Wael El-Matary

Bone Mineral Density, Vitamin D, and Disease Activity in Children Newly Diagnosed with Inflammatory Bowel Disease

Background and AimThe aim of this study was to examine bone mineral density and serum 25-hydroxy vitamin D in relation to disease activity in children newly diagnosed with IBD.MethodsIn a cross-sectional analytic study, 60 children newly diagnosed with IBD (39 with Crohn’s disease [CD], mean age 12.2xa0±xa02.1xa0years; and 21 with ulcerative colitis [UC], mean age 12.4xa0±xa03.7xa0years) were recruited. Fifty-six age- and sex-matched children without IBD were invited as controls (mean age 11.3xa0±xa04.2xa0years). Serum 25-hydroxy vitamin D for patients and controls was measured at diagnosis. Patients’ adjusted lumbar spine bone mineral density (BMD) z scores were measured. Activity indices for both CD and UC were calculated.ResultsThe serum level of 25-hydroxy vitamin D was significantly lower in children with IBD compared to the control group (Pxa0=xa00.04). BMD was significantly lower in patients with CD compared to those with UC (Pxa0=xa00.039). There was no correlation between vitamin D levels, BMD z scores or disease activity indices for both CD and UC.ConclusionsSerum vitamin D level is significantly lower in children with newly diagnosed IBD compared to those without. However, vitamin D levels are not affected by disease severity. It seems that BMD status may not be affected by vitamin D levels or disease severity in this cohort. Larger prospective controlled studies are needed to confirm these findings.

Enteral feeding therapy for newly diagnosed pediatric Crohn's disease: a double-blind randomized controlled trial with two years follow-up

Background: This study compared the efficacy of an elemental formula (EF) to a polymeric formula (PF) in inducing remission for pediatric Crohns disease (CD). Methods: Newly diagnosed CD children were randomized to EF or PF for 6 weeks. Change in the Pediatric Crohns Disease Activity Index (PCDAI), fecal calprotectin, and plasma fatty acids were measured at 0 and 6 weeks. Patients were followed up for 2 years. Time and treatment choice for first relapse were documented. Results: Thirty‐four children completed the study; EF: 15 (7 M, 8 F), PF: 19 (13 M, 6 F). The mean age was (years) EF: 12.6, PF: 11.7. Ninety‐three percent of children (14/15) achieved remission in the EF group and 79% (15/19) in the PF group. One‐third of patients maintained remission for 2 years. Mean time to relapse (days); EF: 183 (63–286), PF: 162 (53–301). Most children who relapsed used feed as a treatment for that relapse (EF: 9/10 and PF: 8/13). With PF, an increase of eicosapentanoic acid (EPA) and alpha linolenic acid was found with a reciprocal decrease in arachidonic acid (AA). With EF, AA and EPA levels were reduced with a significant decrease in docosahexaenoic acid. Fecal calprotectin measurements decreased significantly but did not normalize at the end of week 6. Conclusions: There was no significant difference between EF and PF in inducing remission. One‐third of children maintained remission. Changes in plasma polyunsaturated fatty acid status were subtle and may be relevant; however, further evaluation is recommended. (Inflamm Bowel Dis 2011;)

Inflammatory bowel disease in children of Manitoba: 30 years' experience of a tertiary center.

Objectives: The aim of this study was to describe the incidence and prevalence of inflammatory bowel disease (IBD) in children <17 years of age in 30 years from 1978 to 2007. Methods: From January 1, 1978, to December 31, 2007, the sex- and age-adjusted annual incidence and prevalence of pediatric IBD per 100,000 population were calculated based on the pediatric IBD database of the only pediatric tertiary center in the province. The annual health statistics records for the Province of Manitoba were used to calculate population estimates for the participants. To ensure validity of data, the University of Manitoba IBD Epidemiology Database was analyzed for patients <17 years of age from 1989 to 2000. Results: The sex- and age-adjusted incidence of pediatric Crohn disease has increased from 1.2/100,000 in 1978 to 4.68/100,000 in 2007 (Pu200a<u200a0.001). For ulcerative colitis, the incidence has increased from 0.47/100,000 in 1978 to 1.64/100,000 in 2007 (Pu200a<u200a0.001). During the same time period, the prevalence of Crohn disease has increased from 3.1 to 18.9/100,000 (Pu200a<u200a0.001) and from 0.7 to 12.7/100,000 for ulcerative colitis (Pu200a<u200a0.001). During the last 5 years of the study the average annual incidence of IBD in urban patients was 8.69/100,000 as compared with 4.75/100,000 for rural patients (Pu200a<u200a0.001). Conclusions: The incidence and prevalence of pediatric IBD are increasing. The majority of patients were residents of urban Manitoba, confirming the important role of environmental factors in the etiopathogenesis of IBD.

Omeprazole-induced Hepatitis

Abstract: Omeprazole; the first proton pump inhibitor (PPI) showing an effective acid inhibitory ability, provides the satisfactory therapy either in gastro-esophageal reflux symptom relief or in healing of erosive esophagitis. Its also effective in peptic ulcer disease. Up to date, omeprazole efficacy and safety are well established in many trials. Omeprazole-related hepatotoxicity is not very well recognized especially in pediatric population. We report a child who developed hepatitis following omeprazole intake. We believe that this is the first case report of omeprazole-induced hepatitis in pediatric population.

Tufting enteropathy and skeletal dysplasia: is there a link?

IntroductionTufting enteropathy (intestinal epithelial dysplasia), a rare congenital enteropathy, presents in the first few months of life with chronic watery diarrhoea and impaired growth. The molecular basis for this condition is not known. We report our experience with a case of tufting enteropathy that developed an unusual skeletal dysplasia with an abnormal blood picture. After extensive investigations including repeated gastrointestinal endoscopies and biopsies, the diagnosis of tufting enteropathy was made. During the third year of her life, the patient’s height was static. A full skeletal survey was performed and demonstrated features of generalised skeletal dysplasia, some of them consistent with those of parastremmatic dwarfism. At the age of five years, she developed Coomb’s positive haemolytic anaemia and thrombocytopenia with a negative auto-antibody screen including anti-enterocyte antibodies.ConclusionThere might be generalised matrix (including cartilage matrix protein), basement membrane abnormalities or both. A secondary protein leak might occur in the intestine with autosensitisation and development of autoimmune phenomena. More molecular research is needed to identify a possible link.

Corrigendum: Rural and Urban Residence During Early Life Is Associated with a Lower Risk of Inflammatory Bowel Disease: A Population-Based Inception and Birth Cohort Study.

Objectives:To determine the association between inflammatory bowel disease (IBD) and rural/urban household at the time of diagnosis, or within the first 5 years (y) of life.Methods:Population-based cohorts of residents of four Canadian provinces were created using health administrative data. Rural/urban status was derived from postal codes based on population density and distance to metropolitan areas. Validated algorithms identified all incident IBD cases from administrative data (Alberta: 1999–2008, Manitoba and Ontario: 1999–2010, and Nova Scotia: 2000–2008). We determined sex-standardized incidence (per 100,000 patient-years) and incident rate ratios (IRR) using Poisson regression. A birth cohort was created of children in whom full administrative data were available from birth (Alberta 1996–2010, Manitoba 1988–2010, and Ontario 1991–2010). IRR was calculated for residents who lived continuously in rural/urban households during each of the first 5 years of life.Results:There were 6,662 rural residents and 38,905 urban residents with IBD. Incidence of IBD per 100,000 was 33.16 (95% CI 27.24–39.08) in urban residents, and 30.72 (95% CI 23.81–37.64) in rural residents (IRR 0.90, 95% CI 0.81–0.99). The protective association was strongest in children <10 years (IRR 0.58, 95% CI 0.43–0.73) and 10–17.9 years (IRR 0.72, 95% CI 0.64–0.81). In the birth cohort, comprising 331 rural and 2,302 urban residents, rurality in the first 1–5 years of life was associated with lower risk of IBD (IRR 0.75–0.78).Conclusions:People living in rural households had lower risk of developing IBD. This association is strongest in young children and adolescents, and in children exposed to the rural environment early in life.

Eosinophilic esophagitis in children needing emergency endoscopy for foreign body and food bolus impaction.

Objective The objective of this study was to examine the prevalence of eosinophilic esophagitis (EoE) in children presenting with esophageal foreign body (FB)/food bolus impaction. Methods A retrospective chart review for all children who underwent endoscopic esophageal FB extraction at the Stollery Children’s Hospital between January 2005 and December 2008 was performed. The prevalence of EoE and characteristics of children who had EoE were documented. Results A total of 140 children (mean age, 4.98 [SD, 4] years; range, 0.3–16.9 years; 81 boys) had esophageal FB/food impaction and needed endoscopic removal over the study period. Eleven children (mean age, 9.38 [SD, 5.35] years; range, 1.9–16.2 years; 8 boys) were diagnosed with EoE (8%). Seven (39%) of 18 children with food impaction were diagnosed with EoE. Four (3%) of 122 children with esophageal foreign bodies other than food had EoE. Conclusions Considerable number of children with esophageal FB/food bolus impaction may have EoE. Routine sampling of esophageal mucosa at different levels during esophageal FB extraction may be considered. Well-designed prospective studies with multiple-level esophageal biopsies taken from all children with FB/food impaction are needed to confirm our results.

Successful conservative management of idiopathic fibrosing pancreatitis in children.

Idiopathic fibrosing pancreatitis, a rare cause of obstructive jaundice and abdominal pain in children, which has certain features in common with the emerging entity of autoimmune pancreatitis as described in adults, has frequently been managed surgically. We present our experience of successful conservative management of this condition in children. Three children (6–12xa0years; two girls, one boy) presented with a short history of abdominal pain followed by obstructive jaundice. Abdominal ultrasonographic examination in each case showed dilated intrahepatic and common bile ducts with a bulky pancreas, predominantly the head. These findings were confirmed by magnetic resonance imaging. In two cases, the diagnosis of fibrosing pancreatitis was made by exclusion after extensive investigation. The third case had a percutaneous ultrasound-guided pancreatic needle biopsy. Two patients were managed by supportive medical therapy alone, whilst the third, with symptomatic obstructive jaundice, underwent temporary endoscopic stenting of the common bile duct. Cases have been followed-up for 12–49xa0months. There was complete clinical and biochemical resolution of obstructive jaundice in all three cases. Plasma bilirubin concentrations decreased to normal within 3–8xa0weeks. Serial abdominal imaging showed a gradual resolution of biliary dilatation and abnormal pancreatic morphology with subsequent pancreatic atrophy. Two children developed steatorrhoea that responded to pancreatic enzyme supplements, and one patient developed diabetes mellitus. None of the cases needed invasive surgery for diagnosis or management. Conclusion: With careful radiological and biochemical assessment and monitoring, invasive surgery can be avoided in the management of fibrosing pancreatitis. The eventual outcome is no different from reported surgically treated cases.

Histiocytic sarcoma presenting with chylous ascites in a 7-month-old infant: a case report.

We describe in this report what we believe to be the first report of a rare presentation of a very rare tumor, especially in this age group. We highlight the importance of early consideration of malignancy as a cause of chylous ascites in infancy and we discuss different causes of chylous ascites.

Prevalence of Peripheral Eosinophilia at Diagnosis in Children With Inflammatory Bowel Disease.

Background and Objective: Inflammatory bowel disease (IBD) encompasses 2 disorders of unknown etiology: Crohn disease (CD) and ulcerative colitis (UC). There has been a continuous search for markers for disease activity. Eosinophils are granulocytic leukocytes that are implicated in the pathogenesis of IBD. The aim of this study was to examine the prevalence and significance of peripheral eosinophilia (PE) at diagnosis in children with IBD. Methods: A comprehensive chart review of all children with diagnosed as having IBD between January 2006 and August 2014 was performed. Patients with PE at diagnosis were compared with those without in relation to disease clinical activity and disease course. Results: A total of 109 children (mean age 14.6 ± 2.77, range 4.5–17.9 years, 55 boys) with IBD (68 with CD and 41 with UC) who were studied for a mean duration of 2.82 ± 1.89 (range 0.1–9.2 years) were identified. At diagnosis, 44 (40.4%) children had PE, which was more prevalent in patients with UC compared with those with CD (61.3% vs 36.3%, Pu200a<u200a0.05). At diagnosis, PE was more common in patients with high eosinophilic count in colonic biopsy samples (Pu200a<u200a0.01) and was significantly associated with disease activity as indicated by Pediatric CD Activity Index for children with CD (Pu200a<u200a0.05), Pediatric UC Activity Index for children with UC (Pu200a<u200a0.01). Conclusions: PE is a common finding at diagnosis in children with IBD especially in those with UC. Patients with PE at diagnosis are more likely to present with higher clinical activity indices. PE is associated with more eosinophils in colonic biopsy samples.