David Rawat

Acid and nonacid gastro-oesophageal reflux in neurologically impaired children: investigation with the multiple intraluminal impedance procedure.

Objectives: The diagnosis of gastro-oesophageal reflux (GOR) is more difficult in children with neurological impairment because symptoms are often less interpretable and frequently go undetected. The use of combined pH and multiple intraluminal impedance allows for the detection of both acid (pH < 4) and nonacid (pH > 4) GOR episodes, in addition to the height of the refluxate and the total acid and bolus clearance time in this cohort. Methods: Sixteen neurologically impaired children (9 were fed nasogastrically, 7 were fed orally) underwent 12-hour combined pH and multiple intraluminal impedance. Results: There were a total of 425 reflux episodes during the study period, of which 239 (56.2%) were nonacid. The median of reflux episodes per hour was 1.8 (range, 0.2-6.3/h). The median height of the refluxate was 1.5 channels (range, 1.1-2.9); and 71.3% of reflux episodes reached the upper oesophagus, of which 52.4% were nonacid reflux events. On average there were more GOR events (both acid and nonacid) in the children who were fed via a nasogastric tube, and the median height of refluxate was also higher in this group. However, the median acid clearance time was longer (both proximal and distal) in the children who were fed orally (28.6 s vs 16.2 s proximally; 67.9 s vs 38.3 s distally). The median acid clearance time (21.7 s proximally; 39.5 s distally) was longer when compared with bolus clearance (14.9 s). Conclusions: More than half of the reflux events in neurologically impaired children are nonacidic and would therefore go undetected by conventional pH metry. There are more reflux events in children fed nasogastrically than oral-fed children.

Surgery in Children With Crohn Disease Refractory to Medical Therapy

Objective: The aim of this study was to evaluate the results of surgery in children with Crohn disease (CD) not responding to medical therapy and establish whether surgery improves growth and nutrition. Patients and Methods: Children with CD diagnosed between 1998 and 2008 were reviewed. Relapse was defined by Harvey-Bradshaw index >5. Data, reported as median (range), were compared by Fisher exact test and repeated-measures ANOVA. Results: One hundred forty-one children, ages 12.7 years (3.5–16.8), were identified; 27 (19%) required surgery 14.5 months (1.1–61.8) after diagnosis. Twenty-one had elective surgery (19 isolated ileocaecal disease and stricture, 2 diffuse disease of ileum); 6 had emergency surgery (3 peritonitis, 2 haemorrhage, 1 perforation). Surgery included 18 ileocaecal resection and end-to-end anastomosis, 5 stoma formation, 2 left hemicolectomy and end-to-end anastomosis, and 2 stricturoplasty. Follow-up was 2.5 years (1–9.4). Growth and nutrition improved by 6 and 12 months after surgery, with a significant increase in weight z score (P < 0.0001), height z score (P < 0.0001), albumin (30 [13–36] vs 39 [30–46] vs 40 [33–45], P < 0.0001), and haemoglobin [10 (6.8–13.2) vs 11.7 (8.2–13.7) vs 12.0 (9.3–14.7), P < 0.0001]. All patients of the received azathioprine (2–2.5 mg · kg−1 · day−1) after surgery. Fifteen patients (55%) relapsed with a modified Harvey-Bradshaw index of 8 (6–11) within 11.5 months (4.2–33.4). Of these, 5 patients (18%) relapsed within 1 year. Five patients (18%) had further surgery (2 anastomotic strictures, 2 diseased stoma, and 1 enterocutaneous fistula). Conclusions: Growth and nutrition following surgery for CD improve, but there is a high relapse rate. Despite this, the improved growth and nutrition before relapse may be beneficial during puberty and justify surgery in children not responding to medications.

Percutaneous endoscopic gastrostomy and gastro-oesophageal reflux in neurologically impaired children

AIM To investigate the effects of percutaneous endoscopic gastrostomy (PEG) feeding on gastro-oesophageal reflux (GOR) in a group of these children using combined intraluminal pH and multiple intraluminal impedance (pH/MII). METHODS Ten neurologically impaired children underwent 12 h combined pH/MII procedures at least 1 d before and at least 12 d after PEG placement. METHODS Prior to PEG placement (pre-PEG) a total of 183 GOR episodes were detected, 156 (85.2%) were non-acidic. After PEG placement (post-PEG) a total of 355 episodes were detected, 182 (51.3%) were non-acidic. The total number of distal acid reflux events statistically significantly increased post-PEG placement (pre-PEG total 27, post-PEG total 173, P = 0.028) and the mean distal pH decreased by 1.1 units. The distal reflux index therefore also significantly increased post-PEG [pre-PEG 0.25 (0-2), post-PEG 2.95 (0-40)]. Average proximal pH was lower post-PEG but the within subject difference was not statistically significant (P = 0.058). Median number of non-acid GOR, average reflux height, total acid clearance time and total bolus clearance time were all lower pre-PEG, but not statistically significant. CONCLUSION PEG placement increases GOR episodes in neurologically impaired children.

Health‐related quality of life in children with achalasia

Aims:  To assess self‐reported QoL in children with achalasia aged 5–18 and compare this with both disease and healthy control children in a prospective study.

Graded compression and power Doppler ultrasonography versus endoscopy to assess paediatric Crohn disease activity pre- and posttreatment.

Objective: The aim of this study was to assess whether power Doppler ultrasound (PDU) can serve as a reliable replacement for endoscopy in follow-up assessment of disease activity in children with Crohn disease. Methods: Nineteen children (13 boys), median age 14.8 (5.4–15.8) years, with macroscopically diagnosed Crohn disease were included in the study. Clinical parameters, histological evaluation, and graded PDU assessments were undertaken in all patients at diagnosis and following their initial treatment. Discriminant analysis was used to build predictive models from the PDU data for the histological evaluation. Results: The median Pediatric Crohns Disease Activity Index (PCDAI) was 31.5 (15.5–42.0) at diagnosis. All clinical and ultrasonographic parameters and the histological evaluation showed an improvement between pre- versus posttreatment results; 1-way analysis of variance showed a significant difference because of treatment (P < 0.005) for all variables apart from the superior mesenteric artery flow (SMA); paired sample t tests indicated that these differences were statistically significant (P < 0.001), with the exception of SMA (P = 0.178). There was a statistically significant correlation (P < 0.001) between the platelet count and the bowel wall stratification (STRAT). Significant correlation was also observed between the histology findings and the mean mucosal, transmural, and segmental flow (MFL) and STRAT and between platelets and both MFL and small bowel thickening (SBT) (P < 0.01 in all cases). There was a statistically significant correlation (P < 0.05) between C-reactive protein and MFL and between histology and SBT, MFL, and STRAT. Discriminant analysis using discriminating factors SBT, STRAT, and MFL could assign 84.6% of cases to the correct classification of “no/mild inflammation” or “medium/severe inflammation.” Conclusions: Results obtained using power Doppler ultrasonography and endoscopy showed statistically significant correlations. Power Doppler sonography, in the hands of an experienced examiner, can be used for follow-up assessment of disease activity in children with Crohn disease.