Dorina Barbieri

Serum Soluble Interleukin-2 Receptor, Interleukin-6, and Tumor Necrosis Factor-α Levels in Children with Celiac Disease: Response to Treatment

Objectives T-cell mediated immune response to dietary gluten and cytokines release are important for the enteropathy seen in celiac disease. We investigated the serum levels of soluble interleukin-2 receptor, interleukin-6, and tumor necrosis factor-&agr; in celiac children before and after gluten exclusion. Methods Cytokine levels were determined using enzyme immunoassay in serum from 12 untreated celiac patients, 16 treated celiac patients on a gluten-free diet for at least two years, and from 26 control children. Eight of 12 untreated patients were also investigated at 6 and 12 months after gluten exclusion. Serum IgA antiendomysium antibodies were also assayed by indirect immunofluorescence. Results Soluble interleukin-2 receptor and interleukin-6 levels were significantly increased in untreated celiac patients compared with treated and control children. There was no difference in the tumor necrosis factor-&agr; levels between the groups. Soluble interleukin-2 receptor levels were the only ones significantly decreased at 12 months after gluten exclusion. However, soluble interleukin-2 receptor and interleukin-6 levels at 12 months were significantly higher compared with controls. Antiendomysium antibodies had a diagnostic sensitivity of 100% and the titers decreased significantly after 12 months of gluten exclusion. A significant positive correlation was found between antiendomysium antibody titers with both soluble interleukin-2 receptor and interleukin-6 values. Conclusions The serum soluble interleukin-2 receptor and interleukin-6 levels may be used as a noninvasive measure of celiac disease activity and response to treatment.

Clinical manifestations, treatment, and outcomes of children and adolescents with eosinophilic esophagitis

Objective This study aimed to describe the clinical, endoscopic, and histologic characteristics, as well as the response to conventional treatment of pediatric patients with the classical form of eosinophilic esophagitis (EoE).OBJECTIVE This study aimed to describe the clinical, endoscopic, and histologic characteristics, as well as the response to conventional treatment of pediatric patients with the classical form of eosinophilic esophagitis (EoE). METHODS Study of clinical, laboratory, endoscopic, and histologic data and response to conventional treatment of 43 previously followed pediatric patients with the classical form of EoE. RESULTS A total of 43 patients diagnosed with EoE were included in the study, of which 37 were males (86%), with a mean age of 8.4 years. The most common symptoms were: nausea, vomiting, and abdominal pain (100%) in children younger than 7 years, and loss of appetite (60%), heartburn (52%), and food impaction (48%) in children older than 7 years and adolescents. Regarding the endoscopic findings, 12 (28%) patients had whitish plaques on the esophageal lining, 8 (18.5%) had longitudinal grooves, 2 (4.5%) had concentric rings, 3 (7%) had longitudinal grooves and whitish plaques, and the remaining 18 (42%) had esophageal mucosa with normal appearance. Despite the initial favorable response, 76.7% of patients required more than one course of corticosteroid therapy (systemic or aerosol) and diet (exclusion or elimination of food or elementary allergens). Persistence of eosinophil infiltration was found in some patients despite favorable clinical response. CONCLUSIONS The classic form of EoE typically shows different symptoms according age range. A significant number of patients required more than one treatment cycle to show clinical remission. Endoscopic and histologic improvement was observed; however, eosinophilic infiltration persisted in some patients.

Original ArticleClinical manifestations, treatment, and outcomes of children and adolescents with eosinophilic esophagitisManifestações clínicas, terapêutica e evolução de crianças e adolescentes com eso- fagite eosinofílica*

Objective This study aimed to describe the clinical, endoscopic, and histologic characteristics, as well as the response to conventional treatment of pediatric patients with the classical form of eosinophilic esophagitis (EoE).OBJECTIVE This study aimed to describe the clinical, endoscopic, and histologic characteristics, as well as the response to conventional treatment of pediatric patients with the classical form of eosinophilic esophagitis (EoE). METHODS Study of clinical, laboratory, endoscopic, and histologic data and response to conventional treatment of 43 previously followed pediatric patients with the classical form of EoE. RESULTS A total of 43 patients diagnosed with EoE were included in the study, of which 37 were males (86%), with a mean age of 8.4 years. The most common symptoms were: nausea, vomiting, and abdominal pain (100%) in children younger than 7 years, and loss of appetite (60%), heartburn (52%), and food impaction (48%) in children older than 7 years and adolescents. Regarding the endoscopic findings, 12 (28%) patients had whitish plaques on the esophageal lining, 8 (18.5%) had longitudinal grooves, 2 (4.5%) had concentric rings, 3 (7%) had longitudinal grooves and whitish plaques, and the remaining 18 (42%) had esophageal mucosa with normal appearance. Despite the initial favorable response, 76.7% of patients required more than one course of corticosteroid therapy (systemic or aerosol) and diet (exclusion or elimination of food or elementary allergens). Persistence of eosinophil infiltration was found in some patients despite favorable clinical response. CONCLUSIONS The classic form of EoE typically shows different symptoms according age range. A significant number of patients required more than one treatment cycle to show clinical remission. Endoscopic and histologic improvement was observed; however, eosinophilic infiltration persisted in some patients.

Tratamento da retocolite ulcerativa inespecífica em criança com enemas contendo butirato: relato de caso

Objective - To report a promising therapy to ulcerative colitis in children. Methods - We report a case of ulcerative colitis in 4 years old female, who had this diagnosis since she was 1 year old. The treatment of RCUI had an insatisfatory response to conventional therapys (retal and oral corticosteroids and immunosupressive agent). Results - She showed improvement, using enemas containing butyrate, in clinical, endoscopic and histological parameters. Conclusions - Although the role of butyrate in the treatment of ulcerative colitis still remains to be determined, we find effective response in this case. Despite evidences that butyrate may be benefical and safety in treating refractory distal ulcerative colitis, results of controlled trials, specially in children will be necessary to prove the efficacy of this therapy.Objective - To report a promising therapy to ulcerative colitis in children. Methods - We report a case of ulcerative colitis in 4 years old female, who had this diagnosis since she was 1 year old. The treatment of RCUI had an insatisfatory response to conventional therapys (retal and oral corticosteroids and immunosupressive agent). Results - She showed improvement, using enemas containing butyrate, in clinical, endoscopic and histological parameters. Conclusions - Although the role of butyrate in the treatment of ulcerative colitis still remains to be determined, we find effective response in this case. Despite evidences that butyrate may be benefical and safety in treating refractory distal ulcerative colitis, results of controlled trials, specially in children will be necessary to prove the efficacy of this therapy.

Anticorpos séricos na doença celíaca

Accurate diagnosis of celiac disease is important because patients are advised to adhere to a strict gluten-free diet for life. This management is critical to avoid disease complications such as malignancies. In this review the new terminology for the disease clinical features (active, silent, latent and potential celiac disease) and the disease association with other conditions are commented. The value and efficacy of the assessment of serum antigliadin antibodies and of antireticulin, antiendomysial and tissue transglutaminase autoantibodies in the diagnosis and follow-up of the celiac disease are particularly evaluated.Accurate diagnosis of celiac disease is important because patients are advised to adhere to a strict gluten-free diet for life. This management is critical to avoid disease complications such as malignancies. In this review the new terminology for the disease clinical features (active, silent, latent and potential celiac disease) and the disease association with other conditions are commented. The value and efficacy of the assessment of serum antigliadin antibodies and of antireticulin, antiendomysial and tissue transglutaminase autoantibodies in the diagnosis and follow-up of the celiac disease are particularly evaluated.

Morphometric quantification of plasma cells in the intestinal mucosa of children. A comparative study between two sampling procedures.

In an attempt to obtain a sampling procedure of known accuracy for plasma cell quantification, applicable for routine analysis, we counted IgA, IgM and IgG producing cells in the lamina propria of the small intestine of six children by the method II of Aherne (1976), using two sampling procedures. In the first, we determined the number of cells in each one of 200 successive microscopic fields without specifying their localization in the mucosa. Proper tests upon this data showed that in order to estimate the number of IgA producing cells per mm3 of lamina propria with a confidence of 95% that the mean of the sample would not differ by more than 5% from the mean of the population, it would be necessary to count 850–900 microscopic fields. With a confidence of 90% that the two means cited will not differ between them by more than 10%, the number of fields to be counted would lie in the range of 150 to 200. In the second procedure we arbitrarily divided the mucosa into upper, middle and lower segments, identifying and counting the number of cells in each segment. Consistent results for the number of IgA, IgM and IgG-containing cells were obtained by averaging the data of sufficient number of counts of 30 fields: 10 in the upper segment, 10 in the middle segment and 10 in the lower segment. Means obtained by stratified counts of IgA producing cells in 60 microscopic fields, 20 in each segment, differed, in 93% of the samples, by no more than 10% from the mean derived from the counts of 200 successive fields. Stratified sampling also enabled us to detect a segmental variation which had not thus far been quantified. In all cases, it was observed that the numerical concentration of IgA producing cells was greater in the lower region than in the middle zone, while for both IgM and IgG cells the larger numbers occurred in the middle and lower segments. The lowest concentration of IgA, IgM and IgG cells occurred at the top of the villi.

Protein hydrolysate as a dietetic resource

OBJECTIVE: The central goal of this paper was to study the application of beef meat and poultry (turkey and chicken) hydrolysates to the preparations used in our Brazilian current feeding practices. METHODS: The various kinds of meat were hydrolyzed with fresh pineapple under similar conditions to those daily used at home. The selection of three types of preparation was dependent on whether their contents included starch or gelatin and liquid, like soup, mousse and fruit-shake. Hydrolysate were added to the preparations as part of the liquid content of their recipes. The acceptability of the preparations was checked out by employing the hedonic-scale affective test with untrained tasters. Variance analysis and the Tukeýs test were performed with a 5% level of significance for the results.RESULTS: The selected recipes were the following: bitterroot soup, fruit and vegetable-shakes and grape mousse, all of them containing starch or gelatin as an element to camouflage the bitter taste of the aminoacids. The preparations were well accepted: approximately 76% of the tasters reported having liked the soup at least somewhat; as to the shakes, more than 50% gave positive answers, and as to the mousse, approximately 88% reported having liked it. There were no statistically significant differences (p< 0.05) concerning the application of the three hydrolysates in all the preparations tested. CONCLUSIONS: The use of hydrolysed meat to replace liquid content of recipes is highly practicable, requiring only an adequate selection of recipes and their ingredients, that should include starch and gelatin in order to get fully satisfactory products. These preparations might serve as a basis for other ones, adapted to each diet.

Avaliação manométrica anal de crianças com encoprese

INTRODUCTION: Chronic constipation is a common childhood disorder that affects 5 to 10% of pediatric patients, being the second most common cause for seeking medical help, with the encopresis arising out of severe constipation being associated with fecal impaction in the rectum. Among diagnostic exams, anal manometry is used to evaluate patients with functional disorders such as constipation and fecal incontinence, and in some procedures for the evaluation of patients suffering from encopresis, as it provides information on the defecation mechanism and any potential anal sphincter injuries. OBJECTIVE: To verify manometric alterations in patients with encopresis. METHODS: A study was conducted based on 40 anal manometries of constipated children with encopresis (G1) and 12 constipated children without encopresis (G2). The following data were obtained: pressure at rest, contraction and evacuation of the anal canal and the rectal ampulla, point of highest pressure, anal inhibitory reflex and rectal sensitivity. The manometries were performed with an 8-channel perfusion device manufactured by Alacer. DISCUSSION: No differences were found with respect for pressures at rest, contraction and evacuation of the anal canal between groups. Our attention was drawn to the lack of need for an increased rectal volume to trigger the anal inhibitory reflex. There was no difference in the incidence of anismus between groups, which shows that it is not a relevant factor in the maintenance of the encopresis, but of constipation. CONCLUSION: An increase in rectal volume was not required to trigger the anal inhibitory reflex. Anismus was not different in the two groups, being unimportant in the maintenance of encopresis.

[Breastfed infants with chronic idiopathic constipation: a problem to be studied].

* Livre Docente em Pediatria pela Faculdade de Medicina da Universidade de São Paulo. Na língua portuguesa, o termo “constipação” tem duplo significado: indica resfriado, obstrução nasal, ou indica prisão de ventre. Por esta razão, quando este termo é empregado em gastroenterologia, deve ser seguido do termo intestinal. Em português, o termo “obstipação” tem significado único de prisão de ventre e, portanto, pode ser usado sem a complementação da palavra “intestinal”, porém ele é pouco usado pelos médicos brasileiros.

Inflammatory bowel diseases

OBJECTIVE: To present a review about inflammatory bowel diseases in childhood so that pediatricians become familiar with two diseases (ulcerative colitis and Crohn s disease) that are increasing in incidence. METHODS: Articles of specific gastroenterological journals were analyzed. Information was also obtained from the author s extensive professional experience in the area. RESULTS: The two diseases are described. Etiopathogenesis is obscure. Clinical presentation, diagnosis, and treatment are discussed, with details and practical aspects to enable the pediatrician to promptly understand the subject. CONCLUSIONS: The inflammatory bowel disease is a condition of high morbidity, and the pediatrician who assists the case must have a very good technical knowledge about the disease, and must be very comprehensive and emotionally serene, in order to afford the young patient a better quality of life throughout the complicated evolution of this disease.