Simone Diniz Carvalho

Clinical and Laboratory Predictors of Esophageal Varices in Children and Adolescents With Portal Hypertension Syndrome

Objectives: To determine the clinical and laboratory parameters that may predict the presence of esophageal varices in children and adolescents with portal hypertension. Patients and Methods: Overall, 111 patients with portal hypertension and no previous history of digestive bleeding underwent esophagogastroduodenoscopy for detection of esophageal varices. A univariate analysis initially was carried out, followed by a logistic regression analysis to identify the independent variables associated with the presence of esophageal varices. Sensitivity and specificity rates, positive predictive value, negative predictive value, and the accuracy of the predictive variables identified among cirrhotic patients were calculated with the esophagogastroduodenoscopy as the reference test. Results: Sixty percent of patients had esophageal varices on the first esophagogastroduodenoscopy. Patients with portal vein thrombosis and congenital hepatic fibrosis were 6.15-fold more likely to have esophageal varices than cirrhotic patients. When we analyzed 85 cirrhotic patients alone, splenomegaly and hypoalbuminemia remained significant indicators of esophageal varices. Only spleen enlargement showed appropriate sensitivity and negative predictive value (97.7% and 91.7%, respectively) to be used as a screening test for esophageal varices among cirrhotic patients. Conclusions: In reference services and research protocols, endoscopic screening should be performed in all patients with portal vein thrombosis and congenital hepatic fibrosis. Among cirrhotic patients, the indication should be conditioned to clinical evidence of splenomegaly or hypoalbuminemia. For clinicians, the recommendation is to emphasize the orientations given to guardians of patients with portal vein thrombosis and congenital hepatic fibrosis as to the risk of digestive bleeding. Cirrhotic patients with hypoalbuminemia and splenomegaly should receive the same orientations.

A regulatory instead of an IL-17 T response predominates in Helicobacter pylori-associated gastritis in children

Th17 cells seem to have an important role in the efficacy of vaccines against Helicobacter pylori. Because children are a target group for human vaccination and Th17/T(reg) cells have intrinsically linked and antagonic commitments, we compared the gastric levels of Th17- and T(reg)-associated cytokines of children and adults. IL-6, IL-10 and TGF-β1 levels and Foxp3(+) cell numbers were higher, but IL-1β, IL-17A and IL-23 were lower in infected children than in infected adults. In conclusion T(reg) instead of Th17 cell response to H. pylori-infection predominates in children.

Iron Status and Helicobacter pylori Infection in Symptomatic Children: An International Multi-Centered Study

Objective Iron deficiency (ID) and iron deficiency anaemia (IDA) are global major public health problems, particularly in developing countries. Whilst an association between H. pylori infection and ID/IDA has been proposed in the literature, currently there is no consensus. We studied the effects of H. pylori infection on ID/IDA in a cohort of children undergoing upper gastrointestinal endoscopy for upper abdominal pain in two developing and one developed country. Methods In total 311 children (mean age 10.7±3.2 years) from Latin America - Belo Horizonte/Brazil (n = 125), Santiago/Chile (n = 105) - and London/UK (n = 81), were studied. Gastric and duodenal biopsies were obtained for evaluation of histology and H. pylori status and blood samples for parameters of ID/IDA. Results The prevalence of H. pylori infection was 27.7% being significantly higher (p<0.001) in Latin America (35%) than in UK (7%). Multiple linear regression models revealed H. pylori infection as a significant predictor of low ferritin and haemoglobin concentrations in children from Latin-America. A negative correlation was observed between MCV (r = −0.26; p = 0.01) and MCH (r = −0.27; p = 0.01) values and the degree of antral chronic inflammation, and between MCH and the degree of corpus chronic (r = −0.29, p = 0.008) and active (r = −0.27, p = 0.002) inflammation. Conclusions This study demonstrates that H. pylori infection in children influences the serum ferritin and haemoglobin concentrations, markers of early depletion of iron stores and anaemia respectively.

Toll-like receptor (TLR2, TLR4 and TLR5) gene polymorphisms and Helicobacter pylori infection in children with and without duodenal ulcer

Helicobacter pylori infection is mainly acquired in childhood, and polymorphisms in the host genes coding for Toll-like receptors (TLRs) may influence the innate and adaptive immune response to the infection, affecting the susceptibility to H. pylori or the disease outcomes. Our aim was to investigate whether TLR4, TLR2, and TLR5 polymorphisms were associated with H. pylori susceptibility and risk for duodenal ulcer in children. Gastric biopsy specimens were obtained at endoscopy for evaluation of H. pylori status, TLR4, TLR2 and TLR5 polymorphisms from 486 children (254 H. pylori-negative and 232 H. pylori-positive: 72 with and 160 without duodenal ulcer). cagA status of H. pylori infection was investigated by PCR. The levels of gastric cytokines were detected by ELISA. H. pylori-positivity or duodenal ulcer were not associated with TLR2, TLR4 or TLR5 polymorphisms. Otherwise, the presence of TLR4 polymorphic allele was associated with infection by cagA-positive strains and with increased gastric levels of interleukin-8 and interleukin-10. TLR4 polymorphism might ultimately contribute to more severe consequences of the infection in adulthood since it was associated with susceptibility to cagA-positive H. pylori infection early in life.

Endoscopic dilatation of esophageal strictures in children and adolescents

OBJECTIVE To assess the causes of esophageal stricture in pediatric patients and their response to endoscopic dilatation. METHODS Retrospective analysis of clinical and endoscopic data obtained from children and adolescents with esophageal stricture submitted to endoscopic dilatation between July 1993 and January 2003. RESULTS A total of 125 patients aged between 1 month and 16 years were included in the study. Among the types of stenosis, postoperative (43.2%), corrosive (27.2%) and peptic (21.6%) strictures were the most prevalent. Those patients with corrosive esophageal stricture needed more dilatation sessions. Five cases of esophageal perforation and one case of hemorrhage occurred due to complications during the procedure. Good response to endoscopic treatment was described in 74.4% of cases, but better results were obtained from patients with peptic esophageal stricture. CONCLUSIONS Endoscopic treatment of esophageal strictures in children and adolescents yields good results and has a low rate of complications. Corrosive esophageal strictures have a higher morbidity and require more dilatation sessions.

Clinical and epidemiological characteristics of injuries caused by venomous snakes observed at the hospital for tropical diseases of Araguaína, Tocantins State, Brazil, from 1995 to 2000

Injuries caused by venomous snakes are considered a problem of public health in Brazil, and further studies for a better knowledge are very important. The aim of this work is to describe clinical and epidemiological characteristics that were observed from 1995 to 2000 in the Hospital for Tropical Diseases of Araguaina, Tocantins State, Brazil, which is a unit of health that takes care of patients suffering from tropical diseases. We studied 440 individuals and the most common characteristics observed were masculine sex, age among 15-45 years, bite in low members, and injuries caused by snakes of the Bothrops genus. The signs and symptoms more frequently observed were edema, pain, erythema, and bleeding. The most observed systemic manifestation was alteration of blood coagulation. The most frequent complications were abscess, necrosis, bacterial infection, and renal failure. The mortality rate was 3%. These data are very important for the evaluation of the problem.

Th1 immune response to H. pylori infection varies according to the age of the patients and influences the gastric inflammatory patterns

To compare children and adults in respect to the effect of H. pylori infection on the gastric concentrations of cytokines linked to innate and Th1 immune response, as well as to investigate the changes in the gastric concentrations of the studied cytokines according to the age. We studied 245 children (142 H. pylori-negative and 103 H. pylori-positive) and 140 adults (40 H. pylori-negative and 100 H. pylori-positive). The gastric concentrations of cytokines representative of the innate and Th1 response were higher in the H. pylori-positive than in the -negative children and adults. The gastric concentrations of IL-1α and TNF-α were significantly higher, while those of IL-2, IL-12p70 and IFN-γ were lower in the infected children than in the infected adults. In the infected children, the gastric concentration of IL-1α, IL-2, IL-12p70 and IFN-γ increased, whereas in adults, the gastric concentrations of IFN-γ and IL-12p70 decreased with the aging. Increased gastric concentration of Th1 associated cytokines correlated with increased degree of gastritis that is the background lesion for the development of the H. pylori associated severe diseases. Concluding, Th1 response to H. pylori infection varies according to the age and seems to have determinant implication in the H. pylori infection outcomes.

Tratamento das estenoses esofágicas por dilatação endoscópica em crianças e adolescentes

OBJETIVO: Avaliar as causas de estenose esofagica em pacientes pediatricos e a resposta ao tratamento por dilatacao endoscopica nos diferentes grupos estudados. METODOS: Analise retrospectiva dos dados clinicos e endoscopicos de criancas e adolescentes com estenose esofagica tratadas por dilatacao endoscopica entre julho de 1993 e janeiro de 2003. RESULTADOS: Foram incluidos no estudo 125 pacientes, com idade entre 1 mes e 16 anos. Houve predominio das estenoses de causas cirurgica (43,2%), caustica (27,2%) e peptica (21,6%). O grupo com estenose esofagica caustica necessitou de maior numero de sessoes de dilatacao endoscopica. Cinco casos de perfuracao esofagica e um caso de hemorragia foram observados como complicacoes do procedimento. Houve boa resposta ao tratamento endoscopico em 74,4% dos casos, com melhores resultados nos pacientes com estenose esofagica peptica. CONCLUSOES: O tratamento endoscopico das estenoses esofagicas em criancas e adolescentes apresenta bons resultados e baixo indice de complicacoes. A estenose esofagica de etiologia caustica e a de morbidade mais elevada e com necessidade de maior numero de sessoes de dilatacao esofagica.

Increased Gastric IL-1β Concentration and Iron Deficiency Parameters in H. pylori Infected Children

Association between H. pylori infection, iron deficiency and iron deficiency anaemia has been described, but the mechanisms involved have not been established. We hypothesized that in H. pylori infected children increased gastric concentrations of IL-1β and/or TNF-α, both potent inhibitors of gastric acid secretion that is essential for iron absorption, are predictors for low blood concentrations of ferritin and haemoglobin, markers of early depletion of iron stores and anaemia, respectively. We evaluated 125 children undergoing endoscopy to clarify the origin of gastrointestinal symptoms. Gastric specimens were obtained for H. pylori status and cytokine evaluation and blood samples for determination of iron deficiency/iron deficiency anaemia parameters and IL1 cluster and TNFA polymorphisms that are associated with increased cytokine secretions. Higher IL-1β and TNF-α gastric concentrations were observed in H. pylori-positive (n = 47) than in -negative (n = 78) children. Multiple linear regression models revealed gastric IL-1β, but not TNF-α, as a significant predictor of low ferritin and haemoglobin concentrations; results were reproduced in young children in whom IL1RN polymorphic genotypes associated with higher gastric IL-1β expression and lower blood ferritin and haemoglobin concentrations. In conclusion, high gastric levels of IL-1β can be the link between H. pylori infection and iron deficiency/iron deficiency anaemia in childhood.

Ménétrièr disease in a pediatric patient with particular reference to echoendoscopy, endoscopic and anatomopathological presentation and evolutionary and therapeutic aspects

Ménétrier’s disease (MD) is included in the group of hypertrophic gastropathy; is a rare gastric hyperplasia that affects adults and children, with different behavior between these groups. We know that its etiology is related to allergens and co-infections. It’s characterized by the hypertrophy of the gastric folds, with the appearance of cerebral convolutions on Upper Gastrointestinal Endoscopy (UGE) and, histologically, by the mucosal hypertrophy at the expense of foveolar hyperplasia and atrophy of the glands in body and fundus of the stomach. The UGE together with the gastric tissue biopsy confirms the diagnosis. What concerns us in the following case, however, is patient’s long-lasting evolution, about eight years.