Yoram Elitsur

Helicobacter pylori diagnostic tests in children: review of the literature from 1999 to 2009

The array of tests that can be used for diagnosis of Helicobacter pylori infection is large, and it can be confusing to define which test to use particularly in children where results may not be comparable to those obtained in adult patients. Using PubMed, we reviewed the English literature from January 1999 to May 2009 to identify articles that determined sensitivity and specificity of H. pylori invasive and non-invasive diagnostic tests in children. We excluded articles that presented a review of the literature, abstracts, case reports, or series where children’s results could not be separated from adult populations. Of the tissue based methods, rapid urease tests have better sensitivity than histology to detect presence of H. pylori; however, histology can detect the pathology associated with disease including gastritis, intestinal metaplasia, and other conditions that could be the cause of the child’s symptoms. Culture of gastric tissues or stool has 100% specificity but sensitivity is low. Of the serologic tests, immunoblot has the best sensitivity. The urea breath tests have >75% sensitivity for detection of H. pylori before and after treatment. Immunoassays in stool using monoclonal antibodies have >95% sensitivity for detection of H. pylori before and after treatment. PCR testing can be performed in tissue and stool samples and can detect genes associated to antibiotic resistance. In summary, the current commercial non-invasive tests have adequate sensitivity and specificity for detecting the presence of H. pylori; however, endoscopy with histopathology is the only method that can detect H. pylori and lesions associated with the infection.

7216 Propofol sedation for endoscopic procedures in children.

We routinely suggest Propofol sedation to children whose parents refused conscious sedation or general anaesthesia with intubation. Aim: To evaluate the sedative efficacy of Propofol sedation during endoscopic procedures in children at our facility. Methods: The charts of children who underwent endoscopic procedures with Propofol sedation between 4/1998 to 8/1999 were reviewed. Midazolam and Fentanyl were used in conjunction with Propofol, upon the anaesthesiologists decision. Demographic, cardiovascular monitoring, and recovery time were recorded. Before discharge, children completed a questionnaire to evaluate their assessment of their sedation. Results: A total of 107 procedures were reviewed. Demographic, medication dose, and recovery time are shown in Table 1. Propofol dose was significantly reduced when Fentanyl (p=0.001), but not Midazolam (p=0.64), was added to the sedative protocol. No significant side effect from Propofol sedation was observed during the procedure. Sedation assessment by all participants was graded as excellent and none of the children had any recollection of the procedures. Conclusion: (1) Propofol sedation in children is adequate and safe. (2) Fentanyl has a synergistic effect to Propofol sedation. (3) Propofol sedation should be offered to children who are reluctant to have conscious sedation or tracheal intubation.

Eosinophilic esophagitis disease in children from West Virginia: a review of the last decade (1995-2004).

BACKGROUND:Eosinophilic esophagitis (EoE) is a newly established disease in adults and children. The incidence and prevalence of the disease among children from the United States are largely unknown. We examined the endoscopy reports of children who attended our gastroenterology clinic in the last 10 yr.MATERIALS AND  METHODS: A retrospective review of all diagnostic upper endoscopy procedures was executed between 1995–2004, of which a quarter (25%) per each year was randomly selected for pathological reevaluation of the number of Eos. The diagnosis of EoE was established when higher than 15 Es/hpf was detected in the esophageal biopsy; and the prevalence of EoE was calculated. The clinical symptoms, endoscopic presentation, and treatment of the patients with EoE disease were also reviewed.RESULTS:A total of 1,424 procedures were reviewed, of which 355 esophageal samples were reevaluated. During the study period, 44 patients were diagnosed with EoE. The prevalence rate of EoE disease was 0.73/10,000 children during the study period. Similar results were found when the number of Eos was established at >20 Es/hpf. Abdominal pain (55%), vomiting (43%), and heartburn (39%) were the most common symptoms, and characteristic mucosal appearance was found in only 11% of the patients.CONCLUSION:The rate of EoE in our pediatric patient population is low. Prospective studies are needed to establish the incident and prevalence of EoE disease in children living in the United States.

The seroprevalence of Helicobacter pylori in a referral population of children in the United States

OBJECTIVES:The purpose of this study was to determine the prevalence of serum antibodies directed against Helicobacter pylori (H. pylori) in children referred to childrens hospitals or medical centers throughout the United States.METHODS:This multisite cross-sectional prospective study involved 992 children from 12 states using a validated anti–H. pylori IgG enzyme immunoassay. The children were recruited into two groups: those without any GI complaints (non–GI referral, n = 619) and those who were referred for endoscopy because of abdominal pain (GI referral, n = 373).RESULTS:GI referral children had a higher rate of seropositivity (22.5%) than non–GI referral children (14.1%) from the same geographic regions. In both groups, older children were more likely to be seropositive for H. pylori, as were nonwhite children and those with lower socioeconomic status. H. pylori seropositivity rates were higher in GI referral children with four or more household members (relative risk [RR] = 1.47; CI 1.01–2.14). Multivariate analysis controlling for age, ethnicity, and household income, showed that presence of GI symptoms were associated with a nearly 2-fold risk for H. pylori seropositivity (odds ratio = 1.77, CI 1.27–2.47). Epigastric pain (RR = 2.21; CI = 1.33–3.66) and having three or more episodes of abdominal pain in the last 3 months (RR = 0.59, CI = 0.35–0.99) were the only specific symptoms significantly associated with H. pylori seropositivity.CONCLUSIONS:The H. pylori seropositivity rate of GI referral children with symptoms of abdominal pain was significantly higher. H. pylori infection in early childhood was found to be associated primarily with the childs household size and socioeconomic status.

Non-Helicobacter pylori Related Duodenal Ulcer Disease in Children

In spite of the worldwide distribution of Helicobacter pylori infection, recent data have reported an increased rate of non‐H. pylori, non‐NSAIDs‐duodenal ulcer disease in adults. The estimated rate of these ulcers in children is unknown. We aimed to investigate the prevalence of non‐H. pylori, non‐NSAIDs‐peptic ulcer disease in our pediatric patients who undergo upper endoscopic procedures.

Prevalence of CagA, VacA antibodies in symptomatic and asymptomatic children with Helicobacter pylori infection.

Background. Limited data are available on the prevalence of CagA and VacA Helicobacter pylori antibodies in children. The aim of this study was to investigate the antibody prevalence to the H. pylori virulence factors CagA and VacA in symptomatic and asymptomatic children with H. pylori infection and to correlate these antibodies with the severity of gastric inflammation or density of H. pylori organisms in the gastric mucosa.

Helicobacter pylori Infection Rate Decreases in Symptomatic Children : A Retrospective Analysis of 13 Years (1993-2005) From a Gastroenterology Clinic in West Virginia

Background The rate of Helicobacter pylori is decreasing in the developed countries, but few long-term studies are available from the United States. We retrospectively assessed the annual H. pylori infection rate in symptomatic children seen in our clinic over a 13-year study period. Study A retrospective analysis of all children who had histologic diagnosis of H. pylori infection between January 1993 and December 2005 in our pediatric gastroenterology clinic was performed. The annual infection rate and the overall infection rate were calculated. Results A total of 1743 upper endoscopy reports were reviewed, of which 212 (12.1%) were diagnosed with H. pylori infection. A significant decrease in mean annual H. pylori infection rate was noted in the last 6 years of the study period (2000 to 2005), compared with the first 7 years (1993 to 1999) (18.2% vs. 7.3%, respectively; P=0.001). Conclusions The incidence of H. pylori infection in symptomatic children in our clinic is decreasing. A national multicenter study will be needed to assess whether this drop is a local phenomenon or a national trend.

Stool consistency and stool frequency are excellent clinical markers for adequate colon preparation after polyethylene glycol 3350 cleansing protocol: a prospective clinical study in children

BACKGROUND Colon preparation for a colonoscopy in children is a difficult task because of the unpalatable taste and large volume of cleansing solution that needs to be consumed to ensure a clean colon. Consequently, an unprepared colon frequently occurs in routine practices, which causes early termination and a repeated procedure. OBJECTIVE (1) To assess the effectiveness of polyethylene glycol solution (PEG 3350) in preparing the colon of children scheduled for a colonoscopy and (2) to investigate clinical markers associated with an adequate colon preparation before a colonoscopy. PATIENTS A total of 167 children scheduled for a colonoscopy. DESIGN In a prospective study, children scheduled for a colonoscopy were given PEG 3350 solution (1.5 g/kg per day, up to 100 g/d) over a 4-day preparation period. Each day, a simple questionnaire that documents the amount of liquid consumed, adverse effects, and the number and consistency of stool was completed by the parents. After a colonoscopy procedure, the colon preparation was assigned a number grade. The data were later assessed and were compared to determine the association between the grade of cleansing and the frequency and/or consistency of stool during preparation. RESULTS Colon preparation was completed in 149 children, 133 of whom were adequately prepared. Inadequate preparation was found in 16 children; the procedure was terminated prematurely in 2 of these patients because of unacceptable conditions. No significant adverse effects were noted. A number of >or=5 stools/d, and liquid stool consistency in the last 2 days of preparation were associated with adequate colon preparation. CONCLUSIONS PEG 3350 solution is safe, efficacious, and tolerable for children. Stool frequency and consistency in the last 2 days of preparation were excellent markers (positive predictive value 91%-95%), which predict an adequately clean colon before a colonoscopy in children.

Urea breath test in children: the United States prospective, multicenter study.

Background: The urea breath test (UBT) is generally considered the gold standard for the diagnosis of Helicobacter pylori infections in adults.

Stool antigen test for diagnosis of Helicobacter pylori infection in Children with symptomatic disease: A prospective study

Objective: Noninvasive tests for the diagnosis of Helicobacter pylori (Hp) infection in children are limited by low accuracy rates and lack of validation. Existing studies indicate that the stool antigen test (HpSA) has an acceptable level of accuracy for the diagnosis of Hp infection in adults but not children. The aim of this study was to evaluate the accuracy of the HpSA test for the detection of Hp infection in U.S. children. Methods: Children requiring upper endoscopic procedures were prospectively recruited from two pediatric gastroenterology clinics. Stool samples were collected from each participant before endoscopy. The presence of Hp infection was determined by positive histologic findings and positive rapid urease test (RUT). The presence of Hp organisms in stool was determined by an enzyme-linked immunosorbent assay using a commercially available polyclonal antibody kit (Meridian Diagnostics, Cincinnati, OH, U.S.A.). Results of the stool antigen test were compared with histology findings and RUT results. Results: One hundred twenty-one children (mean age, 10.1 ± 3.7 years) participated, of whom 9 (7.4%) had Hp infection. Histologic findings and RUT results were concordant in 95% of the children. Per study protocol, HpSA had a sensitivity, specificity, positive and negative predictive value, and accuracy rate of 67%, 99%, 86%, 97%, and 96.5%, respectively. Conclusion: HpSA, a polyclonal antibody test, had a low sensitivity for infection in children in the United States and at present cannot replace histologic findings as the gold standard for the diagnosis of Hp infection in the pediatric population.