Gallbladder motility in children with celiac disease before and after gluten-free diet

Background

Gallbladder (GB) hypomotility has been reported in adults with celiac disease (CD), but there is no literature on GB dysfunction in children with CD. We aimed to study GB motility in children with CD, before and after a gluten-free diet (GFD), using ultrasonography (USG) and technetium-99 labeled mebrofenin hepatobiliary scintigraphy (HBS).

Methods

Children with newly diagnosed CD were enrolled and evaluated for GB ejection fraction (GBEF) using HBS and USG. Those with reduced GBEF on initial HBS were again evaluated after 6 months of strict GFD and the results were compared.

Results

Of the 50 children with CD (mean age 9±2.1 years, 54% boys), 16% (n=8) had a low GBEF at baseline (19±13%). These children had a significantly greater delay in diagnosis compared to those with normal GBEF (6.5±2.0 vs. 2.3±1.2 years, P<0.001). A significant improvement in GBEF was noted on HBS post GFD (74±12%1 vs. 9±13%, P<0.001). GBEF also improved significantly as assessed by USG parameters after GFD (P<0.001). The fasting GB volume decreased (5.7±1.4 vs. 10.2±2.6, P=0.002), with a significant improvement in percentage postprandial GB volume change (52±10.5% vs. 24±16.5%, P=0.007) compared to baseline pre-GFD values. Orocecal transit time was also increased in children with reduced GBEF.

Conclusions

GB function is impaired in at least 16% of children with CD at diagnosis and is reversible with GFD. GB dysfunction is significantly associated with a delayed diagnosis and may be a part of general gastrointestinal dysmotility.

Role of Polymerase Chain Reaction in Stool and Duodenal Biopsy for Diagnosis of Giardiasis in Patients with Persistent/Chronic Diarrhea

BACKGROUND

Giardia duodenalis is a common cause of chronic diarrhea especially in tropical countries. Diagnosis is based on microscopy (three stool samples) for trophozoites/cysts. Role of stool or duodenal biopsy PCR as a diagnostic method needs to be defined. We conducted a prospective study to determine the diagnostic characteristics of G. duodenalis stool and duodenal biopsy PCR in comparison to stool microscopy (reference standard). Later, we compared other techniques with stool PCR, considering it as new reference standard and characterized the type of Giardia assemblage.

METHODS

G. duodenalis stool nested PCR was first evaluated using 40 positive controls and 50 negative controls considering stool microscopy as reference standard. Patients with chronic diarrhea (n = 100) were evaluated by stool microscopy and nested PCR. In 30 patients in whom upper gastrointestinal endoscopy was performed, duodenal biopsy samples were obtained and evaluated by histopathology, imprint cytology, and nested PCR. The type of Giardia assemblage was detected by assemblage-specific PCR.

RESULTS

Stool nested PCR was found to have sensitivity and specificity of 100% and 94%, respectively, compared to stool microscopy. In patients with chronic diarrhea, 48% had evidence of Giardia infection. Stool microscopy detected 65%, stool PCR detected an additional 27%, and duodenal biopsy PCR detected an additional 8% of cases. The commonest assemblage found was assemblage B. Clinical and demographic characteristics were similar in patients harboring either assemblage A or B.

CONCLUSION

Stool PCR is more sensitive than stool microscopy. By utilizing stool microscopy, stool nested PCR, and duodenal biopsy PCR in sequential manner, diagnostic yield can be increased.

Correction to: Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update

The article Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update, written by [Shiv Sarin], was originally published electronically on the publisher's internet portal (currently SpringerLink) on June 06, 2019 without open access.

Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the "APASL ACLF Research Consortium (AARC)" was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the 'Golden Therapeutic Window', extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here.

Unusual Cause and Association of Gastrointestinal Bleed in a Young Boy

A 4-year old child, previously operated case of tetralogy of Fallot present with recurrent episodes of massive lower gastrointestinal bleed of one year duration. Endoscopic evaluation revealed multiple bluish vascular lesions in the duodenum and proximal jejunum and a single rectal polyp. Histology of the lesion was suggestive of venous malformation consistent with blue rubber bleb nevus syndrome (BRBNS). Child underwent endoscopic snaring and surgical resection with end to end anastomosis. At six months’ follow-up child was asymptomatic without any bleed episodes.

Zollinger-Ellison syndrome: an unusual case of chronic diarrhoea in a child

Most cases of Zollinger-Ellison syndrome (ZES) are described in adults. It is a rare disorder in childhood. Most cases present with abdominal pain due to peptic ulceration and chronic diarrhoea not responding to general measures. The symptom complex is initially confused with other more common diseases, which lead to a delay in diagnosis. We present a rare case of a-12-year boy who initially presented with abdominal pain, diarrhoea, vomiting and progressive weight loss for over a two-year period before he was finally diagnosed as a case of ZES with the primary tumour in the pancreatic head and with multiple metastasis in both the liver and lymph nodes.

Perforations and fistulae in gastrointestinal tuberculosis

Background: Perforation and fistulae, though uncommon, are serious complications of gastrointestinal tuberculosis. Patients with acute tuberculous perforation are subjected to surgery, whereas localized perforation and fistulae with subtle clinical signs are detected by barium contrast examination. There has been no report on radiological series regarding the incidence of perforation and fistulae, detected by barium contrast studies.

Material and Methods: A retrospective analysis of barium contrast studies of 684 proven cases of gastrointestinal tuberculosis seen over a period of 15 years was done to detect the incidence of perforation and fistulae.

Results: Fifty-two patients (7.6%) with localized perforation and fistulae were seen. Twenty-eight patients had evidence of perforation, and 24 patients showed fistulae formation. The most common site of perforation and fistulae was the small bowel followed by the colon. Associated abnormalities noted were ulcerations, strictures, nodular filling defects and extrinsic compression.

Conclusion: Perforation and fistulae along with other associated abnormalities of the gastrointestinal tract are suggestive of tuberculosis, particularly in a population predisposed to tuberculous infection.

Virulence determinants in enteroaggregative Escherichia coli from North India and their interaction in in vitro organ culture system

Enteroaggregative Escherichia coli (EAEC) is an important diarrhoeal pathogen causing diseases in multiple epidemiological and clinical settings. In developing countries like India, diarrhoeal diseases are one of the major killers among paediatric population and oddly, few studies are available from Indian paediatric population on the variability of EAEC virulence genes. In this study, we examined the distribution of plasmid and chromosomal-encoded virulence determinants in EAEC isolates, and analysed cytokines response generated against EAEC with specific aggregative adherence fimbriae (AAF) type in duodenal biopsies using in vitro organ culture (IVOC) mimicking in vivo conditions. Different virulence marker combinations among strains were reflected as a function of specific adhesins signifying EAEC heterogeneity. fis gene emerged as an important genetic marker apart from aggA and aap Further, EAEC infection in IVOC showed upregulation of IL-8, IL-1β, IL-6, TNF-α and TLR-5 expression. EAEC with AAFII induced significant TLR-5 and IL-8 response, conceivably owing to more pathogenicity markers. This study sheds light on the pattern of EAEC pathotypes prevalent in North Indian paediatric population and highlights the presence of unique virulence combinations in pathogenic strains. Thus, evident diversity in EAEC virulence and multifaceted bacteria-host crosstalk can provide useful insights for the strategic management of diarrhoeal diseases in India, where diarrhoeal outbreaks are more frequent.

Gastrointestinal Fistulization in Amebic Liver Abscess

BACKGROUND

Liver abscess is a common deep seated abscess in children; amebic liver abscess is associated with more local complications.

CASE CHARACTERISTICS

We report two preschool children presenting with short history of pain, fever and right upper quadrant pain. The abscess communicated with gastro-intestinal tract (ascending colon in case 1 and duodenum in case 2), and diagnosis of amebic liver abscess was confirmed by DNA PCR.

OUTCOME

Both children were successfully managed with intravenous antibiotics and catheter drainage.

MESSAGE

Gastrointestinal fistulization may be rarely seen in amebic liver abscess. Conservative management with antibiotics, catheter drainage and supportive care may suffice.

Sonographic evaluation of gallbladder motility in children with chronic functional constipation

Background/Aims

Studies in adults suggest that constipation may not be a purely colonic pathology and may be a component of a generalized gastrointestinal (GI) motor disorder in which proximal GI motility can be impaired. Pediatric data are scarce, and the natural history of the disorder remains undefined. We aimed to evaluate gallbladder motility in a subset of Asian children with chronic functional constipation.

Methods

Abdominal ultrasound was performed on 105 children, including 55 patients (aged 3 to 13 years) with chronic functional constipation who met the inclusion criteria and 50 age- and gender-matched controls. The gallbladder contractility index was calculated based on the preprandial and postprandial gallbladder areas. Preprandial and postprandial values for gallbladder volume and wall thickness were evaluated.

Results

The mean value of the contractility index for the patients (15.77±24.68) was significantly lower than the mean value for the controls (43.66±11.58) (p=0.001). The mean postprandial gallbladder volumes and areas were larger in children with gallbladder hypomotility (p<0.05). The mean duration of constipation (4.8 months) was significantly higher (p=0.004) in the children with gall-bladder hypomotility.

Conclusions

Gallbladder motility is significantly impaired in children with chronic functional constipation. This study contributes to the understanding of the underlying pathophysiology, which will enable advancement in and improved management of children with chronic constipation and associated gallbladder hypomotility.

Fatal cryptococcosis involving multiple sites in an immunocompetent child

Disseminated cryptococcosis is less common in immunocompetent individuals. Herein, we report a fatal case of cryptococcosis in apparently immunocompetent child with multiple site involvement. The yeast isolated from cerebrospinal fluid, blood, endotracheal, gastric and lymph node aspirate was identified by molecular method as Cryptococcus neoformans var. grubii.

Conservative management of a case of traumatic pancreatitis in childhood: a case report

Acute pancreatitis (AP) is relatively uncommon in pediatric age group. Traumatic injury is an important cause of AP in children. Ductal disruption resulting from pancreatic trauma usually needs surgical intervention. A three-and-a-half year old child presented with complaints of abdominal pain and distension following blunt trauma abdomen. Computed tomography of abdomen revealed presence of grade III pancreatic injury with fluid collection in lesser sac. The patient was managed with antibiotics and pigtail drainage and he improved. Therapy for traumatic pancreatitis in paediatric patients must be individualised. Even high grade injuries can be managed non-operatively.

Proximal Myopathy: A Rare Presentation of Celiac Disease

Celiac disease presenting as proximal myopathy is rarely seen, particularly in children. We report a 5-year-old girl who presented with bilateral lower limb weakness and on examination had proximal myopathy. She also had florid rickets and short stature. On investigation, the underlying etiology turned out to be celiac disease. Proximal myopathy with celiac disease can be secondary to the disease per se or due to associated osteopenia and rickets.

Gastric lipoma

We report a 12-year-old-boy with gastric lipoma. Upper gastrointestinal (GI) endoscopy with biopsy and abdominal computed tomogram (CT) scan revealed the diagnosis. Open surgical excision of the mass with stomach preservation was done. The clinical presentation and management are discussed and the literature reviewed here. This is the sixth pediatric case reported in the English literature.

Predictors of outcome in acute-on-chronic liver failure in children

BACKGROUND AND AIMS

Acute-on-chronic liver failure (ACLF) is associated with a high mortality rate in the absence of liver transplantation. There is limited data on predictors of survival in ACLF in children. Therefore, we prospectively studied the predictors of outcome of ACLF in children.

METHODS

A prospective evaluation of 31 children in the age group of 1-16 years who fulfilled the criteria for ACLF according to Asian Pacific Association for the Study of the Liver (APASL) 2008 consensus was done. All consecutive children were evaluated for etiology, diagnosis and severity of ACLF. For grading of organ dysfunction, the sequential organ failure assessment (SOFA) score was calculated. SOFA constitutes the parameters of respiration, coagulation, cardiovascular system, central nervous system, and renal and liver functions. We evaluated possible correlation between outcomes and different variables.

RESULTS

Of the 31 children who fulfilled the criteria for ACLF, the common underlying chronic liver diseases (CLD) were autoimmune hepatitis (AIH) in 41.9% and Wilson disease in 41.9% of the patients. Superinfection with hepatitis A virus (HAV) (41.9%) was the most common etiology of acute deterioration. To find the best predictor for outcome, linear regression analysis was performed. Multivariate analysis revealed that the SOFA score and the International Normalized Ratio (INR) were predictors of survival. Six (19.4%) patients died. Causes of death were multiorgan failure in four and liver failure in two patients.

CONCLUSION

The mortality in ACLF is 19.4% and the causes of death were multiorgan failure and liver failure. The SOFA score and INR were predictors of outcome of ACLF in children.

Small bowel hemangiomas: Diagnostic role of capsule endoscopy

Vascular anomalies involving the small bowel are an uncommon cause of gastrointestinal bleeding in childhood. We present here an 11-year-old boy who presented with severe anemia and malena. The routine investigations did not reveal any pathology. A capsule endoscopy study was performed, which clinched the diagnosis and identified two intestinal hemangiomas. The hemangiomas were resected and the child recovered.

Brush border enzymes and absorptive capacity in extrahepatic portal venous obstruction in children

BACKGROUND AND OBJECTIVE

Portal hypertension may affect intestinal functions, brush border enzymes and absorption parameters. Information about these in extrahepatic portal venous obstruction (EHPVO) in children is limited and poorly reported. We therefore studied the brush border enzymes and absorptive capacity in EHPVO in children.

METHODS

The study was conducted on 52 children of EHPVO. The diagnosis of EHPVO was made on the basis of clinical presentation and ultrasound examination. All patients underwent upper gastrointestinal endoscopy. Endoscopic tissue biopsies from duodenum were taken on aluminum foils and kept immediately at -20°C for estimation of brush border enzymes. Tissue biopsies were homogenized in sodium maleate buffer, 0.1 M pH 6.0, by a homogenizer and processed for the enzymes: lactase, maltase, and sucrase. Enzyme levels were compared to normal healthy controls (n = 20). d-Xylose test, stool acid steatocrit for fat excretion in stools and stool alpha-1 antitrypsin were done to know about the absorptive parameters.

RESULTS

Enzyme levels of lactase (6.21 ± 5.67 IU/mg) and sucrase (37.07 ± 21.06 IU/mg) in EHPVO group were significantly lower as compared to lactase (23.32 ± 10.48 IU/mg) and sucrase (95.96 ± 46.55 IU/mg) in normal healthy controls. Maltase levels were lower, but difference was not statistically significant in EHPVO group (56.90 ± 28.65 IU/mg) as compared to normal controls (63.28 ± 22.88 IU/mg). There was no significant difference of urinary d-xylose and stool fat in patients with normal or short stature EHPVO patients.

CONCLUSION

EHPVO leads to decrease in levels of brush border enzymes in small bowel but their absorption capacity remains normal.

Foreign body oesophagus in a neonate: a common occurrence at an uncommon age

Neonatal ingestion of foreign body is a very uncommon occurrence. We describe a 25-day-old neonate who had a large-sized stone impacted in the cervical oesophagus. The stone was accidently lodged by one of the elder siblings while playing. The stone, after failure to be retrieved endoscopically, was successfully removed by open esophagotomy. The case describes the unusual occurrence at a very uncommon age. It also re-affirms the successful role of open surgery in such situations, which are otherwise commonly treated endoscopically.

Embolization of congenital intrahepatic porto-systemic shunt by n-butyl cyanoacrylate

Congenital intrahepatic portosystemic venous shunt (IHPSVS) is rare vascular anomaly. We present one case of a 14-month male child who presented with global developmental delay. Child had high ammonia levels with low glutamine and high bile salts on the previous investigations and had history of neonatal seizures since day 13 of life. On admission, serum ammonia levels were elevated to 112micromol/L. Other laboratory investigations including liver and renal function test, and electrolytes were normal. He was, diagnosed to have IHPSVS on the basis of Doppler and CT, and treated by embolization with n-butyl cyanoacrylate (glue). A brief review of diagnostic modalities and endovascular management for the IHPSVS is presented including the present case.

Identification and characterization of CFTR gene mutations in Indian CF patients

Cystic fibrosis (CF) is an autosomal recessive disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. This study was performed on Indian CF patients (n = 50) to investigate the spectrum of mutations in the CFTR gene and their association with intragenic and extragenic marker haplotypes. We report identification of 14 previously known and eight novel mutations, namely 3986-3987delC, 876-6del4, 1792InsA, L69H, S158N, Q493L, I530L and E1329Q. The frequency of delta F508 was found to be 27%. Absolute linkage between delta F508 and the KM.19-GATT-TUB9-M470V-T854T haplotype (2-2-1-1-1) predicts a relatively recent appearance of delta F508 in Indian CF patients. Low frequency of delta F508 mutation and detection of eight novel and thirteen rare mutations reflect a heterogeneous spectrum of mutations in Indian CF patients. Failure to detect mutations in 34% of alleles indicates the possible presence of gross deletions involving one or more exons or may indicate the location of the molecular defects in either the noncoding parts of the gene or in the promoter region, which warrants analysis of those regions.

Role of colostrum in gastrointestinal infections

Colostrum is breast milk produced after the birth of the newborn and lasts for 2-4 days. Colostrum is very important part of breast milk and lays down the immune system and confers growth factors and other protective factors for the young ones in mammals. This is the source of passive immunity transferred to the baby from the mother. The biological value of bovine colostrum in present day medical practice is documented in clinical trials and large databases containing case reports and anecdotal findings. The main actions include an antibacterial effect and modulation of immune response with the ability to neutralize lipopolysaccharides arising from gram negative bacterial pathogens. It has been found to be effective in infantile hemorrhagic diarrheas, other diarrheas and reduces the likelihood of disease progressing to hemolytic uremic syndrome. It has also been tested in H. pylori infection and diarrhea in immunodeficiency. Side effects of clinical relevance are limited to possible intolerance due to lactose and sensitivity to milk proteins.

Reassessment of diagnostic value of antral nodularity for Helicobacter pylori infection in children

AIM

Antral nodularity is considered as specific for Helicobacter pylori-associated gastritis in children as well as in adults. The aim of this study is to reassess the accuracy of using antral nodularity as a marker for H. pylori-infection in children with various gastroduodenal diseases.

METHODS

This prospective study included 725 consecutive children in whom upper digestive endoscopy was performed for gastrointestinal symptoms between June 6, 2003 and May 11, 2007 and gastric antral mucosal biopsy was taken. They were divided within three diagnoses groups: Group I, recurrent abdominal pain (N=252); Group II, celiac disease (N=358) and Group III, miscellaneous diagnoses (N=115). One hundred nineteen children were diagnosed as having antral nodularity and were included in the study. H. pylori were recognized in gastric biopsy on hematoxylin and eosin (H&E) sections; a toluidine blue stain was performed in biopsy suspicious for H. pylori. The appropriate statistical method was applied for analysis of data.

RESULTS

The prevalence of antral nodularity in children (M:F:65:54) was 16.4% (119/725). The mean age of children with antral nodularity was 9.4 years (SEM, 0.1 years; range, 2-18 years). The prevalence of antral nodularity increased gradually with age. Fifty out of 119 (42%) children with antral nodularity had recurrent abdominal pain, 26/119 (21.9%) had celiac disease and 43/119 (36.1%) had miscellaneous diagnoses. H pylori-infection was identified in 118/725 (16.3%) children. Antral nodularity had a poor accuracy rate to determine H. pylori-infection (sensitivity, 42%; positive predictive value, 42.4%) and was observed in 50 of 118 (42.4%) H. pylori-positive patients and in 69 of 607 (11.4%) H. pylori-negative patients.

CONCLUSION

The antral nodularity is a poor predictor for H pylori-infection in children. During endoscopy, gastric biopsies should always be obtained in children to establish the presence of H pylori-infection.

Liver function tests and their interpretation

Liver function tests (LFT) are a helpful screening tool, which are an effective modality to detect hepatic dysfunction. Since the liver performs a variety of functions so no single test is sufficient to provide complete estimate of function of liver. Often clinicians are faced with reports that do not tally with the clinical condition of the patient and they face difficulty in interpreting the LFT. An attempt is being made to study and understand the LFT and simplify their interpretation with algorithms.

Comparison of D-xylose hydrogen breath test with urinary D-xylose test in Indian children with celiac disease

D-xylose hydrogen breath test (H2BT) may be better parameter in screening for intestinal malabsorption in patients with celiac disease. This study sought to compare D-xylose H2BT with urinary D-xylose tests in screening for intestinal malabsorption in patients with celiac disease. A total of 68 children with confirmed celiac disease were enrolled for this study. Five-gram urine D-xylose test and D-xylose H2BT were performed simultaneously according to standard methods. Institute ethical clearance and informed consent was taken before starting this study. Of 68 children, 41 were boys and 27 girls of age range 5-14 years; 5-g urine D-xylose test was abnormal in 50% of cases and 5-g D-xylose H2BT in 69.9% of cases. D-xylose H2BT was able to pick up 19.9% more cases of malabsorption in Indian children with celiac disease. This study indicates that performance of 5-g D-xylose H2BT is a better test than 5-g urinary D-xylose test in screening for intestinal malabsorption in patients with celiac disease.

Mitochondrial neuro-gastrointestinal encephalopathy syndrome

Mitochondrial neurogastrointestinal encephalomyopathy is a rare disorder affecting the pediatric age group with a heterogeneous multisystem involvement. We happen to manage a young child with symptoms of constipation since infancy along with cachexia, seizures and peripheral neuropathy. The child later went into encephalopathy preterminally. This clinical syndrome fitted very well with mitochondrial neurogastrointestinal encephalomyopathy. The child had elevated lactate levels and electron microscopy of the rectal biopsy was suggestive of a mitochondrial disorder To the best of our knowledge there is no case report of this syndrome from India and since this presents with diagnostic difficulties so is being reported.

Pancytopenia in a child associated with hepatitis A infection

Pancytopenia is a very rare condition associated with hepatitis A infection. We managed a 12 year old boy who had hepatitis A infection with anemia. His hemogram and bone marrow examination were suggestive of pancytopenia. Pancytopenia recovered without any specific therapy. There are case reports of severe aplastic anemia with hepatitis A infection that required immunosuppressive therapy. The present case did not require any aggressive therapy and recovered. In a young child with hepatitis A infection and anemia, bone marrow depression should be suspected. The pancytopenia may be transient as exemplified by the present case.

Therapeutic potentials of bovine colostrums

Colostrum is the first milk produced by mammals for their young ones. This transfers the passive immunity gained by the mother to the baby. The bovine colostrum (BC) can be obtained in large quantity and has properties similar to human colostrum. It has been used for various disorders of the body. It has properties to stimulate immune system, contains growth factors and many bioactive substances needed for the body to combat with wear and tear. The BC has been used for various gastrointestinal disorders, respiratory tract infection, rheumatoid arthritis, healing injured tissues of body etc. There are not much double blind placebo-controlled trials to prove its efficacy, though a lot of experience about its good effects in various disorders is available in the literature. The dosage and duration of therapy need to be worked up. The BC has potential to treat as well to prevent certain diseases in the body. In future this will prove to be a very useful product to treat and control diseases in a natural way.

Health factors in colostrum

Colostrum is a breast milk produced after the birth of the newborn and lasts for 2-4 days. Colostrum is very important part of breast milk and lays down the immune system and confers growth factors and other protective factors for the young ones in mammals. This is the source of passive immunity achieved by the mother and is transferred to the baby. This is the major source of secretory IgA and gives protection against gastrointestinal infections. In view of so many health factors through colostrum, the use of colostrum has been extended to so many health problems of mankind. Human and bovine colostrums have many similarities barring that bovine colostrum can be obtained in large quantity, so bovine colostrum has been used in various disorders in human beings. This is the nature's gift that is for the young ones to grow as well as for the treatment of many health problems in older age group.

Segmental dilatation of ileum: an unusual cause of severe malnutrition

Segmental dilatation of the ileum causing blind loop syndrome was seen in a 6-year-old boy presenting with nonspecific symptoms and severe malnutrition. Barium meal was characteristic. Resection of the affected segment and an end-to-end anastomosis was curative and restored normal bowel function. Clinicians' awareness of this entity would help in appropriately managing such cases.

Extrahepatic portal hypertension: quality of life and somatic growth after surgery

AIM

This study was carried out in order to determine whether children with extrahepatic portal hypertension show any improvement in growth parameters and quality of life after elective surgery.

PATIENTS AND METHODS

All patients with extrahepatic portal hypertension who underwent surgery between April 1999 and March 2002 were studied prospectively. Height and weight before and after surgery were converted into Z scores for comparison. The quality of life was assessed by changes in scholastic ability, physical activity, social interaction, and economic effects on the family.

RESULTS

At the end of a minimum follow-up period of 1 year, of the 30 children, 50 % and 76 % showed improvement in weight and height Z scores, respectively, compared to their scores while on medical management. Z scores below - 2 SD for weight and height were seen in 57 % and 37 % of patients prior to surgery, and only in 40 % and 20 %, respectively at the end of follow-up, which ranged from 1 - 4 years. The improvement in height and weight was more in those who had undergone splenectomy with either devascularization or central splenorenal shunt compared to those who had undergone side-to-side lienorenal shunt without splenectomy. The children, who had dropped out of school while on medical management, either rejoined school or attended vocational courses after surgery. There was an improvement in school performance and physical activity in 85 % of the children. Improvement in personality was seen in 73 % of the affected patients. The cost incurred for surgery was one-third of the amount spent while on medical management.

CONCLUSIONS

Growth parameters improved significantly in children after surgical intervention for portal hypertension. Overall improvement in scholastic abilities, physical activity, and social interaction was noted in a majority of the patients. As a one-time procedure in a developing country, surgery is also more cost effective.

Detection of avian leukosis virus subgroup J in chicken flocks from Malaysia and their molecular characterization

Previously we have shown that avian leukosis virus subgroup J (ALV-J) might be present in chicken flocks from Malaysia based on serological study and also on detection of tissue samples with myelocytic infiltration. In this study, the polymerase chain reaction was used to detect ALV-J sequences from archived frozen samples. Out of 21 tissue samples examined, 16 samples were positive for proviral DNA and four samples for ALV-J RNA. However, only nine samples were found positive for myelocytic infiltration. A total of 465 base pairs equivalent to positions 5305 to 5769 of HPRS-103 from each of the viral RNA positive samples were characterized. Sequence analysis indicated that the samples showed high identity (95.9 to 98.2%) and were close to HPRS-103 with identities between 97.4 and 99.3%. This study indicates that ALV-J-specific sequences can be detected by polymerase chain reaction from frozen tissue samples with and without myelocytic infiltration.

Extrahepatic portal hypertension in children: observations on three surgical procedures

This paper presents a comparative prospective study of three modalities of surgical treatment for extrahepatic portal hypertension in children: central splenorenal shunt after splenectomy (CSS), side-to-side lienorenal shunt (SSLR) without splenectomy, and splenectomy and gastroesophageal devascularization (SGD). In an 18-month period, 27 procedures were performed: 10 CSS, 10 SSLR, and seven SGD. The outcomes were evaluated by fall in portal pressures, hematological parameters, shunt patency, splenic regression, and disappearance of esophageal varices. All three procedures were comparable in the fall of portal pressure after surgery. The average blood loss and operating time were statistically significant in favor of SSLR compared with CSS. At 3-month follow-up, shunt patency was confirmed by duplex Doppler study in all the patients in the SSLR group and in nine out of 10 patients in the CSS group. In the CSS and SGD groups, hypersplenism resolved in all the patients. In the SSLR group, blood counts improved in only five out of eight affected children. No patient re-bled during a follow-up of 3-5 years. There were no cases of hepatic encephalopathy or overwhelming postsplenectomy sepsis. In conclusion, CSS is useful when there is a large spleen, severe hypersplenism, and a shuntable splenic vein. SSLR is suitable when there is only mild splenomegaly, mild hypersplenism, and a shuntable splenic vein. Splenectomy and devascularization is the choice when there is no shuntable splenic vein.

Radiological spectrum of late sequelae of corrosive injury to upper gastrointestinal tract. A pictorial review

PURPOSE

To evaluate the radiological spectrum of sequelae of corrosive acid and alkali injury to the upper gastrointestinal (GI) tract using barium contrast examination.

MATERIAL AND METHODS

Barium contrast radiographic films of 155 patients with a history of corrosive ingestion, acid in 120 and alkali in 35 patients with grade 2b and 3 injury on initial endoscopy, were retrospectively evaluated. Barium contrast examination of the upper GI tract was performed in the course of follow-up, beyond 3 weeks of corrosive ingestion.

RESULTS

The esophagus was involved in 131 patients and the stomach in 74. Fifty patients had simultaneous involvement of esophagus and stomach. Radiological findings in the esophagus were solitary or multiple strictures of varying length, intramural pseudodiverticula, and carcinoma in long-standing corrosive injury. The stomach showed cicatrization, predominantly involving the antrum, linitis plastica type deformity with multiple pseudodiverticula. There was no difference in the radiological findings as to the type of corrosive ingested.

CONCLUSION

Barium examination of the upper GI tract is useful in the evaluation of late sequelae of corrosive injury (acid/alkali). There was no difference in the radiological findings as to the type of corrosive ingested. Thus, contrary to general belief, we found that acid and alkali damage both the esophagus and the stomach with equal degree of severity.

Gastric augmentation in isolated congenital microgastria

A 10-month-old boy with isolated congenital microgastria is reported. This is an extremely rare condition with only 2 previous similar case reports. The patient was treated successfully with early gastric augmentation. Although the embryologic origin of this anomaly was widely believed to be in the fourth week of gestation, the anatomic features in the current case point to the arrest of development at least after the eighth week of fetal life.

Renal lymphangiomatosis: a rare cause of bilateral nephromegaly

We report the ultrasound, excretory urography and MR findings in a young child with renal lymphangiomatosis who presented with gradually progressive bilateral flank swelling but who was otherwise asymptomatic. The typical perirenal and parapelvic cysts are visualized as hypoechoic lesions on sonography and hyperintense on T2-weighted HASTE images. T1-weighted image could not delineate the cysts clearly. The renal parenchyma was hyperechoic on sonography, and MRI showed reversal of the normal corticomedullary signal intensity, and confirmed the diagnosis by suggesting the non-parenchymal origin of the cysts.

Celiac crisis

Celiac crisis is a life-threatening cause of acute diarrhea and multiple metabolic emergencies. It is extremely rare these days. We successfully managed a 5-year old girl with celiac crisis for multiple metabolic problems viz., hyponatremia, hypokalemia, metabolic acidosis, hyperglycemia and polyuria in Pediatric Intensive Care Unit. Steroid therapy was life saving. The case may serve as a reminder of the condition, which presents a difficult therapeutic challenge.

Familial hemophagocytic lymphohistiocytosis: an autopsy study

We describe four classical cases of familial hemophagocytic lymphohistiocytosis (FHL), a macrophage-related, autosomal recessive fatal disorder. Parental consanguinity was present in three cases. All patients presented with fever, neurological involvement of varying degrees, hepatosplenomegaly, cytopenias, deranged liver function tests, and coagulogram, hypofibrinogenemia (three cases), and hyperlipidemia (one case). An antemortem diagnosis could not be made, although it was suspected in one case. Necropsy (done in three cases and postmortem liver biopsy in one case) revealed classical features of FHL. Florid lymphohistiocytic infiltrate exhibiting hemophagocytosis was seen in the bone marrow, liver, spleen, lymph nodes and brain (examined in two case). In addition to this, focal infiltrates were seen in the kidneys, lung, pancreas, testes, adrenals, and skin. Marked lymphoid depletion was seen in one case in the lymph nodes and spleen.

Perforations and fistulae in gastrointestinal tuberculosis

BACKGROUND

Perforation and fistulae, though uncommon, are serious complications of gastrointestinal tuberculosis. Patients with acute tuberculous perforation are subjected to surgery, whereas localized perforation and fistulae with subtle clinical signs are detected by barium contrast examination. There has been no report on radiological series regarding the incidence of perforation and fistulae, detected by barium contrast studies.

MATERIAL AND METHODS

A retrospective analysis of barium contrast studies of 684 proven cases of gastrointestinal tuberculosis seen over a period of 15 years was done to detect the incidence of perforation and fistulae.

RESULTS

Fifty-two patients (7.6%) with localized perforation and fistulae were seen. Twenty-eight patients had evidence of perforation, and 24 patients showed fistulae formation. The most common site of perforation and fistulae was the small bowel followed by the colon. Associated abnormalities noted were ulcerations, strictures, nodular filling defects and extrinsic compression.

CONCLUSION

Perforation and fistulae along with other associated abnormalities of the gastrointestinal tract are suggestive of tuberculosis, particularly in a population predisposed to tuberculous infection.