Lori Mahajan

Incidence of Dysplasia in Pelvic Pouches in Pediatric Patients After Ileal Pouch-anal Anastomosis for Ulcerative Colitis

BACKGROUND The purpose of this study was to evaluate the incidence of dysplasia and the mucosal adaptation patterns of pelvic pouches in children and adolescents who had undergone ileal pouch-anal anastomosis for ulcerative colitis. METHODS Between 1982 and 1996, 176 pediatric patients with ulcerative colitis underwent ilial pouch-anal anastomosis. Seventy-six patients were followed up after surgery at the Cleveland Clinic. Pouch biopsy specimens were reviewed for dysplasia and to determine mucosal adaptation patterns. Fifty-eight of the 76 patients had an average of three mucosal biopsies during a mean follow-up of 5 years. Demographic and surgical data were abstracted from archives of medical records. All previously obtained pouch biopsy specimens were re-evaluated by a single pathologist to ensure standardized interpretation. RESULTS No dysplasia was identified in screening specimens of 76 children and adolescents including 5 patients who showed dysplasia in resected colon specimens. The pattern of mucosal adaptation was categorized using previously reported criteria. Type A was defined as normal mucosa or mild villous atrophy with no or mild inflammation. Type B mucosa showed transient atrophy with temporary moderate inflammation followed by normalization of architecture. Type C mucosa was defined as a pattern of persistent atrophy with severe inflammation. In the study cohort, the patterns of mucosal adaptation, type A (56.9%; n = 33), type B (32.8%; n = 19), and type C (10.3%; n = 6), were comparable with those reported in adults. The rate of pouch failure and diagnosis of Crohns disease were similar in each group and were not related to the specific adaptation pattern. Most of the patients with type C mucosa had clinical symptoms of pouchitis requiring periodic antibiotic therapy. No dysplasia was identified in any biopsy specimen reviewed. CONCLUSIONS Similar morphologic changes can be seen in ileal pouches in pediatric and adult patients. There seemed to be no increased risk of dysplasia in children and young adults who had undergone ilial pouch-anal anastomosis surgery for ulcerative colitis during a 5 year follow-up. Because the long-term risk of development of dysplasia is unknown, an initial screening should be performed 5 years after the creation of a pelvic pouch in children or when the total disease duration exceeds 7 years. Once identified, patients with Type C mucosa should have annual screening for dysplasia until further data become available.

Risk of capsule endoscope retention in pediatric patients: a large single-center experience and review of the literature.

Objectives: Capsule retention is a potential complication of capsule endoscopy (CE). The aims of our study were to determine the incidence of capsule retention in pediatric patients undergoing CE and to identify potential risk factors for capsule retention. Materials and Methods: We performed an institutional review board–approved retrospective chart review of pediatric patients undergoing CE studies at a single center. Data collected included patient age, sex, prior diagnosis of inflammatory bowel disease (IBD), CE indication, prior small bowel series results, study result, and complications. Results: Two hundred seven CE procedures were performed in pediatric patients during the study period. Capsule retention occurred in 3 (1.4%) of the 207 studies. All 3 patients had known Crohn disease (CD). The risk of capsule retention in pediatric patients with known IBD was 5.2% (3/58). The risk of capsule retention for patients with suspected IBD and all other indications was 0%. If small bowel disease was identified on upper gastrointestinal series in patients with known CD, then the risk of capsule retention was 37.5% (3/8). Only 7 patients with known IBD had a body mass index (BMI) below the 5th percentile. Of these 7 patients, 3 (43%) had capsule retention. Conclusions: Red flags for potential CE retention identified in our study include known IBD (5.2% retention risk), previous small bowel follow-through demonstrating small bowel CD (37.5% retention risk), and BMI <5th percentile with known IBD (43% retention risk). Caution is advised in these pediatric patients before capsule ingestion.

Recent advances in chronic constipation.

Purpose of review Chronic constipation remains one of the most frequent complaints in primary and subspecialty pediatric clinics. It is associated with significant emotional and economic burden for both the children and the caregivers. Recently, advances have expanded our understanding of the pathophysiology and treatment options for children with chronic constipation. Here, we review current strategies addressing the cause, diagnostic technologies and treatments of chronic constipation. Recent findings There is some new information presented here on techniques for diagnosis and long-term complications associated with chronic childhood constipation. Comparative data on current laxatives and the development of medications with novel mechanisms of action are reviewed for a glimpse into the horizon of possible new treatments for children with chronic constipation. Studies on effects of growth, quality of life, dietary fiber and symptoms, which may coexist with constipation, are discussed. Summary The recent literature on chronic constipation has provided some new knowledge providing a more evidence-based approach to treating these patients. We review the scope of this problem and the estimated cost of treating constipation. The availability of long-term outcome data enhances our understanding of the natural history of this problem. Newer pharmacological approaches provide optimism for treatment for this common problem.

Metabolomic analysis of breath volatile organic compounds reveals unique breathprints in children with inflammatory bowel disease: a pilot study.

Breath testing is becoming an important diagnostic method to evaluate many disease states. In the light of rising healthcare costs, is important to develop a simple non‐invasive tool to potentially identify paediatric patients who need endoscopy for suspected inflammatory bowel disease (IBD).

Endoscopic deployment of the wireless capsule using a capsule delivery device in pediatric patients: a case series.

The aim of this study was to review the use of the AdvanCE capsule endoscopy delivery device (US Endoscopy, Mentor, Ohio, USA) in pediatric patients who are too young to safely follow the wireless capsule swallowing instructions. Nine patients (mean age 6.6 years; SD +/- 1.8 years) underwent capsule deployment. Indications for the procedure were the evaluation of suspected inflammatory bowel disease in eight patients and evaluation of protein-losing enteropathy in one patient. The capsule was successfully deployed in the first part of the duodenum in seven patients and in the pyloric canal in one patient. In another patient the capsule was deployed in the gastric antrum and required endoscopic retrieval due to abdominal pain and failure of the capsule to traverse the pylorus. The wireless capsule successfully passed in the remaining eight patients without any complications. The AdvanCE capsule endoscopy delivery device appears to be a safe and technically easy method of wireless capsule delivery in pediatric patients. Capsule deployment should be in the duodenum whenever possible. Further studies of the use of this device in pediatric patients are warranted.

Long-term follow up of ileal pouch anal anastomosis in a large cohort of pediatric and young adult patients with ulcerative colitis

AIM The studys aim is to determine long-term outcomes in a large cohort of pediatric and young adult patients who underwent proctocolectomy with ileal pouch anal anastomsis (IPAA) for ulcerative colitis (UC). METHODS Patients diagnosed with UC in childhood or adolescence (age≤21years) who underwent IPAA in childhood, adolescence, or young adulthood between 1982 and 1997 were contacted to determine pouch history, complications, and quality of life. RESULTS Data were obtained from 74 patients out of a previously reported cohort. Median age at diagnosis of UC was 15years and at surgery was 18years. Median follow-up was 20years. Complications during follow-up were pouchitis (45%), strictures (16%), fistulae (30%), obstruction (20%), and change of diagnosis to Crohns (28%). Twenty-three percent reported no complications. Fourteen percent had pouch failure, with Crohns and fistulae reported to be the most frequent complications. Seventy-nine percent reported being very satisfied at 20years follow-up. CONCLUSION To our knowledge, this study represents the largest cohort with the longest follow-up of pediatric and young adult patients undergoing IPAA for UC. Change in diagnosis to Crohns and development of fistulae are risk factors for pouch failure. Despite reported complications, IPAA remains an excellent option for pediatric patients with UC.

Tolerability, Safety, and Efficacy of Peg 3350 as a 1-day Bowel Preparation in Children

Objective: The aim of the study was to evaluate the tolerability, safety, and efficacy of polyethylene glycol (PEG) 3350 without electrolytes as a 1-day bowel preparation for colonoscopy in children. Methods: A prospective study of 45 children undergoing colonoscopy prescribed PEG 3350 without electrolytes mixed with a commercial electrolyte beverage was performed. Patients <45 kg received 136 g of PEG 3350 without electrolytes mixed in 32 ounces of Gatorade. Patients ≥45 kg were given 255 g of PEG 3350 without electrolytes in 64 ounces of Gatorade. A basic metabolic panel was performed at the time of the clinic visit and just before colonoscopy. Patients completed a survey related to bowel preparation. Endoscopists graded bowel preparation and noted the proximal extent of the examination. Results: A total of 44 patients (14 ± 3 years) completed the study. One patient was excluded due to protocol breach. All subjects reported the preparation was easy (61%) or tolerable (39%). Adverse events included nausea (34%), abdominal pain (23%), vomiting (16%), abdominal distension (20%), bloating (23%), and dizziness (7%). Although significant changes in serum glucose and CO2 were noted, no therapeutic interventions were indicated. Significant changes in sodium, potassium chloride, blood urea nitrogen, or creatinine did not occur. Colonic preparation was rated as excellent in 23%, good in 52%, fair in 23%, and poor in 2% of patients. Intubation of the ileum was successful in 100%. Conclusions: One-day bowel preparation with high dose PEG 3350 mixed with commercial electrolyte solution is tolerable, safe, and effective in children before colonoscopy.

Endoscopic closure of esophagobronchial fistula with fibrin glue.

Operative repair of primary and recurrent tracheoesophageal fistula (TEF) is associated with a high rate of failure and postoperative complications (1–10). Surgical division and closure of recurrent fistulas may be difficult or unsuccessful because of dense adhesions or poor blood supply to the ends of the fistula (1). The first successful bronchoscopic fistula closure using a tissue adhesive was reported in 1975. Subsequently, a variety of obliterating agents have been used (3,11). Histoacryl cement (n-butyl-2-cyanoacrylate), aethoxysclerol, and 30% NaCl have been used in addition to fibrin glue alone or in combination, with mixed results (1–4). Endoscopic diathermy has also been used but typically requires multiple sessions (4,5). We report the successful closure of a recurrent esophagobronchial fistula with fibrin glue in a pediatric patient during simultaneous endoscopy and bronchoscopy. To our knowledge, this technique has not been reported previously in pediatric patients.

Fecal microbiota transplantation in the treatment of refractory Clostridium difficile infection in children: an update.

Purpose of review The use of transplanted fecal material for the treatment of diarrheal illness dates back to the fourth-century China. While fecal microbiota transplant has gained increasing popularity over the past 50 years for the treatment of refractory Clostridium difficile infections (RCDIs) in adults, it has only been recently utilized in children. The purpose of this article is to review the use of fecal microbiota transplant (FMT) in the treatment of pediatric RCDIs. Recent findings Minimal pediatric data, including few case reports and series, document the successful use of FMT for treatment of RCDI in the past 2 years. Patients in these reports included otherwise healthy children, those with inflammatory bowel disease as well as significantly immunocompromised children. Donor fecal infusion via nasogastric tube, gastroscope or colonoscope in children aged 16 months and older demonstrated a high rate of symptom resolution and organism eradication. No complications to date have been reported in children who have undergone FMT. Summary FMT is emerging as a well-tolerated and effective treatment for RCDI in not only adults but also children.

Low-dose naltrexone for treatment of duodenal Crohn's disease in a pediatric patient.

To the Editor: Naltrexone is an opioid receptor antagonist used as an opiate antidote. It acts as a competitive antagonist at several opioid receptor sites, showing the highest affinity for mu receptors. Studies have shown that opioids have immunomodulatory activity, including modulation of the inflammatory response and healing and repair of tissues. Short-term blockade of opioid receptors has been shown to lead to increased endogenous levels of opioids, which is the basis for naltrexone use in Crohn’s disease (CD). The presumption is that high levels of opioid receptor antagonism would lead to a complete block of the receptors and prohibit the effect of the endogenous opioids. Hence, low-dose naltrexone (LDN) therapy has been used in a study of adult patients with CD. This study demonstrated the effectiveness and safety of LDN therapy in subjects with moderate to severe CD. We describe the first case of treating CD with LDN in a pediatric patient.