Jaya Punati

Effect of early immunomodulator use in moderate to severe pediatric Crohn disease

Background: The immunomodulators (IMs) 6‐mercaptopurine and azathioprine decrease corticosteroid dependence and maintain remission in Crohns disease (CD). We describe IM use in newly diagnosed pediatric CD, comparing outcomes of “early” versus “late” initiation of therapy. Methods: Data were obtained from pediatric CD patients enrolled in a prospective, multicenter observational study. Moderate/severe disease patients treated with IM were compared for outcomes of remission, corticosteroid use, infliximab therapy, hospitalizations, and CD‐related surgery based on timing of initiation of IM therapy. Results: In all, 247 children met the criteria (60% male, mean age 11.9 years); 199 were treated with IM within 1 year of diagnosis; 150 between 0–3 months (early), 49 between 3–12 months (late). Both groups showed a decrease in corticosteroid use by 12 months, at which time proportionately fewer early group patients had received corticosteroids in the preceding quarter (22%) than late groups patients (41%)(P = 0.013). The number of hospitalizations per patient was also noted to be significantly lower in the early group over the 2‐year follow‐up (P = 0.03). No difference was noted in the rates of remission, infliximab use over time, or surgery. Conclusions: 80% of children with newly diagnosed moderate to severe CD are treated with IM within 1 year. Early IM use is associated with reduced corticosteroid exposure and possibly fewer hospitalizations per patient.

Ten-Year Experience Using Antegrade Enemas in Children

OBJECTIVE To describe a single-center, 10-year experience with the use of antegrade enemas. STUDY DESIGN Retrospective analysis of 99 patients treated with antegrade enemas at Nationwide Childrens Hospital. RESULTS Study subjects (median age 8 years) were followed for a mean time of 46 months (range 2-125 months) after cecostomy placement. Seventy-one patients had the cecostomy placed percutaneously and 28 by surgery. Thirty-five patients had functional constipation and 64 patients an organic disease (spinal abnormalities, cerebral palsy, imperforate anus, Hirschsprungs disease). While using antegrade enemas, 71% became symptom-free, in 20 subjects symptoms improved, in 2 subjects symptoms did not change, and in 7 subjects symptoms worsened. Poor outcome was associated with surgical placement of the cecostomy (P < .001), younger age (P = .02), shorter duration of symptoms (P = .01), history of Hirschsprungs disease (P = .05), cerebral palsy (P = .03), previous abdominal surgery (P = .001), and abnormal colonic manometry (P = .004). In 88%, successful irrigation solution included use of a stimulant laxative, and subjects who used a stimulant did significantly better (P < .001) than subjects who started without a stimulant. In 13 patients, the cecostomy was removed 49.7 months after placement without recurrence of symptoms. Major complications occurred in 12 patients and minor complications in 47. CONCLUSIONS Antegrade enemas represent a successful and relatively safe therapeutic option in children with severe defecatory disorders. Prognostic factors are identified.

Efficacy of permanent gastric electrical stimulation for the treatment of gastroparesis and functional dyspepsia in children and adolescents.

PURPOSE Permanent gastric electrical stimulation (GES) has been performed in adults as a treatment for gastroparesis and refractory nausea and vomiting in patients who have failed medical therapy. We assessed the feasibility and clinical outcomes of permanent GES in children. METHODS Permanent GES was performed in 16 children (10 females/6 males), median age 15 years (range 4-19 years). All patients had chronic nausea and vomiting refractory to medical therapy and met ROME III criteria for functional dyspepsia. Symptoms, route for nutrition, and satisfaction with procedure were recorded before and after permanent GES. Statistical analysis was performed using paired Students t test. RESULTS After permanent GES, there was significant improvement in severity of vomiting (p=0.0001), frequency of vomiting (p=0.0003), frequency of nausea (p<0.0001), and severity of nausea (p<0.0001). At the time of follow-up, 13/16 were on oral feeds exclusively, two patients on oral plus G-tube feedings, and one patient on oral plus G-tube plus intermittent TPN. CONCLUSIONS 1). Permanent GES improved health in children with functional dyspepsia and gastroparesis who fail medical therapy. 2). No serious adverse effects of permanent GES were noted. 3). Long-term efficacy and safety of GES therapy in children need to be established.

Effect of amoxicillin/clavulanate on gastrointestinal motility in children.

Aim: The aim of the present study was to evaluate the effect of amoxicillin/clavulanate (A/C) on gastrointestinal motility. Methods: Twenty consecutive pediatric patients referred for antroduodenal manometry received 20 mg/kg of A/C into the small bowel lumen. In 10 patients (group A), A/C was given 1 hour after and in 10 (group B), 1 hour before ingestion of a meal. Characteristics of the migrating motor complex, including presence, frequency, amplitude, and propagation of duodenal phase III and phase I duration and phase II motility index (MI), were evaluated 30 minutes before and after A/C administration. Results: There were no statistically significant differences in age and sex between the 2 groups. Manometry studies were considered normal in 8 patients in each group. In group A, 2 patients developed duodenal phase III after receiving A/C, and no significant difference was found in the MI before and after the drug administration. In group B, 9 patients developed duodenal phase III (P < 0.05 vs group A). All phase III occurred within a few minutes from the medication administration. Most duodenal phase III contractions were preceded by an antral component during fasting but never after the medication was administered in either of the 2 groups (P < 0.001 vs fasting). In group B, the duration of duodenal phase I was shorter after drug administration (P < 0.05). There was no significant difference in duodenal phase II MI before and after A/C administration for the 2 study groups. Conclusions: In children, administration of A/C directly into the small bowel before a meal induces phase III-type contractions in the duodenum, with characteristics similar to those present in the fasting state. These data suggest the possible use of A/C as a prokinetic agent. Further studies are needed to clarify its specific mechanism of action and the group of patients most likely to benefit from its use.

Practice patterns of pediatricians and trainees for the management of functional constipation compared with 2006 NASPGHAN guidelines.

Objectives: The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition has formulated guidelines for managing functional constipation. There have been no studies that have investigated how pediatricians apply the constipation guideline since it was revised in 2006. The purpose of this study was to examine how pediatricians approach functional constipation and how closely their approaches adhere to the guidelines. Methods: An anonymous multiple-choice questionnaire was developed by general pediatricians and pediatric gastroenterologists. This was distributed to pediatricians and pediatric residents at 7 academic institutions, and to the American Academy of Pediatrics section on medical students, residents, and fellowship trainees mailing list. Results: A total of 1202 responses were received (952 trainees, 250 attendings). Of these, 84.3% reported being unfamiliar/slightly familiar with the guidelines. The most common initial interventions for constipation without fecal incontinence included fluids (92.1%), fiber (89.5%), juice (77.7%), behavioral interventions (71.2%), follow-up (53.4%), and reducing constipating foods (50.1%). The most common initial interventions for constipation with fecal incontinence included bowel cleanout (73.4%), maintenance medication (70.0%), fluids (67.9%), behavioral interventions (67.6%), fiber (66.1%), and follow-up (57.8%). Osmotics were the most commonly prescribed as needed (83.0%) and maintenance medications (96.8%), with stimulants prescribed PRN by 35.6% and as maintenance by 16.8%. Some individuals (39.7%) reported concern that osmotics could result in dependence, addiction, or electrolyte imbalances, compared with 73.0% for stimulants. Conclusions: Our results show that more education regarding medication in functional constipation is necessary, including the use of medication reducing time to remission, the necessity of disimpaction, and misconceptions regarding adverse effects.

Colonic manometry and colonic scintigraphy as a diagnostic tool for children with severe constipation.

Objective: In adults, colonic manometry and colonic scintigraphy are both valuable studies in discriminating normal and abnormal colonic motility. The objective of this study was to compare the diagnostic yield and tolerability of colonic manometry and colonic scintigraphy in children with severe constipation. Methods: Twenty-six children (mean age 11.4 years, 77% boys) who had received colonic manometry and colonic scintigraphy as part of a colonic motility evaluation were included. Manometry was performed as per department protocol. After swallowing a methacrylate-coated capsule containing indium-111, images were taken at 4, 24, and 48 hours, and geometric centers were calculated. Results of both tests were categorized in 3 groups: normal, abnormal function in the distal part of the colon, and colonic inertia. Cohen &kgr; was used for the level of agreement. Patients and parents completed a questionnaire regarding their experience. Results: Colonic scintigraphy showed normal transit time in 20%, delay in the distal colon in 48%, and colonic inertia in 32% of patients. Colonic manometry was normal in 40%, abnormal in the distal colon in 40%, and colonic inertia was diagnosed in 20%. The &kgr; score was 0.34. All 5 patients with colonic inertia during manometry had a similar result by scintigraphy. Eighty-eight percent of patients preferred scintigraphy over manometry and 28% of parents preferred colonic manometry over scintigraphy. Conclusions: Colonic manometry and colonic scintigraphy have a fair agreement regarding the categorization of constipation. Scintigraphy is well tolerated in pediatric patients and may be a useful tool in the evaluation of children with severe constipation.

Congenital absence of the muscularis propria mimicking Crohn disease.

A 16-year-old girl presented with an 8-hour history of sharp, right lower quadrant abdominal pain and a temperature of 1038F. She had a history of similar pain with a urinary tract infection that resolved. She also had self-diagnosed lactose intolerance and iron deficiency anemia at 11 years of age that resolved with iron supplementation. A paternal uncle had Crohn disease, and a paternal aunt had celiac disease. The patient was at the 50th percentile for weight. On physical examination, she was in moderate distress from pain. Abdominal guarding, distention, and rebound tenderness were noted. Laboratory studies showed an elevated leukocyte count of 17,000 cells per microliter with 84% neutrophils and 5% bands. Otherwise, the results of blood work and urinalysis were normal. An abdominal radiograph was suggestive of subdiaphragmatic free air. Computed tomography confirmed free air and a noninflamed appendix. Emergency laparotomy was performed. A small bowel to small bowel fistula, 10 to 15 cm proximal to the terminal ileum, was found. Creeping fat was noted, a gross finding compatible with mesenteric adipose tissue hypertrophy and a recognized feature of Crohn disease (4–6). As such, the surgical impression was acute presentation of Crohn