h Kooros

Evaluation, Diagnosis, and Treatment of Gastrointestinal Disorders in Individuals With ASDs: A Consensus Report

Autism spectrum disorders (ASDs) are common and clinically heterogeneous neurodevelopmental disorders. Gastrointestinal disorders and associated symptoms are commonly reported in individuals with ASDs, but key issues such as the prevalence and best treatment of these conditions are incompletely understood. A central difficulty in recognizing and characterizing gastrointestinal dysfunction with ASDs is the communication difficulties experienced by many affected individuals. A multidisciplinary panel reviewed the medical literature with the aim of generating evidence-based recommendations for diagnostic evaluation and management of gastrointestinal problems in this patient population. The panel concluded that evidence-based recommendations are not yet available. The consensus expert opinion of the panel was that individuals with ASDs deserve the same thoroughness and standard of care in the diagnostic workup and treatment of gastrointestinal concerns as should occur for patients without ASDs. Care providers should be aware that problem behavior in patients with ASDs may be the primary or sole symptom of the underlying medical condition, including some gastrointestinal disorders. For these patients, integration of behavioral and medical care may be most beneficial. Priorities for future research are identified to advance our understanding and management of gastrointestinal disorders in persons with ASDs.

Recommendations for Evaluation and Treatment of Common Gastrointestinal Problems in Children With ASDs

Children with autism spectrum disorders (ASDs) can benefit from adaptation of general pediatric guidelines for the diagnostic evaluation of abdominal pain, chronic constipation, and gastroesophageal reflux disease. These guidelines help health care providers determine when gastrointestinal symptoms are self-limited and when evaluation beyond a thorough medical history and physical examination should be considered. Children with ASDs who have gastrointestinal disorders may present with behavioral manifestations. Diagnostic and treatment recommendations for the general pediatric population are useful to consider until the development of evidence-based guidelines specifically for patients with ASDs. Pediatrics 2010;125:S19-S29

Management of Constipation in Children and Adolescents With Autism Spectrum Disorders

OBJECTIVES To develop a practical, readily applied algorithm for primary health care providers to identify, evaluate, and manage constipation in children with autism spectrum disorders (ASDs). METHODS The Gastroenterology Committee of the Autism Speaks Autism Treatment Network (ATN), a multisite consortium of centers dedicated to improving standards of medical care for children with ASDs, guided the development of the constipation algorithm through expert opinion and literature review. The algorithm was finalized based on results of field testing by nongastrointestinal, ATN autism medical specialists at 4 ATN sites. A systematic review and grading of the literature pertaining to constipation and children with ASDs was also performed. RESULTS Consensus among the ATN Gastroenterology Committee identified that in children with ASDs, (1) subtle or atypical symptoms might indicate the presence of constipation; (2) screening, identification, and treatment through a deliberate approach for underlying causes of constipation is appropriate; (3) diagnostic-therapeutic intervention can be provided when constipation is documented; and (4) careful follow-up after any intervention be performed to evaluate effectiveness and tolerance of the therapy. Literature review revealed limited evidence for the clinical evaluation or treatment strategies of children with ASD and constipation. CONCLUSIONS Constipation and its underlying etiology have the potential to be effectively identified and managed using a systematic approach. Lack of evidence on this topic in the literature emphasizes the need for research.

Infliximab therapy in pediatric Crohn's pouchitis

Objective:We describe the prolonged clinical benefit of murine chimeric antitumor necrosis factor (TNF)–alpha monoclonal antibody, infliximab, on pediatric patients with Crohns disease and ileal pouch anal anastomosis (IPAA). Methods:A retrospective review of patients originally diagnosed with ulcerative colitis, status post colectomy and IPAA, who developed findings compatible with Crohns disease was undertaken. Refractory pouchitis developed in all patients as well as protracted symptoms of diarrhea, abdominal pain, joint pain, and incontinence. All patients received infliximab. Results:Four pediatric patients (2 males and 2 females) with mean age of 14.5 years (range 11–18 years) were studied. The development of perianal fistulas in 2 patients, granuloma on biopsy in 1 patient and perianal skin tag in 1 patient, led to a diagnosis change of CD. After failure to respond to antibiotics, aminosalicylates and immunomodulators such as azathioprine and 6-mercaptopurine (6-MP), all patients were treated with infliximab. Patients received infliximab infusions at a dose of 5 mg/kg, initially at weeks 0, 2 and 6 and subsequently at 8 weeks intervals in combination with an immunomodulator drug. All patients showed marked improvement clinically, endoscopically, and histologically. Conclusion:Infliximab can be used successfully for the treatment of pediatric patients with Crohns disease and IPAA who are refractory to conventional therapies.

A Report of Two Children with Helicobacter heilmannii Gastritis and Review of the Literature

An 11-year-old boy with epigastric abdominal pain and a 2 year-old girl with failure to thrive underwent esophagogastroduodenoscopy. Endoscopic biopsies from the gastric antrum of both children revealed corkscrew-like spiral bacteria, consistent with the diagnosis of Helicobacter heilmannii infection. H. heilmannii is a rare finding in children and is thought to be present in approximately 0.3% of patients undergoing upper endoscopy. Clinical presentation, gross and histologic appearance, and treatment regimens are discussed. The clinical and histologic features of previously reported cases of H. heilmannii gastritis in children living in the United States are reviewed in table form.

NASPGHAN Capsule Endoscopy Clinical Report

Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.

Acute Abdominal Pain in a Teenager With Anorexia Nervosa

Question: A 14-year-old female competitive figure skater presents with moderate epigastric and bilateral lower quadrant pain for day. Before the onset of pain, she had intermittent nausea, emesis, and diarrhea in the prior 2 weeks, as well as unintended 19-lb eight loss. The patient noted a collision with another skater 6 months ago, but denied any blunt abdominal trauma. On exam, she ad normal vital signs, weight at 35.15 kg (Below the 3rd percentile), height of 160 cm (25th–50th percentile), and a body mass index f 13.73 kg/m2. Her abdominal examination was significant for a non-distended, but tender right upper and lower left quadrant bdomen with guarding. She had normal serum chemistries, complete blood count, and coagulation studies. Additional laboratory tudies, including liver function tests, lipase, alpha-fetoprotein, and human chorionic gonadotropin markers, were all within normal imits. Only abnormal value found was her albumin level of 2.5 g/dL. Computed tomography (CT) showed large abdominal mass n the wall of second and third portion of the duodenum, with obstruction of the proximal duodenum (Figure A). Upper endoscopy howed obstructive mass at the second portion of duodenum (Figure B). Magnetic resonance imaging showed an obstructive mass rising from the wall of the duodenum causing dilatation of the second and third portions of the duodenum (Figure C). Endoscopic ltrasonography showed that this mass had its own muscle and mucosal layer, with some fluid within the lesion. During the atient’s hospital stay, she was also evaluated for a severe eating disorder with impulsive exercise habits, deeming psychiatric valuation. What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.