Cigdem Omur Ecevit

Parenthood in pediatric liver transplant patients

Ecevit Ç, Ünal F, Baran M, Aydoğdu S. Parenthood in pediatric liver transplant patients.

An autoimmune disease refractory to immunosuppressive regimens: Celiac disease diagnosed long after liver transplantation

CD is defined as T‐lymphocyte‐mediated gluten sensitivity. Although CD is known to affect the small intestine, it is nonetheless a multisystem disorder. Liver involvement in CD may vary from isolated hypertransaminasemia to cirrhosis. Because CD is an inappropriate immune response to gluten proteins, strict gluten‐free diet is the principal therapy, along with management of liver dysfunction. In patients who fail to respond to a gluten‐free diet, immunosuppressive drugs may improve intestinal inflammatory activity in untreated CD. The present case report is of a 25‐yr‐old woman with diarrhea lasting several weeks. The patient had received a liver transplant 13 yr earlier, and presented with cryptogenic cirrhosis diagnosed as CD. This appears to be the first case of its kind in which a pediatric long‐term liver transplant patient presents with diarrhea eventually diagnosed as CD whose diet included gluten, and who was treated by an immunosuppressive drug regimen. Because of the normalization of CD‐related antibodies in the post‐transplantation period without gluten restriction, CD should be part of a list of diagnostic possibilities in liver transplant patients presenting with diarrhea of unknown etiology.

The diagnostic value of multimodal evoked potentials in the determination of subclinical neurological involvement of Wilson's disease.

Aims Wilson’s disease (WD) is a progressive degeneration of hepatolenticular tissue caused by excessive tissue-damaging copper accumulation and in which liver involvement most frequently presents in childhood. Neurological signs also accompany liver disease with time. However, subclinical neurological involvement may occur earlier and diagnostic methods that reveal this subclinical involvement are not well established. The aim of the current study is to assess the subclinical neurological involvement by using multimodality evoked potential (EP) measurements and to explore the relationship between neurological disease and the severity of liver damage. Methods The patient group included 28 children (mean age 11.8±2.9 years, range 5.5–17) diagnosed with WD and a control group included 24 age-matched healthy children. Multimodality EP tests (Nihon Kohden Neuropack 8 4200K) of both groups were performed at the Department of Neurology Electrophysiology Laboratory of Ege University. Results At least one abnormal EP value was observed in 53.5% of the children in the patient group. At least on one side, there were abnormal values for visual evoked potential (VEP) P100, brainstem auditory evoked potential (BAEP) and somatosensory evoked potential (SEP), where the ratios were 25, 28.5, and 11%, respectively. Absolute latency values of patients with right-side VEP P100 and left-side BAEP I, and the interpeak latency values of right-side BAEP I–III were significantly high. The difference in right-side BAEP I–III interpeak latency between cirrhotic and noncirrhotic groups was found to be statistically significant (P<0.05). Conclusion The EP examinations can be an indicator of subclinical brain damage in non-neurological WD; however, cirrhosis because of WD does not cause an increase in the EP values. Detection of changes in the EP values periodically, especially at the time of diagnosis and during the treatment follow-up, may be valuable for revealing subclinical impairment.

C-reactive protein in children with active ulcerative colitis

To the Editor: Tsampalieros et al evaluated the significance of C-reactive protein (CRP) levels and erythrocyte sedimentation rate as an inflammation marker to identify children with inflammatory bowel disease (IBD) among children with gastrointestinal symptoms. Among their patient population with ulcerative colitis (UC), normal CRP levels were documented in 59.3% and 40% in mild and moderate-severe disease, respectively. They have found a sensitivity value of 0.54 (95% CI, 0.440.64) for elevated CRP in UC. They have concluded that CRP testing can distinguish patients who will be found to have IBD on endoscopy and recommend the addition of CRP and erythrocyte sedimentation rate in the differential diagnosis. As the authors discuss, the data concerning the relationship between CRP and UC are scarce. Moreover, neither disease site nor activity is taken into consideration in these studies. Forty-four children with UC diagnosed in our institute are evaluated in terms of the association between CRP and UC site and activity. Mean CRP level did not differ according to disease extend or severity (Table). Two cutoff points (<4 and <8 mg/L) were evaluated for CRP negativity similar to the authors’ design. CRP of less than 4 mg/L was found in 60% (n = 27); in 82.2% (n = 37), CRP was less than 8 mg/L. None of the mean values or cut-off points of CRP were associated with disease extent and severity (P > .05). Because IBD is a chronic inflammation of the gut, CRP determination is widely used as a marker of inflammation. However, in a large prospective population-based analysis of adult IBD, CRP level was less than 10 mg/L in 71% of cases. Neither the authors’ series nor the reported series in children could document significantly elevated CRP levels in active UC. We also documented mean CRP level less than 5 mg/L, and about 80% of UC cases presented with CRP less than 8 mg/L. Neither the CRP levels nor the cutoff determinants correlated with disease activity nor extend countering with the reports in the literature. In summary, even if CRP determination is a component of a diagnostic workup, its predictive strength is low. Prospective, controlled, longitudinal studies with larger series are needed to better define the association of CRP with diagnosis, type, and prognosis of IBD.

Invisible Ingested Foreign Body: Aluminum Can Top

We report a patient who ingested a ring pull from a coke can in which could not be seen on radiography. We also want to emphasize the ability of this tool in detecting thin metallic and aluminium objects that are invisible on standard radiograms. Saz et al. found the sensitivity, specifity, positive and negative predictive values (PPV, NPV) of handheld metal detectors to be 88.6%, 100%, 100% and 55.5% respectively (95% confidence intervals) in patients who ingested a metallic foreign body [1].

Steroid response in moderate to severe pediatric ulcerative colitis: a single center’s experience

BackgroundWe aimed to analyze clinical and inflammatory markers of steroid non-response in patients with moderate/severe ulcerative colitis (UC) at the time of diagnosis.MethodsThis study included patients who were graded as having moderate/severe UC and received corticosteroids as first-line therapy. Demographic, clinical and laboratory findings and pediatric ulcerative colitis activity scores (PUCAS) were recorded. Response to corticosteroids was assessed 30 days after the induction and long-term therapy.ResultsTwenty-eight children were diagnosed as having moderate/severe UC. Their mean age ± SD was 1 2.2 ± 4 years, and 17% were under 5 years of age. PUCAS at their initial admission was 56.9 ± 11.8. UC was observed at the left colon in 9 patients (32.1%), and pancolitis in 19 (67.9%). At the end of the 30th day, UC was completely remitted in 15 patients (53.5%), partially remitted in 2 (7.1%), and no response in 11 (39.2%). Short-term follow-up showed partial remission in 2 patients, and overall remission with steroid in 17 (60.7%). Non-responders were given second-line treatment; steroid dependency was documented in 2 patients (7.1%) and another 2 (7.1%) patients underwent colectomy. Predictors for steroid non-response were analyzed and only PUCAS at the initial admission was found to be associated with non-response to steroids (51.4 ± 11.4 vs. 65.4 ± 6.8, P<0.05).ConclusionsApproximately half of the pediatric patients had complete response to steroid therapy in a long period. PUCAS could be used as a potential marker of “failed response” to steroid, but should be supported with a number of prospective randomized controlled studies.

Post-transplant malignancies in pediatric liver transplant recipients: Experience of two centers in Turkey

BACKGROUND/AIMS A liver transplant is the preferred treatment for patients with end-stage liver disease, as it usually results in longterm survival. However, due to the use of chronic immunosuppressive therapy, which is necessary to prevent rejection, de novo cancer is a major risk after transplantation. The aim of this study was to assess the incidence of post-transplant malignancies in children after liver transplantations. MATERIALS AND METHODS The study group consisted of 206 liver transplant recipients, with no history of cancer, including hepatocellular carcinoma, in two liver transplantation centers in Turkey between 1997 and 2015. Data were obtained from patients data chart. RESULTS In the study group, de novo cancer was diagnosed in 13 of the 206 patients. Post-transplant lymphoproliferative disease (PTLD) occurred in seven (53.8%) patients and other malignancies in six of the 13 patients. The types of PTLD were as follows: B-cell origin (n=2), Epstein-Barr virus (EBV)-related (n=2), T-cell origin (n=1), and Hodgkins lymphoma (n=2). EBV DNA was isolated from seven patients, three of whom developed PTLD. The others developed Kaposis sarcomas, Burkitts lymphomas, cutaneous large-cell lymphomas, Hodgkins lymphomas, and liver sarcomas. CONCLUSION After transplantation, immunosuppressive treatment is unavoidable, increasing the risk of malignancies. However, a close follow-up and periodic screening can reduce cancer-related mortality and morbidity.

Stress magnet ingestion in three children: Endoscopist perspective

Abstract The widespread use of magnets in toy industry has resulted in increased reports of magnet ingestions and related complications. Ensconcing within plastic covers and manufacturing larger pieces have been forwarded to avoid ingestion. We report 3 cases of magnet ingestion called “stress magnets” which are large to pass the gastric outlet. Endoscopic retrieval of single and double magnets from the stomach is described, and magnet related health hazard as well as the procedure related adversities is discussed.