Esophagogastric junction outflow obstruction in the differential diagnosis of post-fundoplication dysphagia in children

INTRODUCTION AND AIMS

Post-fundoplication dysphagia is resolved with no therapeutic intervention in the majority of cases but it can persist in 5.3% of children that undergo the procedure. Among the differential diagnoses, esophagogastric junction outflow obstruction (EGJOO) is a disorder that should be suspected if there is a persistence of dysphagia. The aim of our study was to describe the clinical characteristics, treatment, and follow-up in a case series of patients diagnosed with post-fundoplication EGJOO.

MATERIALS AND METHODS

The clinical records of patients diagnosed with EGJOO at a tertiary care hospital within the time frame of September 2015 to September 2019 were reviewed, with respect to manometry, etiology, treatment, and clinical course of the disease.

RESULTS

Of the 213 high-resolution esophageal manometries performed, 4 patients met the criteria for post-fundoplication EGJOO. The primary symptom was dysphagia, presenting 15 days after the procedure. Esophageal dilations were carried out on all the patients but with no improvement. Symptoms related to the condition resolved spontaneously in three of the four patients.

CONCLUSION

The management of children with post-fundoplication EGJOO continues to be a challenge. Even though more than half of the cases resolve with no intervention, optimum management of the motility disorder is still limited, given the scant experience with the condition in the pediatric population.

Foreign body ingestion and associated factors in pediatric patients at a tertiary care center

INTRODUCTION AND AIMS

Foreign body (FB) ingestion is a common problem in children under 5 years of age and is one of the main indications for endoscopy. The aim of the present study was to describe the clinical, radiographic, and endoscopic characteristics of patients with FB ingestion, as well as the factors associated with the anatomic location and the type of object ingested.

MATERIALS AND METHODS

An analytic cross-sectional study was conducted on all patients with FB ingestion seen at the gastroenterology service from January 2013 to December 2018. The data were analyzed using the SPSS program, obtaining frequencies, percentages, medians, and interquartile ranges. Associations were assessed through the chi-square test.

RESULTS

Eighty-five patients (52 males and 33 females) were included, with a median age of 4 years. The most common symptom was vomiting (29.4%). Two radiographic projections were carried out in 72.9% of the cases and the stomach was the site where the FB was most frequently visualized (32.9%). The objects most commonly ingested were coins (36%), with esophageal location (p <0.05), as well as objects with a diameter larger than 2cm (p <0.05). An endoscopic procedure was performed on 76 patients (89.4%) for FB extraction, with findings of erythema (28.9%), erosion (48.6%), ulcer (10.5%) and perforation (1.3%).

CONCLUSIONS

Numerous factors should be taken into account in the approach to FB ingestion in pediatric patients, including type and size of the FB, time interval from ingestion to hospital arrival, and patient clinical status and age.

Anorectal manometry in children with retentive fecal incontinence: What parameters should we evaluate?

INTRODUCTION

Children with functional constipation frequently present with alterations in rectal compliance and the urge-to-defecate sensation that can be evaluated through anorectal manometry (ARM). In the present study, we evaluated the usefulness of the parameters obtained through ARM in children with retentive fecal incontinence (RFI).

MATERIALS AND METHODS

Children with functional constipation, aged 4 to 17years, that underwent ARM were included in the study.

RESULTS

Of the 35 children evaluated, 21 presented with functional constipation and 14 had functional constipation and RFI. The children with both constipation and RFI tolerated greater volumes of air insufflation for triggering the urge to defecate and reaching maximum tolerance of pain, compared with the children that did not have RFI. We identified the cutoff point of 135ml of air as the maximum tolerance sensation for distinguishing children with RFI.

CONCLUSIONS

Maximum tolerance of pain was the most useful parameter for evaluating RFI in children with functional constipation.

Histopathologic findings in children diagnosed with cow's milk protein allergy

BACKGROUND

Cow's milk protein allergy is the most common cause of food allergy. The challenge test, either open or doubled-blind with a placebo control, is regarded as the criterion standard. Endoscopy and histologic findings are considered a method that can aid in the diagnosis of this entity.

AIMS

The aim of this study was to describe the histopathologic findings in children suspected of cow's milk protein allergy that were seen at our hospital.

MATERIAL AND METHODS

A descriptive, observational study was conducted on 116 children clinically suspected of presenting with cow's milk protein allergy that were seen at the Department of Gastroenterology and Nutrition of the Instituto Nacional de Pediatría. Upper endoscopy and rectosigmoidoscopy with biopsies were performed and the findings were described.

RESULTS

Of the 116 patients, 64 (55.17%) were girls and 52 (44.83%) were boys. The rectum was the site with the greatest presence of eosinophils per field in both groups, followed by the duodenum. In general, more than 15 eosinophils were found in 46% of the patients.

CONCLUSIONS

Between 40 and 45% of the cases had the histologic criterion of more than 15 to 20 eosinophils per field and the rectosigmoid colon was the most affected site. Therefore, panendoscopy and rectosigmoidoscopy with biopsy and eosinophil count are suggested.

[Primary intestinal lymphangiectasia: twenty years of experience at a Mexican tertiary care hospital]

BACKGROUND

Primary intestinal lymphangiectasia is a rare congenital disease described by Waldmann in 1961 that is a consequence of obstruction of the lymphatic drainage of the small bowel with secondary lymph vessel dilation. This distorts the architecture of the villi and causes a leakage of lymph into the intestinal lumen, resulting in protein-losing enteropathy and malabsorption.

AIM

To describe the clinical, biochemical, radiologic, endoscopic, and histologic characteristics in children with primary intestinal lymphangiectasia.

METHOD

A retrospective observational, descriptive, cross-sectional study was conducted that reviewed the case records of children diagnosed with primary intestinal lymphangiectasia that were seen at the Department of Gastroenterology and Nutrition of the Instituto Nacional de Pediatría within the time frame of January 1, 1992 to September 30, 2012.

RESULTS

Four patients were found that presented with primary intestinal lymphangiectasia. Three of them had been diagnosed before 3 years of age. All the patients presented with chronic diarrhea, edema, lymphopenia, hypocalcemia, and hypogammaglobulinemia, and 3 patients presented with hypocholesterolemia. Bowel transit time, endoscopy, and intestinal biopsies were characteristic of this pathology.

CONCLUSIONS

Intestinal lymphangiectasia should be suspected when there is a clinical picture of chronic diarrhea and protein-losing enteropathy accompanied with edema at any level, as well as hypoalbuminemia, hypocalcemia, lymphopenia, hypogammaglobulinemia, and hypocholesterolemia, which are the main biochemical findings of this pathology. All children presenting with intestinal lymphangiectasia should undergo an upper gastrointestinal series with bowel transit time and endoscopy with biopsies taken at the level of the duodenum. Treatment includes diet and the periodic administration of albumin and gamma globulin.

[24-h intraesophageal pH determination in children allergic to cow's milk protein at a tertiary care hospital]

BACKGROUND

Cow's milk protein allergy (CMPA) is being seen more frequently on a daily basis in pediatric consultations. It shares symptoms with gastroesophageal reflux (GER), which can complicate the differential diagnosis.

AIMS

To attempt to corroborate the presence of acid GER in children with CMPA, as well as to find a characteristic profile through the 24-hour pH monitoring study in children with GER and CMPA METHODS: The intraesophageal pH monitoring studies performed on 47 children with CMPA were reviewed. The measurements in all the studies were carried out within a 24-hour period using Digitrapper® equipment with a multi-use GeroFlex® catheter, after calibration with pH 7 and pH 1 buffer solutions.

RESULTS

Of the 47 children, 23 were boys (32.4%) and 24 were girls (33.8%) and the mean age was 5±3.7 years. Fourteen of the 47 children (29%) presented with GER, according to the result of the 24-hour intraesophageal measurement. Only 2 of the 47 patients studied fit the phasic profile.

CONCLUSIONS

The findings show the existing relation between the two pathologies. Nevertheless, it is important to determine the presence of non-acid or weak acid reflux, because their existence can increase this association.

Cisapride and QTc interval in children

BACKGROUND

Recent reports about cisapride have raised some concerns about the safety and efficacy of this medication in children. The aim of this study was to identify electrocardiographic changes and a predisposition to develop arrhythmias in children.

METHODS

Patients were divided in 2 groups: 1) 63 children (mean age: 29 months) who received cisapride (0.2 mg/kg/dose 3 times/day), and 2) 57 children (mean age: 27 months) who did not receive cisapride (they served as controls). Both groups did not have any associated disease. Electrocardiogram (EKG) was performed to children when they were included in the study. The QT interval was corrected using Bazett's formula. Twenty-four-hour Holter recording was performed in children with prolonged QT interval (PQTI). When PQTI was identified in group 1, cisapride was discontinued and a new EKG was performed.

RESULTS

Five children from group 1 and 6 from group 2 had PQTI. In 3 children with PQTI, the QTc interval returned to normal values when cisapride was discontinued. In children under 4 months of age, a statistical difference was found, with QTc interval being longer in group 2 (without cisapride) than in group 1. Holter recordings were normal in all children with PQTI.

CONCLUSION

PQTI can be found in normal children with or without cisapride. In our study PQTI was not associated with any life-threatening event.

[Antral membrane. Presentation of a case]

A case of antral membrane in a 23 month old child is presented. He developed an extremely rapid clinical course characterized by vomiting, 4 kg weight loss and acute malnutrition. The UGI showed a probable antropyloric obstruction which was confirmed by endoscopy and lately by surgery. It is suggested that in the approach of a patient with vomit it is very important to make an oriented clinical history and always complete the study of the patients with radiological and endoscopic procedures.