Maureen Caulfield

The Spectrum of Eosinophilic Gastroenteritis Report of Six Pediatric Cases and Review of the Literature

Eosinophilic gastroenteritis is an inflammatory disease of unknown etiology characterized by infiltration of the gastrointestinal tract with eosinophilic leukocytes, accompanied by varying abdominal symptoms and usually by peripheral blood eosinophilia. We report our experience with six pediatric cases presenting to the Cleveland Clinic Foundation over the past eight years. Unusual findings in our patients included ascitic fluid without eosinophilia and eosinophilic pericarditis (one patient), and eosinophilic cholecystitis (one patient). Endoscopic examination and biopsy helped to establish the diagnosis in all patients. Bone marrow aspiration supported the diagnosis by demonstrating eosinophilia and identifying reactivation of the disease, even in cases without peripheral eosinophilia. All six patients responded promptly to prednisone. Diagnosis is challenging and eosinophilic gastroenteritis may be more common than is recognized. This series of cases significantly expands the spectrum of the disease in children, and documents the usefulness of diagnostic endoscopy in this condition.

Dumping syndrome in children

Dumping syndrome developed in seven children after gastric surgery, (Nissen fundoplication in six, Whipple procedure in one). The patients ranged from age 10 months to 13 years, and four of the seven were neurologically impaired. The diagnosis was made by demonstrating an abnormal response to an orally administered glucose challenge. The pediatric literature records only eight cases, but we believe that dumping syndrome is more common in children than once believed. Dietary management can often dramatically diminish the associated symptoms.

Colonoscopy in the pediatric patient

In 1963 the description 1 of the first workable fiberoptic panendoscope heralded a new era of accurate gastrointes- tinal tract diagnosis and therapeutic procedures. Since the introduction of the flexible fiberoptic colonoscope in the early 1970s. colonoscopy has become an established proce- dure for the diagnosis, evaluation, and treatment of large bowel disease in pediatric patients. The number of proce- dures has increased dramatically during the past 10 years. The use and importance of colonoscopy have continued to increase as instruments specifically designed for children come into routine use. Differences between pediatric and adult patients not only influence the approach to the patient but also modify therapeutic decisions when abnormalities are suspected or identified. We review here the value of the procedure, patient selection, instrumentation, and compli- cations. Advances in technique, premedication, and appli-

Chronic Pancreatitis in Late Childhood and Adolescence

Acute pancreatitis is unusual in pediatric patients, and chronic pancreatitis is even less common. Between 1983 and 1988, we diagnosed 24 patients in late childhood and adolescence with chronic pancreatitis. Our review revealed that chronic pancreatitis presents as recurrent abdominal pain in late childhood and adolescence. Individual laboratory and radiological investigations may be normal during acute exacerbations of pain, but the determination of serum amylase and lipase concentrations — combined with ultrasonography — will accurately identify most patients. We found that endoscopic retrograde cholangiopancreatography is a valuable tool in the diagnosis of structural abnormalities. Surgical intervention may reduce symptoms in patients with structural abnormalities. There is a tendency toward decreased frequency and severity of pain as the patients increase in age.

The results of strictureplasty in pediatric patients with multifocal Crohn's disease.

This study is a retrospective review of eight pediatric patients with multifocal intestinal Crohns disease who underwent strictureplasty with or without concomitant bowel resection between January 1978 and April 1992. The patients ranged in age from 9.9 years to 18.5 years. Indications for surgery were partial intestinal obstruction (n = 6), failure of medial therapy or steroid dependence (n = 4), growth failure (n = 2), and entero-cutaneous fistula (n = 2). Thirty-six strictureplasties were performed in the eight patients (median, 4.5 strictureplasties per patient; range, 1–12). Bowel resection was performed in six of the eight patients in areas where strictureplasty was not feasible. The mean length of resection was 40 cm (range, 15–82 cm). The only complication was intestinal hemorrhage, which was conservatively managed in two patients. The patients were followed for a mean of 19 months (range, 3–55 months). Five patients had a weight below the fifth percentile prior to surgery. Postoperatively, there was a weight gain in seven patients, including all five patients who were originally below the fifth percentile. A statistically significant weight gain was found when a paired t test analysis was applied to the entire group (p = 0.04). Five of six patients who were on steroid medication at the time of surgery were successfully weaned within 1.5–3 months (mean, 2.3 months) from the time of surgery. Seven of eight patients had relief of their intestinal symptoms. Strictureplasty with small-bowel resection, or perhaps strictureplasty alone, in pediatric patients with multifocal intestinal Crohns disease can improve gastrointestinal symptoms, promote weight gain, and allow discontinuation of steroid medications. Strictureplasty should be considered for patients who are refractory to medical therapy or dependent on chronic steroid medication for control of their symptoms.

Alpha interferon therapy in children with chronic active hepatitis B and delta virus infection.

Two children with chronic hepatitis B virus and delta virus infection were treated with alpha interferon. Both tolerated the therapy without complications, and one demonstrated clearance of the infection and development of immunity.

Hepatitis B. A disease needing a vaccine or a vaccine needing a disease

positive for both HBsAg and HBeAg place 70% to 90% of these infants at risk for infection if no vaccine is administered. Approximately 25% of the infants may be infected if the mother is HBsAg positive, HBeAg negative.3 A recent report estimates the lifetime risk of acquiring HBV infection, even excluding infants bom to HBsAg-negative mothers, to be 5%.4 One important segment of the hepatitis B problem that is seriously underestimated by the standard statistics on reported cases involves infections in children. Fewer than 1 % of all reported cases occur in children under 10 years of age. This figure does not reflect the real hepatitis B infection risk in that age group, however, since very few infections in infants and children are