Prithviraj Rao

A British Society of Paediatric Gastroenterology, Hepatology and Nutrition survey of the effectiveness and safety of adalimumab in children with inflammatory bowel disease

Aliment Pharmacol Ther 2011; 33: 946–953

Diagnostic and therapeutic utility of double-balloon enteroscopy in children.

Objectives: Diagnostic and therapeutic benefits of double-balloon enteroscopy (DBE) have been documented in adults, with few data available on pediatric patients. We evaluated the diagnostic and therapeutic utility of DBE in children. Methods: A prospective assessment of 113 DBE procedures in 58 consecutive children younger than 18 years (36 boys, 22 girls; median age 12.7 years, range 1–18 years) was performed for a variety of suspected small bowel (SB) disorders from January 2008 to August 2012 in a tertiary referral center for pediatric patients. All of the children had undergone upper gastrointestinal endoscopy and ileocolonoscopy. A total of 19 patients had undergone radiological investigations for SB (n = 11 magnetic resonance imaging; n = 5 barium enterography; n = 3 computed tomography) and 54 patients had undergone wireless capsule endoscopy (WCE). Results: The overall median (range) examination time was 92.5 (45–275) minutes. The median (range) estimated insertion length of SB distal to pylorus was 230 (80–450) cm and proximal to ileocecal valve was 80 (5–275) cm. The common indications for DBE were polyposis syndromes (n = 21) and obscure gastrointestinal bleeding (n = 16). The findings included polyps (n = 19), mucosal ulcers and erosions (n = 8), submucosal elevations with white nodules (n = 4), and angioma/angiodysplasia (n = 2). The overall diagnostic yield for SB lesions using DBE was 70.7% (41/58) and for WCE was 77.7% (42/54). Endotherapeutic intervention was successfully used in 46.5% (n = 27/58). The endoscopic, medical, and surgical contributions to change in management by DBE were 72.4% (n = 42/58). Three complications (5.2%) were noted with uneventful recovery. Conclusions: The diagnostic yield of DBE was comparable to WCE, but with the addition of therapeutic possibility and histological yield. We believe this technique could be a valuable addition to existing endoscopic techniques, complementary to WCE, and may be considered as an alternative diagnostic and therapeutic option in the SB in children.

Graded compression and power Doppler ultrasonography versus endoscopy to assess paediatric Crohn disease activity pre- and posttreatment.

Objective: The aim of this study was to assess whether power Doppler ultrasound (PDU) can serve as a reliable replacement for endoscopy in follow-up assessment of disease activity in children with Crohn disease. Methods: Nineteen children (13 boys), median age 14.8 (5.4–15.8) years, with macroscopically diagnosed Crohn disease were included in the study. Clinical parameters, histological evaluation, and graded PDU assessments were undertaken in all patients at diagnosis and following their initial treatment. Discriminant analysis was used to build predictive models from the PDU data for the histological evaluation. Results: The median Pediatric Crohns Disease Activity Index (PCDAI) was 31.5 (15.5–42.0) at diagnosis. All clinical and ultrasonographic parameters and the histological evaluation showed an improvement between pre- versus posttreatment results; 1-way analysis of variance showed a significant difference because of treatment (P < 0.005) for all variables apart from the superior mesenteric artery flow (SMA); paired sample t tests indicated that these differences were statistically significant (P < 0.001), with the exception of SMA (P = 0.178). There was a statistically significant correlation (P < 0.001) between the platelet count and the bowel wall stratification (STRAT). Significant correlation was also observed between the histology findings and the mean mucosal, transmural, and segmental flow (MFL) and STRAT and between platelets and both MFL and small bowel thickening (SBT) (P < 0.01 in all cases). There was a statistically significant correlation (P < 0.05) between C-reactive protein and MFL and between histology and SBT, MFL, and STRAT. Discriminant analysis using discriminating factors SBT, STRAT, and MFL could assign 84.6% of cases to the correct classification of “no/mild inflammation” or “medium/severe inflammation.” Conclusions: Results obtained using power Doppler ultrasonography and endoscopy showed statistically significant correlations. Power Doppler sonography, in the hands of an experienced examiner, can be used for follow-up assessment of disease activity in children with Crohn disease.

Comparison of quick point-of-care test for small-bowel hypolactasia with biochemical lactase assay in children.

Aim: The aim of the present study was to compare the Biohit Lactose Intolerance Quick Test (BLIQT) to the criterion standard biochemical duodenal lactase (DL) activity assay in the paediatric population using standard statistical comparative tests. Methods: Using standard Olympus endoscopes, 2 postbulbar duodenal biopsies were taken from 38 prospective children (0–16 years) from June 2008–May 2009 at a single tertiary paediatric gastroenterology unit. The biopsies were used for the BLIQT and for biochemical disaccharides assay. Results: Thirty-eight children (19 boys) of median age 5.45 years (0.3–14.8 years) underwent the combined BLIQT and disaccharidase testing. We subdivided the group into those who had biopsies with a larger endoscope (XQ, n = 26) and those who had a smaller endoscope (XP, n = 12) and thus a smaller biopsy forcep. When using a larger endoscope, the BLIQT showed a sensitivity of 100%, specificity of 86%, and positive and negative predictive value of 57.1% and 100%, respectively, on comparing it with DL. With a smaller endoscope, the BLIQT had a sensitivity of 100%, specificity of 80%, positive predictive value of 50%, and a negative predictive value of 100%. Conclusions: As in adult studies, the sensitivity and negative predictive value of the BLIQT was 100%. The specificity too appears to be high but variable, probably because of smaller biopsies obtained, and may warrant the need for 2 biopsies. The high sensitivity, specificity, and negative predictive value of the BLIQT for indicating hypolactasia make it an effective point-of-care test for paediatric hypolactasia.

Contemporary Outcomes for Ulcerative Colitis Inpatients Admitted to Pediatric Hospitals in the United Kingdom

Background:Pediatric ulcerative colitis (UC) care is variable with a lack of appropriate guidelines to guide practice until recently. Methods:UC inpatients <17 years old admitted to 23 U.K. pediatric hospitals had clinical details collected between September 2010 and 2011. Comparative data for 248 patients were available from a previous audit in 2008. Results:One hundred and seventy-six patients (98 males) of median age 13 years (interquartile range, 10–13) were analyzed; 23 were elective surgical admissions, 47 new diagnoses, and 106 needed acute medical care for established UC. Median length of stay was 6 days (interquartile range, 3–10) with no deaths. Eighty-eight of 126 patients (70%) with active disease had standard stool cultures performed (3 [2%] were positive), and 57 (45%) had Clostridium difficile toxin tested (none positive). Twenty-five of 66 (38%) emergency admissions had an abdominal x-ray on admission, and 13 of 66 patients (20%) had a Pediatric Ulcerative Colitis Activity Index score. There were 3 cases of toxic megacolon and 2 thromboses. Eighty-one of 116 patients (71%) responded to steroids. Nineteen patients who did not respond adequately to steroids received rescue therapy (7 infliximab, 11 ciclosporin, and 1 both) with overall response rate of 90%; 7 patients needed surgery acutely, 5 without previous rescue therapy. Compared with the 2008 data, stool culture rates improved significantly (86 of 121 [71%] versus 76 of 147 [52%], P = 0.001) as did heparinization rates (15 of 150 [10%] versus 5 of 215 [2%], P = 0.002) and rescue therapy usage (17 of 33 [52%] versus 10 of 38 [26%], P = 0.03). Conclusions:There were signs of improving UC care with significantly increased rates of stool culture and rescue therapy. The majority of sites, however, did not use Pediatric Ulcerative Colitis Activity Index scores.

Eosinophils in the oesophageal mucosa: clinical, pathological and epidemiological relevance in children: a cohort study

Objectives Eosinophilic oesophagitis (EO) shows eosinophilic infiltration of the mucosa and can present with symptoms indistinguishable from gastrooesophageal reflux disease (GORD). The authors describe the clinical, endoscopic and histopathological features of all cases of histological EO presenting during 2007–2008 with a 2-year follow-up. The incidence of paediatric EO and the features of a subgroup with features of both GORD and EO (‘overlap’ syndrome (OS)) are described. Design Biopsies with an average of 15 eosinophils/high-power field (HPF) were reviewed in the cohort. OS was suggested when there was coexistence of clinical and histological features of EO and GORD (abnormal pH study), which improved with proton pump inhibitors. Setting Tertiary care. Participants All cases with ≥15 eosinophils/HPF entered the study. Primary outcome measures Patients with EO had an average of 15 eosinophils/HPF. Secondary outcome measures Other histological features of EO included microabscesses, dilated intercellular spaces, basal cell hyperplasia, papillary elongation, etc. Results 24 cases of EO were identified, 13 men and 11 women. The incidence of paediatric oesophageal eosinophilia in the region was 9/100 000 children. 11 of the 24 patients (46%) presented with some form of allergy, six with poor feeding/food aversion, five with dysphagia and four with vomiting. After follow-up, 56.5% were confirmed to have EO, 30.5% responded to treatment for GORD and were categorised as OS, 9% developed eosinophilic gastroenteritis and 4% did not have further upper gastrointestinal symptoms. Conclusions Accurate diagnosis of EO, especially the differentiation from GORD, requires appropriate clinicopathological correlation. A significant proportion of patients with eosinophilia in the mucosa also have GORD (OS). These patients improve after treating the underlying GORD. The study was registered as a Service Evaluation with the Trust (number SE74).

Two years' experience of using the Bravo wireless oesophageal pH monitoring system at a single UK tertiary centre

The Bravo wireless pH monitoring system enables oesophageal pH to be monitored in children intolerant to nasal catheters and records measurements over 48 hours. This study aimed to document the minimum child weight that enabled successful capsule placement and any associated complications. We also compared the diagnostic sensitivity of 48 hours versus 24 hours.

G42 Long term safety and efficacy of single dose parenteral iron in children with inflammatory bowel disease in a large tertiary centre

Background Iron-deficiency anaemia is a common complication amongst children with inflammatory bowel disease (IBD). Although single-dose parenteral iron (PIN) preparations are an easily available treatment for children, there are still concerns surrounding its adverse reactions. Aims The primary aim of this study was to evaluate the safety, side effects and efficacy of IV iron maltoside 1000 (Monofer) at 6 weeks, 3 months, 6 months and 1 year after treatment in children with IBD. Also, to look for any evidence of iron overload. Methods A comprehensive search was performed using the hospital’s IBD database to identify patients who have been given PIN from 2012 to 2016. Primary indication, underlying diagnosis, dose of iron, adverse reactions and laboratory values were among the parameters recorded. Dose calculations were based on the Ganzoni formula. PIN was used only if oral iron therapy is ineffective, not tolerated, not advisable or iron-deficiency anaemia with haemoglobin levels of <100 g/L. Repeated measures ANOVA was conducted for statistical analysis. Results A total of 29 patients were identified. The median age was 14 and median weight was 33.4 kg. Two patients did not have the full data set. Repeated-measures ANOVA conducted on 27 patients showed that mean haemoglobin differed significantly between time points [F (4, 104)=29.416, p<0.001]. Residuals were approximately normally distributed. Post-hoc tests using the Bonferroni correction revealed that mean haemoglobin increased significantly by 6 weeks and remained stable thereafter (p<0.001). Only one patient had an acute type 1 allergic reactions (not anaphylaxis). Two patients had hair loss at 3 months post-infusion which were unlikely to be secondary to iron overload. None of the patients had dysmetabolic iron overload syndrome (DIOS). All children had normal LFTs and GGTs with no evidence of diabetes, chronic fatigue or hepatosplenomegaly in their follow up. Conclusion PIN appears to have sustained efficacy in the treatment of iron deficiency anaemia in children with IBD. Iron status increased significantly at 6 weeks and sustained till 1 year post-infusion. The immediate reaction rate was 3.7% and none of the remaining patients had any side effects including any evidence of DIOS.

Recurrent Regurgitation and Vomiting in Children

Vomiting and regurgitation can be a common, nonspecific symptom of a range of childhood illnesses. When they persist and are chronic or recurrent, they carry the risk of potentially harmful complications and can have a significant impact on the quality of life of patients and carers.

Comparison of quick point of care test for paediatric small bowel hypolactasia with biochemical lactase assay: Abstract G110 Table 1

Background The usefulness of a new quick test for endoscopic diagnosis of paediatric-type hypolactasia was tested in duodenal biopsies. In this test, an endoscopic biopsy from the postbulbar duodenum is incubated with lactose on a test plate, and a colour reaction develops within 20 min as a result of hydrolysed lactose (a positive result) in patients with normolactasia, whereas no reaction (a negative result) develops in patients with severe hypolactasia. Aims The aim of this study was to compare the Biohit lactose intolerance quick (BLIQ) test to the “gold standard” biochemical duodenal lactase (DL) activity assay in the paediatric population. Patients and Methods Two postbulbar duodenal biopsies were taken from 38 prospective children (0–16 years) who underwent upper GI endoscopy over a period of 1 year (June 2008–May 2009) at a single tertiary paediatric gastroenterology unit. The biopsies were used for the quick lactase test (Biohit PLC, Helsinki, Finland) and in biochemical disaccharidase (lactase, trehalase, sucrase, and maltase) assays. Abstract G110 Table 1 Dissacharidase assay positive (Normolactasia) Dissacharidase assay negative (Hypolactasia) Using scope XQ, n=26, Mean weight of biopsies=0.0003 gm  Biohit +ve (normolactasia) 4 3  Biohit −ve (hypolactasia) 0 19  Sensitivity 4/4=100% Specificity 19/22=86%  Positive predictive value 4/7=57.1% Negative predictive value 19/19=100% Using scope XP, n=12,Mean weight of biopsies =0.002 gm  Biohit +ve (normolactasia) 2 2  Biohit-ve (hypolactasia) 0 8  Sensitivity 2/2=100% Specificity 8/10=80%  Positive predictive value 2/4=50% Negative predictive value 8/8=100% Results 38 children (19 male) of median age 5.45 years (0.3–14.8 years) had the combined testing. The authors further subdivided this group into those children that had their biopsies with a larger endoscope (XQ, n=26) and thus a bigger biopsy forceps and those children that had a smaller endoscope (XP, n=12) and thus a smaller biopsy forceps. The results are tabulated below. Conclusion The quick lactase test effectively identifies children with severe duodenal hypolactasia. These results are based on small numbers but tend to support findings in adult studies. The sensitivity and negative predictive value of the BLIQ was 100% on comparing it to DL. The specificity too appears to be high but variable (86% in XQ and 80% in XP groups). This would suggest a lower specificity perhaps, secondary to smaller size of the biopsies obtained and may warrant the need for two biopsies. In comparison with biochemical lactase assays, the sensitivity and specificity of BLIQ for indicating hypolactasia is very high and appears to be an effective point of care test for paediatric hypolactasia.