Prevalensi Infeksi Helicobacter pylori pada Anak dengan Gejala Gastrointestinal di Rumah Sakit Umum Pusat Dr. Sardjito Yogyakarta

Latar belakang. Prevalensi infeksi Helicobacter pylori (H. pylori) di berbagai wilayah bervariasi. Infeksi H. pylori pada anak umumnya tidak menunjukkan gejala khas, tetapi dapat mengakibatkan berbagai komplikasi. Tujuan. Melihat prevalensi dan gejala infeksi H. pylori pada anak dengan gejala gastrointestinal di Yogyakarta.Metode. Data dikumpulkan dari pasien anak dengan keluhan dispepsia, nyeri perut berulang, muntah berulang, dan buang air besar disertai darah yang dicurigai mengalami infeksi H. pylori di RSUP. Dr. Sardjito, Yogyakarta. Diagnosis infeksi H. pylori ditegakkan dengan pemeriksaan endoskopi dan histologi.Hasil. Didapatkan 138 subyek yang memenuhi kriteria kemungkinan terinfeksi oleh kuman H. pylori didapatkan pada 16,7% (23/138) pasien anak. Prevalensi infeksi menurut usia pada 3-5 tahun sebesar 14,3% (3/21), usia 6-11 tahun sebesar 16,7% (10/60), dan usia 12-18 tahun sebesar 17,5% (10/57). Tidak ada hubungan bermakna antara infeksi H. pylori dengan gejala spesifik tertentu.Kesimpulan. Prevalensi infeksi H. pylori pada anak yang bergejala klinis di Yogyakarta, Indonesia lebih rendah daripada dari wilayah lain di dunia.

Erasmus Guillain-Barre Syndrome Outcome Score (EGOS) to predict functional outcomes

  Background Guillain-Barre syndrome (GBS) has a highly diverse clinical course and prognosis. Predicting functional  outcomes  is needed in order to give appropriate treatment and counseling. Erasmus Guillaine-Barre Syndrome Outcome Score (EGOS) is simple scoring based on age onset, pre existing diarhea and GDS score obtained from  medical record and physical findings that can be used by clinician to predict the functional outcomes  of the child with GBS.. Objective To assess the usefulness of EGOS to predict functional  outcomes  of GBS patients. Methods A retrospective cohort study to see the functional outcomes which is walking or not walking of children with GBS aged 6 months to 18 years hospitalized in RSUP Dr. Sardjito, Yogyakarta from 2014 to 2019 were enrolled by a purposive sampling method. Bivariate and logistic regression multivariate backward method analyses were used to assess for possible correlations between predictive factors and functional  outcomes  in GBS patients. Results A total of 33 patients were enrolled and analyzed. After six months of weakness, 57.1% of patients with high EGOS (> 4) had poor functional  outcomes  according to the Hughes scale, scoring to asses functional  outcomes . Patient with high EGOS (> 4) had greater risk of poor functional  outcomes  compared to patients with lower EGOS (≤ 4) (P=0.006; OR 33.3; 95%CI 2.74 to 404.94). Poor functional  outcomes  of GBS patients was not influenced by preceding upper respiratory tract infection, cranial nerve involvement, use of ventilator, autonomic dysfunction, immunotherapy, complicating disease, rehabilitation, or nutritional status. Conclusion High EGOS of >4 is a predictor for poor functional  outcomes  in children with GBS.

Predictor of Liver Biochemistry Improvement in Patients with Cytomegalovirus Cholestasis after Ganciclovir Treatment

PURPOSE

Cholestasis resulting from cytomegalovirus (CMV)-induced hepatitis manifests in 40% of patients with a CMV infection. Ganciclovir treatment in children with CMV infections has proven to be highly effective. Until now, there are very few studies have identified predictive factors for liver biochemistry improvement after ganciclovir therapy. This study aimed to identify the predictors of liver biochemistry improvement in patients with CMV cholestasis after ganciclovir treatment.

METHODS

A retrospective cohort study was conducted using medical records from Dr. Sardjito General Hospital Yogyakarta, Indonesia from 2013 to 2018. CMV cholestasis was confirmed based on serum CMV IgG and IgM positivity and/or blood and urine CMV antigenemia positivity. Incomplete medical records and other etiologies for cholestasis, such as biliary atresia, choledochal cyst, metabolic diseases, and Alagille syndrome, were excluded. Patient age at cholestasis diagnosis and ganciclovir treatment, duration of CMV cholestasis, history of prematurity, central nervous system involvement, and nutritional status were analyzed and presented as an odds ratio (OR) with a 95% confidence interval (95% CI).

RESULTS

CMV cholestasis with ganciclovir therapy was found in 41 of 54 patients. Multivariate analysis showed that a shorter duration of CMV cholestasis (OR: 4.6, 95% CI: 1.00-21.07, p=0.04) was statistically significant for liver biochemistry improvement after 1 month of ganciclovir treatment. The remaining factors that were analyzed were not significant predictors of liver biochemistry improvement in patients with CMV cholestasis after ganciclovir treatment.

CONCLUSION

A shorter duration of CMV cholestasis is the predictor of liver biochemistry improvement after 1 month gancyclovir treatment.

Case Report: Complicated Meckel Diverticulum Spectrum in Children

Background: Meckel diverticulum (MD) is the most common congenital anomaly of the intestines, with an incidence of 2% of the general population. It can present as various clinical features with complications and be life threatening if diagnosis is delayed and treatment late.

Case Presentation: We report three pediatric cases with complicated MD: one female presented with small-bowel obstruction, one male with peritonitis, and one female with severe iron-deficiency anemia, without gross gastrointestinal bleeding nor any ectopic gastric mucosa. All patients underwent exploratory laparotomy, segmental small-bowel resection, and primary anastomosis. They successfully recovered and were uneventfully discharged on the fourth, seventh, and 10th postoperative days, respectively.

Conclusions: MD can present with various complication spectrums, including small-bowel obstruction, peritonitis, and severe iron-deficiency anemia, which may cause difficulty in definitive diagnosis, particularly in children. Segmental small-bowel resection and primary anastomosis are effective surgical approaches and show good outcomes for MD patients.

Comparison of nutritional status among children with biliary atresia according to age at the time of Kasai procedure

Background  Recent studies revealed better outcomes among children with biliary atresia (BA) who underwent Kasai procedure at 60 to 90 days of age. Delayed Kasai procedure has a high risk of complications, including nutritional deficits which lead to malnutrition. Objective To determine the nutritional status of children with BA according to age at the time of Kasai procedure. Methods Using medical records, we conducted a retrospective study in children with BA based on magnetic resonance cholangiopancreatography (MRCP) or intraoperative cholangiography, who were admitted between 2015 to 2017 and underwent Kasai surgery at Dr. Sardjito General Hospital, Yogyakarta. Nutritional status was evaluated on the day before Kasai procedure, and classified into 4 groups of subjects based on age at the time the children underwent Kasai procedure (<60 days, 60-90 days, >90-120 days, and >120 days). Normal distribution data was analyzed with Saphiro-Wilk test and mean T-test was used to compare mean age at the time of Kasai procedure between groups of well-nourished and malnourished subjects. Results A total of 39 children with BA underwent Kasai procedure. Of 3 children who underwent Kasai procedure at <60 days of age, 2 were well-nourished and 1 was malnourished. Of the 12 children who underwent Kasai procedure at 60-90 days of age, 6 were well-nourished and 6 were malnourished. Of the 7 children who underwent Kasai procedure at >90-120 days of age, 4 were well-nourished and 3 were malnourished. Of 17 children who underwent Kasai procedure at >120 days of age, 5 were well-nourished and 12 were malnourished. The means of age at the time of Kasai procedure were higher in malnourished subject than well-nourished. Conclusion The highest prevalence of malnourishment is seen in children with biliary atresia who underwent Kasai procedure at >120 days of age.

Nutritional therapy and caloric achievement within the first week of PICU admission

Background Nutritional therapy is an important aspect in managing PICU patients. Careful decisions should be made regarding initiation, route of administration, and achievement based on caloric requirements. Many conditions could affect the application of nutritional therapy.Objective To investigate the implementation of nutritional therapy during the 1st week after PICU admission.Methods We conducted a retrospective study involving 156 children aged 1 month-18 years who were hospitalized for at least 4 days in the PICU during the period of  January 1st, 2015 to  December 31st, 2015. Subjects were divided into three groups according to initiation time of caloric administration, which were: category I (within the first 24 hours of PICU admission), category II (within the first 25-48 hours of PICU admission), and category III: (more than 48 hours after PICU admission). Caloric requirement was calculated using the Caldwell or Schofield formula, whilst caloric achievement was figured up from PICU daily monitoring sheets containing nutritional therapy given to the subjects.Results Of 131 subjects, 72 (55%) had good nutritional status and 59 (45%) children had malnutrition. Caloric administration was initiated within 24 hours of admission in 101 (77.1%) patients, of whom 90 (89.1%) patients received enteral feeding. Nineteen (14.5%) patients received their initial calories within 25-48 hours of admission, with 16 (84.2%) using the enteral route. At the 4th and 7th days of hospitalization, 93 (71%) and 107 (81.7%) patients achieved >70% of their caloric requirements. Delays in feeding initiation were due to shock, gastrointestinal bleeding, inotropic support, and feeding intolerance, which reduced caloric achievement.Conclusion Most patients receive nutritional therapy in the first 48 hours after PICU admission and achieve >70% of their caloric requirements at the 4th day of hospitalization. The enteral route is preferred. Delayed initiation of nutritional therapy reduce caloric achievement.

Nutritional therapy and caloric achievement within the first week of PICU admission

Background Nutritional therapy is an important aspect in managing PICU patients. Careful decisions should be made regarding initiation, route of administration, and achievement based on caloric requirements. Many conditions could affect the application of nutritional therapy.Objective To investigate the implementation of nutritional therapy during the 1st week after PICU admission.Methods We conducted a retrospective study involving 156 children aged 1 month-18 years who were hospitalized for at least 4 days in the PICU during the period of  January 1st, 2015 to  December 31st, 2015. Subjects were divided into three groups according to initiation time of caloric administration, which were: category I (within the first 24 hours of PICU admission), category II (within the first 25-48 hours of PICU admission), and category III: (more than 48 hours after PICU admission). Caloric requirement was calculated using the Caldwell or Schofield formula, whilst caloric achievement was figured up from PICU daily monitoring sheets containing nutritional therapy given to the subjects.Results Of 131 subjects, 72 (55%) had good nutritional status and 59 (45%) children had malnutrition. Caloric administration was initiated within 24 hours of admission in 101 (77.1%) patients, of whom 90 (89.1%) patients received enteral feeding. Nineteen (14.5%) patients received their initial calories within 25-48 hours of admission, with 16 (84.2%) using the enteral route. At the 4th and 7th days of hospitalization, 93 (71%) and 107 (81.7%) patients achieved >70% of their caloric requirements. Delays in feeding initiation were due to shock, gastrointestinal bleeding, inotropic support, and feeding intolerance, which reduced caloric achievement.Conclusion Most patients receive nutritional therapy in the first 48 hours after PICU admission and achieve >70% of their caloric requirements at the 4th day of hospitalization. The enteral route is preferred. Delayed initiation of nutritional therapy reduce caloric achievement.

Profil dan temuan klinis pasien perdarahan saluran cerna di Departemen Kesehatan Anak RSUP Dr. Sardjito 2009 - 2015

Latar belakang. Perdarahan saluran cerna pada anak merupakan salah satu tanda bahaya sehingga diagnosis dan pengobatan dini sangat penting.Tujuan. Mengetahui etiologi dan temuan klinis perdarahan saluran cerna anak yang dirawat di RSUP Dr. Sardjito.Metode. Penelitian retrospektif menggunakan rekam medis pasien anak berusia kurang dari 18 tahun yang menjalani endoskopi dan kolonoskopi karena perdarahan saluran cerna dari Januari 2009 hingga Juni 2015. Data rekam medis yang tidak lengkap tidak diikutkan sertakan dalam penelitian.Hasil. Dari 55 pasien yang memenuhi syarat, terdapat 27 (49%) pasien perdarahan saluran cerna atas dan 28 (51%) pasien perdarahan saluran cerna bawah. Varises esofagus adalah etiologi terbanyak perdarahan saluran cerna atas 10 (37%), sedangkan untuk perdarahan saluran cerna bawah adalah kolitis 17 (60%). Perdarahan saluran pada anak lebih sering terjadi pada perempuan usia 1-6 tahun 29 (53%). Gejala yang lebih sering terjadi yaitu hematemesis 13 (24%) dan hematokezia 27 (49%). Keluhan perdarahan saluran cerna atas terbanyak adalah nyeri perut 13 (48%) sedangkan saluran cerna bawah adalah diare 8 (29%). Anemia berat ditemukan pada 5 (19%) pasien perdarahan saluran cerna atas dan 1 (4%) pasien perdarahan saluran cerna bawah.Kesimpulan. Varises esofagus merupakan penyebab tersering perdarahan saluran cerna atas sedangkan saluran cerna bawah adalah kolitis. Anak yang datang dengan keluhan nyeri perut dan diare harus dipikirkan salah satu penyebabnya adalah perdarahan saluran cerna.

Diare Rotavirus pada Anak Usia Balita

Latar belakang. Rotavirus merupakan penyebab tersering diare akut berat pada anak balita. Peningkatan yang pesat di bidang teknologi diagnostik memungkinkan dilakukan identifikasi genotipe rotavirus penyebab diare. Belum banyak penelitian di Indonesia yang melaporkan hubungan antara genotipe rotavirus dengan manifestasi klinisnya. Tujuan. Mengetahui hubungan antara genotipe rotavirus dengan gambaran klinis.Metode. Penelitian potong lintang dengan subyek pasien diare akut yang berobat di Poliklinik Anak atau dirawat inap di RS DR Sardjito. Subyek yang bersedia berpartisipasi dalam penelitian diambil data klinis dan sampel tinja untuk dilakukan pemeriksaan rotavirus dengan enzyme immunoassaydan deteksi genotipe dengan pemeriksaan RT-PCR (Gentsch, 1992). Dilakukan penilaian derajat keparahan diare menggunakan 20-point severity scoring systemyang dimodifikasiHasil.Selama Januari 2006 - Maret 2007 didapatkan 353 kasus diare akut, 116 (32,68%) di antaranya positif terinfeksi rotavirus. Prevalensi tertinggi dijumpai pada kelompok usia 6-23 bulan (65,5%). Diare rotavirus menunjukkan gejala klinis yang lebih berat (severity score>11) dibanding diare karena penyebab lain (RR=1,27, IK 95% 1,08-1,49). Jenis genotipe rotavirus yang paling banyak ditemukan adalah G1 (27,5%) diikuti dengan G9 (18%), G2 (17%), G4 (3%), G3 (2%). Kombinasi G-P terbanyak adalah G1 P[6] (20%). Tipe untypeable(28.6%) dan G 1 (28.6%) paling sering memberikan gejala klinis berat (severity scoring >11) diikuti dengan G 9 (23.8%). Kesimpulan. Pasien diare rotavirus yang untypeable dan G 1 lebih sering mengalami dehidrasi dan muntah serta memberikan gambaran klinis yang lebih berat. Sangat penting mendeteksi lebih jauh jenis genotipe dari untypeableuntuk kepentingan pembuatan vaksin rotavirus yang mampu melindungi terhadap berbagai macam galur rotavirus.

RET and EDNRB mutation screening in patients with Hirschsprung disease: Functional studies and its implications for genetic counseling

Hirschsprung disease (HSCR) is a major cause of chronic constipation in children. HSCR can be caused by germline mutations in RET and EDNRB. Defining causality of the mutations identified is difficult and almost exclusively based on in silico predictions. Therefore, the reported frequency of pathogenic mutations might be overestimated. We combined mutation analysis with functional assays to determine the frequencies of proven pathogenic RET and EDNRB mutations in HSCR. We sequenced RET and EDNRB in 57 HSCR patients. The identified RET-coding variants were introduced into RET constructs and these were transfected into HEK293 cells to determine RET phosphorylation and activation via ERK. An exon trap experiment was performed to check a possible splice-site mutation. We identified eight rare RET-coding variants, one possible splice-site variant, but no rare EDNRB variants. Western blotting showed that three coding variants p.(Pr270Leu), p.(Ala756Val) and p.(Tyr1062Cys) resulted in lower activation of RET. Moreover, only two RET variants (p.(Ala756Val) and p.(Tyr1062Cys)) resulted in reduced ERK activation. Splice-site assays on c.1880-11A>G could not confirm its pathogenicity. Our data suggest that indeed almost half of the identified rare variants are proven pathogenic and that, hence, functional studies are essential for proper genetic counseling.

Reducing dyspeptic symptoms in children: proton pump inhibitor vs. H2 receptor antagonist

Background Dyspepsia is known as a leading cause of uppergastrointestinal tract morbidity. If left untreated, dyspepsia maybecome chronic. Dyspeptic symptoms manifest as epigastricpain, heartburn, nausea, hematemesis, or melena. Experimentalstudies have shown that omeprazole is more effective at reducingheartburn than ranitidine in adults. However, there have beenfew studies comparing the effects of proton pump inhibitorsto Hz receptor antagonists for reducing dyspeptic symptoms inchildren.Objective To compare the effect of omeprazole with ranitidinefor reducing dyspeptic symptoms .Methods We performed a double-blind randomized controlledtrial (RCT) at Sardjito Hospital and three community h ealthcenters in the Sleman District from June to November 2012.We recruited children aged 3-18 years with dyspepsia. Subjectswere allocated into two groups using block randomization:the proton pump inhibitor (omeprazole) and the Hz receptorantagonist (ranitidine) groups. According to the groups, eitheromeprazole (0.4-0 .8 mg/kg/dose) or ranitidine (2-4 mg/kg/dose) ,respectively, were taken twice daily for 5 days. Dyspepsia wasclinically diagnosed using the new Rome III criteria. Both groupswere monitored for 5 days to assess for a reduction of dyspepticsymptoms.Results Significantly more subjects in the omeprazole grouprecovered from dyspeptic symptoms than in the ranitidine group(RR= 4.87; 95%CI 1.5 to 15.3; P=0.005).Conclusion Omeprazole was 4.87 (95% CI 1.5 to 15.3) timesbetter than ranitidine in reducing dyspeptic symptoms on childrenaged 3-18 years with dyspepsia.

Surveillance of rotavirus diarrhea

Background Rotavirus is a major cause of severe diarrhea anddehydration in children worldwide. Data on the burden of diseasein Indonesia is limited.Objective To provide an epidemiological profile of rotavirusinfection among children hospitalized for diarrhea in MohammadHoesin Hospital, Palembang.Methods In January- December 2006, a prospective, hospitalbasedsurveillance was carried out in children aged less thanfive years, presenting with diarrhea. Stool samples wereexamined for rotavirus using enzyme immunoassay (EIA).G- and P-typing were performed on specimens confirmed tobe positive by EIA.Results A total of 513 fecal specimens from 534 children weretested for rotavirus. Rotavirus was detected in 64% of thespecimens, mostly of the G9 type (62.5%). Incidence ofrotavirusdiarrhea was highest in the 6 month to 2 years age group (60.4%).Children with rotavirus diarrhea were more likely to present withdehydration, compared to those with non-rotavirus diarrhea (94%vs 70%, respectively, P=0.03).Conclusion Rotavirus was the most common pathogen foundin children with diarrhea. Rotavirus was detected in 64% ofpediatric diarrheal specimens tested in our study. This findingwarrants the use of a large-scale program to prevent disease,such as vaccination against rotavirus. [Paediatr lndones.2012;52:22-7].

Burden of severe rotavirus diarrhea in indonesia

Globally, rotavirus is the leading cause of diarrhea-related hospitalizations and deaths among young children, but the burden of rotavirus disease in Indonesia is poorly documented. From January through December 2006, we conducted prospective surveillance (inpatient and outpatient) among children aged <5 years at 6 hospitals in 6 provinces of Indonesia, using standardized methodology. Of 2240 enrolled children hospitalized for diarrhea, 1345 (60%) were rotavirus positive. Of 176 children enrolled in outpatient clinics in 3 hospitals, 73 (41%) were rotavirus positive. Among children hospitalized for diarrhea, dehydration was more common among those who tested positive for rotavirus than among those who did not (91% vs 82%; P < .05), as was vomiting (86% vs 67%; P < .05). Children aged 6-23 months experienced 72% of all rotavirus episodes. Rotavirus prevalence increased slightly in the cool, dry season. The most commonly detected genotypes were G9 (30%) and P[6] (56%). G1P[6] and G9P[6] accounted for 34% and 21% of strains, respectively. A high proportion of genotype P[6] was detected, in combination with the common G types G1 and G9. Available rotavirus vaccines would likely be efficacious against the most common circulating strains, but continued monitoring of uncommon genotypes is needed.