Prashant Mathur

Portal hypertension in north Indian children

Etiological factors associated with portal hypertension in children influence the decision about therapy and the prognosis. This cross-sectional observational study was performed at a tertiary care centre in northern India from January, 1990 to December, 1994. Children below the age of 14 years with suspected portal hypertension were prospectively assembled into a cohort to determine the etiology and clinical profile of portal hypertension. Of the 115 patients with portal hypertension, 76.5% had extrahepatic portal hypertension (EHPH). Remaining 23.5% of the cases had intrahepatic and post-hepatic causes of portal hypertension. Children with EHPH had a significantly earlier onset of symptoms as compared to those with intrahepatic portal hypertension (p = 0.002) and bled significantly more frequently (p = 0.00). Forty per cent of patients with chronic liver disease (CLD) never had jaundice. History suggestive of potential etiological factors could be elicited in only 7% of EHPH patients. The commonest site of block in splenoportal axis was at the formation of the portal vein. An inverse relation of bleeding rates with duration of illness was seen in EHPH. Of the 10 CLD patients in whom liver biopsy could be done, cirrhosis was present in 6 patients.Understanding the natural history of EHPH and portal hypertension due to other etiologies may have significant implications in choosing the appropriate intervention and predicting the outcome.

Upper gastrointestinal bleeding: Etiology and management

Upper gastrointestinal bleeding is a potentially fatal condition at times due to loss of large volumes of blood. Common sources of upper gastrointestinal bleeding in children include mucosal lesions and variceal hemorrhage (most commonly extra hepatic portal venous obstruction) and, in intensive care settings infections and drugs are other etiological factors associated with bleeding. Massive upper Gl bleeding is life threatening and requires immediate resuscitation measures in the form of protection of the airways, oxygen administration, immediate volume replacement with ringer lactate or normal saline, transfusion of whole blood or packed cells and also monitoring the adequacy of volume replacement by central venous lines and urine output. Upper Gl endoscopy is an effective initial diagnostic modality to localize the site and cause of bleeding in almost 85–90% of patients. Antacids supplemented by H2-receptor antagonists, proton pump inhibitors and sucralfate are the mainstay in the treatment of bleeding from mucosal lesion. For variceal bleeds, emergency endoscopy is the treatment of choice after initial haemodynamic stabilization of patient. If facilities for endoscopic sclerotherapy (EST) are not available, pharmacotherapy which decreases the portal pressure is almost equally effective and should be resorted to. Shunt surgery is reserved for patients who do not respond to the above therapy. β blockers combined with sclerotherapy have been shown to be the most effective therapy in significantly reducing the risk of recurrent rebleeding from varices as well as the death rates, as compared to any other modality of treatment. Based on studies among adult patients, presence of shock, co-morbidities, underlying diagnosis, presence of stigmata of recent hemorrhage on endoscopy and rebleeding are independent risk factors for mortality due to upper Gl bleeding. Rebleeding is more likely to occur if the patient has hematemesis, liver disease, coagulopathy, hypotension and or anemia. There is a great need for conducting therapeutic trials as well as identifying predictors of outcome of upper Gl bleeding in children to develop evidence based management protocols.

Nasopharyngeal carriage ofHaemophilus influenzae

Objective: Nasopharyngeal colonization ofHaemophilus influenzae (H. influenzae) in young children may be important in developing countries.Method: In this study, we screened school going children for carriage ofH. influenzae. A total of 44H. influenzae isolates out of a collection of 162 were characterized for biotypes, capsular serotypes and antibiotic resistance.Results:A significant proportion ofH. influenzae (25/44) isolates were serotype b. High antibiotic resistance was observed against commonly administered antibiotics like ampicillin (79%), chloramphenicol (20%), trimethoprim sulfamethoxazole (84%) and erythromycin (95%). Comparison of antibiotic resistance profile of nasopharyngeal isolates was observed to be correlated with those ofH. influenzae from disease.Conclusion: Multidrug resistant nasopharyngealH. influenzae in young healthy children may act as reservoir. Monitoring of antibiotic resistance among nasopharyngealH. influenzae as a surrogate for invasiveH. influenzae seems an attractive option.

Esophageal and gastric vasculature in children with extrahepatic portal hypertension Evaluation by intravenous CT portography

PURPOSEnTo compare the findings related to esophageal/gastric varices and congestive gastropathy on intravenous computed tomography (CT) portography (CTP) and upper gastrointestinal endoscopy (UGIE) in children with extrahepatic portal venous obstruction (EHO) presented with hematemesis.nnnMETHODS/MATERIALSnFifty pediatric patients (age < 15 years) with EHO (initially diagnosed on abdominal ultrasound) presented with hematemesis and underwent UGIE and intravenous CTP using a helical CT scanner. Axial sections of 2 mm each were obtained with a collimation of 2 mm and a table feed of 3 mm. CTP findings on these axial sections were compared with UGIE (gold standard).nnnRESULTSnThe sensitivity of CTP for detection of esophageal varices, gastric varices, and gastropathy was 32/33 (97%), 38/40 (95%), and 30/32 (93%), respectively. CTP showed false positivity as well, which was 5/17 (29%), 2/10 (20%), and 13/17 (76%) for esophageal varices, gastric varices, and gastropathy, respectively. On follow-up UGIE, the endoscopic features appeared in 14/19 (74%) of false positive patients. Therefore, false positivity for all the parameters on CTP when compared to the initial UGIE represented the changes in vasculature before they were endoscopically manifest.nnnCONCLUSIONSnCTP was likely to pick up changes in esophageal and gastric vasculature earlier than UGIE in children with EHO presented with hematemesis.

Erythema annulare centrifugum with autoimmune hepatitis

Erythema annulare centrifugum (EAC) is a rare disease entity characterized by dense perivascular lymphocytic infiltrates in dermis. It has been associated with a few conditions, though its etiology is largely unknown. To our knowledge there has been no reported association with autoimmune hepatitis described earlier. This child also was positive for hepatitis C virus antibodies, though HCV RNA was negative. We should keep in mind the false positivity of hepatitis C antibodies before deciding on its therapy

Pertussis in India

Pertussis outbreaks have occurred cyclically since the early 1980s, with large increases in incidence in 1983, 1986, 1990 and 1993 [documented by the Centers for Disease Control and Prevention (CDC, 1995)]. In recent years, outbreaks due to pertussis have been reported from many parts of the world despite the widespread use of a vaccine (CDC, 2006). Nonimmunized or partially immunized children are at a greater risk of developing infections, and their presence promotes the maintenance of the infectious agent in the community, especially in developing and underdeveloped countries. There is also a shift in the epidemiology of pertussis, with more cases being reported in older age groups, which is due to waning immunity to Bordetella pertussis a number of years after immunization (CDC, 2006).