Barbara Bizzarri

Wireless Capsule Endoscopy for Pediatric Small-Bowel Diseases

OBJECTIVE:Although capsule endoscopy (CE) is becoming an increasingly popular procedure, only recently data on its clinical application in pediatric gastroenterology are just emerging. Our aim is to investigate the diagnostic value of CE in small intestine diseases and to determine its safety, tolerance, and applicability in a large number of pediatric patients referred to our Tertiary Center of Pediatric Gastroenterology Unit, University of Parma.METHODS:A total of 87 Italian patients, 49 of which were male with an age range from 18 months to 18 yr with a suspected small-bowel disease (inflammatory bowel disease 37%, polyps 38%, obscure gastrointestinal bleeding 24%, malabsorption 1%), were investigated with the M2A capsule (GIVEN® Imaging Ltd., Yoqneam, Israel).RESULTS:A total of 77 patients swallowed the capsule, while in 10 it was endoscopically positioned (age range 1.5–11 yr, median age 5.3 yr). Eighty patients naturally evacuated the capsule, one patient needed surgery. The capsule evidenced pathological findings in 62 patients (71%), ileal lymphoid nodular hyperplasia in four subjects (5%), it was negative in 18 subjects (21%), and technically failed in three subjects (3%). In 21 out of 28 patients with known polyposis and in all the five patients with suspected polyposis, small-bowel polyps were found. In 16 out of 22 patients suffering from known inflammatory bowel disease (Crohns disease colitis or indeterminate colitis), small intestine lesions were found. CE examination identified a possible small intestine bleeding source in 13 out of 21 patients with suspected obscure gastrointestinal bleeding. In 5 out of 10 patients with suspected small-bowel inflammatory disease, CE evidenced ileum lesions suggesting Crohns disease, which was subsequently confirmed through diagnostic procedures and the clinical history. A patient with malabsorption presented a negative capsule study.CONCLUSIONS:Our experience, which includes the largest number of pediatric patients and the youngest child reported in literature, confirms that CE is a very useful system for the clinical work in suspected small-bowel diseases in infancy. The high rate of positive examination is due to the very careful selection of the patients, obligatory to conduct a safe examination since CE is not highly tested in children.

Helicobacter pylori Infection: Sequential Therapy Followed by Levofloxacin-Containing Triple Therapy provides a Good Cumulative Eradication Rate

Background:  In the eradication of H. pylori infection, even today, the main international guidelines recommend the triple therapy as first‐line regimen, although its effectiveness is clearly decreasing. As second‐line treatment, the bismuth‐containing quadruple therapy is the most used regimen, although several other therapies are studied. The Italian guidelines recommend, alternatively, sequential therapy or triple therapy as first‐line treatment and levofloxacin‐containing triple therapy as second‐line regimen. We wanted to assess the overall eradication rate of Helicobacter pylori infection in two therapeutic rounds following the Italian guidelines in clinical practice.

Short- and long-term efficacy of endoscopic balloon dilation in Crohn’s disease strictures

AIM To evaluate short- and long-term efficacy of endoscopic balloon dilation in a cohort of consecutive patients with symptomatic Crohns disease (CD)-related strictures. METHODS Twenty-six CD patients (11 men; median age 36.8 year, range 11-65 years) with 27 symptomatic strictures underwent endoscopic balloon dilation (EBD). Both naive and post-operative strictures, of any length and diameter, with or without associated fistula were included. After a clinical and radiological assessment, EBD was performed with a Microvasive Rigiflex through the scope balloon system. The procedure was considered successful if no symptom reoccurred in the following 6 mo. The long-term clinical outcome was to avoid surgery. RESULTS The mean follow-up time was 40.7 ± 5.7 mo (range 10-94 mo). In this period, forty-six EBD were performed with a technical success of 100%. No procedure-related complication was reported. Surgery was avoided in 92.6% of the patients during the entire follow-up. Two patients, both presenting ileocecal strictures associated with fistula, failed to respond to the treatment and underwent surgical strictures resection. Of the 24 patients who did not undergo surgery, 11 patients received 1 EBD, and 13 required further dilations over time for the treatment of relapsing strictures (7 patients underwent 2 dilations, 5 patients 3 dilations, and 1 patient 4 dilations). Overall, the EBD success rate after the first dilation was 81.5%. No difference was observed between the EBD success rate for naive (n = 12) and post-operative (n = 15) CD related strictures (P > 0.05). CONCLUSION EBD appears to be a safe and effective procedure in the therapeutic management of CD-related strictures of any origin and dimension in order to prevent surgery.

Oesophageal mucosal intercellular space diameter and reflux pattern in childhood erosive and non-erosive reflux disease

BACKGROUND AND AIMS We sought to compare intercellular space diameter in children with non-erosive and erosive reflux disease, and a control group. We also aimed to characterize the reflux pattern in erosive and non-erosive reflux disease patients, and to explore the relationship between intercellular space diameter values and reflux parameters. METHODS Twenty-four children with non-erosive reflux disease, 20 with erosive reflux disease, and 10 controls were prospectively studied. All patients and controls underwent upper endoscopy. Biopsies were taken at 2-3 cm above the Z-line, and intercellular space diameter was measured using transmission electron microscopy. Non-erosive and erosive reflux disease patients underwent impedance-pH monitoring. RESULTS Mean intercellular space diameter values were significantly higher in both non-erosive (0.9 ± 0.2 μm) and erosive reflux disease (1 ± 0.2 μm) compared to controls (0.5 ± 0.2 μm, p<0.01). No difference was found between the two patient groups. Acid exposure time, the number of acid, weakly acidic and weakly alkaline reflux events did not differ between the two patient groups. No difference was found in the mean intercellular space diameter between non-erosive reflux disease children with and without abnormal acid exposure time (1 ± 0.3 vs. 0.9 ± 0.2 μm). No correlation was found between any reflux parameter and intercellular space diameter values. CONCLUSIONS Dilated intercellular space diameter seems to be a useful and objective marker of oesophageal damage in paediatric gastro-oesophageal reflux disease, regardless of acid exposure. In childhood, different gastro-oesophageal reflux disease phenotypes cannot be discriminated on the basis of reflux pattern.

Primary Antimicrobial Susceptibility Changes in Children with Helicobacter pylori Infection over 13 Years in Northern Italy.

The eradication therapy of Helicobacter pylori (H. pylori) infection is still a challenge for gastroenterologists. One of the main causes of failure in H. pylori eradication is the antibiotic resistance mainly to clarithromycin. Culture from biopsies is maybe the most used method among the antimicrobial susceptibility techniques. In this study, we compared the antimicrobial susceptibility changes in children with H. pylori infection over 13 years and we confirmed that clarithromycin resistance has been increased (16% versus 26%) though with no statistically signficant value. Therefore, clarithromycin should not be used in empiric treatment of H. pylori eradication therapy in children, but its use should be limited only to children with known antimicrobial susceptibility. On the other hand, metronidazole resistance has decreased over this time period in statistically significant manner (56% versus 33%, p = 0.014). Furthermore, ampicillin resistance has been confirmed to be very rare (3% versus 0%) in children with H. pylori infection. In conclusion, in H. pylori infection, if we do not know the antibiotic susceptibility of patients, we should recommend an eradication therapy based on the local distribution of antibiotic resistance rates trying to limit the therapeutic failures.

Which Treatment in Helicobacter pylori Infection

For many years in Helicobacter pylori-positive patients, the most used eradication regimen has been the triple therapy, consisting by the association of two antibiotics usually chosen between amoxicillin, clarithromycin and metronidazole.

Zonulin, an intestinal tight junction modulator, is involved in the pathogenesis of type I diabetes

Zonulin, an intestinal tight junction modulator, is involved in the pathogenesis of type I diabetes

Racecadotril at the Beginning of Pediatric Gastroenteritis: A Small Experience of a Primary Level Hospital

Background: Oral rehydration (OR) as therapy in pediatric gastroenteritis, although effective, is poorly accepted by parents because of it does not reduce the frequency of bowel movements and the loss of fluids from the gut nor shortens the duration of the disease. Racecadotril reduces secretions of intestinal fluids but it doesn’t inhibit the intestinal motility . Methods: We retrospectively reviewed 61 children affected by mild acute gastroenteritis consecutively admitted to our Pediatric Service along two years (2009 to 2010). The children treated with Racecadotril plus OR were 26 and those treated with OR alone were 35. Results: Out of 35 children treated with Racecadotril+OR, 17 patients (65.4%) were discharged within twentyfour hours after admission because of a marked improvement in symptoms compared with the 14/35 patients (40.0%) of children treated with OR alone with statistically significant values (p<0.05). Children, converted to parenteral therapy due to the worsening of symptoms, were 26.9% and 42.9% in the OR+Racecadotril Group and in the OR Group respectively. We have had no side effects regarding the use of Racecadotril. Conclusions: Our hospital is a Primary Level Hospital and we often assess children at the beginning of their symptoms. This allows us to administer Racecadotril at the onset of diarrhoea. Our sample is small, but it shows that the early use of Racecadotril shortens the hospitalization and decreases the rate of conversion to parenteral rehydration therapy in children with mild gastroenteritis.

Helicobacter Pylori Infection: We Should Always Verify the Intrafamilial Transmission

Background and Aims: Helicobacter pylori infection is one of the most common gastrointestinal infections in humans; it affects about 30% of people in developed countries and about 80% in developing ones. The majority of patients acquire the infection during childhood and the intrafamilial transmission is considered one of the most important routes of infection. The aim of this study was to assess the intrafamilial transmission rate among family members of index subjects. Methods: We have suggested all patients H. pylori-positive (99 patients, symptomatic index subjects) diagnosed during 18 months (Sep 2011-Dec 2012) to screen their family members by stool antigen test (SAT) and, when positive, to perform upper gastrointestinal endoscopy. Results: Through SAT we identified 126 patients belonging to 41 households of 99 initial index subjects, therefore 41 index subjects (41.4%) had at least one family member affected. The entire population studied included 225 H. pylori-positive patients: 99 index subjects (symptomatic) and 126 family members diagnosed by SAT screening and histological examination by gastroscopy. Of these, 103 patients (81.7%) were considered slightly symptomatic (mild clinical history until then not important enough to perform further diagnostic study) and 23 patients (18.3%) were totally asymptomatic. Conclusions: In the spread of H. pylori infection, the intrafamilial transmission is an important route of contamination; besides the known mother-to-child dyad, also the transmission among family members plays a considerable role and it should be always verified.

P93 Situs viscerum inversus and apple peel atresia: a rare association. case report

Background and aims Duodenal atresia is a relatively common anomaly and its frequency ranges from 1 in 3000 to 5000 live births. Association of duodenal atresia with situs viscerum inversus is rare and fewer than 20 patients have been reported in literature. Methods We present a sub-Saharan 1 years old female baby, born at 31 weeks with prenatal diagnosis of situs viscerum inversus with dextrocardia, ventricular septal defect, ductus venous agenesis, duodenal atresia and intestinal malrotation. We considered risk factors, clinical and surgical management, complications and evolution of this rare association. Results A 31 weeks female baby was born by emergency caesarean section for cardiotocographic changes. Her mother history was positive for pre-gestational diabetes on insulin therapy and for Streptococcus beta-haemolytic infection. Incomplete intrapartum amplicillin prophylaxis was made. The baby weighed 2300 g and her Apgar scores were 5 and 5, needing non-invasive ventilation with nCPAP. Because of suspected intestinal obstruction, parental nutrition was started one day after birth and a radiological examination was performed showing the mirror image of a double-bubble configuration of duodenal atresia. She underwent laparotomy at 6 days of life, confirming situs inversus and intestinal necrosis secondary to volvulus on common mesentery (apple peel type 3b): duodeno-cecal anastomosis with saving the ileocecal valve was performed. Histology of the surgical specimen confirmed the transmural necrosis. Six days after, enteral nutrition was progressively introduced with good tolerance and weight gain; parental nutrition was continued with subsequent cholestasis needing the modification of the lipid composition. At 3 months of age, she underwent a Bianchi intestinal lengthening procedure and cholecystectomy. The onset of post-surgical duodenal stenosis two months after required one endoscopic pneumatic dilation (8–10 mm) and a gastrostomy button was placed too. Upper endoscopies performed 1 month and 6 months later were normal. Enteral and parental nutrition was continued and the oral feeding was gradually introduced. Conclusions Duodenal atresia and situs inversus are rare combinations. Outcome is good with appropriate multidisciplinary management and follow-up. Maternal diabetes could be factor risk of laterality, as suggested in literature.