database for the years 2006, 2009, and 2012 for data collection. International Classification of Diseases, Ninth Revision codes were used to identify patients with anorectal malformations and associated anomalies. RESULTS A total of 2396 children <2 years of age with anorectal malformations were identified using weighted analysis; 54.3% of subjects were male. The ethnic subgroups were 40.1% white, 23.6% Hispanic, 9.3% African American, and 27% other ethnicity. Other congenital anomalies were reported in 80% of anorectal malformations and were closely associated with increased length of stay and costs. A genetic disorder was identified in 14.1% of the sample. Urogenital anomalies were present in 38.5%, heart anomalies in 21.2%, and 8.6% had vertebral anomalies, anal atresia, cardiac defects, tracheoesophageal fistula and/or esophageal atresia, renal anomalies, and limb defects association. Anorectal malformations with other anomalies including vertebral anomalies, anal atresia, cardiac defects, tracheoesophageal fistula and/or esophageal atresia, renal anomalies, and limb defects association incurred significant hospital charges when compared with anorectal malformations alone. The average annual healthcare expenditure for surgical correction of anorectal malformations and associated anomalies for the 3 years was US $45.5 million. CONCLUSIONS This large, major nationally representative study shows that majority of children with anorectal malformations have additional congenital anomalies that deserve prompt recognition. The high complexity and need for lifelong multidisciplinary management is associated with substantial healthcare expenditure. This information complements future healthcare resource allocation and planning for management of children with anorectal malformations.
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Affiliation(s)
- Karlo Kovacic
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Sravan R Matta
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Katja Kovacic
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Casey Calkins
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ke Yan
- Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Manu R Sood
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
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Abstract
Chronic intestinal pseudo-obstruction (CIP) is defined by either continuous or intermittent symptoms of bowel obstruction in the absence of fixed lumen excluding lesion. CIP includes a heterogeneous group of disorders which result either from diseases affecting the enteric neurons and smooth muscle lining or those involving the autonomic innervation of the bowel. Symptoms associated with CIP are nonspecific, which can sometimes contribute to the delay in recognizing the condition and making the correct diagnosis. The diagnostic workup should include imaging and manometry studies and, occasionally, full-thickness bowel biopsies for histopathological examination may be required. Multidisciplinary team approach for the management of these patients is recommended, and the team members should include a gastroenterologist, surgeon, chronic pain specialist, clinical nutritionist, and a psychologist. The treatment goals should include optimizing the nutritional status and preventing or delaying the development of intestinal failure. The majority of the patients require enteral or parenteral nutrition support, and chronic pain is a common and distressing symptom. Small bowel transplantation may be required if patients develop liver complications due to parenteral nutrition, have difficult central line access, or have poor quality of life and worsening pain despite aggressive medical management.
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Affiliation(s)
- Khalil El-Chammas
- Division of Pediatric Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Manu R Sood
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin.,Division of Pediatric Gastroenterology, Children's hospital of Wisconsin, Milwaukee, Wisconsin
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Klages KL, Berlin KS, Silverman AH, Mugie S, Di Lorenzo C, Nurko S, Ponnambalam A, Sanghavi R, Sood MR. Empirically Derived Patterns of Pain, Stooling, and Incontinence and Their Relations to Health-Related Quality of Life Among Youth With Chronic Constipation. J Pediatr Psychol 2017; 42:325-334. [PMID: 27474732 DOI: 10.1093/jpepsy/jsw068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 06/30/2016] [Indexed: 12/22/2022] Open
Abstract
Objective Chronic constipation is associated with pain, stress, and fecal incontinence, which negatively impact health-related quality of life (HRQoL); however, it is unclear if patterns of pain, stool frequency, and incontinence are differentially associated with HRQoL in youth with chronic constipation. Methods 410 caregivers completed a demographics and symptoms form, the Parental Opinions of Pediatric Constipation, Pediatric Symptom Checklist, and the Functional Disability Inventory. Results Stooling patterns were derived using Latent Variable Mixture Modeling. A three-class model emerged: withholding/avoiding ( WA ), pain , and fecal incontinence ( FI ). The pain class reported the greatest amount of disease burden/distress, greatest impairments in illness-related activity limitations, more psychosocial problems, and, along with the FI class, elevated levels of family conflict. The FI class reported the greatest amount of parental worry of social impact. Conclusions Youth with chronic constipation who experience pain or fecal incontinence may be at a greater risk for specific HRQoL problems such as illness-related activity limitations, psychosocial issues, disease burden and worry, and family conflict.
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Affiliation(s)
- Kimberly L Klages
- Department of Psychology, The University of Memphis, Memphis, TN, USA
| | - Kristoffer S Berlin
- Department of Psychology, The University of Memphis, Memphis, TN, USA
- University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Alan H Silverman
- Department of Gastroenterology, Children's Hospital of Wisconsin, Milwaukee, USA
- Department of Gastroenterology, Medical College of Wisconsin, Milwaukee, USA
| | - Suzanne Mugie
- Department of Gastroenterology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Carlo Di Lorenzo
- Department of Gastroenterology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Samuel Nurko
- Department of Gastroenterology, Boston Children's Hospital, Boston, MA, USA
| | - Ananthasekar Ponnambalam
- Department of Gastroenterology, Children's and Women's Hospital at University of South Alabama, USA
| | - Rina Sanghavi
- Department of Gastroenterology, University of Texas Southwest Medical Center, Dallas, TX, USA
| | - Manu R Sood
- Department of Gastroenterology, Medical College of Wisconsin, Milwaukee, USA
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10
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Abstract
Functional abdominal pain (FAP) is one of the most common functional gastrointestinal disorders (FGIDs) of childhood. Only a minority of patients with FAP seek medical attention, often presenting to the primary care physician while symptoms are still evolving. The bio-psychosocial model of treatment not only aims to alleviate the illness symptoms but also identifies and remedies the psychological comorbidities and social factors that contribute to illness behavior. Many patients with a mild illness can be managed in the primary care setting. However those with chronic, severe, frequently relapsing, and disabling illness usually are referred to a pediatric gastroenterologist. One of the reason for referral is to exclude organic disorders such as peptic ulcer disease, celiac disease or inflammatory bowel disease which can present with chronic abdominal pain. Recent data suggest that psychological therapy is very effective in alleviating symptoms, a subset of patients may require dietary modification and medications as an adjunct to psychological treatment.
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Affiliation(s)
- Manu R Sood
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, WI, 53045, USA.
| | - Sravan Reddy Matta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, WI, 53045, USA
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11
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Gurram B, Salzman NH, Kaldunski ML, Jia S, Li BUK, Stephens M, Sood MR, Hessner MJ. Plasma-induced signatures reveal an extracellular milieu possessing an immunoregulatory bias in treatment-naive paediatric inflammatory bowel disease. Clin Exp Immunol 2016; 184:36-49. [PMID: 26660358 DOI: 10.1111/cei.12753] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2015] [Indexed: 12/19/2022] Open
Abstract
The inflammatory state associated with Crohn's disease (CD) and ulcerative colitis (UC) remains incompletely defined. To understand more clearly the extracellular milieu associated with inflammatory bowel disease (IBD), we employed a bioassay whereby plasma of treatment naive paediatric IBD patients (n = 22 CD, n = 15 UC) and unrelated healthy controls (uHC, n = 10) were used to induce transcriptional responses in a healthy leucocyte population. After culture, gene expression was measured comprehensively with microarrays and analysed. Relative to uHC, plasma of CD and UC patients induced distinct responses consisting, respectively, of 985 and 895 regulated transcripts [|log2 ratio| ≥ 0·5 (1·4-fold); false discovery rates (FDR) ≤ 0·01]. The CD:uHC and UC:uHC signatures shared a non-random, commonly regulated, intersection of 656 transcripts (χ(2) = P < 0·001) and were highly correlative [Pearson's correlation coefficient = 0·96, 95% confidence interval (CI) = 0.96, 0.97]. Despite sharing common genetic susceptibility loci, the IBD signature correlated negatively with that driven by plasma of type 1 diabetes (T1D) patients (Pearson's correlation coefficient = -0·51). Ontological analyses revealed the presence of an immunoregulatory plasma milieu in IBD, as transcripts for cytokines/chemokines, receptors and signalling molecules consistent with immune activation were under-expressed relative to uHC and T1D plasma. Multiplex enzyme-linked immunosorbent assay (ELISA) and receptor blockade studies confirmed transforming growth factor (TGF)-β and interleukin (IL)-10 as contributors to the IBD signature. Analysis of CD patient signatures detected a subset of transcripts associated with responsiveness to 6-mercaptopurine treatment. Through plasma-induced signature analysis, we have defined a unique, partially TGF-β/IL-10-dependent immunoregulatory signature associated with IBD that may prove useful in predicting therapeutic responsiveness.
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Affiliation(s)
- B Gurram
- Department of Pediatrics, the Medical College of Wisconsin, Milwaukee, WI
| | - N H Salzman
- Department of Pediatrics, the Medical College of Wisconsin, Milwaukee, WI
| | - M L Kaldunski
- Department of Pediatrics, the Medical College of Wisconsin, Milwaukee, WI.,The Max McGee Research Center for Juvenile Diabetes, Children's Research Institute of Children's Hospital of Wisconsin, Milwaukee, WI
| | - S Jia
- Department of Pediatrics, the Medical College of Wisconsin, Milwaukee, WI.,The Max McGee Research Center for Juvenile Diabetes, Children's Research Institute of Children's Hospital of Wisconsin, Milwaukee, WI
| | - B U K Li
- Department of Pediatrics, the Medical College of Wisconsin, Milwaukee, WI
| | - M Stephens
- Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - M R Sood
- Department of Pediatrics, the Medical College of Wisconsin, Milwaukee, WI
| | - M J Hessner
- Department of Pediatrics, the Medical College of Wisconsin, Milwaukee, WI.,The Max McGee Research Center for Juvenile Diabetes, Children's Research Institute of Children's Hospital of Wisconsin, Milwaukee, WI
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12
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Liu X, Silverman A, Kern M, Ward BD, Li SJ, Shaker R, Sood MR. Excessive coupling of the salience network with intrinsic neurocognitive brain networks during rectal distension in adolescents with irritable bowel syndrome: a preliminary report. Neurogastroenterol Motil 2016; 28:43-53. [PMID: 26467966 PMCID: PMC4688218 DOI: 10.1111/nmo.12695] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 08/31/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The neural network mechanisms underlying visceral hypersensitivity in irritable bowel syndrome (IBS) are incompletely understood. It has been proposed that an intrinsic salience network plays an important role in chronic pain and IBS symptoms. Using neuroimaging, we examined brain responses to rectal distension in adolescent IBS patients, focusing on determining the alteration of salience network integrity in IBS and its functional implications in current theoretical frameworks. We hypothesized that (i) brain responses to visceral stimulation in adolescents are similar to those in adults, and (ii) IBS is associated with an altered salience network interaction with other neurocognitive networks, particularly the default mode network (DMN) and executive control network (ECN), as predicted by the theoretical models. METHODS Irritable bowel syndrome patients and controls received subliminal and liminal rectal distension during imaging. Stimulus-induced brain activations were determined. Salience network integrity was evaluated by the functional connectivity of its seed regions activated by rectal distension in the insular and cingulate cortices. KEY RESULTS Compared with controls, IBS patients demonstrated greater activation to rectal distension in neural structures of the homeostatic afferent and emotional arousal networks, especially the anterior cingulate and insular cortices. Greater brain responses to liminal vs subliminal distension were observed in both groups. Particularly, IBS is uniquely associated with an excessive coupling of the salience network with the DMN and ECN in their key frontal and parietal node areas. CONCLUSIONS & INFERENCES Our study provided consistent evidence supporting the theoretical predictions of altered salience network functioning as a neuropathological mechanism of IBS symptoms.
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Affiliation(s)
- Xiaolin Liu
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alan Silverman
- Division of Pediatric Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mark Kern
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B. Douglas Ward
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shi-Jiang Li
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Reza Shaker
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Manu R. Sood
- Division of Pediatric Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
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13
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Kovacic K, Sood MR, Mugie S, Di Lorenzo C, Nurko S, Heinz N, Ponnambalam A, Beesley C, Sanghavi R, Silverman AH. A multicenter study on childhood constipation and fecal incontinence: effects on quality of life. J Pediatr 2015; 166:1482-7.e1. [PMID: 26008173 DOI: 10.1016/j.jpeds.2015.03.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 01/16/2015] [Accepted: 03/09/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To describe the effects of childhood functional constipation compared with functional constipation plus fecal incontinence on quality of life, evaluating effects on physical, psychosocial, and family functioning. STUDY DESIGN This prospective, multicenter study collected data from 5 regional children's hospitals. Children meeting Rome III criteria for functional constipation were included. Parents completed the following 5 instruments: Pediatric Quality of Life Inventory (PedsQL), PedsQL-Family Impact Module, Functional Disability Inventory-Parent Version, Pediatric Inventory for Parents (PIP), and Pediatric Symptom Checklist-Parent Report. RESULTS Families of 410 children aged 2-18 years (mean [SD], 7.8 [3.5] years; 52% male) were included. Children with functional constipation+fecal incontinence had worse quality of life than children with functional constipation alone (PedsQL Total Score, P ≤ .03). Older children with functional constipation + fecal incontinence had lower quality of life than their younger counterparts (PedsQL Total Score, P ≤ .047). Children with functional constipation+fecal incontinence had worse family functioning (PedsQL-Family Impact Module Total Score, P ≤ .012), greater parental stress (PIP-F Total Score, P ≤ .016; PIP-D Total Score, P ≤ .013), and poorer psychosocial functioning (Pediatric Symptom Checklist Total Score, P ≤ .003). There were no statistically significant between-group differences in physical functioning based on the functional Disability Inventory. CONCLUSION Fecal incontinence significantly decreases quality of life compared with functional constipation alone in children. Older children with functional constipation+fecal incontinence may be at particular risk. Strategies for early identification and treatment of constipation along with diagnosis and treatment of related adjustment difficulties may mitigate the negative impact of this highly prevalent condition.
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Affiliation(s)
- Katja Kovacic
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Manu R Sood
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Suzanne Mugie
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, OH
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, OH
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, MA
| | - Nicole Heinz
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, MA
| | - Ananthasekar Ponnambalam
- Division of Pediatric Gastroenterology, University of South Alabama Children's and Women's Hospital, Mobile, AL
| | - Christina Beesley
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Rina Sanghavi
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Alan H Silverman
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
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14
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Silverman AH, Berlin KS, Di Lorenzo C, Nurko S, Kamody RC, Ponnambalam A, Mugie S, Gorges C, Sanghavi R, Sood MR. Measuring Health-Related Quality of Life With the Parental Opinions of Pediatric Constipation Questionnaire. J Pediatr Psychol 2015; 40:814-24. [DOI: 10.1093/jpepsy/jsv028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 03/04/2015] [Indexed: 11/14/2022] Open
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15
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Kovacic K, Chelimsky TC, Sood MR, Simpson P, Nugent M, Chelimsky G. Joint hypermobility: a common association with complex functional gastrointestinal disorders. J Pediatr 2014; 165:973-8. [PMID: 25151198 DOI: 10.1016/j.jpeds.2014.07.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 05/12/2014] [Accepted: 07/08/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the prevalence of joint hypermobility (JH) and comorbid conditions in children and young adults referred to a tertiary care neurogastroenterology and autonomic disorders clinic for functional gastrointestinal complaints. STUDY DESIGN This was a retrospective chart review of 66 new patients aged 5-24 years who fulfilled at least 1 pediatric Rome III criteria for a functional gastrointestinal disorder (FGID) and had a recorded Beighton score (n = 45) or fibromyalgia tender point score (n = 45) based on physician examination. Comorbid symptoms were collected and autonomic testing was performed for evaluation of postural tachycardia syndrome (POTS). RESULTS The median patient age was 15 years (range, 5-24 years), 48 (73%) were females, and 56% had JH, a significantly higher rate compared with population studies of healthy adolescents (P < .001; OR, 10.03; 95% CI, 5.26-19.13). POTS was diagnosed in 34% of patients and did not correlate significantly with hypermobility. Comorbid conditions were common, including sleep disturbances (77%), chronic fatigue (93%), dizziness (94%), migraines (94%), chronic nausea (93%), and fibromyalgia (24%). CONCLUSION JH and other comorbid symptoms, including fibromyalgia, occur commonly in children and young adults with complex FGIDs. POTS is prevalent in FGIDs but is not associated with hypermobility. We recommend screening patients with complex FGIDs for JH, fibromyalgia, and comorbid symptoms such as sleep disturbances, migraines, and autonomic dysfunction.
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Affiliation(s)
- Katja Kovacic
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | | | - Manu R Sood
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Pippa Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Melodee Nugent
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Gisela Chelimsky
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
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16
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Sood MR, Di Lorenzo C, Hyams J, Miranda A, Simpson P, Mousa H, Nurko S. Beliefs and attitudes of general pediatricians and pediatric gastroenterologists regarding functional gastrointestinal disorders: a survey study. Clin Pediatr (Phila) 2011; 50:891-6. [PMID: 21464079 DOI: 10.1177/0009922811398041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Manu R Sood
- Medical College of Wisconsin, Milwaukee, WI, USA.
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17
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Sood MR. Treatment approaches to irritable bowel syndrome. Pediatr Ann 2009; 38:272-6. [PMID: 19476300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2023]
Affiliation(s)
- Manu R Sood
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA.
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Abstract
The enteric nervous system is an integrative brain with collection of neurons in the gastrointestinal tract which is capable of functioning independently of the central nervous system (CNS). The enteric nervous system modulates motility, secretions, microcirculation, immune and inflammatory responses of the gastrointestinal tract. Dysphagia, feeding intolerance, gastroesophageal reflux, abdominal pain, and constipation are few of the medical problems frequently encountered in children with developmental disabilities. Alteration in bowel motility have been described in most of these disorders and can results from a primary defect in the enteric neurons or central modulation. The development and physiology of the enteric nervous system is discussed along with the basic mechanisms involved in controlling various functions of the gastrointestinal tract. The intestinal motility, neurogastric reflexes, and brain perception of visceral hyperalgesia are also discussed. This will help better understand the pathophysiology of these disorders in children with developmental disabilities.
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Affiliation(s)
- Muhammad A Altaf
- Division of Pediatric Gastroenterology, The Medical College of Wisconsin, Milwaukee, WI 53226, USA
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19
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Venkatasubramani N, Rudolph CD, Sood MR. Erythromycin lacks colon prokinetic effect in children with functional gastrointestinal disorders: a retrospective study. BMC Gastroenterol 2008; 8:38. [PMID: 18718006 PMCID: PMC2529327 DOI: 10.1186/1471-230x-8-38] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Accepted: 08/21/2008] [Indexed: 11/17/2022] Open
Abstract
Background Motilin, a peptide hormone has a direct excitatory effect on circular smooth muscle strips derived from the human colon. Reduced plasma motilin concentration has been reported in adults with chronic constipation. Erythromycin, a non-peptide motilin receptor agonist, induces phase 3 of the migrating motor complex (MMC) in the antro-duodenum and also reduces oro-cecal transit time. A pediatric study has reported an improvement in clinical symptoms of constipation following erythromycin administration, but the effect on colon motility in children has not been formally evaluated. We used colon manometry to study the effect of intravenous erythromycin lactobionate at 1 mg/kg on colon motiltiy in ten children. Methods We selected patients with normal antroduodenal and colon manometry studies that were performed simultaneously. All studies were performed for clinically indicated reasons. We quantified the effect of erythromycin on colon contraction by calculating the area under the curve (AUC). Results The mean (SE of mean) AUC in the colon during the fasting, post-erythromycin and postprandial phases of the study was 2.1 mmHg/sec (0.35), 0.99 mmHg/sec (0.17) and 3.05 mmHg/sec (0.70) respectively. The AUC following erythromycin was significantly less compared to the fasting phase of the study (p < 0.01). Conclusion Erythromycin lacks colon prokinetic effect in children with chronic constipation evaluated by colon manometry.
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Affiliation(s)
- Narayanan Venkatasubramani
- Division of Pediatric Gastroenterology and Nutrition, The Children's Hospital of Wisconsin and The Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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20
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Abstract
A wide spectrum of gastrointestinal motility disorders present in childhood. Some are unique to children, especially congenital disorders including certain pseudo-obstruction disorders or those associated with anatomic developmental defects, whereas others are common adult disorders, such as achalasia, that rarely manifest in children. This article reviews the pediatric presentations and sequelae of childhood gastrointestinal motility disorders and then discusses long-term management issues for these children as they progress into adulthood. The goal is to optimize medical care and ensure the adequate nutritional status essential for neurocognitive and psychosocial development of the child. Multidisciplinary care from specialists, including gastroenterologists, psychologists, and pain specialists, is often required to optimize the lives of these patients.
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Affiliation(s)
- Manu R Sood
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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21
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Abstract
Food impaction in patients with eosinophilic esophagitis is being recognized increasingly. Retrieval of impacted food may be necessary if it does not resolve spontaneously. The present report describes a new technique for removal of friable impacted food from the esophagus using a modified version of the Saeed banding device. With this technique, impacted food was safely removed in a single attempt in each of 3 patients.
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Affiliation(s)
- Cass R Smith
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee 53226, USA
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22
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Abstract
Over the past decades our knowledge of normal and abnormal gastrointestinal motility has increased tremendously. The availability of manometry to study bowel contraction patterns, laparoscopy to perform full thickness bowel biopsies for histological examination, have added to the investigative armamentarium and helped better diagnose motility disorders. However, the development of newer therapies for bowel motility disorders has been disappointingly slow. Newer modalities such as gastric and bowel pacing provides some hope for the future. In this article we have provided an overview of some of the common motility disorders in children and discussed their management.
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Abstract
AIMS To compare the height, weight, and body mass index (BMI) of children presenting with dyspeptic symptoms and Helicobacter pylori infection, to those with dyspepsia but without the infection. METHODS A retrospective chart review of 257 children was performed. 13C urea breath test was performed to detect H pylori infection; weight and height were recorded and BMI was calculated. Weight, height, and BMI SD scores were determined using the 1990 UK normative data. The Index of Multiple Deprivation 2004 (IMD 2004) scores, which measure deprivation at small area level, were calculated from the patients' postcodes. RESULTS Ninety seven of the 257 children were H pylori positive. The mean age at diagnosis and presenting symptoms of H pylori positive and negative patients were similar. The mean IMD 2004 scores for children with H pylori infection were significantly higher compared to H pylori negative patients, suggesting that children with the infection came from relatively more deprived areas. The mean weight and height SD score were significantly lower for children with H pylori infection compared to those without. However, this difference was no longer significant after adjusting for socioeconomic deprivation and ethnic differences between the groups. CONCLUSION Children with dyspepsia and H pylori infection were shorter and lighter than patients with similar symptoms but no infection. The differences in anthropometry may be due to socioeconomic and ethnic factors rather than H pylori infection.
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Affiliation(s)
- M R Sood
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Abstract
Gastroesophageal reflux disease (GERD) occurs in adolescents but its frequency and severity is less than in adults. Typical symptoms of heartburn and regurgitation generally do not require a diagnostic evaluation unless they are associated with alarm signs including odynophagia, dysphagia, upper gastrointestinal bleeding, weight loss, atypical chest pain, or respiratory disease. Empiric treatment with proton pump inhibitors (PPIs) provides relief in most patients. Patients with persistent symptoms requiring PPI therapy should undergo endoscopy. Those with chronic GERD require medical or surgical therapy, whereas those with nonerosive reflux disease often benefit from changes in lifestyle or intermittent, on-demand medical therapy with a therapeutic aim of symptom relief. Surgical therapy is rarely required but may have a role in adolescents with respiratory complications of gastroesophageal reflux or neurologic handicap.
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Affiliation(s)
- Manu R Sood
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA.
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Abstract
Our aim was to analyse the patterns of ileal contractions in children. We reviewed the charts of 23 children who had ileal manometry studies (16 males), mean age 7 years (range 2 months to 17 years). We positioned the manometry catheters with 4-8 recording sites, 5 or 15 cm apart, through ileostomies fashioned for clinically indicated reasons. We studied six additional children with persistent faecal soiling following endorectal pull through for Hirschsprung's disease; the catheters were positioned through the anus and colon into the ileum. We recorded phasic and tonic intermittent contractions in all the subjects, clustered contractions (rate 5-9 min-1, duration 20-120 s) in 19 subjects with ileostomies and four with endorectal pull throughs. In 13 children there were prolonged propagated contractions, > 60 mmHg in amplitude, > 15 s in duration, propagating at rates of 2-6 cm s-1 over at least 20 cm. The migrating motor complex was rare; in 55 h of fasting recording there were two phase III sequences. There are four distinctive features of ileal manometry recordings in children: random intermittent contractions, clustered contractions, prolonged propagated contractions and tonic contractions. The features of ileal motility differ from motility in the proximal small bowel.
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Affiliation(s)
- M R Sood
- Department of Paediatric Gastroenterology, Booth Hall Children's Hospital, Manchester, UK.
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Abstract
OBJECTIVE The purpose of this study was to estimate values for the water load test in healthy elementary school children. METHODS We measured the volume of water consumed by 176 children (71 boys and 105 girls) using the water load test at school. Children completed a questionnaire, which included self-efficacy and abdominal pain history. Then subjects drank water for 3 minutes or until full. RESULTS Children drank 630 +/- 260 ml. Water consumption correlated with age, weight, and height. Children who believed they could drink a lot, drank more than those who thought they could not, < 0.01. CONCLUSION The water load test is a simple and inexpensive method to estimate onset of satiety and may be useful in future studies now that there are values for healthy children.
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Affiliation(s)
- Manu R Sood
- Gastrointestinal Motility Center, Children's Hospital of Orange, County, Orange, California, USA
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