Stuart Berezin

Fructose intolerance in children presenting with abdominal pain.

Objectives: We determined the occurrence of fructose malabsorption in pediatric patients with previous diagnoses of abdominal pain caused by a functional bowel disorder, whether the restriction of fructose intake changes the reporting of symptoms, the role of fructose dosage, and the severity of resultant symptoms. Patients and Methods: We administered a fructose breath test to children presenting with persistent unexplained abdominal pain. Patients randomly received 1, 15, or 45 g fructose, and breath hydrogen was measured for 3 hours after ingestion. Test results were positive when breath hydrogen was 20 ppm greater than baseline and was accompanied by gastrointestinal symptoms. Results: A total of 32 patients was enrolled, and none of the 9 who received 1 g had positive results. Three of 10 who received 15 g and 8 of 13 who received 45 g had positive results. All patients with positive test results restricted their fructose intake. Among the group with positive results, 9 of 11 had rapid improvement of their gastrointestinal symptoms. After 2 months, all 9 patients continued to report improvement. Conclusions: We concluded that fructose malabsorption may be a significant problem in children and that management of dietary intake can be effective in reducing gastrointestinal symptoms.

Campylobacter pylori-related gastrointestinal disease in children

Over a one-year period, 95 children and adolescents presenting with epigastric pain and/or vomiting, and without associated risk factors for development of peptic disease, underwent endoscopic antral biopsies for pathologic diagnosis and to detect presence of Campylobacterss. pylori (C. pylori). Additional biopsies of the esophagus, stomach, and duodenum were obtained for histologic evaluation. C. pylori was identified in 16 patients (16.8%), all of whom had evidence of acute and/or chronic gastritis. Significant discriminating factors between C. pylori-positive and -negative subjects included age at presentation (positive vs negative=14.6 vs 9.9 years, P<0.01, biopsy-confirmed gastritis (100% vs 30.4%, P<0.001), and diagnosis of duodenitis alone (0% vs 46.8%, P<0.001). Risk for bacterial colonization was significantly higher in the presence of endoscopic gastritis (P<0.001). Among C. pylori-positive patients, none responded to standard antiulcer therapy (H2-receptor antagonists, antacids). Symptomatic and histologic remission was achieved utilizing combined therapy with bismuth subsalicylate and antibiotics. Seven of 79 C. pylori-negative patients with biopsyproven gastritis who responded poorly to antisecretory therapy had the organism identified in follow-up antral biopsies; these patients improved clinically following treatment for C. pylori. These data suggest that C. pylori is a significant factor in the etiology of upper gastrointestinal tract inflammatory disease in pediatrics, and presence of the organism should be evaluated, particularly in children with evidence of acute and/or chronic gastritis.

Esophageal food impaction in children.

Objectives To determine the clinical presentation, radiographic, endoscopic and manometric findings, and clinical outcome of esophageal food impaction (EFI) in pediatric patients. Methods We retrospectively reviewed the clinical course of 12 pediatric patients with EFI over a 10-year period. Results All 12 patients described initially presented to our emergency department for care. Four patients (25%) required previous endoscopic intervention for disimpaction of EFI. Eleven required endoscopic removal of their EFI, and 1 patient’s food impaction resolved spontaneously. The mean duration of food impaction was 20 hours prior to endoscopic intervention. Endoscopy demonstrated an esophageal stricture in 1 patient with a history of trisomy 21 and tracheoesophageal fistula repair. While there was no visual evidence of esophagitis in any patient, 5 of 7 had histologic evidence of esophagitis. Upper gastrointestinal series demonstrated the esophagus to be anatomically normal in 10 of 12 patients (83%); 1 patient had an esophageal stricture and another an esophageal web. Four of 8 patients studied had nonspecific esophageal motility abnormalities. Conclusions EFI in children is not generally associated with underlying esophageal anatomic abnormalities. Esophagitis and nonspecific esophageal motility disorder abnormalities may be etiologic factors. Endoscopic removal of the EFI was safe and effective and is recommended as there is little likelihood of spontaneous resolution of EFI in children.

Patterns of gastroesophageal reflux (GER) in patients with apparent life-threatening events.

The incidence and temporal patterns of gastroesophageal reflux (GER) in infants presenting with an apparent life-threatening event (ALTE) was compared with GER characteristics of infants evaluated for persistent emesis, utilizing continuous 24 h intraesophageal pH monitoring. These data indicate that the incidence of significant GER was similar in both groups, despite the absence of a clinical vomiting history in 46% of ALTE patients. Furthermore, infants with ALTE demonstrate a significantly higher incidence of steep reflux when compared with control infants presenting with vomiting alone (27 vs. 0%, p < 0.001). Awake GER beyond the first two postprandial hours was not observed in either study group. Monitoring results, therefore, indicate that significant GER is common in infants with ALTE; and these infants manifest an apparently unique pattern of GER distinct from that observed in age-matched controls with GER alone. Possible relationships between GER in ALTE patients and the development/onset of apneic episodes are discussed.

Spectrum of esophageal disorders in children with chest pain

The charts of 83 children with chest pain who underwent esophageal manometry followed by esophagogastroscopy were reviewed. Forty-seven (57%) had normal esophageal histology and normal motility (group I). Esophagitis and normal motility were demonstrated in 15 children (group II), normal esophageal histology and esophageal dysmotility in 13 (group III), and both esophagitis and abnormal motility in 8 (group IV). Diffuse esophageal spasm and achalasia were the most common motility disorders identified (in seven and four patients, respectively). The presence and duration of symptoms, the age, and the gender were not different among the four patient groups. After six months of H2-receptor blockade, 12 of 15 group II patients were asymptomatic, whereas a significantly smaller percentage (five of 18) of patients with abnormal esophageal motility responded to esophageal dilation or treatment with calcium channel blockade, H2-receptor antagonist, and/or prokinetic agents (P<0.01). These data suggest that the evaluation of children with chest pain should include esophageal motility testing and esophagoscopy, even in the absence of other gastrointestinal-associated symptoms, and that while treatment of esophagitis results in resolution of symptoms, motility disorders were relatively refractory to therapy.

Nonspecific esophageal motility disorders in children without gastroesophageal reflux.

BACKGROUND Nonspecific esophageal motility disorders (NEMDs) have been identified in up to 50% of adults with noncardiac chest pain or dysphagia. This study sought to determine the incidence of NEMDs in children with upper gastrointestinal tract symptoms and to evaluate the clinical course of pediatric patients with these manometric abnormalities. METHODS The study involved 154 children aged 4 to 18 years (mean age, 11.6+/-2.6 years [SE]) who had upper gastrointestinal, swallowing-related symptoms. The children were evaluated by 24-hour intraesophageal pH monitoring, esophageal manometry, and esophagogastroduodenoscopy. RESULTS Gastroesophageal reflux (GER) was diagnosed by pH study in 109 (71%) of 154 patients, and examination of biopsy specimens demonstrated esophagitis in 70 children with GER. Results of esophageal manometry were abnormal in 30 (67%) of 45 children without GER. A variety of motility disorders were diagnosed in 17 of the patients without GER, whereas NEMDs were diagnosed in the remaining 13 children (mean age, 10.6+/-2.7 years; 10 boys, 3 girls). Patients with GER showed normal esophageal wave propagation; however, mean lower esophageal sphincter pressure was significantly lower in patients with GER than in children with NEMDs. The children with NEMDs exhibited a diverse array of symptoms, including esophageal food impaction in 4 of the 13 patients. During a 36.2+/-4.3-month follow-up period, no correlation was found between therapeutic intervention and clinical course in the 13 patients with NEMDs. Symptomatic improvement occurred in 6 of 13 patients, including 3 children for whom no pharmacologic therapy was prescribed. CONCLUSIONS These data indicate that NEMDs represent a common group of esophageal manometric abnormalities in children with upper gastrointestinal tract symptoms and without GER. Food impaction appears to be a relatively frequent complication, and NEMDs should be considered in children who have this finding.

Esophagitis as a cause of infant colic

once a day. Fourteen of the 18 patients had been tried on a hydrolyzed casein formula for at least 1 week without improvement. Parental counseling, as previously described by Taubman,4 had been tried for each patient without a decrease in crying time. Esophagogastroduodenoscopy (EGD) was performed in each patient using a flexible Olympus XP10 endoscope (Olympus Corp., Lake Success, New York) after intravenous sedation with meperidine (1 mg/kg) or after receiving chloral hydrate 50-75 mg/kg 1 hour prior to the procedure. Esophagitis was diagnosed endoscopically by the presence of friability, erythema, ulceration, or granularity. Biopsies were taken under di-

Treatment of Helicobacter pylori-associated gastroduodenal disease in children : clinical evaluation of antisecretory vs antibacterial therapy

The charts of 54 children diagnosed with antral H. pylori were reviewed, to establish the incidence of gastroduodenal inflammation and compare therapeutic efficacies of antisecretory vs. antibacterial therapy. Histology demonstrated normal mucosa in three cases (6%) and gastric/duodenal inflammation (> or = Whitehead grade 3) in 51 biopsies (94%). 23/43 children (53%) initially responded to H2-blockers; however, by 10 mo, 13 had relapsed clinically. All of these patients subsequently responded to amoxicillin plus bismuth subsalicylate. Of the 20 children who failed to enter remission after an initial course of H2-blockers, all became symptom-free after treatment with amoxicillin/bismuth. Compared to antisecretory agents, antibacterial treatment induced clinical remission in 11/11 patients (p < 0.001), who remained symptom-free for 10 +/- 0.2 mo. Clinical remissions were maintained in significantly more patients following amoxicillin/bismuth vs. H2-blockers (44/54 vs. 10/43 courses, p < 0.001); and, the cumulative probability of remaining asymptomatic was significantly greater in the antibiotic group (p < 0.001). These data suggest that gastric colonization by H. pylori is highly predictive of mucosal pathology in children. Initial therapy should be directed toward achieving bacterial eradication, as opposed to gastric acid suppression.

Noncardiac chest pain in adolescents and children with mitral valve prolapse

Chest pain in adolescents and children is usually not of cardiac origin. Of cardiac conditions commonly linked to chest pain in childhood, mitral valve prolapse (MVP) is the most prevalent, but this association has recently been questioned. In light of recent reports of gastroesophageal sources of chest pain in adults with MVP, we performed a comprehensive gastroesophageal evaluation of 17 preadolescents and adolescents with mitral valve prolapse who had chest pain as their presenting symptom. Evaluation consisted of esophageal manometry, Bernstein test, esophageal pH probe, and/or esophagogastroscopy. Fourteen of the 17 patients had at least one abnormal finding. Five patients had esophagitis, five had gastritis, one had high-amplitude esophageal contractions, one had abnormal esophageal manometry with positive Bernstein test, one had esophageal reflux and positive Bernstein test, and one had abnormal manometry with esophageal reflux. The 13 patients with esophagitis, gastritis, reflux, or positive Bernstein test were treated with antacid, with resolution of chest pain in 12 patients. Two of these patients underwent follow-up endoscopy with documentation of improvement. The patient with high-amplitude esophageal contractions was treated with dicyclomine, which resulted in resolution of chest pain. The observation that the chest pain was not related to mitral valve prolapse is important in clinical practice and raises further questions as to whether mitral valve prolapse causes chest pain.

Esophageal chest pain in children with asthma.

Sixteen patients with asthma and chest pain of >2 months duration underwent gastroenterological evaluation utilizing fiber-optic esophagogastroduodenoscopy (EGD), esophageal manometry, and Bernstein testing. Eleven of 16 patients (75%) had endoscopic and histologic evidence of esophagitis. One patient with esophagitis exhibited high-amplitude peristaltic contractions during motility testing. Four of these 11 patients (36%) had a positive Bernstein test. Extended intraesophageal pH monitoring of seven patients with esophagitis revealed significant gastroesophageal reflux (GER) in all of these patients. Chest pain was associated with an episode of GER in three patients (43%). Nine of 11 patients (82%) with esophagitis responded to medical therapy, resulting in resolution of esophageal inflammation and chest pain. One patient required Nissen fundoplication surgery after failure of medical therapy, and one patient who refused surgery progressively developed more severe esophagitis during 9 months of medical therapy. Children with asthma may have chest pain due to gastroesophageal reflux-associated esophagitis that usually responds to medical therapy.