Seema Khan

Eosinophilic esophagitis: strictures, impactions, dysphagia.

Eosinophilic esophagitis, long known to be a feature of acid reflux, has recently been described in patients with food allergies and macroscopically furrowed esophagus. The pathophysiology and optimal management of patients with eosinophilic esophagitis is unclear. We describe our clinical experience related to eosinophilic esophagitis and obstructive symptoms in children and propose etiopathogenesis and management guidelines. Twelve children with obstructive esophageal symptoms (11 male), median age 5 years, and identified to have eosinophilic esophagitis with >5 eosinophils per high-power field (eos/hpf) are reported. Of these, four had strictures, six had impactions, and two had only dysphagia. A diagnostic evaluation included esophagogastroduodenoscopy with biopsies in all and upper gastrointestinal series, IgE, radioallergosorbent tests, and skin tests for food allergies in some cases. Esophageal histology specimens were independently analyzed for eosinophil density by two authors. Four of five children with >20 eos/hpf responded to elimination diets/steroids. The fifth child responded to a fundoplication. Seven children had 5–20 eos/hpf and three of them with no known food allergies responded to antireflux therapy alone. Three others in this group with positive food allergies responded to treatment with elimination diets and/or steroids. The seventh patient in this group was lost to follow-up. In conclusion, on the basis of response to therapy, eosinophilic esophagitis can be subdivided into two groups: those with likely gastroesophageal reflux disease if <20 eos/hpf and no food allergies, and others with allergic eosinophilic esophagitis associated with food allergies and often with >20 eos/hpf.

Eosinophilic Gastroenteritis Epidemiology, Diagnosis and Management

Eosinophilic gastroenteritis is a heterogeneous and uncommon disorder characterized by eosinophilic inflammation of the gastrointestinal tissues. The location and depth of infiltration determine its varied manifestations, and the latter is also the basis for the proposed classification into mucosal, muscular and serosal eosinophilic gastroenteritis. Abdominal pain, vomiting, and diarrhea are each present in nearly 50% of the patients, with some overlap. Peripheral eosinophilia is seen in approximately two-thirds of patients with eosinophilic gastroenteritis.It is now clear that eotaxin, a specific eosinophil chemoattractant, plays a pivotal role in the process of eosinophil production. The differential diagnosis of eosinophilic gastroenteritis in children includes parasitic infections, inflammatory bowel disease, connective tissue diseases, some malignancies and adverse effects of drugs.Eosinophilic gastroenteritis itself has been strongly associated with food allergies, and concomitant atopic diseases or a family history of allergies is elicited in about 70% of cases. The pediatric experience is unique with respect to recognition of distinctive entities such as allergic procto-colitis, almost exclusively seen in infants, and eosinophilic esophagitis being increasingly reported among children and young adults. The gold standard for diagnosis, usually demonstrated on endoscopie biopsies, is prominent tissue eosinophilia. However, the diagnosis may be obscured by the patchy nature of the disease, and muscular and serosal eosinophilic gastroenteritis subtypes. In the latter cases, full thickness biopsies would be indicated for a definitive diagnosis.There are many reports of successful treatment of eosinophilic gastroenteritis in children, using a variety of treatment regimens including elimination diets. Corticosteroids remain the most effective agents for controlling symptoms, but unfortunately the relapsing nature of the disease would mandate prolonged corticosteroid use. Reports of favorable responses to new leukotriene inhibitors in patients with eosinophilic gastroenteritis are encouraging; these responses should stimulate future research on the pathophysiology and management of eosinophilic gastroenteritis.

GASTROESOPHAGEAL REFLUX DISEASE IN CHILDREN

In the pediatric population, gastroesophageal reflux most often presents in infancy as effortless regurgitation, but pathologic GERD is accompanied by signs of malnutrition, respiratory diseases, and esophagitis or its complications. Because of the distinctive pathophysiology predisposing infants to GERD, the diagnostic approach must begin with a thorough history that determines the extent of further diagnostic tests and the course of management. Empiric therapy assumes importance in infants with GERD because of the limited differential diagnoses in consideration. Conservative therapy is of utmost importance because of the unique provocative factors in the pathophysiology of infantile GERD. Prokinetic pharmacotherapy takes precedence over acid suppression because of the more important role of motility factors compared with acid secretion in infantile GERD.

Seasonal variation in the presentation of abdominal pain.

Background: Anxiety and depression, conditions frequently associated with childhood chronic abdominal pain (AP), are characterized by seasonal exacerbations. A seasonal pattern characterized by a higher frequency of consultations for AP during winter has been suspected but has never, to our knowledge, been demonstrated. We hypothesize the presence of a seasonal variation in AP consultations with a winter predominance. Aims: To determine the seasonal distribution of AP consultations among centers across time and geographic latitude. Patients and Methods: This was a retrospective cohort study. The number of outpatient consultations from primary care clinics and every pediatric specialty clinic that resulted in a diagnosis of AP and the total number of outpatient consultations (2001–2004) from 6 tertiary care institutions (Chicago, Pittsburgh, Wilmington, Pensacola, Orlando, Jacksonville) was determined. Rates of consultations were compared across time and between cities. Four time periods of interest, with 2- and 3-month definitions, were arbitrarily selected. Seasonal rates across time were compared separately for each of the 2-month (January–February vs June–July) and 3-month periods (January–March vs June–August). Logistic regression models for each city were used to determine variations in the rate of outpatient AP cases by season or by year. Results: A total of 3,929,522 outpatient consultations and 73,591 AP consultations were analyzed. The rates of AP consultations were consistently higher in the winter months at all of the sites. The results differed between sites at northern and southern latitudes. Conclusions: There seems to be a seasonal variation in consultation patterns for AP at the tertiary care level. A possible role of daylight hours, climate, latitude, and stress is proposed.

Clostridium difficile colitis in children with cystic fibrosis

Children with cystic fibrosis (CF) have a higher carriage rate of C. difficile compared with normal children, likely because of more frequent use of broad-spectrum antibiotics for recurrent pulmonary infections and repeated hospitalizations (1). C. difficile infection in CF patients may vary from the asymptomatic carrier state to severe disease such as pseudomembranous colitis leading to toxic enterocolitis or megacolon (1, 2). In view of our recent experience with a 15-year-old CF patient presenting with fulminant C. difficile colitis, we present an updated review of the subject after a thorough electronic literature search back to 1966 using Medline and Pub Med.

CASE REPORT: Pancreatic Ascites in an Infant: Lack of Symptoms and Normal Amylase

A 4-month-old boy presented with 9 days of abdominal distension. The abdomen was tense, distended, and nontender, with a fluid wave. Hypoalbuminemia, hyponatremia, high lipase, normal amylase, high ascitic fluid: lipase, amylase, and serum-ascites albumin gradient < 1.1 were present. Abdominal CT showed large ascites, edema, and pancreatic cyst. No improvement was noted with bowel rest, TPN, albumin, furosemide, octreotide, and paracentesis. Endoscopic retrograde cholangiopancreatography showed disrupted pancreatic duct and a cyst. Pancreatic duct stenting was complicated by early outward migration of the stent and was thus ineffective. An exploratory laporatomy revealed a cyst. Cystogastrostomy resolved the pancreatitis and ascites. The patient was discharged off TPN and tolerating enteral nutrition. Pancreatic ascites is rare, producing few or no symptoms in infants. In conclusion, our patient may have had viral pancreatitis, complicated by a disrupted duct and/or ruptured pseudocyst with ascites formation. Medical management was ineffective. Surgery appears to have been curative.

Gastroesophageal Reflux Disease in Infants and Children

Gastroesophageal reflux is the most common esophageal disorder in children, and is responsible for heterogeneous presentations ranging from effortless regurgitation in “happy spitters” to complex esophageal and extra-esophageal GERD. The frequency and noxiousness of refluxate in proportion to the various esophageal defense mechanisms, and genetic, physiological and environmental influences ultimately determine the pathogenicity and complications of the disorder. While most children may be confidently diagnosed solely on the basis of a detailed history followed by appropriate response to therapy, diagnostic tools may be useful to clarify the role of reflux in extra-esophageal, and complicated GERD. Prompt identification and intervention for GERD in children is crucial to the prevention of strictures, Barrett’s esophagus and adenocarcinoma that are associated with long-standing reflux exposure. The first line of anti-reflux therapy in children is conservative therapy emphasizing thickened feeds, smaller volume meals, proper positioning, and elimination of smoke exposure. Proton pump inhibitor therapy has an established role in the management of those with GERD sequelae, and as empiric therapy in those with extra-esophageal GERD. Fundoplication, reserved for children who are refractory to pharmacotherapy, is being performed successfully; results of laparoscopic surgery in children are favorable with respect to shorter hospital stay, and lower complication rate than open fundoplication.