Oesophageal wall thickness assessment at endoscopic ultrasound in children and adolescents with eosinophilic oesophagitis: a case-control study

PURPOSE

Eosinophilic oesophagitis (EoE) is a chronic immune-mediated disease, and an endosonographic evaluation may help the diagnosis. The main objectives of this study were to measure the thickness of the oesophageal wall using a radial endoscopic ultrasound (EUS), mucosa/submucosa (MSM), muscularis propria (MP) and mucosa to muscularis propria (MMP); to compare these measurements between patients with and without EoE; to correlate them with the Endoscopic Reference Score (EREFS); and to evaluate the diagnostic accuracy of these measurements.

METHODS

Children and adolescents (aging from 4 to 17 years) were evaluated in this prospective cross-sectional study. A radial EUS at 12 MHz frequency was used, and EREFS was employed to grade macroscopic findings. Accuracy of the measurements for the diagnosis of EoE was assessed by receiver operating characteristics (ROC) curve.

RESULTS

Twenty-six (19 M/7 F) patients (median age 10.83 years, range 5.65-17.46) were evaluated. EoE was diagnosed in 6 patients. The mean (and SD) oesophageal wall thicknesses in the distal oesophagus in millimetres in groups with and without EoE, respectively, were: MSM 1.07 (0.44) and 1.11 (0.33); MP 0.67 (0.25) and 0.60 (0.19); and MMP 1.73 (0.46) and 1.72 (0.32). Mid-oesophagus: MSM 1.16 (0.34) and 1.15 (0.34); MP 0.63 (0.16) and 0.60 (0.2); and MMP 1.79 (0.41) and 1.74 (0.34). In the ROC curve, the distal MP layer thickness presented better discriminative performance, with an area under the curve of 0.61 (95% CI 0.28-0.93) at 0.73 mm cut-off (66.67% sensitivity, 80% specificity, likelihood ratios of 3.33 for positive and 0.42 for negative test).

CONCLUSION

The evaluation of oesophageal thickness measurements by EUS is not useful for diagnosing EoE.

A NORMOCALORIC, LOW-FIBER DIET FOR COLONOSCOPY PREPARATION IS MORE ACCEPTABLE AND NON-INFERIOR TO A LIQUID, LOW-CALORIE DIET: A RANDOMIZED CONTROLLED TRIAL

•This is the first study in Brazil about diets to prepare for colonoscopy. •The normocaloric diet was not inferior to the liquid diet regarding the quality of the colonoscopy preparation. •Both diets were well tolerated, but the normocaloric diet was more accepted than the liquid diet. Background - Several publications have shown greater acceptance of less restrictive diets for colonoscopy preparation, without impairing the quality of the preparation, when compared to the clear liquid diet. Objective - To evaluate the quality, tolerance and preference regarding the colonoscopy preparation of a low-fiber, normocaloric diet compared with a hypocaloric liquid diet. Methods - This is a randomized, controlled, observer-blind study to compare two low-fiber colonoscopy preparation diets (hypocaloric liquid diet vs. normocaloric diet). The Boston Bowel Preparation Scale was used to evaluate the qua-lity of the preparations, being considered adequate BBPS ≥6 in the global assessment and ≥2 in each segment. The same laxative was used in both groups as well as the "split-dose" regimen. Results - A total of 136 individuals were enrolled in each group. Adequate preparation was achieved in 90.4% of the individuals allocated to the liquid diet group and 92.6% to the normocaloric group. There was no significant difference in the quality of preparation and tolerance between groups. A higher patient acceptance to repeat the procedure if necessary was observed in the normocaloric diet group compared with the liquid diet group (P=0.005). Conclusion - The normocaloric diet has shown to be not inferior to the liquid diet regarding the quality of the colonoscopy preparation. Patient tolerance rates were similar between both diets, but a higher accep-tance rate was observed with the normocaloric diet as compared with the liquid diet.

Efficacy and safety of endoscopic ultrasound-guided drainage of pancreatic pseudocysts using double-pigtail plastic stents: A single tertiary center experience

OBJECTIVES

Pancreatic pseudocysts (PPC) are fluid collections with a well-defined wall that persist for more than 4 weeks inside or around the pancreas as a result of pancreatic inflammation and/or a ductal lesion. PPC have been successfully treated with endoscopic ultrasound (EUS)-guided drainage using different stents. This study aimed to evaluate the safety and efficacy of EUS-guided drainage of PPC using double-pigtail plastic stents in a tertiary hospital.

METHODS

Patients with PPC referred for EUS-guided drainage between May 2015 and December 2019 were included in this case series. The primary endpoint was to evaluate the efficacy (clinical success) and safety (adverse events and mortality) of EUS-guided drainage of PPC. Secondary endpoints included technical success and pseudocyst recurrence.

RESULTS

Eleven patients (mean age, 44.5±18.98 years) were included in this study. The etiologies for PPC were acute biliary pancreatitis, chronic alcoholic pancreatitis, and blunt abdominal trauma. The mean pseudocyst size was 9.4±2.69 cm. The clinical success rate was 91% (10/11). Adverse events occurred in three of 11 patients (27%). There were no cases of mortality. The technical success rate was 100%. Pseudocyst recurrence was identified in one of 11 patients (9%) at 12 weeks after successful clinical drainage and complete pseudocyst resolution.

CONCLUSION

EUS-guided transmural drainage of PPC using double-pigtail plastic stents is safe and effective with high technical and clinical success rates.

Antiproliferative and photoprotective activities of the extracts and compounds from Calea fruticosa

In this paper, we complement our previous study on the antiproliferative activity of Calea fruticosa (Asteraceae) by isolating the compounds apigenin-4',7-dimethyl ether (1), budlein A (2), quercetin (3), and cichoriin (4) from the plant’s aerial parts. The antiproliferative activity of these compounds was evaluated by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) method against human tumor cell lines. Compound 3 displayed moderate antiproliferative activity in three cell lines (HCT-116, PC-3, and SF-295, with cell growth inhibition values of 72.97, 74.55, and 68.94%) and high antiproliferative activity (90.86%) in the HL-60 cell line. The in vitro sun protection factor (SPF) of the extracts and compound 4, with and without sunscreen, was determined by a spectrophotometric method. The ethanol extract exhibited the highest SPF (9.67) at a concentration of 0.100 mg/mL, while compound 4, isolated from this extract, showed a SPF of 13.79 at the same concentration. A relative increased efficacy of SPF was observed for the extracts and compound 4 when sunscreen was also used. Compound 4 has not been reported previously from any species within the genus Calea. Compounds 1–4 were obtained from this species for the first time.

Gastroesophageal reflux in cystic fibrosis across the age spectrum

Background

Scientific advances have improved longevity in cystic fibrosis (CF) patients and many of these patients can expect to experience age-related gastrointestinal co-morbidities. We aimed to assess the extent to which age might impact gastroesophageal reflux (GER) in patients with CF.

Methods

Our esophageal pH-multichannel intraluminal impedance monitoring database was searched for tracings belonging to CF patients ≥2 years old without prior fundoplication and not taking anti-reflux medications immediately prior (within 7 days) and during the study. Tracings were retrospectively analyzed; Impedance and pH variables were evaluated with respect to age and pulmonary function.

Results

Twenty-eight patients were enrolled; 16 children (3.1-17.7 years) and 12 adults (18.2-48.9 years). Among pH probe parameters, correlation analysis showed DeMeester score (P=0.011) and number of acid reflux events lasting >5 minutes (P=0.047) to be significantly correlated with age. Age was not significantly correlated with any of the impedance parameters. Age was negatively correlated with baseline impedance (BI) in the distal esophagus (r=-0.424, P=0.023) and BI was negatively correlated with several pH parameters, including reflux index (r=-0.553, P=0.002), number of total acid reflux events (r=-0.576, P=0.001), number of acid reflux events lasting >5 minutes (r=-0.534, P=0.003), and DeMeester score (r=-0.510, P=0.006). Pulmonary function (percent predicted forced expiratory volume in one minute; ppFEV₁) was negatively correlated with age (r=-0.494, P=0.0007). The interaction of age and ppFEV₁ and any of the reflux parameters, however, was not significant (P>0.05); the strongest evidence for an interaction was found for the number of acid reflux events reaching the proximal esophagus, but this interaction still did not reach statistical significance (P=0.070).

Conclusions

In a small cohort, we found evidence that age may be associated with increased acid exposure and that both age and increased acid exposure are associated with reduced BI in the distal esophagus. The negative relationship between pulmonary function and age in our cohort is not related to GER. This pilot study supports the need for esophageal assessment and treatment of GER as standard components of clinical care for an aging CF population.

Not All Children with Cystic Fibrosis Have Abnormal Esophageal Neutralization during Chemical Clearance of Acid Reflux

PURPOSE

Acid neutralization during chemical clearance is significantly prolonged in children with cystic fibrosis, compared to symptomatic children without cystic fibrosis. The absence of available reference values impeded identification of abnormal findings within individual patients with and without cystic fibrosis. The present study aimed to test the hypothesis that significantly more children with cystic fibrosis have acid neutralization durations during chemical clearance that fall outside the physiological range.

METHODS

Published reference value for acid neutralization duration during chemical clearance (determined using combined impedance/pH monitoring) was used to assess esophageal acid neutralization efficiency during chemical clearance in 16 children with cystic fibrosis (3 to <18 years) and 16 age-matched children without cystic fibrosis.

RESULTS

Duration of acid neutralization during chemical clearance exceeded the upper end of the physiological range in 9 of 16 (56.3%) children with and in 3 of 16 (18.8%) children without cystic fibrosis (p=0.0412). The likelihood ratio for duration indicated that children with cystic fibrosis are 2.1-times more likely to have abnormal acid neutralization during chemical clearance, and children with abnormal acid neutralization during chemical clearance are 1.5-times more likely to have cystic fibrosis.

CONCLUSION

Significantly more (but not all) children with cystic fibrosis have abnormally prolonged esophageal clearance of acid. Children with cystic fibrosis are more likely to have abnormal acid neutralization during chemical clearance. Additional studies involving larger sample sizes are needed to address the importance of genotype, esophageal motility, composition and volume of saliva, and gastric acidity on acid neutralization efficiency in cystic fibrosis children.

Prevalência de infecção por Helicobacter pylori em uma comunidade indígena em São Paulo e fatores associados: estudo transversalPrevalence of Helicobacter pylori infection in an indigenous community in São Paulo and associated factors: cross-sectional study

CONTEXT AND OBJECTIVE:

The prevalence of Helicobacter pylori infection is unevenly distributed among different populations. The aim here was to evaluate the factors associated with Helicobacter pylori infection among children up to five years of age living in a high-risk community.

DESIGN AND SETTING:

Cross-sectional study in an indigenous community of Guarani Mbya ethnicity, Tekoa Ytu and Tekoa Pyau villages, Jaraguá district, city of São Paulo (SP), Brazil.

METHODS:

74 children aged 0.4 to 4.9 years (mean 2.9 ± 1.3 years; median 3.1), and 145 family members (86 siblings, 43 mothers and 16 fathers) were evaluated for Helicobacter pylori infection using the validated 13C-urea breath test. Clinical and demographic data were collected.

RESULTS:

The prevalence was 8.3% among children aged 1-2 years and reached 64.3% among those aged 4-5 years (P = 0.018; overall 31.1%). The prevalence was 76.7% among siblings and 89.8% among parents. There was a negative association with previous use of antibiotics in multivariate analysis adjusted for age (odds ratio, OR: 0.07; 95% confidence interval, CI: 0.01 to 0.66; P = 0.02). The prevalence was higher among males (OR: 1.55), and was associated with maternal infection (OR: 1.81), infection of both parents (OR: 1.5), vomiting (OR: 1.28), intestinal parasitosis (OR: 2.25), previous hospitalization (OR: 0.69) and breastfeeding (OR: 1.87).

CONCLUSIONS:

The prevalence was high among subjects older than three years of age, thus suggesting that the incidence of infection was higher over the first three years of life. Previous use of antibiotics was inversely associated with current Helicobacter pylori infection.

Gastroesophageal Reflux Affects Sleep Quality in Snoring Obese Children

PURPOSE

This study was performed to evaluate the quality of sleep in snoring obese children without obstructive sleep apnea (OSA); and to study the possible relationship between sleep interruption and gastroesophageal reflux (GER) in snoring obese children.

METHODS

Study subjects included 13 snoring obese children who were referred to our sleep lab for possible sleep-disordered breathing. Patients underwent multichannel intraluminal impedance and esophageal pH monitoring with simultaneous polysomnography. Exclusion criteria included history of fundoplication, cystic fibrosis, and infants under the age of 2 years. Significant association between arousals and awakenings with previous reflux were defined by symptom-association probability using 2-minute intervals.

RESULTS

Sleep efficiency ranged from 67-97% (median 81%). A total of 111 reflux episodes (90% acidic) were detected during sleep, but there were more episodes per hour during awake periods after sleep onset than during sleep (median 2.3 vs. 0.6, p=0.04). There were 279 total awakenings during the sleep study; 56 (20.1%) of them in 9 patients (69.2%) were preceded by reflux episodes (55 acid, 1 non-acid). In 5 patients (38.5%), awakenings were significantly associated with reflux.

CONCLUSION

The data suggest that acid GER causes sleep interruptions in obese children who have symptoms of snoring or restless sleep and without evidence of OSA.

Helicobacter pylori infection & immune thrombocytopenic purpura in children and adolescents: A randomized controlled trial

Helicobacter pylori and immune thrombocytopenic purpura (ITP) association is not well established in chronic ITP (cITP) in children, although the cure of thrombocytopenia in approximately half of H. pylori eradicated adult patients has been described. The aim of this study was to investigate the effect of H. pylori eradication on platelet (PLT) recovery in cITP children and adolescents through a randomized, controlled trial. A total of 85 children (mean age 11.4 years) with cITP were prospectively enrolled. Diagnosis of H. pylori was established by two locally validated tests, (13)C-urea breath test and monoclonal stool antigen test. Twenty-two infected patients were identified, and randomly allocated into two groups: H. pylori treatment group (n = 11) and the non-intervention control group (n = 11). The control group was offered treatment if the thrombocytopenia persisted after the follow-up. At baseline, there were no differences regarding age, sex, duration of disease, and PLT count between groups. Sixty three of 85 patients were uninfected. PLT response was classified as complete response: PLT > 150 × 10(9 )l(-1); partial response: PLT 50-150 × 10(9 )l(-1), or an increase of 20-30 × 10(9 )l(-1); no response: PLT < 50 × 10(9 )l(-1) or an increase of <20 × 10(9 )l(-1) after at least 6 months of follow-up. Complete response was observed in 60.0% (6/10, one excluded) H. pylori eradicated patients vs. 18.2% (2/11) in non-eradicated patients (p = 0.08; OR = 6.75) after 6-9 months of follow-up. Among uninfected patients, only 13.8% (8/58) presented complete response. Two non-treated controls were treated after 6-12 months of follow-up, and PLT response was observed in 61.5% (8/13) of H. pylori eradicated patients, and in 19.0% (11/58) of uninfected patients (p = 0.004). Cytotoxin associated gene A and vacuolating cytotoxin gene A IgG antibodies were present in almost all infected patients. Therefore, the study suggests that H. pylori eradication plays a role in the management of H. pylori infected cITP children and adolescents.

Prevalence of Helicobacter pylori infection and intestinal parasitosis in children of the Xingu Indian Reservation

OBJECTIVE

To evaluate the prevalence of Helicobacter pylori infection and its association with intestinal parasitoses in children from indigenous communities of the Xingu Indian Reservation, in Brazil.

METHODS

A total of 245 Native Brazilian children between 2 and 9 years of age, from six villages of the Xingu River region, a tributary of the Amazon River, were assessed. H. pylori was detected using the (13)C-urea breath test. Breath samples were collected at baseline and 30 minutes after ingestion of 50 mg of (13)C-urea diluted with 100 mL of water flavored with passion fruit juice and sweetener. Stool samples were collected for the stool ova and parasites exam for 202/245 (82.4%) children.

RESULTS

The overall prevalence of H. pylori was 73.5%. A significant association of H. pylori with increased age was observed among the different villages and ethnic groups. Positive results for the presence of parasites - 97.5% (198/202) - from the stool samples collected showed no association with H. pylori. Giardia showed an association with H. pylori in the multivariate analysis. Risk factors for H. pylori infection were observed in Kisêjê and Kaibi ethnic groups (OR [odds ratio] = 3.36 and 4.00, respectively), as well as in Tuiararé, Ngojwere, Capivara, Diauarum, and Pavuru villages (OR = 8.10, 4.10, 4.88, 1.85, and 1.40, respectively).

CONCLUSIONS

H. pylori infection is highly prevalent in these communities, as well as intestinal parasitoses. However, there were significant differences in the prevalence of H. pylori among the diverse villages studied. Giardia was closely associated with H. pylori infection.

Prevalence of intestinal parasitoses in children at the Xingu Indian Reservation

OBJECTIVE

To evaluate the prevalence of intestinal parasitoses in Native Brazilian children from 2 to 9 years old.

METHODS

A search for ova and parasites was conducted in the stools of children between 2 to 9 years old living in six indigenous villages located in the Middle and Lower Xingu River, to wit: Pavuru, Moygu, Tuiararé, Diauarum, Capivara, and Ngojwere. The study utilized the Paratest kit® (Diagnostek, Brazil) to preserve collected stools. Fecal samples were shipped to the Laboratory of the Pediatric Gastroenterology Division of the UNIFESP/EPM, in São Paulo, for analysis. The search for ova and parasites was performed utilizing the Hoffman method, and later through optical microscopic evaluation. Fecal samples were collected one year apart from each other.

RESULTS

There were no significant statistical differences between the mean ages of the children from the six indigenous villages studied. The search for ova and parasites found positive results for the stools of 97.5% (198/202) and 96.1% (98/102) of children in the first and second collections, respectively. There was no statistical association with the children's age. The search performed one year later found no differences in the proportion of parasites identified in the first collection for protozoa (93.3% in 2007 versus 93.3% in 2008, McNemar = 0.01, p = 0.1) or for helminths (37.1% in 2007 versus 38.2% in 2008, McNemar = 0.03, p = 0.85). There were significant differences in prevalence of Entamoeba coli between 2007 (43.8%) and 2008 (61.8%) (McNemar Chi 6.1; p = 0.0135). There were no significant differences for other parasites when comparing the results of the two studies.

CONCLUSION

The high prevalence of intestinal parasitosis matched the elevated rates of environmental contamination in this indigenous community.

Evaluation of gastric histology in children and adolescents with Helicobacter pylori gastritis using the Update Sydney System

CONTEXT

Although Helicobacter pylori infection is prevalent in our country, there are few studies evaluating the associated histological abnormalities in children.

OBJECTIVE

To evaluate the histological features of the gastric mucosa in children and adolescents with Helicobacter pylori gastritis.

METHODS

One hundred and thirty two gastric biopsies from 22 symptomatic patients infected with H. pylori (14F/8M, median age 10 y 5 mo, age range 2 y 11 mo to 16 y 9 mo) were evaluated. Evaluated gastric regions included: antrum (lesser and greater curvature), corpus (lesser and greater curvature), incisura angularis and fundus. Histological examination was performed according to the Updated Sydney System, and regional scores for polymorphonuclear and mononuclear cell infiltrate as well as bacterial density were generated.

RESULTS

Fifteen (68.2%) patients presented H. pylori-chronic active gastritis, six (27.3%) presented antrum-predominant H. pylori-chronic active gastritis, and one (4.5%) presented corpus-predominant H. pylori-chronic active gastritis. Polymorphonuclear cell infiltrate and mononuclear cell infiltrate were observed in 93.9% and 98.5% of the biopsy specimens, respectively. Higher histological scores for polymorphonuclear infiltrate, mononuclear infiltrate, and bacterial density were observed in the gastric antrum. Intestinal metaplasia and gastric atrophy were not identified in any patient. Lymphoid aggregates and lymphoid follicles were observed in the gastric antrum of three (13.6%) and seven (31.8%) patients, respectively, but they were not related to antral nodularity.

CONCLUSIONS

Chronic active gastritis was observed in all patients with H. pylori infection. However, antral or corporeal predominance was not observed in most patients.

Seroprevalence of Helicobacter pylori infection among children of low socioeconomic level in São Paulo

CONTEXT AND OBJECTIVE

Helicobacter pylori infection is mainly acquired during childhood, and is associated with significant morbidity in adults. The aim here was to evaluate the seroprevalence and risk factors of H. pylori infection among children of low socioeconomic level attended at a public hospital in São Paulo, Brazil.

DESIGN AND SETTING

Cross-sectional study, among patients attended at an outpatient clinic.

METHODS

326 children were evaluated (150 boys and 176 girls; mean age 6.82 ± 4.07 years) in a cross-sectional study. Patients with chronic diseases or previous H. pylori treatment, and those whose participation was not permitted by the adult responsible for the child, were excluded. The adults answered a demographic questionnaire and blood samples were collected. The serological test used was Cobas Core II, a second-generation test. Titers > 5 U/ml were considered positive.

RESULTS

H. pylori infection was diagnosed in 116 children (35.6%). Infected children were older than uninfected children (7.77 ± 4.08 years versus 5.59 ± 3.86 years; p < 0.0001). The seroprevalence increased from 20.8% among children aged two to four years, to 58.3% among those older than 12 years. There were no significant relationships between seropositivity and gender, color, breastfeeding, number of people in the home, number of rooms, bed sharing, living in a shantytown, maternal educational level, family income or nutritional status. In multivariate analysis, the only variable significantly associated with H. pylori seropositivity was age.

CONCLUSION

Infection had intermediate prevalence in the study population, and age was associated with higher prevalence.

Gastric emptying evaluation in children with erosive gastroesophageal reflux disease

BACKGROUND/AIMS

Delayed gastric emptying may be an important contributing factor to gastroesophageal reflux disease (GERD) in children, but there are limited data on its evaluation in children with erosive-GERD. This study aims to evaluate the gastric emptying of a solid meal in patients with erosive-GERD.

METHODS

Nineteen patients (age range 8.79-17.9 years) with erosive esophagitis and 14 healthy controls (age range from 8.04 to 18.7 years) were compared. Esophagitis was graded according to Los Angeles classification. The gastric emptying was evaluated by (13)C-octanoic breath test, which was performed after a 344 kcal standardized solid test meal. Symptoms were evaluated using a standardized questionnaire.

RESULTS

The two most prevalent symptoms were nausea and epigastric pain, which were reported by 12 (63.2%) patients. Irritable bowel syndrome was present in 26.3% (5/19). The median gastric emptying half-time in patients was 160 min (interquartile range [IQR] 140-174 min), which was not different from the controls' figure (median 157 min, IQR 143-170 min). Additionally, the lag time and the gastric emptying coefficient were not significantly different between the study groups.

CONCLUSION

Delayed gastric emptying is not associated with erosive esophagitis in children with GERD, when compared to controls.

Avaliação da lidocaína tópica como pré-medicação para a endoscopia digestiva alta em crianças

OBJETIVO: Avaliar a eficácia da lidocaína spray tópica como droga adjuvante na sedação e analgesia de crianças e adolescentes para endoscopia digestiva. MÉTODOS: Foram incluídos 80 pacientes (49 femininos e 31 masculinos, idade média 12±3 anos), 40 no grupo placebo e 40 no grupo lidocaína. Os pacientes foram alocados aleatoriamente e um paciente de cada grupo foi excluído. Lidocaína a 10% ou placebo (ácido tânico 0,5%) aerossol (dois jatos) foram aplicados na orofaringe antes da infusão de propofol. Os pacientes foram monitorizados durante o procedimento e após, sendo respondido questionário para avaliar odinofagia e a pré-medicação. O desfecho primário foi a dose de propofol empregada, enquanto os desfechos secundários foram incidência de complicações, tempo de sala e duração do procedimento. RESULTADOS: Não houve diferenças entre os grupos quanto à idade, sexo e indicação da endoscopia. A dose de propofol empregada não foi diferente nos dois grupos (grupo placebo 3,1±1,1 e grupo lidocaína 2,9±1,3mg/kg; p=0,69), mesmo quando considerada a dose bruta (p=0,33). No entanto, o tempo de sala médio foi maior no grupo placebo do que no lidocaína (23±7 versus 20±5 minutos; IC95% da diferença: 0,47-5,89 minutos, p=0,02). Não houve diferenças entre os grupos quanto à duração do procedimento, incidência de complicações e aceitação pelo paciente. CONCLUSÕES: O emprego de medicação tópica anestésica em endoscopia reduz o tempo de sala sem aumentar a incidência de efeitos adversos (NCT00521703).

Decrease in prevalence of Helicobacter pylori infection during a 10-year period in Brazilian children

BACKGROUND

Decreasing prevalence of H pylori infection has been reported in some countries.

AIM

To evaluate the prevalence of Helicobacter pylori infection in a 10-year period in children submitted to upper digestive endoscopy.

METHODS

It was a retrospective observational study. The records of 1,165 endoscopies performed during a 10-year period in a public hospital of the City of São Paulo, SP, Brazil, in patients up to 18-year-old. Only the first endoscopy was considered. Helicobacter pylori infection was defined by the rapid urease test, performed with one fragment of antral mucosa. Chi-square for trend has been estimated to compare Helicobacter pylori prevalence across the period.

RESULTS

The main indication for endoscopy was epigastric pain (47.4%). There were 392 patients with H pylori infection (33.6%), 12.8% being infants, 19.4% toddlers, 28.8% schoolchildren and 46.3% adolescents. Prevalence was 60.47% in the first year of the study and 30.43% in the last. Among the less than 6-year-old patients there was a decrease in infection prevalence from 25% for the 1993--6 period to 14.3% in the 2000--02 period, while among the over 12-year-old patients the decrease was from 55.5% in the first period to 39.6% in the latter. The decrease in H pylori infection prevalence was more intense within patients with epigastric pain, in which prevalence has decreased from 48.2% (92/191) in 1993--6, to 41.9% (65/155) in 1997--9 and 27.7% (57/206) in 2000--02.

CONCLUSION

The study suggests a significant decrease in the prevalence of H pylori infection regarding the studied patients. The trend was mainly observed in the younger age group and in patients with epigastric pain.

Decrease in prevalence of Helicobacter pylori infection during a 10-year period in Brazilian children

BACKGROUND

Decreasing prevalence of H pylori infection has been reported in some countries.

AIM

To evaluate the prevalence of Helicobacter pylori infection in a 10-year period in children submitted to upper digestive endoscopy.

METHODS

It was a retrospective observational study. The records of 1,165 endoscopies performed during a 10-year period in a public hospital of the City of São Paulo, SP, Brazil, in patients up to 18-year-old. Only the first endoscopy was considered. Helicobacter pylori infection was defined by the rapid urease test, performed with one fragment of antral mucosa. Chi-square for trend has been estimated to compare Helicobacter pylori prevalence across the period.

RESULTS

The main indication for endoscopy was epigastric pain (47.4%). There were 392 patients with H pylori infection (33.6%), 12.8% being infants, 19.4% toddlers, 28.8% schoolchildren and 46.3% adolescents. Prevalence was 60.47% in the first year of the study and 30.43% in the last. Among the less than 6-year-old patients there was a decrease in infection prevalence from 25% for the 1993--6 period to 14.3% in the 2000--02 period, while among the over 12-year-old patients the decrease was from 55.5% in the first period to 39.6% in the latter. The decrease in H pylori infection prevalence was more intense within patients with epigastric pain, in which prevalence has decreased from 48.2% (92/191) in 1993--6, to 41.9% (65/155) in 1997--9 and 27.7% (57/206) in 2000--02.

CONCLUSION

The study suggests a significant decrease in the prevalence of H pylori infection regarding the studied patients. The trend was mainly observed in the younger age group and in patients with epigastric pain.

Low Prevalence of Helicobacter pylori infection evaluated by stool antigen test in preschool and school children

The study evaluated the prevalence of Helicobacter pylori infection in toddlers using the stool antigen test. Helicobacter pylori was detected in 28/113 (13.1%). Crowding and age were risk factors significantly associated to the infection. We conclude there is a low prevalence of the infection in the studied children.

Furazolidone, tetracycline and omeprazole: a low-cost alternative for Helicobacter pylori eradication in children

OBJECTIVES

To evaluate furazolidone, tetracycline and omeprazole as first line therapy for Helicobacter pylori in children with digestive symptoms.

METHODS

Prospective and consecutive open trial. The study included patients older than 8 years old with functional dyspepsia, functional abdominal pain, severe histological abnormalities (intestinal metaplasia, gastric atrophy or mucosa-associated lymphoid tissue lymphoma) or peptic ulcer. H. pylori status was defined based both upon histology and rapid urease test. Drug regimen was a 7-day course of omeprazol, tetracycline (or doxycycline) and furazolidone twice daily. Eradication was assessed by upper endoscopy 2 months after treatment (histology and rapid urease test). Further clinical evaluation was done 7 days and 2 months after treatment.

RESULTS

Thirty-six patients (21 female/15 male) were included. Age ranged from 8 to 19 years (mean 12.94+/-2.89 years). On intention-to-treat analysis (n = 36), eradication rate was 83.3% (95%CI 77.1-89.5) whereas in per-protocol analysis (n = 29), it was 89.7% (95%CI 84.6-94.7). Compliance was better when doxycycline was used, but the success rates were similar for the two tetracyclines. There was no variable associated with treatment failure. Side effects were reported in 17 patients (47.2%), mainly abdominal pain (11/30.5%), nausea (seven/19.4%) and vomiting (five/13.9%).

CONCLUSION

Triple therapy with furazolidone and tetracycline is a low-cost alternative regimen to treat H. pylori infection.

The regular arrangement of collecting venules pattern evaluated by standard endoscope and the absence of antrum nodularity are highly indicative of Helicobacter pylori uninfected gastric mucosa

AIM

To evaluate the accuracy of antrum nodularity and the regular arrangement of collecting venules for diagnosing Helicobacter pylori gastritis.

METHODS

Ninety-nine consecutive children and adolescents (1.07 years-17.69 years, mean+/-S.D.=9.71+/-3.80 F:M 54:45) undergoing upper digestive endoscopy were assessed for the presence of antrum nodularity and regular arrangement of collecting venules pattern to determine the status of H. pylori infection. Antrum nodularity was observed by a tangential view of the greater curvature of the gastric antrum. Regular arrangement of collecting venules was visualized as being the regular pattern of red points evaluated with a standard endoscope. Two biopsies from the antrum were collected for histology and rapid urease test. The accuracy of diagnosis based on antrum nodularity and regular arrangement of collecting venules was evaluated considering the sensitivity, specificity and likelihood ratio.

RESULTS

H. pylori was detected in 32/99 patients (32.3%). Antrum nodularity provided 59.4% sensitivity (95% confidence interval 50.7-68.1), 98.5% specificity (95% confidence interval: 97-100), likelihood ratio+ 39.78, and likelihood ratio- 0.41. A regular arrangement of collecting venules pattern provided 96.9% sensitivity (95% confidence interval: 93.8-100), 88.1% specificity (95% confidence interval: 84.1-92), likelihood ratio+ 8.11, and likelihood ratio- 0.04.

CONCLUSION

Antrum nodularity is a specific finding, although its sensitivity is low. A regular arrangement of collecting venules pattern and the absence of antrum nodularity are highly indicative of normal gastric mucosa that is negative for Helicobacter pylori.

Furazolidone-based triple therapy for H pylori gastritis in children

AIM: To evaluate the furazolidone-based triple therapy in children with symptomatic H pylori gastritis.

METHODS: A prospective and consecutive open trial was carried out. The study included 38 patients with upper digestive symptoms sufficiently severe to warrant endoscopic investigation. H pylori status was defined based both on histology and on positive ¹³C-urea breath test. Drug regimen was a seven-day course of omeprazole, clarithromycin and furazolidone (100 mg, 200 mg if over 30 kg) twice daily. Eradication of H pylori was assessed two months after treatment by histology and ¹³C-urea breath test. Further clinical evaluation was performed 7 d, 2 and 6 mo after the treatment.

RESULTS: Thirty-eight patients (24 females, 14 males) were included. Their age ranged from 4 to 17.8 (mean 10.9 ± 3.7) years. On intent-to-treat analysis (n = 38), the eradication rate of H pylori was 73.7% (95% CI, 65.2%-82%) whereas in per-protocol analysis (n = 33) it was 84.8% (95% CI, 78.5%-91%). All the patients with duodenal ulcer (n = 7) were successfully treated (100% vs 56.2% with antral nodularity). Side effects were reported in 26 patients (68.4%), mainly vomiting (14/26) and abdominal pain (n = 13). Successfully treated dyspeptic patients showed improvement in 78.9% of H pylori-negative patients after six months and in 50% of H pylori-positive patients after six months of treatment.

CONCLUSION: Triple therapy with furazolidone achieves moderate efficacy in H pylori treatment. The eradication rate seems to be higher in patients with duodenal ulcer.

Urease activity does not reflect the degree of colonization by Helicobacter pylori in children

BACKGROUND

Urea breath test is an accurate method for the diagnosis of Helicobacter pylori infection in children. This test could estimate the bacterial load by measuring the urease activity in gastric mucosa. The aim of the study was to correlate the result of 13C-urea breath test (13C-UBT) and histological estimative for bacterial colonization and severity of inflammatory infiltrate.

METHODS

Forty-four patients (mean age 8.54 +/- 3.9 years) with dyspeptic symptoms were evaluated. Patients were evaluated through endoscopy and 13C-UBT. Helicobacter pylori infection was defined by histology, rapid urease test and 13C-UBT. Breath test results were expressed by delta over baseline (DOB) and urea hydrolysis rate (UHR). Test results were treated logarithmically for statistical analysis.

RESULTS

There was a significant inverse correlation between age and Log DOB (-0.501, P= 0.0005), but there was no relationship between Log UHR and age (-0.148, P= 0.336). The study did not find correlation between the breath test result and histological grades for mononuclear infiltrate, neutrophilic infiltrate and bacterial density.

CONCLUSION

The 13C-UBT does not estimate the severity of histological findings in children with Helicobacter pylori infection. The results of the breath test should be interpreted in a qualitative way.

13C-urea breath test to diagnose Helicobacter pylori infection in children aged up to 6 years

BACKGROUND

13C-urea breath test (13C-UBT) is an accurate noninvasive tool for diagnosis of Helicobacter pylori infection. It is considered the best method for epidemiological studies, but there are few studies to evaluate the 13C-UBT in infants and toddlers.

AIM

To evaluate the 13C-UBT performed with infrared spectroscopy in children aged up to 6 years.

PATIENTS

Sixty-eight patients (6 months. to 5 years 11 months.) were evaluated prospectively and consecutively.

METHODS

Helicobacter pylori infection was detected by positive culture, or rapid urease test and histological examination, both positive. 13C-UBT was performed with 50 mg of 13C-urea diluted in 100 ml of commercial orange juice. Two expired air samples were collected: before and 30 minutes after tracer ingestion. Cutoff of delta over baseline (DOB) was 4.0 per thousand and urea hydrolysis rate 10 microg/minute.

RESULTS

Fifteen of 68 (22.1%) patients were H. pylori infected. Sensitivity was 93.3% (95% CI; 86.8%-99.7%) and specificity was 96.2% (95% CI; 93.6%-98.8%), and these values were equal for DOB and urea hydrolysis rate. Negative DOB values in noninfected patients ranged from -1.5 per thousand to 2.6 per thousand and positive DOB values ranged from 10.8 per thousand to 105.5 per thousand. There was no relationship between DOB values and age. Conclusion. 13C-UBT performed with infrared spectroscopy proved to be a reliable and accurate noninvasive diagnostic tool for H. pylori infection detection in children aged up to 6 years. Results far from cutoff value can clearly distinguish positive from negative 13C-UBT results in children up to 6 years old.

[Hemorrhagic gastritis due to cow's milk allergy: report of two cases]

OBJECTIVE

To report two cases of infants with hemorrhagic gastritis due to cow's milk allergy.

DESCRIPTION

The clinical features included hematemesis, vomiting and malnutrition. All patients had eosinophilic infiltrate in gastric biopsies and got favorable clinical outcome after cow's milk free diet.

COMMENTS

Hemorrhagic gastritis due to cow's milk allergy is an uncommon diagnosis. Clinical findings in 10 patients (including ours) reported with allergic gastritis were vomiting, malnutrition, anemia, and hematemesis. Gastritis occurs in cow's milk allergy in a wide range of severity, and it could remain hidden in most patients. Unless appropriate management is ensued, patients develop severe malnutrition and severe anemia. Allergic compromise of upper gastrointestinal tract might be considered in all vomiting infants particularly if complicated by hematemesis. Diagnosis of allergic gastritis relies on clinical suspicion helped by endoscopy and gastric biopsies.

13 C-urea breath test with infrared spectroscopy for diagnosing helicobacter pylori infection in children and adolescents

BACKGROUND AND OBJECTIVE

Studies support the accuracy of 13C-urea breath test for diagnosing and confirming cure of Helicobacter pylori infection in children. Three methods are used to assess 13CO2 increment in expired air: mass spectrometry, infrared spectroscopy, and laser-assisted ratio analysis. In this study, the 13C-urea breath test performed with infrared spectroscopy in children and adolescents was evaluated.

METHODS

Seventy-five patients (6 months to 18 years old) were included. The gold standard for diagnosis was a positive culture or positive histology and a positive rapid urease test. Tests were performed with 50 mg of 13C-urea diluted in 100 mL orange juice in subjects weighing up to 30 kg, or with 75 mg of 13C-urea diluted in 200 mL commercial orange juice for subjects weighing more than 30 kg. Breath samples were collected just before and at 30 minutes after tracer ingestion. The 13C-urea breath test was considered positive when delta over baseline (DOB) was greater than 4.0%.

RESULTS

Tests were positive for H. pylori in 31 of 75 patients. Sensitivity was 96.8%, specificity was 93.2%, positive predictive value was 90.9%, negative predictive value was 97.6%, and accuracy was 94.7%.

CONCLUSIONS

13C-urea breath test performed with infrared spectroscopy is a reliable, accurate, and noninvasive diagnostic tool for detecting H. pylori infection.

[Cryptosporidiosis and persistent diarrhea]

OBJECTIVE: The association between cryptosporidiosis and persistent diarrhea has been studied in many countries. The aim of this study was to verify the incidence of this parasite in children with persistent diarrhea. Children infected or not with protozoan cryptosporidium were compared in relation to laboratory and clinic analysis.METHODS: Retrospective study in 70 inmate suckling at pediatrics hospital due persistent diarrhea, younger than 2 year, negative HIV, and other causes of diarrhea were ruled out. The duration of diarrhea, hospitalization, clinic modifications, preceding history of diarrhea, nutrition, d-xilosis and diet management were appraised.RESULTS: Criptosporidium sp was founded in 14 (20%) sucking and it was more frequent between children younger than 3 months (13/57, 23%). The duration of hospitalization and diarrhea were similar in both. Malnutrition was been present in 91.5% of patients, 13/14 of infected cryptosporidium children and 51/56 of not infected. The diet management was similar in both. There was a tendency to underdose xilosis of infected patients; mainly at the first year of life (15.9 +/- 8.2 and 33.8 +/- 19.9 p=0.007). CONCLUSION: Cryptosporidiosis is frequent in children with persistent diarrhea. Nevertheless, the infected patients did not differ of others if we consider theirs clinics, prognosis and therapeutics characteristics.

2-Oxo-3-alkynoic acids, universal mechanism-based inactivators of thiamin diphosphate-dependent decarboxylases: synthesis and evidence for potent inactivation of the pyruvate dehydrogenase multienzyme complex

A new class of compounds, the 2-oxo-3-alkynoic acids with a phenyl substituent at carbon 4 was reported by the authors as potent irreversible and mechanism-based inhibitors of the thiamin diphosphate- (ThDP-) dependent enzyme pyruvate decarboxylase [Chiu, C.-F., & Jordan, F. (1994) J. Org. Chem. 59, 5763-5766]. The method has been successfully extended to the synthesis of the 4-, 5-, and 7-carbon aliphatic members of this family of compounds. These three compounds were then tested on three ThDP-dependent pyruvate decarboxylases: the Escherichia coli pyruvate dehydrogenase multienzyme complex (PDHc) and its E1 (ThDP-dependent) component, pyruvate oxidase (POX, phosphorylating; from Lactobacillus plantarum),and pyruvate decarboxylase (PDC) from Saccharomycescerevisiae. All three enzymes were irreversibly inhibited by the new compounds. The 4-carbon acid is the best substrate-analog inactivator known to date for PDHc, more potent than either fluoropyruvate or bromopyruvate. The following conclusions were drawn from extensive studies with PDHc: (a) The kinetics of inactivation of PDH complexes and of resolved E1 by 2-oxo-3-alkynoic acids is time- and concentration-dependent. (b) The 4-carbon acid has a Ki 2 orders of magnitude stronger than the 5-carbon acid, clearly demonstrating the substrate specificity of PDHc. (c) The rate of inactivation of PDH complexes and of resolved E1 by 2-oxo-3-alkynoic acids is enhanced by the addition of ThDP and MgCl2. (d) Pyruvate completely protects E1 and partially protects PDHc from inactivation by 2-oxo-3-butynoic acid. (e) E1 but not E2-E3 is the target of inactivation by 2-oxo-3-butynoic acid. (f) Inactivation of E1 by 2-oxo-3-butynoic acid is accompanied by modification of 1.3 cysteines/E1 monomer. The order of reactivity with the 4-carbon acid was PDHc > POX > PDC. While the order of reactivity with PDHc and POX was 2-oxo-3-butynoic acid > 2-oxo-3-pentynoic acid > 2-oxo-3-heptynoic acid, the order of reactivity was reversed with PDC.

Effect of substitutions in the thiamin diphosphate-magnesium fold on the activation of the pyruvate dehydrogenase complex from Escherichia coli by cofactors and substrate

The homotropic regulation of the Escherichia coli pyruvate dehydrogenase multienzyme complex (PDHc) by its coenzyme thiamin diphosphate and its substrate pyruvate was re-examined with complexes containing three and one lipoyl domains per E2 chain, and several variants of the latter, containing substitutions in the putative thiamin diphosphate fold of E1 (G231A, G231S, C259S, C259N, and N258Q). It was found that all of the E1 variants had significantly reduced specific activities, as reported elsewhere (Russell, G. C., Machado, R. S., and Guest, J. R. (1992) Biochem. J. 287, 611-619). In addition, extensive kinetic studies were performed in an attempt to determine the effects of the amino acid substitutions on the Hill coefficients with respect to thiamin diphosphate and pyruvate. All but one of the variants were incapable of being saturated with thiamin diphosphate, even at concentrations > 5 mM. Most importantly, the striking activation lag phase lasting for many seconds in the parental complexes containing three and one lipoyl domains per E2 chain was totally eliminated in the variants. Furthermore, activation by the coenzyme was localized to the E1 subunit, because resolved E1 exhibits virtually the same behavior during the activation lag phase as does the complex. In the parental complexes two distinct lag phases could be resolved, the duration of both decreases with increasing ThDP concentration. A mechanism that is consistent with all of the kinetic data on the parental complexes involves rapid equilibration of the first ThDP with the E1 dimer, followed by a slow conformational equilibration, that in turn is followed by slow addition of the second ThDP to form the fully activated dimer. When the diphosphate site is badly impaired, the binding affinity is very much reduced, this perhaps eliminates the slow step leading to the activated dimer form of the E1.

Mobility in pyruvate dehydrogenase complexes with multiple lipoyl domains

High-field NMR studies were carried out with genetically-reconstructed pyruvate dehydrogenase (PDH) complexes of Escherichia coli containing from zero to nine lipoyl domains per lipoate acetyltransferase (E2p) subunit. The only significant differences between the NMR spectra were the increasing intensities of the signals derived from the lipoyl domains and their associated linkers, and the much enhanced signal from the E3-binding domain and its linker in complexes that are devoid of lipoyl domains. The results suggest an explanation for the presence of three lipoyl domains per E2p subunit in the wild-type PDH complex, based on its greater inherent mobility, and potentially more efficient active-site coupling, than any of the other complexes.

Construction and properties of pyruvate dehydrogenase complexes with up to nine lipoyl domains per lipoate acetyltransferase chain

The lipoate acetyltransferase (E2p) subunits of the pyruvate dehydrogenase (PDH) complex of Escherichia coli have three tandemly repeated lipoyl domains, although net deletions of one or two has no apparent effect on the activity of the purified complexes. Plasmids containing IPTG-inducible aceEF-lpd operons, which encode PDH complexes bearing from one to nine lipoyl domains per E2p chain (24-216 per complex), were constructed. They were all capable of restoring the nutritional lesion of a strain lacking PDH complex and they all expressed active sedimentable multienzyme complexes having a relatively normal range of subunit stoichiometries. The extra domains are presumed to protrude from the E2p core (24-mer) without significantly affecting the assembly of the E1p and E3 subunits on the respective edges and faces of the cubic core. However, the catalytic activities of the overproduced complexes containing four to nine lipoyl domains per E2p chain were lower than those with fewer lipoyl domains. This could be due to under-lipoylation of the domains participating in catalysis and interference from unlipoylated domains.

Overproduction of the pyruvate dehydrogenase multienzyme complex of Escherichia coli and site-directed substitutions in the E1p and E2p subunits

The aceEF-lpd operon of Escherichia coli encodes the pyruvate dehydrogenase (E1p), dihydrolipoamide acetyltransferase (E2p) and dihydrolipoamide dehydrogenase (E3) subunits of the pyruvate dehydrogenase multienzyme complex (PDH complex). An isopropyl beta-D-thiogalactopyranoside-inducible expression system was developed for amplifying fully lipoylated wild-type and mutant PDH complexes to over 30% of soluble protein. The extent of lipoylation was related to the degree of aeration during amplification. The specific activities of the isolated PDH complexes and the E1p component were 50-75% of the values normally observed for the unamplified complex. This could be due to altered stoichiometries of the overproduced complexes (higher E3 and lower E1p contents) or inactivation of E1p. The chaperonin, GroEL, was identified as a contaminant which copurifies with the complex. Site-directed substitutions of an invariant glycine residue (G231A, G231S and G231M) in the putative thiamine pyrophosphate-binding fold of the E1p component had no effect on the production of high-molecular-mass PDH complexes but their E1p and PDH complex activities were very low or undetectable, indicating that G231 is essential for the structural or catalytic integrity of E1p. A minor correction to the nucleotide sequence, which leads to the insertion of an isoleucine residue immediately after residue 273, was made. Substitution of the conserved histidine and arginine residues (H602 and R603) in the putative active-site motif of the E2p subunit confirmed that H602 of the E. coli E2p is essential, whereas R603 could be replaced without inactivating E2p. Deletions affecting putative secondary structural elements at the boundary of the E2p catalytic domain inhibited catalytic activity without affecting the assembly of the E2p core or its ability to bind E1p, indicating that the latter functions are determined elsewhere in the domain. The results further consolidate the view that chloramphenicol acetyltransferase serves as a useful structural and functional model for the catalytic domain of the lipoate acyltransferases.

Evidence for two protein-lipoylation activities in Escherichia coli

The lipoate acyltransferase subunits of the 2-oxo acid dehydrogenase complexes are post-translationally modified with one or more covalently-bound lipoyl cofactors. Two distinct lipoate-protein ligase activities, LPL-A and LPL-B, have been detected in E. coli by their ability to modify purified lipoyl apo-domains of the bacterial pyruvate dehydrogenase complex. Both enzymes require ATP and Mg2+, use L-lipoate, 8-methyllipoate, lipoyl adenylate and octanoyl adenylate as substrates, and both activate lipoyl-deficient pyruvate dehydrogenase complexes. In contrast, only LPL-B uses D-lipoate and octanoate and there are differences in the metal-ion and phosphate requirements. It is suggested that LPL-B may be responsible for the octanoylation of lipoyl domains observed previously under lipoate-deficient conditions.