Inci Nur Saltik

Bone mineral density in children with untreated and treated celiac disease.

Objectives Osteopenia is a common complication in adults with celiac disease. The effect of a gluten-free diet on bone mineral density is a matter of controversy. The aim of this study was to investigate bone mineral density in children with celiac disease at diagnosis and in patients treated for 1 year. Methods Bone mineral density and bone mineral content were measured in 34 children with untreated celiac disease at diagnosis and in 28 patients on a gluten-free diet for 1 year. The results were compared with those of 64 gender- and age-matched healthy control subjects. Serum calcium, phosphate, alkaline phosphatase, 25 -hydroxy vitamin D, and intact parathormone levels were determined in treated and untreated patients. Results The mean values of bone mineral density and bone mineral content of untreated patients with celiac were significantly lower than the control group (P = 0.006 and P = 0.005, respectively) and treated patients (P = 0.015 and P = 0.011 respectively). Treated patients had mean bone mineral density and bone mineral content values not significantly different from those of healthy control subjects. Minor hypocalcemia was detected in 17.6% of the patients with new diagnoses and 3.6% of the treated patients. Of the untreated patients, 29.4% had high intact parathormone concentrations; in untreated patients, the total was 14.3%. Untreated patients had significantly lower serum calcium and significantly higher intact parathormone levels than did treated patients. The other bone metabolism parameters were similar in the two celiac groups. Conclusion Children with celiac disease are at risk for reduced bone mineral density. A strict gluten-free diet improves bone mineralization, even in 1 year. Early diagnosis and treatment of celiac disease during childhood will protect the patient from osteoporosis.

Role of flumazenil for paradoxical reaction to midazolam during endoscopic procedures in children

1. Said M, Ledochowski M, Dietze O, et al. Colonoscopic diagnosis and treatment of acute appendicitis. Eur J Gastroenterol Hepatol 1995;7:569–71. 2. Minocha A. An endoscopic view of appendicitis. N Engl J Med 1998;339:1481. 3. Johnson TR, DeCosse JJ. Colonoscopic diagnosis of grumbling appendicitis. Lancet 1998;351:495. Reprint requests and correspondence:Akira Uehara, M.D., Ph.D., Department of Internal Medicine, Nakashibetsu Town Hospital, West 10, South 9, Nakashibetsu, Hokkaido 086-1110, Japan. Received May 2, 2000; accepted May 8, 2000.

Peptic Ulcer Disease in Children Without Helicobacter pylori Infection

W e read with interest the study by Elitsur and Lawrence [1], in which they investigated the prevalence of peptic ulcer disease in children who were Helicobacter pylori negative and nonsteroidal anti-inflammatory drugs (NSAIDs) negative. In this study a total of 622 upper endoscopic procedures was carried out and 11 [1.8%] of them had mucosal ulceration. Duodenal ulceration was detected in 10 and 3 [30%] were associated with H. pylori infection. They concluded that H. pylori infection and/or NSAIDs are not the major etiologic factors for the development of peptic ulcer disease in children in developed countries. We have also evaluated the frequency of H. pylori infection in children with duodenal/ gastric ulcer. During the period January 1999 to September 2001, a total of 324 children underwent upper gastrointestinal endoscopy. The presence of H. pylori was determined by culture, rapid urease test, and histology. The main symptoms of the patients were abdominal pain, vomiting, nausea and hematemesis. No patient had a history of NSAID using. Out of 324 children, eight [2.5%] patients had duodenal/gastric ulcer. Six patients (four boys; mean age, 12.8 ± 2.1 years; range, 9–15 years) were positive for H. pylori and two patients (one boy; mean age, 10.5 ± 0.7; range, 10–11 years) were negative. Five of seven [71%] children with duodenal ulcer were H. pylori positive. Three of them also had antral nodularity, whereas all five had gastritis. Two patients who had peptic ulcer and were H. pylori negative did not have associated gastritis. The only patient with gastric ulcer was also H. pylori positive with antral nodular gastritis. H. pylori infection in children is associated with gastritis and peptic ulcer disease [2]. It has been suggested as a major cause of peptic ulcer disease [3,4]. Prieto et al. [3] showed that 90.9% of patients with duodenal ulcer were H. pylori positive. Similarly, we found H. pylori positivity in 71% of the patients with duodenal ulcer. Our results indicate that H. pylori infection should be considered as the main cause of duodenal ulcer in children, especially, in developing countries with a higher prevalence of H. pylori infection. However, as H. pylori infection was not found in 29% of duodenal ulcers, other causes should be looked for.

Is There Any Relation Between Helicobacter pylori Infection and Iron Deficiency Anemia in Children with Celiac Disease

Celiac disease is a permanent gluten intolerance characterized by histopathologic abnormalities in the proximal intestine. It has a large spectrum of gastrointestinal and extra-intestinal manifestations. Iron deficiency anemia caused by malabsorption is common and may be the only presenting manifestation of celiac disease [1]. Helicobacter pylori infection in children is associated with gastritis and peptic ulcer disease [2]. It has been suggested that H. pylori infection may lead to iron deficiency anemia [3]. The mechanisms by which H. pylori infection can cause iron deficiency anemia are still unclear [4]. In this study, we wanted to investigate the association between H. pylori infection and iron deficiency anemia in patients with celiac disease. Thirty-six children (17 boys, 47%) with untreated celiac disease were evaluated. The mean age of the patients was 11.4 ± 3.1 years, ranging from 2 to 17 years. Diagnosis of celiac disease was made on the basis of the presence of positive anti-gliadin immunoglobulin A (IgA) and IgG antibodies, and anti-endomysium antibodies, and was confirmed by histological findings. The presence of H. pylori infection was determined by culture, rapid urease test (Dio-Helico; Diomed, Nürnberg, Germany), and histology. Iron deficiency anemia was defined as a hemoglobin concentration < 11.5 g/dl aged 2–12 years, < 12 g/dl in girls aged 12–18 years and < 13 g/dl in boys aged 12–18 years, in the presence of low serum iron levels (normal range, 22–184 μg/dl) and high iron-binding capacity (normal range, 250– 400 μg/dl) [5]. In the 36 children with celiac disease, 15 (42%) had H. pylori infection and 21 (58%) did not. Of the 15 H. pylori-positive patients, 7 (47%) had iron deficiency anemia while of the 21 H. pylorinegative patients, 10 (48%) showed iron deficiency anemia (p > .05) (Table 1). Mean values of hemoglobin concentrations were 10.7 ± 1.6 and 10.7 ± 2.1 in H. pylori-infected and noninfected children with celiac disease, respectively ( p > .05). In a recent study, a relation between H. pylori infection and iron deficiency anemia has been suggested in patients with celiac disease. However, iron deficiency anemia does not develop in all H. pyloriinfected patients [6]. We did not find any significant association between H. pylori infection and iron deficiency anemia in our patients with celiac disease. Our findings suggest that celiac disease itself plays a major role, rather than H. pylori infection, in the development of iron deficiency anemia.

Long-term prognosis of interferon nonresponder children with hepatitis B.

TO THE EDITOR: We read with interest the article by Mazzellaet al. (1) reporting long-term results in 64 adult patients with chronic hepatitis B (CHB). Patients were randomized into two groups; 33 of them received lymphoblastoida-interferon (IFN, 5 MU/m of body surface areat.i.w. for 6 months) and 31 were not treated. The two groups were prospectively followed for a mean of 86.4 6.9 and 79.76 6.8 months, respectively. IFNa was found to accelerate hepatitis B virus (HBV) DNA, HBeAg, and HBsAg clearance rates (78.9% vs 58.1%, 90.9% vs 61.2%, and 36.4%vs 9.8%, respectively) in treated patientsversus controls. Four treated patients (three of them nonresponders) and six controls developed cirrhosis at the end of follow-up. Among these patients with cirrhosis, one responder and two controls also developed hepatocellular carcinoma (HCC) after 60, 48, and 98 months of follow-up, respectively. We also want to report the follow-up findings with respect to long-term complications of CHB in children who have not responded to different protocols of IFNa therapy (5 or 10 MU/m of body surface area, s.c., t.i.w. for 24 or 48 wk). At the beginning of therapy, all 23 children (16 male, 69%) had abnormal or fluctuating transaminases for

Letter to the editorDiagnostic accuracy of 13C-urea breath test for Turkish children with Helicobacter pylori infection

6 months and were positive for serum HBeAg and HBVDNA. The mean age of the patients was 11.3 6 3 yr (median 11 yr, range 7–17). The patients were followed by periodic biochemical and serological tests; in addition, abdominal ultrasonography was performed for long-term complications of CHB such as cirrhosis, portal hypertension, and HCC, every year. At the end of therapy all patients were nonresponders and were followed for a mean of 54.3 6 12.3 months (median 50 months, range 46 –96). During this period, no physical or biochemical sign of cirrhosis, portal hypertension, or HCC was detected. Repeat ultrasonograms were all normal. Although the long-term prognosis of hepatitis B carrier children with normal liver enzymes is good (2), the data on the long-term results in IFN-nonresponder children with CHB are rare, especially with respect to complications. In the study by Mazzella et al., three of the IFN-nonresponders developed cirrhosis after a follow-up period of 7 yr. In our study, after 4.5 yr, we have not seen cirrhosis or other long-term complications in 23 IFNnonresponder children with CHB. Controversial data exist concerning a possible prophylactic effect of IFN against HCC in adult patients with chronic HBV hepatitis (3). Although larger controlled studies and longer follow-up is necessary, it may be speculated that CHB is relatively benign in IFN-nonresponder children, compared with adults.

Detection of Helicobacter pylori with stool antigen test in children with gastroesophageal reflux disease

Diagnostic Accuracy of 13 C-Urea Breath Test for Turkish Children With Helicobacter pylori Infection

Letter to the editorRole of flumazenil for paradoxical reaction to midazolam during endoscopic procedures in children

TO THE EDITOR: Gastroesophageal reflux disease (GERD) is a common problem in childhood and characterized by reflux of acidic gastric contents into the esophagus. Major pathophysiological factors for GERD include transient lower esophageal sphincter relaxation, decreased esophageal clearance, and delayed gastric emptying. Gastric acid hypersecretion has also been found in refractory GERD (1). The relationship between Helicobacter pyloriand GERD is not fully understood. It has been shown that there is an inverse correlation and H. pylori may have a protective role against GERD. Ammonia, a powerful neutralizing substance, and hypochlorhydria caused by severe corpus gastritis have been accepted as potential protective mechanisms (2–4). It has also been reported that GERD incidence increased after eradication of H. pylori infection (5). In this study, we wanted to determine the prevalence of H. pylori infection in patients with GERD. A total of 15 patients with GERD (eight boys, 53.3%), 1–8 yr of age (mean 3.3 6 2.5) were included. Diagnosis of GERD was established by 24-h esophageal pH monitoring. The patients had no symptoms of gastritis, and the most common symptoms were vomiting in 13 patients (86.7%), chronic cough in seven (46.7%), and wheezing in two (13.3%). The presence of H. pylori was defined by theH. pylori stool antigen test with a commercial kit (Premier Platinum, Meridian Diagnostics, Cincinnati, OH) using ELISA. The H. pylori stool antigen test is a noninvasive, simple, and fast method, especially in young patients, and has a sensitivity and specificity ranging from 93% to 100% (6, 7). Of the 15 patients, H. pylori was positive in one (6.7%). In our study, the prevalence of H. pylori infection was low, similar to other studies in which the prevalence has been found to be 8–16% (8, 9). Larger controlled studies need to be performed to examine the possible relationship between H. pylori infection and GERD.

Subnormal growth in children with Helicobacter pylori infection

Role of flumazenil for paradoxical reaction to midazolam during endoscopic procedures in children