M.T. Illiceto

Natural history of pancreatic involvement in paediatric inflammatory bowel disease.

BACKGROUND Few case reports describe the clinical features of pancreatic involvement in inflammatory bowel disease. AIM To investigate prevalence and disease course of inflammatory bowel disease children with pancreatitis and with exclusive hyperamylasemia and hyperlipasemia. METHODS We used a web-registry to retrospectively identify paediatric inflammatory bowel disease patients with hyperamylasemia and hyperlipasemia. Participants were re-evaluated at 6 months and 1 year. RESULTS From a total of 649 paediatric patients, we found 27 with hyperamylasemia and hyperlipasemia (4.1%). Eleven patients (1.6%) fulfilled diagnostic criteria for acute pancreatitis. Female gender was significantly associated with acute pancreatitis (p=0.04). Twenty-five children (92.5%) had colonic disease. At 6 months 1/11 children with acute pancreatitis (9%) showed acute recurrent pancreatitis, while 1 patient (9%) had persistent hyperamylasemia and hyperlipasemia. At 12 months, 1 patient showed chronic pancreatitis (9.1%). Of the 16 children with exclusive hyperamylasemia and hyperlipasemia, 4 developed acute pancreatitis (25%), while 1 patient (6.2%) still presented exclusive hyperamylasemia and hyperlipasemia at 6 months. At 12 months, 11/16 patients (68.7%) reached a remission of pancreatic involvement, whereas 5 remaining patients (32.3%) had persistent hyperamylasemia and hyperlipasemia. CONCLUSIONS In inflammatory bowel disease children, acute pancreatitis is more common in colonic disease and in female gender. Pancreatic function should be monitored, considering that pancreatic damage may evolve.

Clinical features and risk factors of autoimmune liver involvement in pediatric inflammatory bowel disease

Objectives: Autoimmune liver disease is reported in up to 7.8% of children with inflammatory bowel disease. A distinct inflammatory bowel disease phenotype has been suggested in adults and in small pediatric cohorts. The aim of the study was to evaluate the features of inflammatory bowel disease associated with autoimmune liver diseases and to analyze the characteristics of the liver disease. Methods: Information on patients was obtained from the Italian Pediatric Inflammatory Bowel Disease Registry. Data of patients with and without autoimmune liver disease were compared. Results: Autoimmune liver disease was detected in 6.8% of the 677 patients enrolled and was significantly associated with the diagnosis of ulcerative colitis (83%), with pancolonic involvement (84%), and with perinuclear antineutrophil cytoplasmic antibody positivity (41%) (all Ps < 0.05). Autoimmune liver disease was defined as sclerosing cholangitis in 61% of the patients and as an overlap syndrome in 33%. Concomitant intra- and extrahepatic biliary involvement was reported in 61% of cases, whereas exclusive extrahepatic lesions were reported in 21%. Hepatobiliary complications were observed in 9% of the patients during follow-up. Conclusions: Autoimmune liver disease, especially sclerosing cholangitis, was significantly more common in patients with extensive ulcerative colitis. Although complications are relatively rare in the pediatric age, monitoring is recommended.

Effect of Early Versus Late Azathioprine Therapy in Pediatric Ulcerative Colitis

Background:We aimed at describing the efficacy of azathioprine (AZA) in pediatric ulcerative colitis, comparing the outcomes of early (0–6 months) versus late (6–24 months) initiation of therapy. Methods:Children with ulcerative colitis treated with AZA within 24 months of diagnosis were included. Corticosteroid (CS)-free remission and mucosal healing (MH), assessed by endoscopy or fecal calprotectin, at 12 months were the primary outcomes. Patients were also compared for CS-free remission and MH, need for treatment escalation or surgery, number of hospitalizations, and adverse events during a 24-month follow-up. Results:A total of 121 children entered the study (median age 10.5 ± 4.0 years, 59% girls). Seventy-six (63%) started AZA between 0 and 6 months (early group) and 45 (37%) started between 6 and 24 months (late group). Seventy-five percent and 53% of patients in the early and late group, respectively, received CS at the diagnosis (P = 0.01). CS-free remission at 1 year was achieved by 30 (50%) of the early and 23 (57%) of the late patients (P = 0.54). MH occurred in 37 (37%) patients at 1 year, with no difference between the 2 groups (33% early, 42% late; P = 0.56). No difference was found for the other outcomes. Conclusions:Introduction of AZA within 6 months of diagnosis seems not more effective than later treatment to achieve CS-free remission in pediatric ulcerative colitis. MH does not depend on the timing of AZA initiation; however, because of the incomplete comparability of the 2 groups at the diagnosis and the use of fecal calprotectin as a surrogate marker of MH, our results should be further confirmed by prospective studies.

Equipment in Pediatric Endoscopy

With the development of a sub-specialty focused on pediatric gastrointestinal disorders, new technologies such as pediatric endoscopy were developed for diagnostic and therapeutic aims. Current endoscopic technology permits safe visualization, tissue sampling, and therapeutic procedures. Outer tip and working channel diameters have the greatest importance in the selection of an endoscope for the smaller children. The use of a smaller endoscope could represent the limiting element for the use of accessories, which are needed primarily for therapeutic purposes. Gastroscopes with outer diameters ranging from 4.9 to 12.8 mm are at present available, and colonoscopes range from 9.8 to 13.3 mm. Working channel diameters range from 1.5 mm of the slimmest instruments up to 4.2 mm of the largest adult therapeutic endoscopes. In 2017, the European Society of Gastrointestinal Endoscopy (ESGE) and European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) published the executive summary of the Guideline on pediatric gastrointestinal endoscopy that refers to infants, children, and adolescents aged 0–18 years.

Early “surgical” life events and functional gastrointestinal disorders (FGID): Pyloric stenosis vs. inguinal hernia

of the mother. Any sign/symptom was recorded weekly for the first three months of life, together with type of feeding. Statistical analysis (SPSS software): chi quadro test, Student t-test, linear regression. Results: 37 (32.7%) newborns were exclusively breast feeding. 16 (14.2%) newborns had regurgitation, 10 (9.7%) colics, 4 (3.5%) dischezia and 10 (9.7%) constipation. 60 (53.1%) mothers had postpartum depression and/or anxiety. 53.6% of infants with regurgitations had a depressed mother vs 23% of infants without regurgitations (chi quadro=10.63, p=0.003); 45.2% of infants with colics had a depressed mother vs 15.9% of infants without colics (chi quadro=10.63, p=0.001). A mother’s insecure attachment style was found in 36% of infants with persistence of regurgitations until third months of life vs 1.8% of infants with mother’s secure attachment style (p<0.001). Conclusions: Postpartum maternal depressive symptoms and anxiety are associated with infantile colic and regurgitations. Screening and early intervention in cases of postpartumdepression could be useful to avoid inappropriate nutritional and pharmacologic treatments, promoting the health of both mother and infant.

PO5 GIARDIASIS IN SUSPECTED CELIAC DISEASE

Background and Objectives: Celiac disease (CD) is an immunemediated enteropathy induced by gluten ingestion in a genetically susceptible patient. Giardia lamblia is the most common human parasite with a worldwide distribution and fecal-oral way of transmission. Giardia lamblia has a cosmopolitan distribution. Infected children may have acute or chronic diarrhea, crampy abdominal pain, anorexia, malasorption and poor weight gain and may be misdiagnosed as celiac disease. Diagnosis is usually made by finding the characteristic cysts in stool specimens or by duodenal aspiration. In most cases histology reveals a dense accumulation of the parasites on the surface of the duodenal mucosa with no or only slight inflammation. In rare cases, a dense inflammatory infiltrate with severe mucosal atrophy and increased count of intraepithelial lymphocytes may be seen. If in such cases the amount of parasites is low, the histological picture may mimic celiac disease. We report the case of a child 2 years old who presented poor growth, recurrent aphtous stomatitis, abdominal pain and recurrent diarrhea. No family history of CD. Material and Methods: In suspected CD, were assayed the IgA anti-endomysium antibodies (EmA-IgA) that resulted doubt and the IgA anti-tissue transglutaminase antibodies (TgA-IgA) that were found weakly positive (17.50UA; normal value 16UA). He was referred to our hospital for further diagnostic. We performed the search for genetic susceptibility of CD; the antibodies assay was repeated after 3 months. These investigations documented the presence of HLADQ2, positivity of EmA-IgA and an increase value of TgA-IgA (20.70UA). In the meantime symptoms worsened, so we proceeded performing the esophagogastroduodenoscopy and duodenal biopsies. The macroscopic appearance of duodenal mucosa was of villous atrophy, but microscopic examination showed a parasitic duodenitis, with the presence of microorganisms like Giardia lamblia. Then was started medical therapy with metronidazole per os for 10 days, and the child continued to eat gluten. Results: Abdominal pain and diarrhea disappeared gradually but rapidly; the parasitological examination was negative on 3 consecutive samples (at 3 weeks after eradication therapy); EmA-IgA and TgAIgA were negative at 1 month after eradication. The follow up to 1 year had confirmed that the increase in IgA was secondary to giardiasis, and that the symptoms were due to the histological damage of the parasite. Conclusions: When investigating a patient with suspected celiac disease (CD), several other conditions must be considered, including potential infection with Giardia lamblia. In doubtful cases like our patient, are of fundamental support an accurate assessment and appropriate follow up.

PA31 ESOPHAGEAL PERFORATED ULCER SECONDARY TO PROLONGED DECUBITUS OF A NOT-HARMFUL FOREIGN BODY (COIN) AT THE CERVICAL ESOPHAGUS

association of a clinical picture of gastroenteritis, we set the therapeutic process by supporting the second hypothesis, while allowing for endoscopic follow up of the evolution of the lesions. Faced with rapid resolution of the findings of EGD and gastrointestinal infection, the persistence of the painful symptoms has rekindled the suspicion of gastric disease due to malposition, probably exacerbated from the episode of infection. It was then performed radiological examination which led to diagnose gastric volvulus. The patient was then sent to the pediatric surgeon for surgical correction.