Francisco Larraín B

Litiasis biliar en niños: un estudio clínico-morfológico

Background: The use of ultrasonography increased the frequency of diagnosis of cholelithiasis in childhood. Aim: To determine the clinical and laboratory features and follow up of children with biliary stones. Patients and methods: Twenty six children (13 male, aged 1 month to 14 years) were prospectively enrolled. Results: Nine children had a past medical history of factors potentially predisposing to stones. A clinical presentation with vomiting (50%), abdominal pain (46%) and jaundice (23%) was the most common indication for surgery. The diagnosis was based on abdominal ultrasound in all children. Cholecystectomy was performed in 15 children (laparoscopy in 13 and open surgery in 2). Children who underwent surgery were older than those who did not undergo surgery (p <0.001), but they did not have differences in liver function tests. Eight children had pigmented stones and seven had cholesterol stones. Conclusions: In our patients, neither family history nor laboratory tests were useful in the diagnosis as well as in the clinical decision of surgery, which was based on symptoms. The presence of cholesterol stones in a high proportion of these children may be a unique situation in Chile, considering the high prevalence of this disease in the adult population (Rev Med Chile 2003; 131: 37-45)

Evaluación prospectiva de la seguridad y tolerancia de los procedimientos colonoscópicos en pacientes pediátricos

Prospective study of 123 children referred for colonoscopy. Demographic data,type of colon preparation, sedation, type of endoscope and endoscopic results were obtained.The following day, a phone interview was carried out inquiring about duration, quality andadverse effects of the sedation and procedure.

Sedación, Seguridad y Utilidad de la Endoscopia Digestiva Alta en Pediatría

Introduccion: El estudio endoscopico alto es un procedimiento diagnostico y terapeutico considerado de rutina, pero su realizacion en pediatria se encuentra limitada dada la necesidad de sedacion y monitoreo adecuados. Objetivos: Evaluar la sedacion, indicacion y percepcion de los padres del examen. Materiales y Metodos: Estudio prospectivo de 190 ninos sometidos a endoscopia digestiva alta. Se obtuvieron datos bio-demograficos, tipo de sedacion y resultados del examen. Resultados: La edad fue 8,5 + 4,2 anos, la mayoria referidos por pediatra (60%). La principal indicacion del estudio fue el dolor abdominal recurrente (29,8%). Los pacientes fueron clasificados de acuerdo al ASA (93% ASA I y II). En la mayoria se requirio de 2 o mas drogas para lograr sedacion optima. La calidad del procedimiento fue satisfactoria en mas del 90%. Un 75,5% presentaron amnesia completa y un 42,7% molestias leves posterior al procedimiento. Entre los hallazgos destacaron signos de esofagitis en el 13,9%, observandose un 61% de los examenes normales. Al analizar los pacientes por peso (mayores y menores de 14 kg), se encontraron diferencias en edad (p < 0,00001), ASA (p = 0,001), indicacion de endoscopia (p = 0,001) y evaluacion de la sedacion por enfermera (p = 0,038). Conclusion: Procedimientos endoscopicos en ninos pueden realizarse de manera segura en forma ambulatoria mediante sedacion moderada. Una adecuada monitorizacion y conocimiento de tecnicas de reanimacion son basicos al momento de realizar dichos procedimientos.

Reflujo gastroesofágico: un intento de clarificar conceptos

Resumen El reflujo gastroesofagico (RGE) es uno de los temas de gastroenterologia pediatrica que tal vez suscite mayor controversia. Pese a las numerosas publicaciones aparecidas en los ultimos anos, persiste aun bastante confusion respecto a sus aspectos conceptuales y practicos, lo que se traduce con frecuencia en un manejo inadecuado de los pacientes que lo presentan. La mayor confusion conceptual deriva de la dificultad de discriminar entre lo que constituye un reflujo fisiologico de uno patologico. La existencia de numerosas tecnicas de estudio que se han desarrollado en los ultimos anos indica que ninguna de ellas es completamente satisfactoria; por otra parte la utilizacion de dichas tecnicas no siempre es la mas adecuada. En el presente articulo se hace una discusion critica del tema en relacion a los aspectos conceptuales, patogenicos, diagnosticos y terapeuticos, en base a las publicaciones mas recientes aparecidas en la literatura medica.

Constipación crónica idiopática: Estudio longitudinal en cuarenta casos

Chronic constipationChronic constipation is a common condition in childhood, and despite current diagnostic methods its etiologyremains unknown in 70% to 80% of the cases. Apropriate medical treatment is frequently effective but it has to besustained and carefully done in order to restore intestinal function. Data from 40 children (21 girls) with chronicidiopathic constipation who were seen along a 10 years period at a pediatric gastroenterology clinic from a universityassociated hospital at Santiago, Chile, is shown. Symptoms begun before one year of age in 62% and before age3 years in 82% of these patients. Sixty percent of them needed frequent use of laxatives, one third looked for me-dical care because of fecal runoff and 22.5% had psychological symptoms. A cross sectional study after one yearfollow up in 36 remaining patients showed that 21 (61-7%) of them were free of symptoms and apparently cured.After ten years it was possible to regain information from 16 patients, 14 of them were considered to be healthyand their x-ray studies were normal. The two remaining cases showed clinical, radiological and manometric evidenceof an organic disease (myogenic achalasia, megarectus and megacolon) and both required surgical treatment. Possiblecauses of protracted course in children with chronic idiopathic constipation include genetic predisposition, failureto comply with treatment and chronic local inflamation and fibrosis due to persistent fecal mass.(Key words: Constipation, chronic, idiopatic, treatment, prognosis.)

Evaluación de los índices de monitoreo de pH esofágico y su relación con indicaciones clínicas: MePeache Fase I

Objetivos: Establecer valores promedio y rangos de normalidad de parametros pHmetricos diferentes al Indice de Reflujo (IR) en monitoreos de pH esofagico (MpHe), segun nuevos valores de IR y correlacionarlos con el diagnostico clinico. Pacientes y Metodo: Estudio retrospectivo de parametros de MpHe incluyendo IR, no y duracion de episodios (DPE), no episodios > 5 min y duracion episodio mayor. Se reagrupo a los 153 pacientes segun edad (Grupo I 1 ano) y segun IR como: Grupo Normal (NL) a aquellos con IR en rango fisiologico (IR < 12% GI y < 6% GII) y Grupo Patologico (PT), cuando el IR superaba estos valores. Resultados: Las indicaciones mas frecuentes fueron estudio de RGE (41,7%), patologia de vias aereas (19,9%) y otorrinolaringologicas (17,2%). Al comparar MpHes en GI (n = 53) no se encontraron diferencias significativas segun genero, medico referente o indicacion. En el Grupo NL de GII (n = 100) se encontro un IR en ninos referidos por pediatras mayor al de aquellos referidos por gastroenterologos (p = 0,002). Segun grupos NL y PT, todos los parametros pHmetricos resultaron significativos (p < 0,005), excepto la DPE. 84,9% y 77% de los MpHes en GI y GII, respectivamente fueron normales. Conclusion: Los indices de MpHe permiten separar los grupos NL y PT bajo los nuevos puntos de corte del IR. Existe escaso correlato entre sospecha clinica y diagnostico pHmetrico lo que sugiere la necesidad de reevaluar sus indicaciones clinicas

Actualización del tratamiento de la enfermedad inflamatoria intestinal en niños

Ulcerative colitis (UC) is an important disease of childhood because of its chronic character, high morbidity and its malignant potential. The objective of this study is to present an update of the treatment options in inflammatory bowel disease, especially ulcerative colitis, in children. This is a challenging issue, especially with the lack of controlled randomized trials in paedriatric patients. The accepted management of UC is with corticosteroids and aminosalicylates; while immunosupression with azathioprine or 6-mercaptopurine are useful for mantenance treatment. In severe or refractory UC, cyclosporine is a useful alternative, but only postpones colectomy. Despite favourable preliminary studies with infliximab, there still lacks evidence for its use in children with UC. We present the available evidence of the different medical treatments of UC and some reviews of the evidence in Crohn´s disease.

Clinical and morphological features of cholelithiasis in children

Background: The use of ultrasonography increased the frequency of diagnosis of cholelithiasis in childhood. Aim: To determine the clinical and laboratory features and follow up of children with biliary stones. Patients and methods: Twenty six children (13 male, aged 1 month to 14 years) were prospectively enrolled. Results: Nine children had a past medical history of factors potentially predisposing to stones. A clinical presentation with vomiting (50%), abdominal pain (46%) and jaundice (23%) was the most common indication for surgery. The diagnosis was based on abdominal ultrasound in all children. Cholecystectomy was performed in 15 children (laparoscopy in 13 and open surgery in 2). Children who underwent surgery were older than those who did not undergo surgery (p <0.001), but they did not have differences in liver function tests. Eight children had pigmented stones and seven had cholesterol stones. Conclusions: In our patients, neither family history nor laboratory tests were useful in the diagnosis as well as in the clinical decision of surgery, which was based on symptoms. The presence of cholesterol stones in a high proportion of these children may be a unique situation in Chile, considering the high prevalence of this disease in the adult population (Rev Med Chile 2003; 131: 37-45)

Una familia con síndrome de Peutz-Jeghers: a therapeutic approach

El sindrome de Peutz-Jeghers (SPJ) es una condicion autosomica dominante caracterizada por pigmentacion mucocutanea y poliposis gastrointestinal de tipo hamartomatoso. Con frecuencia causa intususcepcion y hemorragias intestinales, y se asocia a una mayor incidencia de cancer gastrointestinal y extraintestinal. El objetivo de este trabajo es reportar un caso de SPJ familiar, discutir la mutacion genetica asociada a este sindrome en el gen STKI 1 y comentar las pautas actuales de manejo, destacando entre ellas la posibilidad de tratamiento ambulatorio mediante la reseccion endoscopica de los polipos. Se plantea que los parientes de primer grado de un caso indice deben ser seguidos anualmente desde el nacimiento. Una vez realizado el diagnostico, el manejo debe ser agresivo, con remocion de los polipos mayores de 5 mm en el estomago y colon, y mayores de 15 mm en el intestino delgado. La pesquisa precoz de los polipos es importante por el mayor riesgo de cancer

Hipertension portal extrahepatica: Desconexion acigos-portal

The partial or complete obstruction of portal vein and or one of its branches is the most frequent cause of portal hypertension in children. A patient with extrahepatic portal hypertension and progressive course is presented, with great development of esophagogastric varices and multiple episodes of upper gastrointestinal hemorrhage. At the age of 9 years he was submitted to an azygos-portal disconnection by abdominal route, with manual transection of the esophagus, covered and protected by a gastric fundoplication. Postoperative endoscopic control demonstrated significant reduction in the size of esophageal varices and disappearance of gastric varices. Eleven months after surgery the patient was asymptomatic and a new endoscopic control showed no recurrence of varices.