First evidence of a possible association between gastric acid suppression during pregnancy and childhood asthma: a population-based register study

BACKGROUND

Recent data in mice suggest that acid suppression during pregnancy yields offspring with type 2 T helper-dominant immunity, suggesting a predisposition for allergy.

OBJECTIVE

To determine the association of in utero exposure to acid-suppressive medications and the subsequent development of allergic diseases in children.

METHODS

We studied a population-based observational cohort formed by linking data from three Swedish national healthcare registers: the Medical Birth Register, the Hospital Discharge Register, and the Swedish Prescribed Drug Register. Main outcome measures included a hospital discharge diagnosis of an allergic disease or prescription for asthma medications, epinephrine auto-injectors, antihistamines or steroid ointments in children. Data were analysed using the Mantel-Haenszel procedure.

RESULTS

Twenty-nine thousand four hundred and ninety (5.03%) children had a discharge diagnosis of allergy or prescriptions for allergy medications. Five thousand six hundred and forty-five (0.96%) children had been exposed to acid suppression therapy during pregnancy; of these, 405 (0.07%) were treated for allergic diseases. Exposure to acid-suppressive medications in utero was associated with an increased odds ratio (OR) for developing allergy (OR 1.43, 95% confidence interval (95% CI) 1.29-1.59). We observed this association irrespective of the type of drug, time of exposure during pregnancy, and maternal history of allergy. The use of maternal acid-suppressive medication was associated with an increased OR for the development of childhood asthma (3.7% in the population at large vs. 5.6% in exposed children, OR 1.51, 95% CI 1.35-1.69), but not for other allergic diseases.

CONCLUSION

These data provide first evidence of a significant association between in utero exposure to acid-suppressive drugs and the risk of developing childhood asthma.

Oral tacrolimus treatment of severe colitis in children

OBJECTIVE

To evaluate the efficacy of oral tacrolimus as an induction agent in steroid-refractory severe colitis.

STUDY DESIGN

Open-label, multicenter trial of oral tacrolimus in patients with severe colitis. Patients not responding to conventional therapy received tacrolimus, 0.1 mg/kg/dose given twice a day, and the dosage was adjusted to achieve blood levels between 10 and 15 ng/mL. Response was defined as improvement in a number of clinical parameters (including abdominal pain, diarrhea, rectal bleeding, and cessation of transfusions). Patients who responded by 14 days continued to receive tacrolimus, and 6-mercaptopurine or azathioprine was added as a steroid-sparing agent 4 to 6 weeks after the tacrolimus was instituted.

RESULTS

Fourteen patients were enrolled in the study. One patient elected to withdraw after 48 hours. Of the 13 remaining, 9 (69%) responded and were discharged. Tacrolimus was continued for 2 to 3 months in the responders, except for 1 patient who was given tacrolimus for 11 months. After 1 year of follow-up, only 5 (38%) patients were receiving maintenance therapy; the other 4 responders had undergone colectomy.

CONCLUSION

Although tacrolimus is effective induction therapy for severe ulcerative or Crohn's colitis, fewer than 50% of patients treated will successfully achieve a long-term remission.

Allergic esophagitis in children: a clinicopathological entity

Infiltration of esophageal epithelium by eosinophils is seen in reflux esophagitis and allergic gastroenteritis. This study was performed to identify differences between patients with acid reflux esophagitis and those with non-acid reflux, possibly allergic, esophagitis. Intraepithelial eosinophils were demonstrated in posttherapy esophageal biopsy specimens in 28 children treated for gastroesophageal reflux disease (GERD). These patients were divided into three groups based on their response to treatment and the results of esophageal pH probe monitoring. Eleven patients (Group A) had incomplete clinical response and normal pH probe monitoring results. Ten patients (Group B) had incomplete response but did not have pH probe monitoring. These two groups formed the index population. Seven patients (Group C) had clinical improvement with GERD therapy and abnormal pH probe monitoring characteristic of GERD; they constituted the control population. Clinical, laboratory, and pathologic features were evaluated to detect differences between index and control populations. Dysphagia, food impaction, failure to thrive, peripheral eosinophilia, and abnormal allergen skin test results were detected only in Group A and B patients. Biopsy specimens of the distal 9 cm of the esophagus, after GERD therapy, contained larger numbers of eosinophils in Groups A and B than in Group C as shown on high-power fields (HPF) (A: 31/HPF +/- 19.5; B: 28/HPF +/-23.7; versus C: 5/HPF +/-6.7; p = 0.009). Eosinophil aggregates were identified only in Groups A and B (p = 0.07). Eosinophils located preferentially in the superficial layers of the squamous epithelium were noted only in Groups A and B (p = 0.02). Group A and B patients demonstrated clinical improvement when given antiallergic therapy. The authors identified a group of pediatric patients characterized by an allergic history, lack of adequate response to GERD therapy, normal esophageal pH probe monitoring results, and large numbers of eosinophils in esophageal biopsy specimens obtained after GERD treatment. On the basis of these features, the authors propose that these patients represent examples of allergic esophagitis.

Human intestinal M cells display the sialyl Lewis A antigen

The biochemical features that distinguish human M cells from other intestinal epithelial cell types are important for understanding microbial pathogenesis and for targeting vaccines to the mucosal immune system. We applied a large panel of carbohydrate-specific monoclonal antibodies and lectins to Peyer's patch and cecum biopsy specimens from three normal individuals and a patient with inflammatory bowel disease. The results show that human M-cell glycosylation patterns are distinct from those of other species examined and that human M cells preferentially display the sialyl Lewis A antigen. This carbohydrate epitope is also present in a small subpopulation of enterocytes in the follicle-associated epithelium and in goblet cell mucins.

Quality-of-life assessment after ileoanal pull-through for ulcerative colitis and familial adenomatous polyposis

BACKGROUND/PURPOSE

The ileoanal pull-through procedure (IAP) is gaining increasing favor and use in the surgical treatment of children with ulcerative colitis (UC) and familial adenomatous polyposis (FP). Although physiological studies have been performed to assess the outcome of these children, no long-term quality-of-life assessment after the procedure has been performed.

METHODS

Forty-three patients were identified who had an IAP at our institution in the last 10 years and were at least 6 months postsurgery. Thirty-four were contacted, and 32 agreed to participate in the survey, which was approved by the Human Studies Committee. Participants completed the standardized Medical Outcome Study Short Form-36 (SF-36), which has well-established normative values. Several supplemental questions were prepared in a similar format dealing with issues specific to the ileoanal pull-through procedure.

RESULTS

Of the 32 participants, 19 (59%) were girls and 26 (81%) had ulcerative colitis. Mean age at the time of survey was 18.1 years with 12 less than 18 years and 20 > or =18 years. Data from the latter group could be compared with national normative values for this age. The study group was not statistically different from age-appropriate US population normal values on all assessable scales of physical and mental health in the SF-36 survey including physical functioning, role limitations-physical, bodily pain, general health, vitality, social functioning, role limitations-emotional, and mental health (all P>.05 or mean difference SD units <0.8). The supplemental questionaire demonstrated little adverse effect of the surgery. There was limited consumption of medications to control bowel frequency and little restriction of activity because of the frequency of bowel movements or fear of incontinence. The surgical scar was the sole negative factor of significance.

CONCLUSIONS

The ileoanal pull-through procedure is an excellent surgical option for children with ulcerative colitis or familial adenomatous polyposis, and it produced minimal, if any, adverse effects on their long-term quality of life.

Gastrointestinal manifestations of vascular anomalies in childhood: varied etiologies require multiple therapeutic modalities

BACKGROUND/PURPOSE

Vascular anomalies, including hemangiomas and vascular malformations afford complex diagnostic and therapeutic challenges when gastrointestinal (GI) manifestations are present.

METHODS

Twenty-one patients evaluated or treated in our Vascular Anomalies Program from 1993 through 1997 were reviewed retrospectively with regard to presentation, treatment modalities, and outcome.

RESULTS

Four patients had hemangiomas, and 17 had various vascular malformations. GI symptoms began in infancy or early childhood in all patients. Manifestations included GI bleeding (n = 15), obstruction (n = 2), diarrhea (n = 2), ascites (n = 2), pain (n = 1), emesis (n = 1), ileo-ileal intussusception (n = 1), protein-losing enteropathy (n = 1), and hypersplenism (n = 1). Four patients had proven portal hypertension. Fourteen had associated musculoskeletal or cutaneous lesions. Congestive heart failure, partial anomalous pulmonary venous return, pulmonary edema, and pleural or pericardial effusion occurred in one patient each. Bleeding was the most common symptom of both hemangiomas and malformations. Of four patients with hemangiomas, three were treated with corticosteroids or interferon. Endoscopic banding and embolization of an associated arterioportal hepatic shunt were each used in one patient. One patient died. The malformations were treated with resection (n = 8), endoscopic banding or sclerosis (n = 7), percutaneous or intraoperative sclerosis (n = 5), embolization or device interruption (n = 3), and portosystemic shunt (n = 2). GI symptoms were ameliorated in 12 patients with malformation, improved in two, unchanged in two, and one died after prolonged palliation.

CONCLUSIONS

Vascular anomalies with gastrointestinal manifestations are heterogeneous in their presentation and type. Although bleeding is the most common symptom of both hemangiomas and vascular malformations, treatment differs. Pharmacological angiogenesis inhibition is the mainstay of hemangioma therapy. Resection, endoscopic or radiologic vascular obliteration, and portal decompression are important in treating vascular malformations. An individualized and interdisciplinary approach is often required to successfully diagnose and treat these complex lesions.

Serum leptin in children and young adults with inflammatory bowel disease

BACKGROUND

Pediatric inflammatory bowel disease is often associated with growth failure and inadequate energy intake. Although several circulating cytokines are known to be elevated in inflammatory bowel disease, the mechanism for the related anorexia has not been described. Leptin is a newly recognized circulating protein that is an important regulator of appetite and energy metabolism; leptin levels are elevated in several animal models of inflammation. This study was conducted to determine whether serum leptin levels are elevated in young patients with inflammatory bowel disease.

METHODS

One hundred twelve children and young adults with Crohn's disease or ulcerative colitis were studied prospectively. Forty-two patients with other gastrointestinal illnesses were used as control subjects. Height, weight, erythrocyte sedimentation rate, serum albumin concentration, and clinical information were collected prospectively, and leptin was measured by radioimmunoassay of stored serum.

RESULTS

No significant differences in leptin levels were found among disease groups or control subjects. Body mass index and gender were the only independent predictors of serum leptin in all groups examined. Disease activity varied inversely with serum leptin in patients with Crohn's disease, but these differences were explained entirely by variations in body mass index.

CONCLUSIONS

The determinants of serum leptin were the same in young patients with inflammatory bowel disease as in normal populations, indicating that alterations in leptin levels are unlikely to mediate the anorexia and growth failure associated with this disease.

Vitamins A and E serum levels in children and young adults with inflammatory bowel disease: effect of disease activity

BACKGROUND

Hypovitaminosis and fat-soluble vitamin deficiency have been reported in adults with inflammatory bowel disease (IBD). A prospective study was undertaken to determine the prevalence of low serum levels of vitamins A and E in children and young adults with IBD.

METHODS

Clinical information and serum for vitamin levels was gathered prospectively from 61 patients with Crohn's disease, 36 patients with ulcerative colitis, and 23 control subjects. Disease activity and disease location were determined for IBD patients. Serum retinol and alpha-tocopherol levels were determined by high-performance liquid chromatography.

RESULTS

The prevalence of hypovitaminosis A (defined as serum vitamin A < 20 micrograms/dl) or hypovitaminosis E (defined as serum vitamin E < 5 mg/l) was 16% in the pediatric IBD population studied. Low vitamin A levels were more common than low vitamin E levels. Serum retinol levels correlated significantly with alpha-tocopherol levels. Hypovitaminosis was significantly more prevalent in the Crohn's disease patients who had active disease, an erythrocyte sedimentation rate of more than 25 mm/hour, or a serum albumin level less than 3 mg/dl.

CONCLUSIONS

Children and young adults with active IBD frequently have low serum levels of vitamin A or vitamin E. The severity of disease activity is a better predictor of risk for hypovitaminosis than is nutritional status. Further work is necessary to determine whether the hypovitaminosis seen in children with IBD reflects true deficiency.

Surgery for Crohn's disease in infants and children

The course of Crohn's disease is quite variable in children. To assess the frequency and indications for surgery with current medical therapy, the authors reviewed the cases of 204 children (ages, 0.2 to 18.8 years at diagnosis, median, 12.8 years) who had Crohn's disease treated at a single institution from December 1968 to January 1994, with a median of 3.8 years of follow-up (range, 0.0 to 22.2 years). Ninety-four children (46%) required surgical resection for the following indications: (1) failure of medical therapy with persistent symptoms or growth retardation (n = 44, 47%), (2) intraabdominal abscess or perforation (n = 15, 16%), (3) fistula formation (n = 13, 14%), (4) obstruction (n = 15, 16%), (5) hemorrhage (n = 4, 4%), and (6) appendectomy at exploration for diagnosis (n = 3, 3%). The probability for surgery 3 years after diagnosis is 28.8% and by 5 years is 47.2%. Resections included ileocolectomy (71 children), colectomy (n = 16), small bowel resection (n = 4), and appendectomy (n = 3). Fourteen fistulas in 13 children required surgical intervention (7 enteroenteral, 3 enterovesical, 2 enterovaginal, and 2 enterocutaneous). The median duration from diagnosis to surgery for the fistulas was 2.6 years (range 0.1 to 9.8 years). Forty patients experienced recurring disease after resection during follow-up with a median of 1.8 years (range 0.4 to 18.1 years). The authors found that the course of the disease was unpredictable, with some children requiring early surgical intervention and others continuing with medical therapy for years.

Serum basic fibroblast growth factor in pediatric Crohn's disease. Implications for wound healing

Basic fibroblast growth factor is a heparin-binding protein known to stimulate angiogenesis and promote wound healing in tissues. Since Crohn's disease is characterized in part by submucosal vascular proliferation, we sought to determine whether serum basic fibroblast growth factor is elevated in children with Crohn's disease and whether serum levels reflect disease activity. Sera were obtained from 64 children with Crohn's disease, 44 children with ulcerative colitis, 20 children with functional abdominal pain, and 29 from children with documented inflammatory disease evaluated in our gastroenterology program. Disease activity indices and clinical data were gathered prospectively for the inflammatory bowel disease patients. Serum basic fibroblast growth factor levels were measured by enzyme-linked immunosorbent assay. Although the mean basic fibroblast growth factor level did not significantly differ between children with Crohn's disease and other conditions, there was a strong (r = 0.53, P < 0.001) correlation between basic fibroblast growth factor level and disease activity. The relationship of basic fibroblast growth factor with disease activity persisted even after adjusting for other covariates (including age, sex, hematocrit, albumin, and sedimentation rate) in a multivariate linear regression model. There was also a statistically significant, although less strong correlation (r = 0.33, P = 0.03) between basic fibroblast growth factor level and disease activity in ulcerative colitis. While basic fibroblast growth factor is not a specific marker for Crohn's disease, serum levels reflect disease activity. Therefore, basic fibroblast growth factor release may be important in mediating the angiogenesis and wound healing seen in Crohn's disease.

Complications following percutaneous endoscopic gastrostomy and subsequent catheter replacement in children and young adults

BACKGROUND

Percutaneous endoscopic gastrostomy has gained wide acceptance for patients who require prolonged tube feeding support. We sought to identify complications and associated risk factors of endoscopic gastrostomy and subsequent catheter replacement in pediatric patients.

METHODS

Medical records were reviewed for 137 patients. Odds ratios were calculated for complications related to patient age, weight, weight-for-age Z score, and principal diagnosis.

RESULTS

Seventeen patients (12.4%) developed significant complications after gastrostomy: cellulitis occurred in 10 patients (7.3%); other complications included gastrocolic fistula (2), duodenal hematoma (1), complicated pneumoperitoneum (1), necrotizing fasciitis (1), gastric perforation (1), and catheter migration (1). Patients with cancer had significantly greater odds for developing a wound infection, and patients with AIDS had significantly greater odds for total complications. A trend toward increased wound infection was observed in patients with cardiac disease. Age, weight, and weight-for-age Z score were not associated with adverse outcome. Two complications occurred in 85 patients (2.4%) after gastrostomy catheter replacement.

CONCLUSIONS

Pediatric patients with cancer and AIDS are at increased risk for complications after endoscopic gastrostomy regardless of age, weight, or nutritional status. Infrequent yet life-threatening complications may occur after replacement of initial gastrostomy catheter.

Elevation of serum interleukin-6 but not serum-soluble interleukin-2 receptor in children with Crohn's disease

Previous studies have demonstrated elevated serum levels of interleukin-6 (IL-6) and the soluble interleukin-2 receptor (IL-2R, CD25) in individuals with inflammatory bowel disease (IBD). The aim of our study was to compare serum IL-6 and IL-2R levels to see if one marker better distinguished IBD from other intestinal disorders or better reflected disease activity. Blood samples were obtained from 41 pediatric patients with Crohn's disease, 22 with ulcerative colitis, 19 with other gastrointestinal inflammatory disorders, and 13 with functional abdominal pain. Disease activity and disease location were determined for patients with Crohn's disease and ulcerative colitis. Serum levels of IL-6 and IL-2R were determined by using an enzyme-linked immunosorbent assay. Mean serum levels of IL-6 were significantly elevated (p < 0.05) in patients with Crohn's disease when compared with individuals with ulcerative colitis, other gastrointestinal inflammatory disorders, or functional abdominal pain. By comparison, there was no significant difference in mean serum levels of IL-2R in individuals with Crohn's disease compared with these other groups. Patients with moderate/severe Crohn's disease had elevated mean serum levels of IL-6 and IL-2R when compared with those with mild and inactive disease (p < 0.05); however, neither marker distinguished between inactive and mild disease. IL-6 correlated better with the erythrocyte sedimentation rate (ESR; r = 0.57, p < 0.001) than did IL-2R (r = 0.28, p < 0.01). Our results suggest that elevated IL-6 levels a.e more likely to be seen in patients with Crohn's disease. Although IL-6 may be a better marker for Crohn's disease and active disease than IL-2R, it does not appear to offer any advantage over the ESR.

Treatment of pediatric autoimmune enteropathy with tacrolimus (FK506)

Autoimmune enteropathy is characterized by chronic secretory diarrhea, villous atrophy, associated autoantibodies, and a partial response to immunosuppression. Currently available therapy (including steroids and cyclosporine) has resulted in remission only in a subset of patients. We evaluated the effects of tacrolimus (FK506) in patients with autoimmune enteropathy refractory to steroids and cyclosporine. Three patients with diagnosed autoimmune enteropathy who continued to have intractable diarrhea despite treatment with steroids and/or cyclosporine were treated with oral tacrolimus. Despite documented histological villous atrophy and poor absorption of oral cyclosporine, therapeutic tacrolimus levels were easily achieved in all 3 patients. All patients showed clinical improvement as documented by decreased stool output and ability to be weaned off parenteral nutrition; response time ranged from 1 to 4 months after tacrolimus was begun. Histological improvement was noted in all patients, and the small bowel biopsy specimens of 2 of the 3 patients showed a return to normal. All patients have been followed up for at least 6 months and are in clinical remission; 1 has received a bone marrow transplant for underlying immunodeficiency. Tacrolimus is a useful drug in the treatment of autoimmune enteropathy, even in patients who have not responded to steroids or cyclosporine. No long-term follow-up of patients with autoimmune enteropathy treated with tacrolimus is currently available.

Long-term hepatic regeneration and function in infants and children following liver resection

BACKGROUND

Hepatic regeneration and function after resection has been evaluated in adults, but long-term quantitative assessment has not been performed in children. Semiquantitative short-term evaluations, including radioisotope scans, have suggested that hepatic regeneration occurs quickly in children, but the effect of chemotherapy on hepatic regeneration has not been evaluated. Treating hepatoblastoma in children increasingly includes chemotherapy before resection, hence evaluating regeneration is critical.

STUDY DESIGN

A retrospective evaluation was done of ten children older than one year following anatomic hepatic resection for benign or malignant tumors. Three components were evaluated. First, hepatic function was evaluated by a series of tests of synthetic function. Second, the metabolic function of the liver was evaluated by measuring the hepatic conversion of lidocaine to its breakdown product, monoethylglycinexylidide (MEGX). Third, hepatic volume was assessed by magnetic resonance imaging scan.

RESULTS

All children were clinically well at the time of evaluation. Results of tests of synthetic function were essentially normal in all patients. Serum ammonia levels were mildly elevated in six patients. Hepatocellular enzymes were mildly elevated in several children, and the alkaline phosphatase level was mildly elevated in three. A lidocaine infusion study demonstrated normal levels of MEGX in all of the children except one with positive hepatitis C serology. Studies demonstrated that hepatic volumes were below but near the expected levels in most children. Sequential studies in six children demonstrated progressive growth of the livers. No adverse effect on hepatic size was noted in the children who received chemotherapy.

CONCLUSIONS

The cohort of children had adequate regeneration and function of the liver following hepatic resection. No adverse effect of perioperative chemotherapy could be identified.

Intraoperative enteroscopy in the diagnosis of partial intestinal obstruction in infancy

We present the case of a 4-month-old infant with a prolonged illness due to an occult intestinal stricture. Diagnosis of the lesion escaped conventional radiologic and surgical methods and required intraoperative enteroscopy. Resection of the stricture lead to prompt clinical improvement. Our patient illustrates a primary diagnostic use of intraoperative enteroscopy in the detection of a partial intraluminal small bowel obstruction. As further experience accumulates with small bowel endoscopy, roles for therapeutic enteroscopy (such as polypectomy, photocoagulation, and perhaps balloon dilatation) will certainly arise. Such endeavors will depend on the continued productive collaboration between members of the surgical and gastroenterological teams.

Endoscopic ligation of esophageal varices in children

Seven consecutive patients presenting acutely with suspected variceal hemorrhage underwent endoscopic variceal ligation (EVL) of esophageal varices. Active bleeding had ceased by the time of the initial EVL session in all patients, although active variceal hemorrhage was controlled by EVL in one patient during a subsequent episode of bleeding. Treatment sessions were repeated at approximately monthly intervals until varices were reduced in size to grade 1 (< 4 mm diameter) or eradicated. All patients had portal hypertension secondary to intrahepatic disease. Patient age ranged from 2.4 to 14.5 years (mean, 8.5 years). One patient underwent successful liver transplantation 1 week after the initial treatment session. The remaining six patients required a mean (+/- SD) of 4.0 +/- 1.3 treatment sessions for elimination of varices. One episode of recurrent variceal hemorrhage and one episode of treatment-related hemorrhage occurred in two separate patients. Transient, mild dysphagia or odynophagia occurred in all patients. No other complications were reported during a mean (+/- SD) follow-up period of 13.8 +/- 4.6 months (range, 8-20 months). Recurrent varices were seen in three of four (75%) patients returning for follow-up endoscopy between 5 and 8 months from initial eradication. All underwent repeat EVL without complication. Endoscopic variceal ligation may be a suitable substitute for sclerotherapy in children with bleeding esophageal varices.

Long-term nutritional and metabolic consequences of pancreaticoduodenectomy in children

BACKGROUND

The long-term nutritional and metabolic consequences of pancreaticoduodenectomy in children are unknown.

METHODS

Five children were evaluated in a clinical research center 2.5 to 10 years after pancreaticoduodenectomy to assess their nutritional status based on patterns of growth and to assess their gastrointestinal function. Investigation included vitamin levels, a bentiromide study, and serum immunoreactive trypsinogen levels to evaluate pancreatic function and a d-xylose absorption and a radionuclide gastric emptying scan for intestinal absorption and motility.

RESULTS

Children were able to grow after pancreaticoduodenectomy. Three remained in low percentile groups for height/weight ratio, and two were near or above normal. Low normal levels of the fat-soluble vitamins were present. Very low levels of pancreatic function were found based on the bentiromide and trypsinogen studies, whereas intestinal absorption of d-xylose was normal except for one patient with extremely rapid gastric emptying.

CONCLUSIONS

After pancreaticoduodenectomy children can grow and develop normally if given adequate levels of oral pancreatic supplements to replace the severely decreased level of endogenous pancreatic enzymes after operation. Routine supplementation of the fat-soluble vitamins should be considered.

Allergic proctocolitis in infants: a prospective clinicopathologic biopsy study

Allergic proctocolitis is a major cause of rectal bleeding in infants, but its clinical features and laboratory results are often nonspecific. Our previous retrospective study demonstrated that large numbers of eosinophils in colonic mucosal biopsy specimens were highly associated with cases of allergic proctocolitis. Therefore, we prospectively examined 60 colonic mucosal biopsy specimens from the same sites (4, 8, and 12 cm from the anal verge) in 20 infants with clinically confirmed allergic proctocolitis to validate this morphologic feature, to characterize its distribution, and to correlate these data with the clinical information. The patients (age range, 4 to 304 days) were fed breast milk or a variety of formulas and all presented with rectal bleeding. Sigmoidoscopic examination was abnormal in 19 cases, typically characterized by focal areas of mucosal erythema. The major histologic finding was a strikingly focal increase in the number of eosinophils in all mucosal compartments, with a predilection to aggregate in close association with lymphoid nodules. Eosinophilic infiltration varied not only between biopsies at different sites, but also within individual biopsy specimens. Only 12 of 20 patients (60%) had all three of their biopsy specimens categorized as abnormal; in the remainder, only one (four patients) or two (four patients) of the three biopsy specimens were abnormal. The average number of eosinophils per high-power field of lamina propria for all cases was 15.6. No significant correlation was identified between the number of eosinophils in the mucosa and the patient's age, length of illness, endoscopic appearance, or type of inciting formula. In summary, eosinophils appear to be an excellent marker for infantile allergic proctocolitis. Given the focal distribution of the eosinophils, multiple mucosal biopsy specimens should be obtained and several levels of each examined to confirm the diagnosis.

The antegrade colonogram: extending the small bowel follow through for children suspected of having colonic disease

Fifty pediatric patients suspected of having colonic disease were evaluated by antegrade barium study ("antegrade colonogram") and by colonoscopy with multiple biopsy specimens. Radiographic patterns of mucosal irregularity, nodularity, or ulceration, haustral asymmetry or edema, and narrowing of the colonic lumen were easily recognized. Correlation between colonographic patterns, biopsy findings, and gross appearance at colonoscopy showed the colonogram to have an overall accuracy of 77-88%. The antegrade colonogram is easily performed and often provides information regarding areas of the colon not seen by the endoscopist. In some cases it may also be useful in the evaluation of response to therapy for inflammatory bowel disease.

Pancreatitis following scoliosis surgery in children and young adults

Forty-four patients undergoing single-stage surgery for scoliosis were monitored for biochemical and clinical evidence of pancreatitis. Six patients (14%) developed elevation of both serum amylase and lipase levels. Four of these had symptoms or signs suggestive of pancreatitis. Mean intraoperative blood loss was significantly higher in the group with pancreatitis. No significant differences were noted with regard to age, surgical technique, degree of initial or residual deformity, or length of surgery. The patients with pancreatitis required a longer average period of fasting time. Patients with prolonged ileus or abdominal pain after scoliosis surgery should be investigated for possible pancreatitis.

Longitudinal assessment of type I procollagen in children with inflammatory bowel disease subjected to surgery

Using radioimmunoassay we have measured the serum concentrations of the C-terminal propeptide of type I procollagen (pColl-I-C) in 12 Tanner I-II subjects (aged 9-16 years) with severe Crohn's disease (8 patients) or ulcerative colitis (4 patients) and markedly decreased growth velocity who were subjected to surgery and 50 similarly aged children with either ulcerative colitis (20 patients) or Crohn's disease (30 patients) and normal growth. Prior to operation, the mean growth velocity and pColl-I-C concentration in the former group of 12 children were 0.03 +/- 0.02 cm/month (normal greater than or equal to 0.5 cm/month) and 14.1 +/- 1.9 micrograms/dl, respectively. This pColl-I-C concentration is comparable with that previously reported for adults (5-17 micrograms/dl) and significantly lower than found in the 50 normally growing children with inflammatory bowel disease (IBD) (46.9 +/- 2.0 micrograms/dl) (p less than 0.001). All 12 children subjected to surgery had a marked increase in growth velocity and pColl-I-C concentration to 0.73 +/- 0.08 cm/month and 59.1 +/- 5.6 micrograms/dl, respectively (p less than 0.001 compared with preoperative values). Changes in pColl-I-C concentrations antedated measurable changes in linear growth. These data suggest that pColl-I-C concentrations can reflect growth velocity in children with IBD subjected to surgery and may provide a rapidly available measure of current "growth activity."

Carbohydrate malabsorption following fruit juice ingestion in young children

We performed breath hydrogen analyses in 13 healthy children (9 to 36 months of age) and seven children (14 to 27 months of age) with chronic nonspecific diarrhea after they had ingested pear, grape, and apple juices and a 2% sorbitol solution. Excess breath H2 excretion was found in virtually all study subjects following the ingestion of either pear juice (with approximately 2% sorbitol content) or the 2% sorbitol solution, in approximately 50% of those ingesting apple juice (0.5% sorbitol), and in 25% of those ingesting grape juice (no sorbitol) (P less than .001, analysis of variance). No differences were noted between the healthy children and those with chronic nonspecific diarrhea. Forty percent of all study subjects in whom excess breath hydrogen excretion occurred also had diarrhea and abdominal cramping. Carbohydrate malabsorption appears to be frequent following the ingestion of common fruit juices and in some children may be associated with nonspecific gastrointestinal symptoms.

Relationship of type I procollagen to corticosteroid therapy in children with inflammatory bowel disease

We determined the serum concentration of the C-terminal propeptide of type I procollagen (pColl-I-C) in 60 children and adolescents (ages 4 to 17 years) with inflammatory bowel disease (24 ulcerative colitis, 36 Crohn disease) and in seven children (ages 2 to 15 years) with nongastrointestinal disease (asthma) during varying regimens of corticosteroid therapy. Patients with inflammatory bowel disease were grouped according to disease severity (mild, and moderate to severe). Significantly lower pColl-I-C concentrations and growth velocities were found in each severity group among those subjects receiving daily corticosteroid therapy compared with those receiving alternate-day or no corticosteroid therapy (P less than 0.01). When daily corticosteroid therapy was initiated and then maintained for 7 to 14 days in 11 patients with exacerbation of inflammatory bowel disease clinical improvement resulted, but mean procollagen concentrations decreased significantly (P less than 0.001). In seven children with asthma receiving methylprednisolone intravenously, significant decreases in pColl-I-C concentrations were noted within 24 to 48 hours of therapy (P less than 0.001). These data indicate that serum procollagen values decrease during both short- and long-term daily administration of corticosteroid therapy. Longitudinal assessment of procollagen concentrations may provide rapid assessment of the effects of different corticosteroid regimens on growth.

Clinical and laboratory correlates of esophagitis in young children

To develop clinical and laboratory criteria to identify young children with gastroesophageal reflux (GER) who are at particular risk for esophagitis and then to monitor their clinical course we have prospectively studied 40 subjects (ages 2-22 months, mean 8 months) with persistent symptoms of GER with 18 h intraesophageal pH monitoring, endoscopy, and grasp and suction esophageal biopsies. Esophagitis was found in 16 of 20 patients under 7 months, 12 of 14 between 7 and 12 months, and five of six between 12 and 24 months. Esophagitis was equally frequent in those patients with or without poor weight gain, wheezing, or irritability. Only 15% of patients with esophagitis had occult blood in their stool. No parameter of intraesophageal pH monitoring was both sensitive and specific in identifying patients who were ultimately found to have either mild or severe esophagitis. Follow-up data (37 patients) revealed that fundoplication was eventually required in four of eight patients with severe esophagitis, three of 22 with mild esophagitis, and none of seven without esophagitis. Currently used clinical and laboratory assessments of GER have limited value in identifying those children with either normal esophageal mucosa or at risk for varying degrees of esophagitis. Preliminary observations suggest that the presence of severe histologic esophagitis at the time of initial evaluation may have prognostic value in identifying those patients most likely to fail medical therapy and require fundoplication.

Hypertension associated with unilateral hydronephrosis as a complication of Crohn's disease

Obstructive uropathy with hydronephrosis is a well-known complication of Crohn's disease. The treatment for this condition is still controversial. This is the case study of a 14-year-old girl with documented right-sided obstructive uropathy secondary to Crohn's disease associated with renin-mediated hypertension secondary to her obstructive uropathy. The patient had complete resolution of her hypertension following surgery, which involved only resection of the involved bowel without ureterolysis.

Cyclosporine treatment of autoimmune chronic active hepatitis

A 14-yr-old boy with a 5-yr history of autoimmune chronic active hepatitis refractory to corticosteroid therapy was given cyclosporin A (5 mg/kg X day). Before cyclosporine therapy, serum aminotransferase levels were 20 times normal and immunoglobulin G was 4 g/dl. Within 2 wk of starting cyclosporine therapy, aminotransferase levels decreased; by 2 mo they were almost normal, and at 1 yr into therapy they were normal. A decrease in cyclosporine dosage was associated with an increase in aminotransferase levels, which then again decreased as the dose was increased. Severe growth failure observed during previous corticosteroid therapy reversed during cyclosporine treatment and the patient displayed "catch-up" growth. No significant side effects were noted after 1 yr of cyclosporine therapy. Further evaluation of cyclosporine in the treatment of corticosteroid-unresponsive autoimmune chronic active hepatitis appears warranted.

Type 1 procollagen as a biochemical marker of growth in children with inflammatory bowel disease

Using radioimmunoassay, we measured the levels of the C-terminal propeptide of type I procollagen (pColl-I-C) in sera from 69 children with functional bowel disease (control population), 18 children with ulcerative colitis, and 35 children with Crohn disease. Sexually mature fully grown adolescents from all three patient groups had mean pColl-I-C concentrations (12.0 +/- 0.8 micrograms/dl) similar to those previously reported for adults (5 to 17 micrograms/dl). Children with functional bowel disease and normal growth had significantly higher concentrations (32.8 +/- 1.7 micrograms/dl) (P less than 0.001) than did the fully grown adolescents. In patients with inflammatory bowel disease a significant relationship between growth velocity and pColl-I-C concentrations was noted (P less than .001). Lower pColl-I-C concentrations were found in patients receiving daily prednisone therapy compared with those receiving alternate-day therapy (P less than 0.01) or those not taking the drug (P less than 0.01). These data suggest that pColl-I-C concentrations reflect growth activity in children. Repeated determinations may allow rapid assessment of the effects of various therapeutic modalities on growth in children with inflammatory bowel disease.

Effect of metoclopramide on prolonged intraesophageal pH testing in infants with gastroesophageal reflux

The effect of metoclopramide (MCP) on prolonged intraesophageal pH testing was evaluated in 42 infants with gastroesophageal reflux (GER). Following a baseline period of intraesophageal pH monitoring, MCP was administered by injection at 0.1 mg/kg/dose (10 patients), 0.2 mg/kg/dose (11 patients), or 0.3 mg/kg/dose (21 patients). The percentage of time of intraesophageal pH less than 4, reflux frequency, and acid clearance time were calculated for each subject before and after MCP for both 5% dextrose and formula feedings. These parameters were further separated into 2-hour or shorter and more than 2-hour postprandial periods. No significant differences with either type of feeding were noted at either 0.1 or 0.2 mg/kg/dose. Significant decreases in the percentage of time the intraesophageal pH was less than 4 (30.0 +/- 2.9 versus 15.6 +/- 3.1, p = 0.001), the reflux frequency (episodes/hour; 6.5 +/- 0.9 versus 4.0 +/- 0.6, p = 0.004), and the acid clearance time (minutes/episode; 3.8 +/- 0.7 versus 2.2 +/- 0.3, p = 0.047) were noted in the 2-hour or shorter period following 5% dextrose feedings but not following the formula feedings in the subjects receiving 0.3 mg/kg/dose. Three of the 42 study patients developed increased irritability, and one developed dystonia following MCP. These data suggest that if a clinical trial of MCP in infants with GER is performed, a larger dose of the medication than previously appreciated might be required.

Chronic diarrhea associated with hypogammaglobulinemia and enteropathy in infants and children

In order to define the gastrointestinal manifestations and small intestinal structure and function in a group of infants with chronic nonspecific diarrhea and hypogammaglobulinemia, we retrospectively identified 55 such patients from a population of 518 children evaluated for chronic diarrhea over a 6-year span (10.6%). All patients had IgG levels 2.0 SD or more below the mean values for age. Patients with biochemical evidence of protein loss (enteropathy or nephropathy) were excluded. There was a 50% incidence of small intestinal mucosal injury among these patients, with a spectrum of morphological findings ranging from healing enteritis to severe active enteritis. Carbohydrate malasorption, and infection with Giardia lamblia or Clostridium difficile occurred in 34% and 24% of patients tested, respectively. These structural, functional, and infectious complications were all statistically more common in patients than in a control group of children with chronic diarrhea, normal growth, and normal immunoglobulin levels. This study suggests that immunoglobulin determination, in children who would otherwise carry a diagnosis of chronic nonspecific diarrhea, identifies a group with hypogammaglobulinemia, having an increased incidence of treatable intestinal dysfunction or infection, and a spectrum of small intestinal histologic abnormalities.

Apple juice. An unappreciated cause of chronic diarrhea

Chronic nonspecific diarrhea (CNSD) remains a common pediatric problem. Previous reports have suggested disordered small intestinal motility, food intolerances, dietary fat restriction, and excessive fluid consumption as possible contributory factors. We have recently encountered a subset of children with CNSD in whom nonexcessive apple juice intake seemed to cause their diarrhea. In five subjects, ingestion of 240 mL of apple juice disclosed evidence of significant carbohydrate malabsorption by breath-hydrogen testing and resulted in diarrhea. Withdrawal of apple juice from the diets of these subjects was curative in all cases. Before embarking on an expensive and time-consuming evaluation for CNSD in otherwise healthy children, a brief restriction of apple juice intake may be warranted.

Recent advances in diagnosis and treatment of gastrointestinal hemorrhage in infants and children

Gastrointestinal bleeding is a common and occasionally life-threatening problem in infants and children. A careful history and physical examination as well as the application of new endoscopic and radiographic techniques will reveal the source of hemorrhage in most patients. The utility of recently introduced pharmacologic agents and endoscopic techniques in the treatment of peptic disease and variceal hemorrhage in children remains to be determined. A cooperative effort among pediatricians, radiologists, and surgeons should minimize the morbidity and mortality from gastrointestinal tract bleeding in this population.

Regulation of low density lipoprotein receptor function in a human hepatoma cell line

Low density lipoprotein (LDL) processing was investigated in a human hepatoma-derived cell line, Hep G2. Hep G2 cells bound, internalized and degraded LDL via a saturable, high affinity (Kd approximately 2 X 10(-8)M) pathway similar to that present in other mammalian cells. Although 80% of the uptake and degradation of 125I-LDL was inhibited by 40-fold excess native LDL, the same concentration of methylated LDL, which cannot bind to LDL receptors, had virtually no effect on processing. When added at low concentrations, the lysosomotropic agent, chloroquine, inhibited degradation (I50 approximately 15 microM) without affecting the rate of lipoprotein internalization. Receptor activity was decreased 60% by preincubation of the cells in medium containing a source of cholesterol (LDL or unesterified cholesterol) and increased 1.7-fold by preincubation with compactin, a competitive inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A reductase. The Hep G2 cell line may prove a useful system both for the further study of hepatic lipoprotein metabolism and for the evaluation of new antihypercholesterolemic agents.

Addition of a mannose-6-phosphate-containing oligosaccharide alters cellular processing of low density lipoprotein by parental and LDL-receptor-defective Chinese hamster ovary cells

Low density lipoprotein (LDL) was chemically modified by the addition of omega-(6-phospho)-tetra(alpha 1–3)mannosyl-(alpha 1–2)mannose (M56P), a phosphorylated oligosaccharide containing a terminal mannose 6-phosphate residue. Uptake and degradation of this modified LDL (M56P-LDL) by Chinese hamster ovary (CHO) cells occurred via the lysosomal enzyme (mannose 6-phosphate) receptor pathway. Cellular processing of M56P-LDL was saturable, specific for the mannose 6-phosphate marker, and occurred with approximately threefold higher affinity than that of native LDL by the LDL receptor pathway. Mannose 6-phosphate receptor activity, as measured by degradation of M56P-LDL, was ninefold lower than the LDL receptor activity. Degradation of M56P-LDL was more sensitive to inhibition by the lysosomotropic agent chloroquine than was degradation of LDL, suggesting differences in the intracellular processing of mannose 6-phosphate-bearing ligands and LDL. Previously isolated CHO cell lines defective in LDL receptor activity resembled parental CHO cells in their ability to process M56P-LDL. The potential use of M56P-LDL in the isolation of cells with pleiotropic mutations affecting receptor-mediated endocytosis is discussed.

Horizontal nonparenteral spread of hepatitis B among children

Two families with an unusually high incidence of hepatitis B infection (15 of 21 persons) were investigated over an 18-month period. Serologic evidence of past or present infection--hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), or antibody to hepatitis B core antigen (anti-HBc)--was found in 11 of the 12 members of one family, four of whom were chronic HBsAg carriers, and in four of nine members of a contact family. Anti-HBc was the only serologic marker of infection in five persons. Histocompatibility leukocyte antigen (HLA) typing failed to show an association between carriage of HBsAg and specific HLA markers. Chewing gum was a potential vehicle as HBsAg was detected in gum samples from three of four children who were chronic HBsAg carriers. Horizontal, nonparenteral transmission of hepatitis B virus probably accounted for the clustering of infection in these families, especially via the exchange among children of objects contaminated with oral secretions.