Dharamveer Basude

G81(P) Impact of socio-economic position on incidence of Inflammatory Bowel Disease

Background Inflammatory bowel disease (IBD) is understood to result from the interaction of genetic, immunological and environmental factors. There has been a marked increase in the incidence of IBD over the last 25 years, suggesting environmental factors are important. A previous study found a higher incidence of Coeliac disease in the least deprived socioeconomic groups.1 The objective of this study was to investigate the relationship between IBD and socioeconomic position. Methodology Bristol Children’s Hospital is the single regional centre where all children with suspected IBD from the South-west of England are referred. Data was collected prospectively on all children diagnosed between May 2004–March 2013. Socioeconomic status was determined by quintile rank of Index of multiple deprivation score (IMD-10 score) based on postcode at diagnosis. This has been shown to provide a nationally consistent measure of how deprived an area is. Population data was obtained from the 2011 Census. Data was analysed using Pearson Chi Squared test. Children with a postcode outside of the City of Bristol were excluded from the analysis. Results 384 children aged 0–17 years were diagnosed with IBD over the study period of which 50 had a postcode of residence within the City of Bristol. The incidence of IBS was higher in the three lower socio-economic classes compared to the two highest socio-economic classes (see Figure 1). However, the difference in incidence between the socio-economic classes was not statistically significant. Abstract G81(P) Figure 1 Conclusion Our data suggests a higher incidence of diagnosed IBD in children from lower socioeconomic classes which may favour an environmental aetiology. However this did not reach statistical significance, possibly due to small numbers. A larger study is warranted. Reference Whitburn and Sandhu. Coeliac disease and relationship to socio-economic status. Arch Dis Child 2013;98:A86

Non-pharmacological management of abdominal painrelated functional gastrointestinal disorders in children

BackgroundAbdominal pain-related functional gastrointestinal disorder (AP-FGID) comprises of 4 main conditions: functional dyspepsia, irritable bowel syndrome, abdominal migraine and functional abdominal pain. AP-FGIDs are diagnosed clinically based on the Rome IV criteria for FGIDs of childhood. There is limited evidence for pharmacological therapies.Data sourcesThis review article discusses nonpharmacological management of AP-FGID based on the current literature including systematic reviews, randomized controlled trials, cohort and case control studies. We aim to provide a comprehensive overview on the available evidence for the pediatricians and pediatric gastroenterologists involved in managing children with AP-FGID.ResultsManaging AP-FGIDs can be challenging. This should follow a stepwise approach with focused history, identification of “red flag” signs and symptoms, physical examination and investigations done following initial consultation. Family needs explaining that there is nothing seriously wrong with the child’s abdomen. This explanation and reassurance can achieve symptom control in large number of cases. Non-pharmacological interventions are delivered through lifestyle and dietary changes and bio-psychosocial therapies. Dietary interventions vary depending on the type of AP-FGID. Bio-psychosocial therapies such as hypnotherapy, cognitive behavioral therapy and yoga aim at stress reduction.ConclusionThere is increasing evidence for use of non-pharmacological interventions in children with APFGID.

Congenital Oesophageal Web Treated Successfully With Endoscopy and Balloon Dilatation.

FIGURE 3. Endo-cut followed by balloon dilatation. T o the Editor: Oesophageal webs are membranes of normal oesophageal tissue typically presenting with dysphagia in children. They form approximately 16% of all congenital oesophageal strictures (1). Surgery is the treatment of choice; endoscopic balloon dilatation can be a useful alternative (1–3). Balloon dilatation combined with electrocauterization was reported to be successful in a previous case study of a 3-year-old boy with oesophageal web (2). A 9-month-old girl presented with choking, heaving followed by coughing and vomiting within 10 minutes of eating solids. She tolerated liquids well. Barium swallow showed oesophageal stricture at the level of the 8th cervical vertebra. Endoscopic assessment at 10 months of age revealed circumferential membranous oesophageal stricture of <5 mm diameter at 20 cm from the lips (Fig. 1) confirming diagnosis of congenital oesophageal-web. Balloon dilatation to 10 mm was performed to disrupt the membrane (Fig. 2). Symptomatic benefit was briefly achieved and she presented acutely with recurrence of symptoms. Savary-Gillard dilatation was performed with no significant symptomatic benefit. Repeat endoscopy revealed

G183(P) Awareness of espghan guidelines on coeliac disease among general paediatricians in southwest england

Background ESPGHAN 2012 guidelines on coeliac disease (CD) recommend that symptomatic children with anti-tissue-transglutaminase (anti-tTG) >10 x upper-limit-of-normal (ULN), positive EMA and HLA-DQ2/8, can be diagnosed without biopsy. Serological diagnosis is not appropriate for certain groups of patients. Aims Gain understanding of awareness and use of ESPGHAN guidelines for diagnosing paediatric CD among general paediatricians Methods Telephone/email survey was conducted among general paediatric consultants (n»140) across Southwest England. Survey included 8-questions incorporating 3 main themes: when nonbiopsy diagnoses can be made, HLADQ2/8 genotyping should be requested and whether asymptomatic children from high-risk groups with anti-tTG >10xULN can be diagnosed serologically. Results 85/140 (61%) responses obtained. 83% of paediatricians were unable to state all conditions required for non-biopsy diagnosis. None could describe all situations where HLA-DQ2/8 genotyping should be requested. 33% of paediatricians responded that asymptomatic children with anti-tTG >10xULN can be diagnosed with CD without a biopsy while 24% said they were unsure or would seek advice. Summary and Conclusions Survey highlighted need for greater in-depth awareness of non-biopsy pathway and situations where HLA-DQ2/8 genotyping is indicated. There is possible misinterpretation regarding the ESPGHAN guidelines as 1/3rd of paediatricians considered non-biopsy pathway is applicable for asymptomatic children. Adequate knowledge of the ESPGHAN guidelines for CD is required among paediatricians. A userfriendly Apps is planned to improve the diagnostic process.

Role of Dentists in Managing Pediatric Celiac Disease.

To the Editor: We read with interest the article by Singh et al., highlighting an important aspect of recognizing pediatric celiac disease (CD) [1] from its extraintestinal manifestation. The case of dental enamel defect (DED) in primary dentition is described in an 11-yold girl who also had a history of chronic diarrhea and abdominal pain. It is surprising that the intestinal features [2] alone did not trigger a suspicion of CD. It is however, commendable that the diagnosis was made following detection of DED. This case highlights the importance of considering CD as a multi-organ disorder and the importance of collaborative working between pediatricians, gastroenterologists and other health professionals, particularly dentists [1, 2]. Other oro-dental manifestations of CD worth considering are: delayed eruption of teeth, dental caries, recurrent aphthous ulceration, oral manifestations of dermatitis herpetiformis and cheilitis [3]. We describe a 14-y-old girl with CD who was asymptomatic at diagnosis. She underwent serological screening with IgA-based anti-tissue-transglutaminase antibodies (TTG) suggested for a first degree relative [2] following her father’s diagnosis of CD at 45-y of age. The TTG was raised at 56 IU/ml (normal <10 IU/ ml) and the diagnosis was established following endoscopic duodenal biopsies which showed typical histological changes (Marsh type 3 A). Strict gluten-free-diet (GFD) was recommended and advised by a pediatric dietician. At annual review the repeat TTG was still 45 IU/ml. Further probing revealed that she was not adhering strictly to GFD as she had no apparent symptoms. However, her dentist noticed that she had developed features of DED in her permanent dentition. The family was counselled again regarding the need for strict adherence to GFD. Her dentist monitored the DED which gladly resolved a year later when adherence had improved. Apart from identifying dental features attributable to CD, where non-adherence to GFD remains an issue, dentists can also help in their early recognition as highlighted in our case. It is important that the child’s dentist is informed of the diagnosis of CD as it also affects other aspects of future dental treatments for the child. This was noted in a published case of 9-y-old girl with CD who continued to be symptomatic despite strict adherence to GFD. On careful evaluation, it turned out that she was regularly exposed to gluten from her orthodontic retainer that contained a plasticised methacrylate polymer [4]. Our brief case summary demonstrates that features of CD can develop post diagnosis due to non-adherence to GFD, even in children who may be asymptomatic [2, 5] at initial presentation. It also reinforces the role of dentists in care of these children.

G79(P) Does Inflammatory Bowel Disease (Unclassified) evolve into Crohn’s disease or Ulcerative Colitis?

Background In 5–15% of children diagnosed with inflammatory bowel disease (IBD), the histological picture at diagnosis doesn’t fit in with either ulcerative colitis (UC) or Crohns disease (CD) and is classified as unclassified-IBD (IBDU) or indeterminate colitis.1 The aim of this prospective study is to determine whether IBDU evolves into UC or CD. Methods Prospective data has been collected on all the newly diagnosed children with IBD at the only regional paediatric gastroenterology centre covering southwest of England. All patients suspected of IBD had upper and lower gastrointestinal endoscopy and MRE scan or barium meal as recommended by BSPGHAN.2 Patients diagnosed with IBDU during 2004–2011 were included in the study and followed up for a minimum of 2 years (range 2–9 years). The patient notes were reviewed in 2013 and any changes in diagnosis recorded. Results 333 children were diagnosed with IBD between 2004–2011: 193 (58%) had CD, 115 (34.5%) UC and 25 (7.5%) IBDU. Age (mean) at diagnosis: 10.2 years (IBDU), 11.5 years (CD) and 11.6 years (UC). 7/26 (27%) IBDU had pan-colitis and 19/26 (63%) had patchy or left-sided colitis on lower gastrointestinal endoscopy. After 2 to 9 years, IBDU evolved into CD in 5 patients (22.8%), UC in 3 (13.6%) and remained IBDU in 14 patients (63.6%). Latest data was unavailable for 3 (11.6%) because of transfer to distant adult services. ANCA was positive in 3 out of 4 patients whose diagnosis was revised as CD. Conclusion This large prospective study has documented that over 2–9 years, 22.8% IBDU evolved into CD, 13.6% into UC and 63.6% remained IBDU. IBDU patients tended to be younger at diagnosis. Positive ANCA was not an useful predictive marker. This has implications for management of IBDU patients especially where surgical treatment is considered. References De Bie CL, et al. (2012). J Pediatr Gastroenterol Nutr. 54(3):374-80 Sandhu BK, et al. (2010). J Pediatr Gastroenterol Nutr. 50:S1-S13