T and B cell repertoire in gastric lymph follicles in children with Helicobacter pylori infection

Helicobacter pylori infection has been implicated in the development of gastrointestinal malignancy in adults and children. The histopathological processes that lead to such development are unknown. We compared the immune cell repertoire of mucosal lymph follicles in children with H. pylori infection to B cell type mucosal associated lymphoid tissue (MALT)-lymphoma of adults. The B and T cell populations residing within the lymph follicles and/or within B cell type MALT lymphoma were characteriZed by an immunohistochemical technique, utilizing B and T cell markers including: CD3, CD4, CD8 (T cells); CD20, CD40, GD74, BLA36, CD80, CD86 (B cells). Stain intensity was compared between the samples. T cell repertoire was observed within the lymph follicles, but not in the B cell MALT-lymphoma specimens. No significant difference was observed between the staining of CD40, CD74, CD8, and BLA36. The B cell markers, CD80 and CD86, were found within the centrocytic zone of the lymph follicle. In the B cell repertoire, no significant difference was observed between the lymph follicles of children with H. pylori infection and the adult MALT-lymphoma specimens except in CD20. B and T cells were in close anatomical proximity, enabling them to interact and exchange immunological information.

The use of an oral fluid immunoglobulin G ELISA for the detection of Helicobacter pylori infection in children

BACKGROUND

Enzyme linked immunosorbent assay (ELISA) evaluation of oral fluid immunoglobulin G (IgG) antibodies to Helicobacter pylori is a unique approach for both epidemiological studies and the diagnosis of infection, especially in children. The use of oral fluid sampling to evaluate specific H. pylori IgG antibodies has advantages over serum, including reduced biohazard risk and noninvasive collection. Oral fluid sampling is fast and involves minimal patient discomfort. Since children facilitate transmission of H. pylori infection, a simple, accurate, noninvasive diagnostic test is necessary for large epidemiologic studies. The aim of our study was to evaluate a new oral fluid ELISA for detection of IgG antibodies to H. pylori in children.

MATERIALS AND METHODS

We compared this new oral fluid ELISA with the HM-CAPTM serum ELISA and gastric biopsy histology using 779 oral fluid samples from children collected at 11 clinical sites across the United States. This cohort included 315 children symptomatic for abdominal pain and 464 asymptomatic. All samples were evaluated in a double blind manner. The oral fluid ELISA demonstrated a sensitivity of 76.2% and a specificity of 94.0% in children 2 months old to 201/2 years, as compared with the HM-CAPTM serologic assay. The assay's sensitivity improved to 81.3% in children aged 5 or greater and the specificity remained at 94.0%. When compared with gastric biopsy histology in the same age group, the oral fluid ELISA demonstrated a sensitivity of 71.7% and a specificity of 90.4%.

RESULTS

This new oral fluid ELISA is moderately sensitive and offers a very specific method for detecting H. pylori infection in older children, but it is of little value in children under the age of 5 years.

CONCLUSIONS

Overall, we conclude that this oral fluid ELISA does not appear to be a helpful clinical tool for the diagnosis of H. pylori infection in children.

T and B cell repertoire in gastric lymph follicles in children with Helicobacter pylori infection

Helicobacter pylori infection has been implicated in the development of gastrointestinal malignancy in adults and children. The histopathological processes that lead to such development are unknown. We compared the immune cell repertoire of mucosal lymph follicles in children with H. pylori infection to B cell type mucosal associated lymphoid tissue (MALT)-lymphoma of adults. The B and T cell populations residing within the lymph follicles and/or within B cell type MALT lymphoma were characteriZed by an immunohistochemical technique, utilizing B and T cell markers including: CD3, CD4, CD8 (T cells); CD20, CD40, GD74, BLA36, CD80, CD86 (B cells). Stain intensity was compared between the samples. T cell repertoire was observed within the lymph follicles, but not in the B cell MALT-lymphoma specimens. No significant difference was observed between the staining of CD40, CD74, CD8, and BLA36. The B cell markers, CD80 and CD86, were found within the centrocytic zone of the lymph follicle. In the B cell repertoire, no significant difference was observed between the lymph follicles of children with H. pylori infection and the adult MALT-lymphoma specimens except in CD20. B and T cells were in close anatomical proximity, enabling them to interact and exchange immunological information.

Non-Helicobacter pylori related duodenal ulcer disease in children

BACKGROUND

In spite of the worldwide distribution of Helicobacter pylori infection, recent data have reported an increased rate of non-H. pylori, non-NSAIDs-duodenal ulcer disease in adults. The estimated rate of these ulcers in children is unknown. We aimed to investigate the prevalence of non-H. pylori, non-NSAIDs-peptic ulcer disease in our pediatric patients who undergo upper endoscopic procedures.

METHODS

A retrospective analysis of 622 upper endoscopic reports was performed. Reports that documented mucosal ulcerations were included in our study. The demographic, clinical, endoscopic, and histological data were retrieved. The H. pylori-negative, duodenal/gastric ulcer-positive patients were compared with H. pylori-positive, duodenal/gastric ulcer-positive patients.

RESULTS

Out of the 622 upper endoscopy reports, a total of 11 (1.8%) children with mucosal ulceration were studied. Mucosal ulceration was distributed in the following locations: stomach-3 (27%), and duodenal bulb-10 (91%) (two children had ulcers in both the stomach and duodenal bulb). Helicobacter pylori infection was only detected in three (27%) children with duodenal ulcer. Gastritis was more severe in patients with H. pylori infection/duodenal ulcer compared with H. pylori-negative/duodenal ulcer group. No statistical difference in clinical symptoms or endoscopic appearance was observed between the H. pylori-negative and H. pylori-positive groups.

CONCLUSION

'Idiopathic' (H. pylori-negative, NSAIDs-negative) duodenal/gastric ulcers are present in symptomatic children. Clinical or endoscopic characteristics are insufficient markers to identify those 'idiopathic' ulcers. Investigating the 'risk factors' for those ulcers will be helpful in reducing the morbidity in these children.

Diagnosis and treatment of Helicobacter pylori infection in children: a survey of WV primary care physicians

Helicobacter pylori infection has been implicated in the development of peptic ulcer disease in children. Although clinical protocols for the diagnosis and treatment of this infection in children are available, the implementation of those guidelines by primary physicians are insufficient. In this study, we surveyed the clinical practices of 409 primary physicians who practice in West Virginia and treat children with H. pylori infection. Results showed in contradiction with the recommendation, primary physicians are still using serology as the preferred diagnostic method for this disease. Most of the physicians treat this disease with a combination of two antibiotics and anti-acid medication (H2 blockers or PPI) for at least one week. We conclude that an increase in knowledge of those guidelines among primary physicians may improve physicians' compliance with H. pylori guidelines.

Reuse of negative CLOtest kits in children

BACKGROUND

The rapid urease test, CLOtest, is used frequently in endoscopy suites. In the developed world, a negative CLOtest result is extremely common. The question of whether reuse of previously negative CLOtest kits is appropriate in children and the cost saving of such a practice were investigated.

METHODS

Children who underwent diagnostic endoscopic procedures were prospectively recruited to the study. In each procedure gastric biopsy specimens were obtained for 2 rapid urease tests, one a new kit and the other a used negative kit obtained from previous procedures. In addition gastric specimens were also obtained for routine histologic examination.

RESULTS

In 121 (99.2%) patients a complete concordance between new and used CLOtests was observed. Chi-square analyses showed a significant association between CLOtest results and each of the following factors: gastritis, the presence of Helicobacter pylori organisms, and H pylori-associated gastritis. Assuming an average rate of 15% positive CLOtest results in our pediatric population, the annual savings at the rural hospital was $265 and at the urban children's hospital, $1958.

CONCLUSION

Reuse of a negative CLOtest is reliable and may reduce costs, especially in facilities with a high volume of endoscopic procedures.

Is sudden infant death syndrome associated with Helicobacter pylori infection in children?

Helicobacter pylori infection has recently been implicated in the pathogenesis of sudden infant death syndrome (SIDS). We investigated this association. Twenty-five pairs of gastric and tracheal tissue specimens obtained from autopsies of 25 children with previous diagnoses of SIDS were available for this study. The presence of H. pylori organisms was evaluated by three different methods: histology (hematoxylin-eosin or Giemsa staining), immunohistochemistry, and nested polymerase chain reaction technique. We were unable to confirm the presence of H. pylori organisms by the first two methods. H. pylori DNA was identified by nested polymerase chain reaction in six different tissue specimens (stomach, 4; trachea, 2). In no case was H. pylori DNA detected in both tissues. We concluded that H. pylori infection is most likely not associated with SIDS.

Propofol sedation for endoscopic procedures in children

BACKGROUND AND STUDY AIMS

Propofol sedation has been used successfully in various outpatient minor procedures in children. Limited data are available on the usefulness of propofol sedation during gastrointestinal endoscopic procedures in children. The aim of this study was to evaluate our experience of propofol sedation in pediatric gastrointestinal endoscopic procedures.

MATERIALS AND METHODS

The charts of all children who had undergone diagnostic endoscopic procedures, and were sedated by propofol, were retrospectively reviewed. Demographic data, cardiovascular monitoring, and drug dosages were recorded. Patients evaluated their sedation efficacy by answering a questionnaire before discharge.

RESULTS

A total of 104 children underwent 107 procedures. Propofol alone was given in 19 procedures and in combination with midazolam and/or fentanyl in 88 procedures. All procedures were completed and significant complication occurred in only one patient. No significant difference was observed in the amount of sedative drugs or recovery time between upper and lower endoscopic procedures. A lower propofol dosage was needed when a combination of drugs was given compared to propofol drug alone. Patients' assessment of their sedation showed that the vast majority had experienced postendoscopic amnesia.

CONCLUSION

Propofol sedation for endoscopic procedures is safe and acceptable for children. Propofol sedation should be offered to young children, especially those who express significant anxiety.

Helicobacter pylori serology and the diagnosis of H. pylori infection in children

Serological screening accuracy rate may be dependent on clinical and pathological determinants. The aim of this study was to evaluate the accuracy of Hp serology test (Roche Biomedical Lab., Labcorp), in the diagnosis of Hp infection in 121 children who were seen in the Pediatric Gastoenterology Clinic at the Marshall University Joan C. Edwards School of Medicine in Huntington. Positive serology detected children with Hp-associated gastritis with a sensitivity of 51.6%. Positive serology significantly correlated with the degree of gastric inflammation and density of Hp organisms in the gastric mucosa (ANOVA p < 0.001). The Labcorp. Hp-ELISA test had a poor accuracy rate for the detection of Hp-gastritis in children. Gastric biopsies should always be performed to establish the diagnosis of Hp infection in children.

Is gastric nodularity a sign for gastric inflammation associated with Helicobacter pylori infection in children?

The aim of this study was to investigate the accuracy of using gastric nodularity (GN) as a marker for gastric inflammation associated with Helicobacter pylori infection in children. A retrospective analysis of 395 upper endoscopies done in children between 1990-1996 was performed. Demographics, clinical symptoms, endoscopic features, rapid urease test (RUT), and histological results were collected from each report. GN was found in 13 (3.5%) children. GN showed a significant correlation with age but not with gender. Multiple regression analysis showed a significant correlation between GN and gastritis with RUT but not with other histological determinants alone (gastritis, RUT, or H. pylori organisms). Nevertheless, GN had a poor accuracy rate to determine H. pylori-associated gastritis (sensitivity, 61%; positive predictive value, 12%). GN is a poor predictor for gastric inflammation associated with H. pylori infection in children. During endoscopy, gastric biopsies should always be obtained in children to establish the presence of mucosal inflammation.

Tryosine kinase and ornithine decarboxylase activation in children with Helicobactor pylori gastritis

H. pylori infection has been considered a risk factor for the development of gastric malignancy. Ornithine decarboxylase and tyrosine kinases activities are increased in patients with colon or esophageal cancer. In this study we compared the ODC and tyrosine kinases activities in the gastric mucosa of children with H. pylori infection and normal mucosa. Gastric biopsies were prospectively collected from children during routine upper endoscopic procedure. H. pylori infection was determined histologically. Biopsies were analyzed for ODC activity, total tyrosine kinases activities, and for the activity of protooncogene tyrosine kinase pp60(c-src). The mean ODC activity (pmol 14CO2/mg. protein/hr) and total tyrosine kinases activity (pmol 32P/mg. protein) were 186 and 5877 for H. pylori infected mucosa; and 229 and 4300, for normal mucosa, respectively (p> 0.05). Tyrosine kinase pp60(c-src) protein levels were similar between H. pylori infected mucosa and normal mucosa (3.12 and 2.15 pmol 32P/mg. protein, respectively; p>0.05). There was no correlation between gastric inflammation and the level of ODC or tyrosine kinase activities. ODC and tyrosine kinase activities in the gastric mucosa are similar in children with H. pylori infection compared to normal mucosa. The data suggest that these enzymes cannot be used as markers for future cancer development in children.

Cow's milk allergy in infants

Cow's milk allergy (CMA) is one of the most common food allergies in young infants affecting up to 7% of children less than six months of age. The clinical presentation of these infants may be very traumatic to their parents, as significant rectal bleeding is the most common symptom in this disease. This article describes our experience treating 44 infants who were diagnosed with CMA in the Pediatric Gastroenterology Clinic at Marshall University. The clinical symptoms, treatment and outcome are presented. To reduce apprehension from the parents, primary physicians should be familiarized with this disease.

Helicobacter pylori antibody profile in household members of children with H. pylori infection

Intrafamilial spread is implicated as a major route for acquisition of Helicoobacter pylori infection. Investigating H. pylori cytotoxin-associated protein (CagA) and vacuolating toxin (VacA) antibodies within family members enabled the authors to evaluate this possibility further. Serum samples were collected prospectively from household members after their index children were diagnosed with active H. pylori infection. Serum samples were evaluated for anti-H. pylori immunoglobulin G antibody using the enzyme immunoassay (IEA) method and for H. pylori CagA and VacA antibodies with the commercially available immunoprobing Western blot kit. Ten different families participated in the study, including 10 pediatric patients and 31 household members. All patients and 28 household members (90%) were seropositive for H. pylori antibody by IEA and Western blot tests. Overall, 17 subjects (41.4%) were CagA positive, 14 (34.1%) were VacA positive, 11 (26.8%) were positive for both antibodies, and 22 (53.6%) were negative for both antibodies. A significant association in bacterial antibody profile was found between the patient index members and all household members (Cohen's kappa and Mentel-Haenszel methods). In four families, more than 66% of the household members harbored the same antibody profile, and in two families a completely different profile was observed. Moreover, a similar H. pylori antibody profile between the index patient and the mother was found in six families, and between the index patient and the father in two families. The data strongly suggest an intrafamiliar transmission for H. pylori infection.

Detection of Helicobacter pylori organisms by Hp-fast in children

Hp-fast is a new rapid urease test (RUT) that has not been evaluated in children. The aim of the study was to prospectively compare the Hp-fast test to the CLOtest in children. Children with gastrointestinal symptoms who undergo diagnostic upper endoscopy were prospectively enrolled to the study. Antral gastric biopsies were evaluated for histology and for CLO-test and Hp-fast. Results were then compared to histology. Of the 94 children who participated, gastritis was found in 38 (40%), of whom 16 (42%) had associated H. pylori organisms. In two children, H. pylori organisms were identified without gastritis. The concordance between both RUT tests was 98%. A significant correlation was found between RUT results and histological factors or serology. The accuracy rate of both RUT increased significantly when different gold standards were utilized to detect Hp infection in children. The best correlation was found when histology and serology were considered as the gold standard for the diagnosis of H. pylori infection in children (sensitivity: 100% compared to 43-80% with other standards, respectively). In conclusion, the Hp-fast test result is comparable to CLOtest, but neither alone is sufficient to establish the diagnosis of Hp infection in children.

Prevalence of CagA, VacA antibodies in symptomatic and asymptomatic children with Helicobacter pylori infection

BACKGROUND

Limited data are available on the prevalence of CagA and VacA Helicobacter pylori antibodies in children. The aim of this study was to investigate the antibody prevalence to the H. pylori virulence factors CagA and VacA in symptomatic and asymptomatic children with H. pylori infection and to correlate these antibodies with the severity of gastric inflammation or density of H. pylori organisms in the gastric mucosa.

MATERIALS AND METHODS

Twenty-three symptomatic children and 132 asymptomatic children with positive H. pylori serology participated in this study. Anti-H. pylori IgG antibody and CagA or VacA H. pylori antibodies were measured by enzyme immunoassay (HM-CAP; sensitivity and specificity > 90%) and Western immunoblot (Helicoblot 2.0) methods, respectively. Gastric inflammation and H. pylori density were graded histologically using the revised Sydney criteria.

RESULTS

The prevalence of CagA and VacA antibodies were 69% and 35% in symptomatic children and 54% and 52% in asymptomatic children, respectively. Multiple regression analysis showed a correlation between CagA antibody and the severity of gastritis but no correlation with other histological features, including the number of neutrophils or lymphoid follicles. Neither antibody correlated with the degree of bacterial density in the gastric mucosa.

CONCLUSION

CagA and VacA H. pylori antibodies are common in the pediatric population. The combined CagA/VacA antibodies correlated weakly with the degree of mucosal inflammation.

Pancreas divisum--the role of ERCP in children

Pancreas Divisum (PD) is the most common congenital anomaly of the pancreas leading to chronic pancreatitis in children. The best diagnostic procedure to establish this diagnosis is Endoscopic Retrograde Cholangiopancreatography (ERCP). Utilizing ERCP as a therapeutic modality (sphincterotomy, stone removal), enables the clinician to improve symptoms and reduce morbidity. In this report, we describe the clinical presentation and outcome of three children with chronic pancreatitis who were subsequently diagnosed with PD by ERCP. We recommend that ERCP should be considered in children with chronic pancreatitis of unknown etiology.

Identification of a hereditary pancreatitis mutation in four West Virginia families

Hereditary pancreatitis (HP) is the second most common cause of chronic childhood pancreatitis in the United States. Mutations in the cationic trypsinogen gene on chromosome 7 are known to cause HP. We identified four families in West Virginia with symptoms consistent with HP. To determine whether members of these families had defects in the trypsinogen gene, we tested for linkage between the HP gene and simple tandem repeat markers on chromosome 7q and screened for a specific mutation in the cationic trypsinogen gene. Two-point linkage analysis indicated that the disease gene is closely linked to three 7q markers (D7S661, D7S2511, and D7S1805). Restriction fragment length polymorphism analysis showed that all clinically affected members and nonpenetrant carriers from the four families carried a G to A mutation in the third exon of the trypsinogen gene. These findings indicate that this mutation is the cause of HP in the families in our study. The observation that most individuals who carry the mutation have symptoms of HP is consistent with the high but incomplete penetrance of the trait. The presence of a single mutation and a common linked haplotype indicates that the defective allele arose in an ancestor common to all four families.

Prevalence of Helicobacter pylori infection in children from urban and rural West Virginia

Our objective was to evaluate the prevalence rate of Helicobacter pylori (HP) in children from urban and rural areas of West Virginia. In all, 1164 blood samples were collected from children who attended a local health fair, pediatric clinics, and emergency departments of four different hospitals located in urban and rural counties. Socioeconomic status was determined in 303 children. Serum HP antibody (IgG) was measured by enzyme immunoassay (EIA). A total of 468 (40%) samples were HP positive. HP acquisition correlated with increasing age, family crowding, and community location (urban/rural) but not with gender, water source used (city/well), or socioeconomic status. The prevalence rate of HP in the children of West Virginia is higher than any data previously reported from the United States. The results correlated with only few socioeconomic criteria, suggesting that other factors may contribute to the increased prevalence of HP infection in the children of West Virginia.

Human vaginal mucosal immune system: characterization and function

OBJECTIVE

The mucosal immune system has been recognized as the first line of defense against foreign antigens. The limited information available on the mucosal immunity of the lower reproductive organs have restricted our ability to fight infections, especially, the sexually transmitted disease. The aim of this study was to characterize in-vitro the human vaginal lamina propria lymphocytes (VLPL), their cell surface phenotypes, and cellular function.

METHODS

VLPL were isolated from human vaginal mucosa by enzymatic techniques. Cell surface characteristics were investigated by immunohistochemistry and flow cytometric analysis. Cellular immune function was evaluated by 3H-thymidine incorporation studies and ornithine decarboxylase (ODC) activity.

RESULTS

Immunohistochemistry and flow cytometric analysis showed that the CD4/CD8 ratio of the human vaginal mucosa is reversed compared to the gut lamina propria lymphocytes (0.55 +/- 0.17). PHA and ConA mitogens enhanced VLPL thymidine incorporation, while PWM did not have any significant effect. Very high level of ODC activity was observed in VLPL after PHA stimulation.

CONCLUSIONS

The human VLPL can be isolated, characterized, and respond to a mitogenic stimulus. We postulate that further analysis of the vaginal immune system will enhance our understanding of local defence mechanisms which will help in the development of new therapeutic modalities against vaginal infections.

Prospective comparison of rapid urease tests (PyloriTek, CLO test) for the diagnosis of Helicobacter pylori infection in symptomatic children: a pediatric multicenter study

OBJECTIVE

Rapid urease tests are reliable methods to diagnose Helicobacter pylori (HP) infection in the endoscopy suite. The PyloriTek test kit is a new rapid urease test that has the advantage of a 1-h final reading. The aim of this study was to compare the accuracy of PyloriTek and the test in the diagnosis of H. pylori infection in children.

METHODS

Children from four different pediatric gastroenterology centers were recruited prospectively into the study. These children were >5 yr old and had an upper endoscopy procedure. Antral biopsies were examined for both rapid urease tests in the endoscopy suite, and others were sent for routine histological examination.

RESULTS

A total of 242 children were recruited into the study over approximately 1 yr. The concordance between PyloriTek and CLO test was 98% (238 of 242). Twenty-five children were positive for HP organisms by PyloriTek and CLO test, whereas four children were positive by PyloriTek but negative by CLO test. PyloriTek was comparable to CLO test for the diagnosis of HP organisms and HP-associated gastritis. Moreover, in 48% of the positive results, PyloriTek gave significantly faster results than CLO test.

CONCLUSIONS

We conclude that PyloriTek is an appropriate rapid urease test to use in children and may have an advantage over the CLO test because of its shorter reading time.

Immunosuppressive effect of budesonide on human lamina propria lymphocytes

Budesonide, a beta-adreno-receptor agonist, is comparable to corticosteroid in the treatment of patients with inflammatory bowel disease with the advantage of minimal side effect. Although the immunomodulatory effects of budesonide on the circulatory and respiratory mucosal immune system have been reported, its effect on the human gut immune system has not been published. In this study, the effect of budesonide on the human gut immune system was compared to methyl-prednisolone. The cellular immune function was measured in-vitro by DNA synthesis, ornithine decarboxylase (ODC) activity and TNFalpha secretion. We found that both drugs have a comparable inhibitory effect on DNA synthesis, ODC activity and suppression of TNFalpha secretion. Exogenous addition of IL-2, did not restore the antiproliferative effect of both drugs. We conclude that budesonide has a comparative suppressive effect to methyl-prednisolone on the gut immune system which is not related to IL-2 secretion. The antiproliferative response may explain the therapeutic effect of budesonide on patients with inflammatory bowel disease.

Comparison between a rapid office-based and ELISA serologic test in screening for Helicobacter pylori in children

BACKGROUND

The rapid diagnostic serological test for detection of Helicobacter pylori (H. pylori) infection in children has a significant advantage over the standard enzyme immunoassay (EIA) method, for its simplicity and rapid availability of results in a physician's office setting. We compared the immunochromatographic test with a standard enzyme immunoassay test in the pediatric population.

MATERIALS AND METHODS

A retrospective analysis of 1147 serum samples from asymptomatic children and prospective analysis of 62 serum samples from symptomatic children undergoing diagnostic upper endoscopy were evaluated for the detection of H. pylori antibody by two commercially available serology tests. Each serum sample was tested by a rapid test (FlexSure HP, SmithKline Diagnostics, Inc.) and compared to the standard EIA method (HM-CAP, Enteric Products, Inc.).

RESULTS

The rapid test, FlexSure HP, was comparable to the rapid EIA test in screening for H. pylori infection in symptomatic and asymptomatic children with sensitivity and specificity of 83-90% and 90-100%, respectively. Both methods had a comparable sensitivity and specificity for the detection of H. pylori-associated gastritis (60-70% and 94%, respectively).

CONCLUSION

The rapid test is comparable to the standard EIA test and may be used by physicians in symptomatic children. The use of FlexSure HP as a screening tool for the prevalence of H. pylori infection in asymptomatic children may be limited by its low positive predictive value compared to the EIA method.

Is duodenal gastric metaplasia a consequence of Helicobacter pylori infection in children?

BACKGROUND

Duodenal gastric metaplasia (DGM) is commonly found in association with Helicobacter pylori (Hp)-associated gastritis in adults. DGM is also considered a risk factor for duodenal ulcer development. The prevalence of DGM in children and its association with gastritis, duodenitis, or the presence of Hp organisms is not clear. We investigated the prevalence of DGM in children and explore its association with several possible risk factors, including age, gender, gastritis, duodenitis, or Hp presence in the gastric antrum.

METHODS

A retrospective analysis of 173 upper endoscopy procedures performed between 1993 and 1995 at Cabell Huntington Hospital, Huntington, WV, was done. Gastric and duodenal biopsies were stained with Giemsa for Hp detection, periodic acid-Schiff for DGM, and hematoxylin and eosin for histologic assessment. Gastric mucosal inflammation was graded according to Sydney criteria.

RESULTS

Duodenal gastric metaplasia was identified in 23 of 173 (13%) patients. Duodenitis but not age, gender, gastritis, or the presence of Hp in the gastric antrum was associated with DGM development. In 4 of 23 DGM foci, Hp was identified.

CONCLUSIONS

In children, DGM is not the consequence of Hp infection.

Hereditary pancreatitis and the risk of pancreatic cancer. International Hereditary Pancreatitis Study Group

BACKGROUND

Hereditary pancreatitis is an autosomal-dominant disease, with a variable expression and an estimated penetrance of 80%. The gene for this disease has recently been mapped to chromosome 7q35, and the defect is believed to be caused by a mutation in the cationic trypsinogen gene. Acute attacks of abdominal pain begin early in life and the disease often progresses to chronic pancreatitis. Although the risk of pancreatic cancer is thought to be increased in more common types of chronic pancreatitis, the frequency of pancreatic cancer in the inherited type of pancreatitis is uncertain.

PURPOSE

The aim of this study was to assess the frequency of pancreatic cancer and other tumors in patients with hereditary form of pancreatitis.

METHODS

To determine the natural history of hereditary pancreatitis, we invited all members of the American Pancreatic Association and the International Association of Pancreatology to participate in a longitudinal study of this rare form of pancreatitis. The initial criteria for patient eligibility were as follows: early age (< or = 30 years) at onset of symptoms, positive family history, and absence of other causes. From April 1995 through February 1996, 37 physicians from 10 countries contributed medical records of 246 (125 males and 121 females) patients thought to have hereditary pancreatitis as the most likely diagnosis. This group included 218 patients where the diagnosis appeared to be highly probable and 28 additional patients where the diagnosis of hereditary pancreatitis was less certain: 25 patients who had relatively late onset of disease and a positive family history and three patients with onset of disease before age 30 years but with an uncertain family history. We reviewed all causes of death and compared the observed to the expected frequency of cancer in this historical cohort of patients with hereditary pancreatitis. The strength of the association between pancreatitis and pancreatic cancer was estimated by the standardized incidence ratio (SIR), which is the ratio of observed pancreatic cancer cases in the cohort to the expected pancreatic cancers in the background population, adjusted for age, sex, and country.

RESULTS

The mean age (+/- standard deviation [SD]) at onset of symptoms of pancreatitis was 13.9 +/- 12.2 years. Compared with an expected number of 0.150, eight pancreatic adenocarcinomas developed (mean age +/- SD at diagnosis of pancreatic cancer: 56.9 +/- 11.2 years) during 8531 person-years of follow-up, yielding an SIR of 53 (95% confidence interval [CI] = 23-105). The frequency of other tumors was not increased: SIR = 0.7 (95% CI = 0.3-1.6). Eight of 20 reported deaths in the cohort were from pancreatic cancer. Thirty members of the cohort have already been tested for the defective hereditary pancreatitis gene: all 30 carry a mutated copy of the trypsinogen gene. The transmission pattern of hereditary pancreatitis was known for 168 of 238 patients without pancreatic cancer and six of eight with pancreatic cancer. Ninety-nine of the 238 patients without pancreatic cancer and six of the patients with pancreatic cancer inherited the disease through the paternal side of the family. The estimated cumulative risk of pancreatic cancer to age 70 years in patients with hereditary pancreatitis approaches 40%. For patients with a paternal inheritance pattern, the cumulative risk of pancreatic cancer is approximately 75%.

CONCLUSIONS

Patients with hereditary pancreatitis have a high risk of pancreatic cancer several decades after the initial onset of pancreatitis. A paternal inheritance pattern increases the probability of developing pancreatic cancer.

Vitamin A and retinoic acids immunomodulation on human gut lymphocytes

Epidemiological studies have suggested an important immunomodulatory role for vitamin A and other related vitamin A compounds in adults and children. Although vitamin A is absorbed via the gastrointestinal tract, its affect on the gut mucosal immune cells has not been adequately investigated. We investigated the in-vitro effect of vitamin A (retinol) and its retinoid acid (RA) compounds (13-cis- and all trans-retinoic acids) on the human gut mucosal immune system as represented by colonic lamina propria lymphocyte (LPL) proliferation, and ornithine decarboxylase (ODC) activity. Results showed that retinol suppressed and trans-retinoic acid enhanced thymidine incorporation into LPL. 13-cis retinoic acid did not significantly affect LPL DNA synthesis. Similarly, retinol (0.025 microgram/ml and 10 micrograms/ml) and 13-cis retinoic acid (conc. 10 micrograms/m) suppressed, while all trans-retinoic acid (conc. 10 micrograms/ml) enhanced ODC activity in PHA-stimulated LPL. Interestingly, the effects of retinol and all trans-RA were abolished when LPL were previously depleted of macrophages. Addition of monocyte-associated lymphokines, IL-1 and IL-6, showed that IL-1 partially replaced the enhancing effect of all trans-RA previously observed on LPL thymidine incorporation. IL-6 did not affect LPL DNA synthesis irrespective of the vitamin A compound used. We conclude that retinol and retinoid acids (13-cis, all trans-) may alter the human colonic immune system possibly via IL-1 cytokine, but not via IL-6. The data suggest that vitamin A and its retinoid compounds may participate in the modulation of the gut immune system.

Autoimmune hepatitis in children

Autoimmune hepatitis (AIH) is usually diagnosed after other viral, metabolic or drug-induced etiologies have been ruled out. Although uncommon in children, the disease can manifest itself with severe hepatocellular damage and early fibrosis. Early diagnosis and aggressive treatment may improve morbidity and decrease mortality. In other cases, liver transplantation is the final rescue for these children. We describe our experience with five children who were diagnosed with autoimmune hepatitis. Their diagnosis, medical treatment and clinical outcome are presented with a review of the literature.

Juvenile polyps and their distribution in pediatric patients with gastrointestinal bleeding

Juvenile polyps (JPs) are the most common colonic tumor in childhood. The total number and anatomical distribution have changed significantly since the introduction of flexible colonoscopy. This article reviews our experiences treating 29 pediatric patients with JPs, and evaluates the 66 polyps we removed and their distribution in the colon. Thirteen patients (45%) had multiple polyps and 35% of all polyps were found proximal to the sigmoid colon. In the 14 patients who underwent a complete colonoscopy, eight had multiple polyps and 55% of these polyps were found proximal to the sigmoid colon. As a result, we conclude that there is a trend toward more polyps per patient and a more distal colonic distribution in children with JPs than previously reported. We recommend that a complete colonoscopy and possible polypectomy be performed on all children with unexplained rectal bleeding.

Ornithine decarboxylase and tyrosine kinase activity in juvenile polyps of childhood

Juvenile polyps (JP) are the most common colonic tumor in children. Although considered benign, malignant transformation has been reported in JP. Ornithine decarboxylase (ODC) and tyrosine kinase (TyK) enzymes are markers for a rapid cell proliferation index. DNA aneuploidy score and p53 gene expression are late malignant changes seen in patients with colon cancer. In this study, we investigated ODC and TyK activities as well as DNA aneuploidy score and p53 expression in juvenile polyps compared with the adjacent normal colonic mucosa. Results showed that ODC was significantly increased in JP compared with the adjacent normal colonic mucosa. TyK activity was increased in 3/5 polyps and decreased in 2/5 polyps compared with the mucosa. Mean TyK activity was higher in JP compared with normal mucosa but did not reach significance (707 and 632 pmol/mg pmol, respectively). Moreover, changes in phosphorylization of TyK proteins was also observed in JP but not in normal mucosa. JP had a normal DNA aneuploidy score and showed no expression of p53 gene. We conclude that JP do not express p53 gene and aneuploidy but had higher activity of ODC and TyK enzymes, suggesting a higher stage of cell proliferation.

FK-506 and cyclosporine A (CsA) immunomodulation of the human gut mucosal immune system

FK-506 and cyclosporine A (CsA) are two immunosuppressive drugs used in the treatment of patients after liver and small intestine transplantation. A clinical advantage of FK-506 over CsA has been observed in these patients. Although the immunomodulation of both drugs has been well documented in the circulatory immune system, their effect on the mucosal immune system is not well established. In this study, the effect of FK-506 on the human gut mucosal immune system was compared to CsA. Proliferation of human colonic lamina propria lymphocytes (LPL) was measured by DNA synthesis and ornithine decarboxylase (ODC) activity. Results show that FK-506 and CsA suppress LPL DNA proliferation in a dose-dependent manner. FK-506 had a stronger antiproliferative effect compared to CsA. Moreover, the antiproliferative effect of both drugs was not dependent on monocytes or monocyte-associated factors (IL-1 beta, IL-6). In addition, exogenous addition of IL-2 did not restore the suppressive effect of either drug on LPL DNA synthesis. We conclude that: (1) both drugs have an antiproliferative effect on the human mucosal immune system; and (2) the stronger effect of FK-506 on human LPL compared to CsA may explain its superior clinical response observed in patients after liver/small intestine transplantation.

Keep the change, doc!: coins in the upper GI tract of children

Many children are brought to the Emergency Room each year because they have swallowed foreign bodies (FBs), particularly coins. Whether to remove these foreign bodies or let them pass through naturally is a constant dilemma for ER physicians. This article reviews our experiences in treating pediatric patients who underwent FB retrieval for coins, food particles and toy parts, and discusses their clinical and endoscopic findings. The vast majority (82%) of the swallowed FBs were lodged in the esophagus. A review of the literature and a suggested medical protocol to manage patients who have swallowed coins are also discussed in this article.

A study of Helicobacter-pylori in 100 pediatric patients from the Tri-State area

Helicobacter pylori (HP) is a newly discovered pathogen implicated in the pathophysiology of peptic ulcer disease. The aim of this study was to review all pediatric patients who were evaluated by upper endoscopy through the Pediatric Gastroenterology Service at the Marshall University School of Medicine between July 1990 and March 1993. A total of 100 charts were retrospectively reviewed. HP was diagnosed by CLO-test and confirmed histologically. Results showed that the major presenting symptom was abdominal pain (53%). GI mucosal inflammation was found in 77 patients, and 41% of these cases were associated with HP. Two patients had duodenal ulcer; both were HP+. The incidence of gastritis was significantly higher in patients with HP+ compared to HP-. Follow-up on the HP-associated gastritis showed no significant difference in their clinical response irrespective to the treatment, we conclude that HP in children is highly associated with gastritis, but not duodenitis or esophagitis; and in our experience, that CLO has a high failure rate in identifying HP in the mucosa.

Neuropeptide Y (NPY) enhances proliferation of human colonic lamina propria lymphocytes

Neuropeptide Y (NPY) is one member of a family of peptides with a wide range of physiological effects on the CNS, cardiovascular, and respiratory systems. NPY is widely distributed throughout the peripheral and central nervous systems. It has also been found within the colon, liver and gallbladder in close anatomic proximity to the mucosal immune system. In this study, we investigated the effect of NPY on human gut mucosal immune function. We examined colonic lamina propria lymphocyte (LPL) proliferation by measuring DNA synthesis, ornithine decarboxylase (ODC) activity, and polyamine biosynthesis. NPY enhanced ODC activity and polyamine biosynthesis in Con A-stimulated LPL, and enhanced thymidine incorporation into Con A-stimulated LPL but not into monocyte-depleted LPL. Moreover, exogenous IL1-beta partially restored NPY's stimulatory effect on monocyte-depleted LPL DNA synthesis. Our results demonstrate that NPY enhances human colonic LPL proliferation and that this effect is partially IL1-beta dependent. Our data also suggest that NPY's effect may be mediated via polyamine biosynthesis. We postulate that the NPY may have an important impact on human mucosal immune function.

Ornithine decarboxylase (ODC) levels in children with reflux esophagitis

Reflux esophagitis is a common disease in infants and can be diagnosed largely by esophageal biopsy. In adults, chronic esophagitis may lead to Barrett's esophagus, a premalignant condition for esophageal cancer development. Ornithine decarboxylase (ODC) is used as an early marker for colon cancer development. No data are available on the role of ODC in reflux esophagitis in the pediatric population. In this study we retrospectively analyzed ODC activity in esophageal biopsies of children who underwent upper endoscopy. According to the esophageal histology, patients were divided into three groups: normal mucosa, mild, and moderate/severe esophagitis. None of our patients had esophageal metaplasia or cancer. ODC level was significantly higher in the moderate/severe esophagitis group compared to mild and normal mucosa group. We conclude that ODC activity is directly proportional to the severity of the esophageal inflammation/regenerative process in children with reflux esophagitis.

Mucosal origin and shedding of an early colonic tumor marker defined by Adnab-9 monoclonal antibody

Recent attention has been drawn to the diagnostic potential of tests based on shed colonic tumor markers. Adnab-9 monoclonal antibody raised against neoplastic, potentially premalignant colonic adenomas recognizes a marker in colonic effluent or tissue which correlates with the presence of tumors or risk of colorectal cancer. The origin of this antigen and optimal collection of colonic effluent were investigated by enzyme-linked immunosorbent assay and Western blotting. Mean Adnab-9 binding in effluent samples from colorectal cancer patients even after resection is high as compared with that in normal subjects (P < 0.05). Effluent samples are best collected in the morning hours. Antigen proteolysis may be significant depending on the site and timing of effluent collection, but breakdown products are reactive. Tissue and effluent Adnab-9 binding at any one anatomic site of collection appear to correlate (r = 0.88, P = 0.01). The Adnab-9 antigen is constitutively expressed at low levels throughout the distal bowel and localized to the deepest regions of the mucosal crypts. Other than meconium, no significant levels of binding are found in other body fluids. This antigen is specific for the gastrointestinal tract, its binding in conveniently collected effluent samples correlates with tissue content, and the antigen is constitutively expressed in the crypts of the distal small bowel and colonic mucosa.

A prospective randomized study with mineral oil and oral lavage solution for treatment of faecal impaction in children

Faecal impaction with or without encopresis is a very common problem. We performed a randomized, open-label, prospective study to compare the efficacy and acceptability of the treatment of faecal impaction using either mineral oil or pineapple-flavoured isotonic intestinal lavage solution containing polyethylene glycol-3350 (Colyte). Thirty-six patients over 2 years of age were randomized to receive either mineral oil or flavoured lavage solution. The dose of mineral oil was 2 to 8 tablespoons twice a day for two days (17 patients--Group I) and of lavage solution was 20 ml/kg/h for 4 hours on two consecutive days (19 patients--Group II). The patients were assessed for the presence of abdominal faecal masses, presence and consistency of rectal mass, perineal soiling before and two days after either of the randomly assigned treatment. The patients and parents were asked regarding the compliance with treatment, side-effects, number of bowel movements after treatment and willingness to try similar treatment if faecal impaction recurred. Patients in the lavage group had more frequent bowel movements, and showed more effective clearance of abdominal and rectal lumps (P < 0.01) at the time of repeat examination at two days. However, they had some vomiting and were less compliant (P < 0.01) when compared to mineral oil patients. We conclude that balanced lavage solution effectively relieves faecal impaction, however, compliance with its use is poorer than that with mineral oil.

Hepatitis B surface antigen prevalence in blood samples tested at Cabell Huntington Hospital

Hepatitis B is a major cause of chronic liver disease which leads to morbidity and mortality among patients. In the current era, when federal and governmental support for health care is shrinking, the HBsAg+ carrier state in West Virginia becomes an important factor for future health care planning. In this study, we retrospectively investigated the HBsAg+ carrier rate in serum samples studied in the Cabell-Huntington Hospital Laboratory from January 1990-January 1993. Only 50/6,209 (0.8%) serum samples were positive for HBsAg. These positive samples represented 10 different patients, 8/10 were females and only 4/8 were of child-bearing age. We conclude that HBsAg+ carrier state in patients from Cabell County is below the national average.

Inhibition of ornithine decarboxylase activity decreases polyamines and suppresses DNA synthesis in human colonic lamina propria lymphocytes

Ornithine decarboxylase (ODC) and the polyamines are essential for cell proliferation in a variety of cells including lymphocytes. In this study, we investigated the potential role of ODC and polyamines in human colonic lamina propria lymphocytes (LPL) compared to peripheral blood lymphocytes (PBL). Our results show that con A stimulation of LPL and PBL was associated with marked increases in ODC and polyamines. The specific inhibitor of ODC, alpha-difluoromethylornithine (DFMO), resulted in a complete inhibition of ODC activity and depletion of putrescine, spermidine and spermine levels. DFMO also suppressed DNA synthesis of LPL and PBL by up to 48% and 62% respectively. This antiproliferative effect was reversed by adding back the polyamines putrescine (1 mM), spermidine (10 microM) or spermine (10 microM) to the culture medium. We conclude that ODC and the polyamines are important for human LPL proliferation, and hence may play a role in human mucosal immune function.

ODC activity and polyamine levels in isolated human colonocytes

Ornithine decarboxylase (ODC) is the first and often rate-limiting enzyme in polyamine biosynthesis. ODC and polyamines (putrescine, spermidine, spermine, and cadaverine) have an essential role in cell proliferation. In this study, we investigated ODC activity and the polyamine levels of normal human colonocytes isolated from the upper and lower crypt regions. We found no significant differences in ODC activity between upper and lower crypt regions (mean +/- SEM: 105 +/- 60 and 103 +/- 52 pmol CO2/mg protein/hr, respectively). This result was further substantiated by ODC immunoreactive antibody staining technique. Levels of polyamines (putrescine, spermidine, spermine, and cadaverine) were similar in the upper and lower crypt regions (mean +/- SEM; upper/lower: 79 +/- 29/79 +/- 18; 189 +/- 116/ 137 +/- 38; 174 +/- 58/204 +/- 35; and 52 +/- 10/51 +/- 10 nmol/mg protein, respectively). Acetyl-polyamines (acetyl-putrescine, acetyl-spermidine, and acetyl-spermine) levels in human colonocytes showed no significant differences between upper and lower crypt regions (mean +/- SEM; U/L: 368 +/- 109/408 +/- 89, 63 +/- 22/51 +/- 12, and 39 +/- 12/41 +/- 14 nmol/mg protein, respectively). Our results suggest that in isolated normal human colonocytes, ODC activity and polyamine levels are similar in the upper and the lower crypt regions.

Polyamine levels, ornithine decarboxylase (ODC) activity, and ODC-mRNA expression in normal and cancerous human colonocytes

Ornithine decarboxylase (ODC) and polyamines (putrescine, spermidine, and spermine) are crucial for cell proliferation. Recently, elevated ODC activity and polyamine levels have been suggested as biological markers for human colon cancer. In this study, we measured ODC activity and the levels of polyamines (putrescine, spermidine, spermine, and cadaverine) and acetyl-putrescine in human colonocytes isolated from cancerous areas compared to the adjacent normal colon tissue. In addition, ODC mRNA expression was compared between both groups. We found that colonocytes isolated from cancerous areas had significantly higher mean value of ODC activity, putrescine, spermidine, spermine, and cadaverine levels up to 1480%, 470%, 260%, 380%, and 510% respectively compared to colonocytes isolated from the adjacent normal colonic mucosa. No difference was found in acetyl-putrescine levels between cancerous and normal colonocytes. Steady-state levels of ODC mRNA were slightly elevated in cancerous colonocytes relative to normal colonocytes in two of three paired samples. However, the increase in ODC mRNA levels is not sufficient to account for the increase in ODC activity suggesting that colonocyte ODC activity is regulated post-transcriptionally.