Cameron Imrie

Focally enhanced gastritis in children with Crohn's disease and ulcerative colitis

OBJECTIVES:Focally enhanced gastritis (FEG) has been suggested as a specific diagnostic marker for patients with Crohns disease. However, the utility of FEG for distinguishing Crohns disease from ulcerative colitis is uncertain in adults, and the occurrence of this lesion in children has not been defined. The aim of this study was to evaluate the occurrence of FEG and other gastric histological abnormalities in children with inflammatory bowel disease (IBD) and to examine the utility of FEG in discriminating between ulcerative colitis and Crohns disease.METHODS:This is a retrospective, case-controlled study of upper GI histopathological findings in children with IBD. Gastric histopathology was defined and graded according to the Updated Sydney System.RESULTS:FEG was present in 28 of 43 (65.1%) children with Crohns disease and five of 24 (20.8%) children with ulcerative colitis, compared to three of 132 (2.3%) children without IBD or one of 39 (2.6%) children with Helicobacter pylori infection. There were no differences between those with and without FEG with regard to upper GI symptoms or previous anti-inflammatory drug ingestion (5-aminosalicylic acid compounds or steroids). All patients with H. pylori infection had chronic antral gastritis, but only one child with H. pylori had FEG. In addition, mild to moderate chronic gastritis was present in 15 of 43 (34.9%) children with Crohns disease and in 12 of 24 (50%) patients with ulcerative colitis.CONCLUSIONS:The presence of FEG suggests underlying IBD. Although FEG is particularly common in children with Crohns disease, it does not reliably differentiate between Crohns disease and ulcerative colitis.

Effect of Helicobacter pylori eradication on the natural history of duodenal ulcer disease

BACKGROUND Duodenal ulcer disease is strongly associated with Helicobacter pylori infection of the gastric mucosa. Eradication of H pylori from the gastric mucosa in adults is associated with long term healing of ulcers. AIMS To follow a cohort of children with duodenal ulcer disease for a minimum of two years after the eradication ofH pylori. PATIENTS AND METHODS Over a three year period, all children diagnosed with duodenal ulcer disease had their symptoms documented and their H pylori status evaluated. The histories of these children were carefully screened to determine previous symptoms and to document previous treatment regimens. RESULTS Sixteen children were diagnosed with ulcers and 15 were available for treatment and long term follow up. The median age at which symptoms first occurred was 10.5 years (range, 6–14) and the median duration of symptoms was 24 months (range, 2–60). Ten of the children had been treated with H2receptor antagonists for a median of 3.5 months (range, 1–60). Duodenal ulcers healed in all children after eradication of H pylori and all children have remained asymptomatic for a median of 37 months (range, 26–62). No child has required subsequent admission to hospital. CONCLUSION Eradication of H pylori is very effective in the long term healing of duodenal ulcer disease.H pylori eradication should be the standard treatment for all infected children who present with duodenal ulcer disease.

How should Helicobacter pylori infected children be managed

It is now recognised that Helicobacter pylori, like most enteric infections, is mainly acquired in childhood. Adults rarely become infected, with seroconversion rates varying between 0.33and 0.5% per person year. The age at which children are most likely to become infected is still unclear, but findings in a number of cross-sectional studies suggest that infection is acquired before the age of five. The prevalence of infection is highest in children in the developing world where up to 75% of children may be infected by the age of 10. In the developed world the prevalence of infection is noticeably increased among socially deprived children. The diagnosis of H pylori infection in childhood is most often made at endoscopy, for which there are many indications. Symptoms such as abdominal pain, vomiting, and haematemesis may be associated with duodenal ulcer and H pylori infection. However, in the case of children undergoing endoscopy for assessment of oesophagitis, failure to thrive, coeliac disease, Crohns disease, or portal hypertension, the finding of H pylori infection is likely to be incidental. How should we manage these children with a diagnosis of H pylori infection? Currently, there are no consensus guidelines for the management of H pylori infected children. In 1994 the National Institutes of Health consensus statement recommended that adults with gastric or duodenal ulcer disease, who are infected with H pylori, should receive antimicrobial treatment. The European Maastricht Consensus Report suggested broader indications for treatment of infected adults. It states that treatment is advisable for all H pylori infected dyspeptic patients diagnosed non-invasively under 45 years of age at a primary care level. Patients older than 45 years with dyspeptic symptoms should be treated for H pylori infection but only after endoscopy to rule out any other underlying pathology. The European guidelines also recommend treatment for infected patients with mucosa associated lymphoid tissue lymphoma and patients who are found to have intestinal metaplasia and gastric atrophy.

Pancreatic Duct Stenting as a Treatment for Hereditary Pancreatitis

Hereditary pancreatitis is a genetically transmitted condition usually presenting in childhood or adolescence. The natural history of the condition is that recurrent episodes of pancreatitis may be followed by the development of pancreatic exocrine and endocrine failure. Treatment options are limited, usually consisting of surgical drainage procedures whose efficacy is uncertain and whose effect on disease progression is unknown. We report a child with hereditary pancreatitis treated by means of a pancreatic duct stent placed via endoscopic retrograde cholangiopanctreatography resulting in long-term control of symptoms and speculate that earlier intervention may alter the disease course.

Sensitivity of urease-based test on diagnosis of Helicobacter pylori in children and the elderly

were demonstrated in a case report in which a patient with Crohn’s disease treated with both 6-MP and olsalazine subsequently developed two episodes of severe bone marrow depression, requiring withdrawal of both drugs.4 We have performed experiments to determine whether balsalazide, like other 5-ASA derivatives, is capable of inhibiting recombinant human TPMT. The TPMT assay was based on the conversion of 6-MP to radioactively labeled 6-methylmercaptopurine with [14C]methyl-Sadenosyl-L-methionine as the methyl donor.5 Balsalazide was found to be a relatively potent inhibitor of TPMT activity, with an IC50 value of 197 μmol/L (Figure 1). IC50 values for olsalazine, sulfasalazine, and 5-ASA were 31, 104, and 1380 μmol/L, respectively, similar to values reported previously.3,4 Our results suggest that caution should be exercised when balsalazide and azathioprine or 6-MP are coadministered, because the risk of clinically important myelosuppression may be increased as a result of the inhibition of TPMT.4 We obtain a measure of TPMT activity in the red blood cells of all patients before initiating azathioprine or 6-MP therapy to identify patients potentially at risk for toxicity on a genetic basis.2 In addition, we also recommend careful monitoring of complete blood counts if the patient is placed on combination therapy with thiopurines and aminosalicylic acid derivatives.

Sa1150 What Do Young People and Parents Want From an Inflammatory Bowel Disease (IBD) Service

Introduction At present, there are guidelines from the US and Europe regarding the formation of transition clinics for adolescents with IBD. This includes a UK Inflammatory Bowel Disease (IBD) Standards guidance on optimal service provision for paediatric and adolescent care. However most of these guidelines come from intuitive reasoning and opinion, as there is a lack of data on what constitutes an ideal service for young patients with IBD. The aim of this study was to develop a comprehensive knowledge and understanding of the key service requirements of young people with IBD as well as their parents. Methods Paediatric and adolescent patients age 6–18 years, were identified from databases in two teaching hospitals and from the membership of the N Ireland branch of Crohn9s and Colitis UK, which is a patient support group. Anonymous questionnaires were sent to these patients and their parents separately. The questionnaires asked about their perceived quality of care, clinic care, general comments, input from specialists, support and information, plus any suggestions. Results 105 questionnaires were sent and 51 responded (49%); of these 21 were from patients and 30 from their parents. Over 84% were happy with the quality of care they are receiving. Reasons patients and parents were reluctant to attend clinics included: blood tests, nurse specialist or doctor not available, lack of car parking. 90% preferred to see the attending (Consultant) rather than a fellow. Nurse specialist, dietetics, specialist IBD surgeon, psychologist, skin/eye specialist input was thought to be beneficial by 95%, 81%, 71%, 59%, and 45% respectively. The following support service and information were considered important: immediate contact with healthcare personnel for disease flare, support groups for young adults, insurance and financial advice, knowledge about IBD developments and research, email service, surgical input regarding stomas. Conclusion The majority of young patients with IBD and their parents are satisfied with the care they are receiving. Support from specialist services such as nurse specialist, dietitians, specialist IBD surgeons, psychologist, plus rapid access to services when the disease flares were thought to be important by the patients and their parents. Knowledge of what these patients and their parents want will help to design an optimal IBD service. Competing interests R Little: None Declared, C Imrie Conflict with: Mead Johnson, Falk Pharma, Nutricia, Warner Chilcott, SHS, Norgine, Wyeth, A Derby: None declared, P Gillespie: None declared, G Caddy: None declared, T Tham Speaker bureau with: Warner Chilcott, Shire, Conflict with: Abbott, MSD.