Ethan A. Mezoff

Clostridium difficile Infection and Treatment in the Pediatric Inflammatory Bowel Disease Population

Objective: Recent changes in the epidemiology of Clostridium difficile infection include an increase in the incidence of C difficile–associated disease (CDAD) and the identification of patients with inflammatory bowel disease (IBD) as a group at risk. In addition, the effectiveness of antimicrobial therapies has been questioned. Our aim was to estimate the incidence of CDAD in a pediatric IBD population and review treatment efficacy. Patients and Methods: We identified patients ages 18 years or younger from our centers IBD database who tested positive for C difficile toxin A and/or B between August 1, 2007 and December 31, 2008. Demographic information and treatment details were recorded. Chi-square and Fisher exact tests were used to compare categorical variables and the Student t test was used for continuous variables. Results: From 372 pediatric patients with IBD, we identified 29 patients who experienced a total of 40 cases of CDAD. The annualized incidence rate of CDAD was 7.2%. Initial treatment was successful in 17 cases (43%). Eventual success was documented with metronidazole in 15 cases (41%), with vancomycin in 16 cases (43%), and with other agents or a combination of agents in 6 cases (16%). Age, sex, and IBD type were not associated with initial treatment outcome or recurrence. The choice of initial antimicrobial treatment was not associated with treatment outcome. The type of IBD therapy medication was not associated with the likelihood of CDAD recurrence, although the use of anti-inflammatory therapy was positively associated with initial antimicrobial treatment success. Conclusions: CDAD occurred frequently in our cohort of pediatric patients with IBD. Antimicrobial treatment success was achieved equally with either metronidazole or vancomycin. Initial treatment failed more than half of the time, regardless of medication choice. Apparent lack of antimicrobial efficacy in resolving symptoms may reflect resistant C difficile infection or increased IBD severity in a subset of patients who are C difficile carriers. Awareness of the potential for a high incidence of CDAD and frequent failure rate of initial therapy is important in the management of children with IBD.

Ethanol Lock Efficacy and Associated Complications in Children With Intestinal Failure

BACKGROUND Prophylactic ethanol lock therapy (ELT) reduces central line-associated bloodstream infections (CLA-BSIs) in children with intestinal failure (IF). However, the risk of associated complications is unclear. We aim to describe our experience with prophylactic ethanol locks in a cohort of patients with IF. MATERIALS AND METHODS Thirty patients on ELT from 2010-2013 were identified by review of our intestinal rehabilitation registry. Patient demographics, CLA-BSI events, and line complications were extracted. Comparisons in infection and complication rates when on and off ELT were made using a Poisson mixed-effect regression model. RESULTS CLA-BSIs when on and off ELT were 3.1 and 5.5 per 1000 catheter days, respectively (P <015). Overall complication rates were similar in both groups. In those patients who experienced a complication, the complication rates on ELT compared with time off ELT were significantly lower (P <003). Line perforation or breakage rates declined significantly when on ELT, from 1.8 to 1.53 per 1000 catheter days (P <006). Line occlusion rates also decreased on ELT, from 0.6 to 0.3 per 1000 catheter days (P =056). Infecting organisms were not different on and off ELT, and patients experienced a similar number of polymicrobial infections on or off therapy. Klebsiella pneumoniae was the most common infecting organism in both groups. CONCLUSIONS Ethanol lock therapy use reduces both CLA-BSI and central line complication rates in children with IF. These results underscore the safety and efficacy of ELT use in this population.

Focus on diagnosis: Dysphagia.

1. Ethan A. Mezoff, MD 1. Fellow in Pediatric Gastroenterology, Cincinnati Children’s Hospital, Cincinnati, OH. Dysphagia, or difficulty with swallowing, may present alone or with accompanying signs and symptoms. The evaluation of dysphagia is guided by an accurate and thorough history, taken in consideration of the vast differential diagnosis. A brief review of the physiology of swallowing is followed by a differential diagnosis and historical points that should direct the diagnostic evaluation. Finally, a review of diagnostic and treatment options is presented. Swallowing prepares and transfers a bolus of consumed or secreted substance from the mouth to the stomach. Initially, the pooling of oral secretions forms a bolus, with or without masticated food. This bolus is then transferred to the upper esophagus during the oropharyngeal phase of swallowing. During this phase, the epiglottis covers the larynx to prevent aspiration of the bolus. Additionally, the soft palate is elevated against the nasopharynx to prevent nasal regurgitation of the bolus. Transfer of the bolus to the stomach then occurs through peristaltic muscle contractions of the circular and longitudinal smooth muscles of the esophagus and relaxation of the lower esophageal sphincter. The developmental milestone of swallowing typically is reached at 34 weeks gestational age in premature infants. It is best to separate oropharyngeal from esophageal causes when considering the differential diagnosis of dysphagia. Oropharyngeal causes, in general, are grouped as neuromuscular, infectious/inflammatory, or structural (Table 1). Esophageal causes are divided into …

Medical Management of Duodenum Inversum Presenting With Partial Proximal Intestinal Obstruction in a Pediatric Patient.

D uodenum inversum has been reported in adults (1–4) with only 2 published reports in children (5,6). Associated conditions include malrotation, incomplete rotation, annular pancreas, and pancreas divisum (2,4,5). In addition, patients may be predisposed to pancreatitis, hypoalbuminemia, peptic ulcer disease, duodenitis, and proximal duodenal obstruction (1–3,5,6), but the majority are asymptomatic (1–3,5,6). Although duodenum inversum is usually an incidental finding in asymptomatic individuals, patients can present with abdominal pain and nausea. It can go unrecognized on upper gastrointestinal (UGI) contrast examination because when the duodenojejunal junction is found in the expected location, the anomaly may be overlooked despite an abnormal duodenal course (5,6). Additionally, it may mimic superior mesenteric artery (SMA) syndrome if associated with medial linear extrinsic impression on the duodenum (6) or from compression against the psoas muscle with acute weight loss. A representative image is shown in Figure 1 from a patient ‘‘without’’ duodenal inversum who presented with acute weight loss and emesis and subsequently was found to have partial proximal duodenal obstruction from the psoas muscle. Management in symptomatic patients varies, with medical management remaining the first line (3–5). In the 2 published pediatric cases, surgical exploration was indicated (5,6). We report the first case of duodenum inversum presenting as partial proximal intestinal obstruction in a pediatric patient that was successfully managed with medical and nutritional therapy alone.

The Changing Face of Very Early-Onset Inflammatory Bowel Disease

As pediatricians, we are fully aware that our patients are not “little adults.” During childhood, the body undergoes remarkable developmental change, impacting all facets of medical care. Drugs are metabolized differently, diseases may present in a unique manner, and pediatric patients recover from illness at a different pace than adults. Although the pathophysiologic basis of inflammatory bowel disease (IBD) may be similar between children and adults, the anticipated course and rate of complications are clearly different. Given a high rate of mood disorders, the need for early surgery, and unique potential comorbidities, including growth and pubertal delay, the approach to pediatric patients with IBD must be tailored to meet their specific needs and understood in the context of their developmental progression.1–4 In order to do this, we must first characterize the disease course in contrast with that of older patients in order to discover salient differences that would allow a more personalized approach to treatment. Oliva-Hemker et al in this issue of The Journal contributes to this task, describing the presentation and therapeutic requirements of children aged 1–5 years with very early-onset (VEO)-IBD in contrast with that of IBD in an older teenage cohort aged 11–16 years.5

Constipation: a Brown Herring.

A 14-year-old African American female with a history of constipation was evaluated for abdominal pain and vomiting for 3 days. Examination revealed a full but soft abdomen, generalized tenderness, no peritoneal signs, and stool in the rectum. Abdominal radiograph showed dilated bowel loops in the right hemi-abdomen and a heavy stool burden. At the recommendation of surgical consultants, the patient was started on an osmotic laxative solution (Miralax; Merck & Co, Whitehouse Station, New Jersey). Soon after initiation of bowel cleanout, she developed bilious emesis. Her examination was unchanged, with no focal findings or rebound tenderness. Repeat abdominal radiograph showed an increase in the size and number of dilated small bowel loops, as well as persistence of intraluminal air-fluid levels (Figure 1). The surgeon felt that the findings and exam remained consistent with unaddressed constipation. Colonic irrigations were recommended. Further review of the film with radiology prompted computed tomography evaluation of the abdomen; findings were consistent with a small bowel obstruction with obvious transition point (Figure 1). Ultimately, an exploratory laparotomy revealed an obstructing trichobezoar in the ileum (Figure 2). Other than reportedly mild anxiety, this normally developed adolescent gave no indication of psychiatric distress. Therefore, despite concerning findings of obstruction on

A Procedural and Educational Experience Following Creation of an Advanced Pediatric Endoscopy Service.

ABSTRACT Advanced endoscopic procedures occur infrequently enough in pediatric patients to preclude effective maintenance of competence among all pediatric gastroenterologists. A recent study suggests that fellows are largely unable to achieve the prescribed case volume recommended to achieve competence. We sought to describe the procedural and educational experience following the creation of an advanced pediatric endoscopy service in response to declining confidence among practice members regarding advanced procedures. We found most advanced endoscopy cases (90%) were accomplished during routine business hours with little seasonal variation. Esophageal dilations occurred far more than all other procedures provided by this service. Control of nonvariceal bleeding, feeding tube placement, enteroscopy, and needle knife therapy, among others, were performed exclusively but relatively infrequently by members of this advanced endoscopy service. Fellows were present for many cases, although they participated in relatively few. We conclude that the creation of an advanced endoscopy service permits distillation of rare but technically demanding cases to few providers, ensuring maintenance of skills, although the role of fellows remains in question.