Mark S. Glassman

Breast-feeding and maternal smoking in the etiology of Crohn's disease and ulcerative colitis in childhood

Medical records concerning pediatric or adolescent patients first diagnosed with Crohns disease or ulcerative colitis in two New York hospitals during a 5-year period (1986 to 1990) were abstracted, and information concerning sex, age, race, birthplace, sibship size, birth order, maternal age at birth, month of birth, duration of breast-feeding, and maternal smoking was recorded. Medical records of patients presenting at the respective pediatric gastroenterology departments immediately before or after the patients with inflammatory bowel disease were seen were also abstracted in order to generate a control series. Data concerning 68 patients with Crohns disease, 39 patients with ulcerative colitis, and 202 control patients were analyzed through multiple logistic regression. Breast-feeding was negatively associated with Crohns disease (P approximately 0.04) and ulcerative colitis (P approximately 0.07), with relative risk point estimates around 0.5 and with evidence of duration-dependent trends in both instances. There was no evidence of association of either disease with maternal age at birth, birth order, maternal smoking, or season of birth.

Campylobacter pylori-related gastrointestinal disease in children

Over a one-year period, 95 children and adolescents presenting with epigastric pain and/or vomiting, and without associated risk factors for development of peptic disease, underwent endoscopic antral biopsies for pathologic diagnosis and to detect presence of Campylobacterss. pylori (C. pylori). Additional biopsies of the esophagus, stomach, and duodenum were obtained for histologic evaluation. C. pylori was identified in 16 patients (16.8%), all of whom had evidence of acute and/or chronic gastritis. Significant discriminating factors between C. pylori-positive and -negative subjects included age at presentation (positive vs negative=14.6 vs 9.9 years, P<0.01, biopsy-confirmed gastritis (100% vs 30.4%, P<0.001), and diagnosis of duodenitis alone (0% vs 46.8%, P<0.001). Risk for bacterial colonization was significantly higher in the presence of endoscopic gastritis (P<0.001). Among C. pylori-positive patients, none responded to standard antiulcer therapy (H2-receptor antagonists, antacids). Symptomatic and histologic remission was achieved utilizing combined therapy with bismuth subsalicylate and antibiotics. Seven of 79 C. pylori-negative patients with biopsyproven gastritis who responded poorly to antisecretory therapy had the organism identified in follow-up antral biopsies; these patients improved clinically following treatment for C. pylori. These data suggest that C. pylori is a significant factor in the etiology of upper gastrointestinal tract inflammatory disease in pediatrics, and presence of the organism should be evaluated, particularly in children with evidence of acute and/or chronic gastritis.

Spectrum of esophageal disorders in children with chest pain

The charts of 83 children with chest pain who underwent esophageal manometry followed by esophagogastroscopy were reviewed. Forty-seven (57%) had normal esophageal histology and normal motility (group I). Esophagitis and normal motility were demonstrated in 15 children (group II), normal esophageal histology and esophageal dysmotility in 13 (group III), and both esophagitis and abnormal motility in 8 (group IV). Diffuse esophageal spasm and achalasia were the most common motility disorders identified (in seven and four patients, respectively). The presence and duration of symptoms, the age, and the gender were not different among the four patient groups. After six months of H2-receptor blockade, 12 of 15 group II patients were asymptomatic, whereas a significantly smaller percentage (five of 18) of patients with abnormal esophageal motility responded to esophageal dilation or treatment with calcium channel blockade, H2-receptor antagonist, and/or prokinetic agents (P<0.01). These data suggest that the evaluation of children with chest pain should include esophageal motility testing and esophagoscopy, even in the absence of other gastrointestinal-associated symptoms, and that while treatment of esophagitis results in resolution of symptoms, motility disorders were relatively refractory to therapy.

Esophagitis as a cause of infant colic

once a day. Fourteen of the 18 patients had been tried on a hydrolyzed casein formula for at least 1 week without improvement. Parental counseling, as previously described by Taubman,4 had been tried for each patient without a decrease in crying time. Esophagogastroduodenoscopy (EGD) was performed in each patient using a flexible Olympus XP10 endoscope (Olympus Corp., Lake Success, New York) after intravenous sedation with meperidine (1 mg/kg) or after receiving chloral hydrate 50-75 mg/kg 1 hour prior to the procedure. Esophagitis was diagnosed endoscopically by the presence of friability, erythema, ulceration, or granularity. Biopsies were taken under di-

Treatment of Helicobacter pylori-associated gastroduodenal disease in children : clinical evaluation of antisecretory vs antibacterial therapy

The charts of 54 children diagnosed with antral H. pylori were reviewed, to establish the incidence of gastroduodenal inflammation and compare therapeutic efficacies of antisecretory vs. antibacterial therapy. Histology demonstrated normal mucosa in three cases (6%) and gastric/duodenal inflammation (> or = Whitehead grade 3) in 51 biopsies (94%). 23/43 children (53%) initially responded to H2-blockers; however, by 10 mo, 13 had relapsed clinically. All of these patients subsequently responded to amoxicillin plus bismuth subsalicylate. Of the 20 children who failed to enter remission after an initial course of H2-blockers, all became symptom-free after treatment with amoxicillin/bismuth. Compared to antisecretory agents, antibacterial treatment induced clinical remission in 11/11 patients (p < 0.001), who remained symptom-free for 10 +/- 0.2 mo. Clinical remissions were maintained in significantly more patients following amoxicillin/bismuth vs. H2-blockers (44/54 vs. 10/43 courses, p < 0.001); and, the cumulative probability of remaining asymptomatic was significantly greater in the antibiotic group (p < 0.001). These data suggest that gastric colonization by H. pylori is highly predictive of mucosal pathology in children. Initial therapy should be directed toward achieving bacterial eradication, as opposed to gastric acid suppression.

Noncardiac chest pain in adolescents and children with mitral valve prolapse

Chest pain in adolescents and children is usually not of cardiac origin. Of cardiac conditions commonly linked to chest pain in childhood, mitral valve prolapse (MVP) is the most prevalent, but this association has recently been questioned. In light of recent reports of gastroesophageal sources of chest pain in adults with MVP, we performed a comprehensive gastroesophageal evaluation of 17 preadolescents and adolescents with mitral valve prolapse who had chest pain as their presenting symptom. Evaluation consisted of esophageal manometry, Bernstein test, esophageal pH probe, and/or esophagogastroscopy. Fourteen of the 17 patients had at least one abnormal finding. Five patients had esophagitis, five had gastritis, one had high-amplitude esophageal contractions, one had abnormal esophageal manometry with positive Bernstein test, one had esophageal reflux and positive Bernstein test, and one had abnormal manometry with esophageal reflux. The 13 patients with esophagitis, gastritis, reflux, or positive Bernstein test were treated with antacid, with resolution of chest pain in 12 patients. Two of these patients underwent follow-up endoscopy with documentation of improvement. The patient with high-amplitude esophageal contractions was treated with dicyclomine, which resulted in resolution of chest pain. The observation that the chest pain was not related to mitral valve prolapse is important in clinical practice and raises further questions as to whether mitral valve prolapse causes chest pain.

Helicobacter pylori Infection in Children: A Clinical Overview

controversial. Although the prevalence of gastric infection with H. pylori is markedly lower in children than in adults, it has been identified in 52% of children with gastritis and/or gastric ulcers and in 60% of children with duodenitis and/or duodenal ulcers. These data suggest that H. pylori plays a role in the etiology of gastroduodenal disease in the pediatric population. The prevalence of H. pylori varies directly with age and inversely with socioeconomic status and level of education; it also varies with ethnic background. Results of culture, Gram’s stain, urease testing of gastric biopsy specimens, and serologic testing for anti-Helicobacterantibodies are reliable indi-

Anorectal Motility Abnormalities in Children with Encopresis and Chronic Constipation

OBJECTIVE To evaluate the response to rectal distension in children with chronic constipation and children with chronic constipation and encopresis. STUDY DESIGN We studied 27 children, aged 3 to 16 years, with chronic constipation; 12 had encopresis. Anorectal motility was measured with a solid state catheter. When the catheter was located in the internal sphincter, the balloon was inflated to 60 mL with air. RESULTS There were no differences in age, sex distribution, and duration of constipation in the two groups. Comparing groups, anorectal manometry showed no differences in the resting sphincter pressure, recovery pressure, the lowest relaxation pressure, and percent relaxation. However, time to maximum relaxation, time to recovery to baseline pressure, and duration of relaxation were significantly higher in patients with constipation and encopresis, compared with patients who had constipation alone. CONCLUSIONS There may be an imbalance in neuromuscular control of defecation in constipated patients with encopresis that results in incontinence as a consequence of the increased time to recovery and duration of relaxation of the internal anal sphincter.

Respiratory methane excretion in children with lactose intolerance

Two evaluate the relationship between colonic methane production and carbohydrate malabsorption, we measured end-expiratory methane levels in 70 normal and 40 lactose-intolerant children. Time-dependent excretion of hydrogen and methane was determined every 30 min for 120 min following a fasting oral lactose challenge (2 g/kg). Mean breath hydrogen levels in normals (lactose-tolerant) equaled 3.7 parts per million (ppm) throughout the study, but increased to >10 ppm by 60 min and remained elevated in lactose-intolerant subjects. Breath methane in normal children averaged 1.6 ppm from 0 to 120 min. In contrast, CH4 excretion by lactose-intolerant children averaged 5.1 ppm at 90 min; and, by 120 min levels increased significantly compared with control. Breath methane levels in lactose-intolerant subjects following a lactose load continued to increase, however, despite the coingestion of exogenous lactase in amounts calculated to result in complete hydrolysis of the disaccharide. These data demonstrate that lactase-deficient children manifest significant increases in breath methane excretion following lactose ingestion and that enhanced methane production may be a consequence of several factors, including altered fecal pH and increased methanogenic substrates provided by colonic lactose fermentation. Further studies are required to determine the clinical significance of elevated methane production in lactose intolerance.

Use of the intraesophageal acid perfusion test in provoking nonspecific chest pain in children

The intraesophageal acid perfusion (Bernstein) test was evaluated as a provocative test for nonspecific chest pain in children with esophagitis. Sixty patients with atypical chest pain were studied. None of the patients had heartburn or other characteristic symptoms of esophagitis. Forty-five patients had esophagitis; in 18 (40%) of these patients, pain replicating their usual symptoms developed during esophageal acid perfusion, whereas in 15 patients without esophagitis, chest pain did not develop during esophageal acid perfusion. In three patients with esophagitis, esophageal manometric abnormalities and chest pain developed as a result of esophageal acid perfusion. Treatment with either ranitidine or antacids had equivalent effectiveness. We conclude that a positive Bernstein test result in children with nonspecific chest pain indicates that the pain is likely associated with esophageal disease.