Biomedical subjects
Publications and source records attributed to E Hassall.
This article focuses on the special features of esophageal stenosis which pertain to children. In order to focus on stenoses intrinsic to the esophagus, esophageal stenosis due to extrinsic compression is excluded. While the causes of esophageal stenosis may be grouped as either congenital or acquired, congenital causes account for less than 5% of cases.
Regurgitation is a common manifestation in infants below the age of 1 year and a frequent reason of counselling of general practitioners and paediatricians. Current management starts with postural and dietary measures, followed by antacids and prokinetics. Recent issues such as an increased risk of sudden infant death in the prone sleeping position and persistent occult gastro-oesophageal reflux in a subset of infants receiving milk thickeners or thickened "anti-regurgitation formula" challenge the established approach. Therefore, the clinical practices for management of infant regurgitation have been critically evaluated with respect to their efficacy, safety and practical implications. The updated recommendations reached by the working party on the management of infant regurgitation contain five phases: (1 A) parental reassurance; (1 B) milk-thickening agents; (2) prokinetics; (3) positional therapy as an adjuvant therapy; (4 A) H2-blockers; (4 B) proton pump inhibitors; (5) surgery.
Children with columnar-lined esophagus (CLE) become adults with CLE. Therefore, an understanding of the disorder as it occurs in children may be important for physicians caring for adults with CLE and for pediatric gastroenterologists and surgeons. Although there are many features of CLE common to children and adults, this article focuses on those special features of CLE in children and the issues that pertain particularly to children.
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UNLABELLED: Successful eradication of Helicobacter pylori infection in children has required long treatment regimens that may result in noncompliance with failure to eradicate this organism. Despite full compliance with shorter therapeutic regimens, such as amoxycillin and omeprazole for 2 wk, the H. pylori eradication rate is poor in children. OBJECTIVES: The aim of this study was to evaluate the efficacy of, and compliance with, a 2-wk treatment with metronidazole, omeprazole, and clarithromycin in eradicating H. pylori disease in children. METHODS: Over a 15-month period, children diagnosed to be H. pylori positive by Steiner's stain of gastric antral biopsy specimens were treated with metronidazole, omeprazole, and clarithromycin. Follow-up upper GI endoscopy was performed 6-8 wk after completion of therapy. RESULTS: Of 15 patients with H. pylori-positive antral gastritis, 11 had duodenal ulcer disease; three patients with severe abdominal pain and one with vomiting had H. pylori gastritis only. H. pylori eradication was seen in 11 of 11 (100%) patients with duodenal ulcer disease and in three of four (75%) with gastritis only; the overall success rate was 93%. Duodenal ulcer disease healed when H. pylori was eradicated in all but one patient, who at presentation had a penetrating ulcer with a duodenobiliary fistula. Fourteen of 15 patients (93%) were fully compliant, and no adverse reactions were reported. CONCLUSIONS: Two weeks of therapy with metronidazole, omeprazole, and clarithromycin is effective H. pylori therapy in children. It is well tolerated, and full compliance can be achieved.
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Regurgitation in infants is a common problem. Recent issues, such as the increased risk of sudden infant death in the prone sleeping position, the finding of persisting occult gastro-oesophageal reflux with feed thickeners, and the increasing awareness of the cost-benefit ratio of medications may challenge the currently recommended management approach. A round table was organized to elaborate on the impact of (i) the pro supine sleeping campaigns in relation to sudden infant death and (ii) advancement in medical treatment on therapeutic strategies in regurgitating infants. The participants were opinion leaders from Europe and North America (Belgium, Canada, France, UK, Italy, Switzerland and The Netherlands). The importance of parental reassurance is stressed. As a consequence of the supine sleeping campaigns aiming to decrease the incidence of sudden infant death syndrome, the "prone elevated sleeping position" is no longer advised as a first-line therapeutic approach, although it is still recommended in "complicated reflux". It is emphasized that milk thickeners are an adequate therapeutic tool for regurgitation, but not in reflux disease. According to the literature, the efficacy of (alginate )antacids, although very popular in some countries, is questionable. These recommendations will be of interest to first-line paediatricians, since about 40% of their patients, according to the literature, present because of regurgitation.
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OBJECTIVES: This prospective, open trial of treatment was conducted to determine whether cyclosporine A (CSA) is effective in inducing remission in children with severe, active Crohn's colitis refractory to other medical treatment and if remission may be maintained by 6-mercaptopurine (6-MP) and 5-aminosalicylic acid (5-ASA) after discontinuing CSA. METHODS: Ten children (five males, five females), ages 1.2-16 yr (mean 11), all had failed to respond to 4 wk of treatment with i.v. methylprednisolone and total parenteral nutrition/elemental diet; three were already receiving 6-mercaptopurine. CSA was initially given as a twice daily i.v. dosage and was switched to oral CSA when a clinical response was observed. At the same time, corticosteroids were switched to the oral route and tapered over the next 3 months. Patients were grouped by treatment outcome. "Responders" were those who achieved remission with i.v. CSA therapy, "relapsers" were those who achieved remission with i.v. CSA but relapsed later, and nonresponders had not achieved remission after 4 wk of i.v. CSA. Responders were given 6-MP with intent to discontinue CSA after 6 months and maintain remission by 6-MP and 5-ASA. RESULTS: There were seven responders to CSA. For all patients, the Pediatric Crohn's Disease Activity Index (PCDAI) (score range 0-100) had a mean value of 55 (range 40-65) just before treatment; PCDAI improved to a mean of 19 (range 5-42.5) after 2 wk of CSA therapy. Four of the seven responders discontinued CSA after 6 months and remain well on 6-MP and 5ASA alone for 22, 13, 8, and 3 months. One patient had massive GI bleeding (from active Crohn's colitis), which stopped within 48 h of CSA treatment. There were three relapsers (at 2-6 months of CSA), and three were nonresponders. Three patients who were already receiving 6-MP before CSA therapy either did not respond to CSA or relapsed while receiving it. The six nonresponders and relapsers required surgical resection. Transient side effects included hypertension responding to nifedipine in one child and hirsutism and tremors in another. CONCLUSIONS: We conclude that CSA offers a good remission rate for children with severe Crohn's colitis failing other medical treatment, although relapse was common especially if the child was already on 6-MP. In addition, CSA may offer "temporizing" therapy in severe, active Crohn's colitis; this may allow surgery to be performed electively, with time for psychosocial and nutritional preparation before surgery.
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OBJECTIVES: To evaluate the safety of gastrostomy tube (G-tube) placement in children with Crohn's disease and the efficacy of prolonged enteral hyperalimentation in children with growth failure complicating Crohn's disease. METHODS: Twenty children with Crohn's disease and growth failure were offered enteral hyperalimentation via nasogastric tube (NG-tube) for treatment of growth arrest, with follow-up for complications, compliance, and response to nutritional support. The use of a G-tube was offered to children who refused to use the NG-tube. Medical and surgical management were provided as dictated by the disease activity. RESULTS: Thirteen children were started on NG-tube feeds, and five were started on G-tube feeds after refusal to use an NG-tube at the outset. Two children required surgery at the time of diagnosis and had a G-tube placed during the operation. Nine of 13 children found the use of an NG-tube too disruptive and were later changed to a percutaneous endoscopic gastrostomy (PEG) or surgically-placed G-tube. A total of 16 children had a percutaneous endoscopic gastrostomy (eight children) or a surgically-placed G-tube (eight children) for 6-29 months. Two of those children had endoscopic evidence of gastroduodenal Crohn's disease, and six had microscopic patchy chronic gastritis. Minor complications occurred in five of the 16, including external leakage, button dislodgement, local pain, and local wound infection. At this time, the G-tube has been removed from 13 children, 12 of whom had prompt and complete healing of the G-tube site and one of whom had a small gastrocutaneous fistula that required suture for successful closure. Poor compliance with G-tube feeds was observed in four of 16 children. During the period of nutritional support, there was resumption of normal growth rates for all; in addition, eight of 16 had catch-up growth. CONCLUSION: Nutritional therapy is important in the management of children with growth failure due to Crohn's disease, though it may not be the only factor affecting growth. G-tubes are safe and well tolerated by children with Crohn's disease and should be offered to those children who do not tolerate prolonged use of an NG-tube.
For over 20 yr, antireflux surgery has been the treatment of choice for severe gastroesophageal (GE) reflux disease in children, and antireflux operations are said to be the commonest major surgical procedures performed by pediatric surgeons in North America. Yet, only recently have the results of surgery been more closely examined; both the surgical morbidity and operative failure rates have been found to be particularly high in children with neurological impairment, repaired esophageal atresia, and chronic lung disease. Of interest, these groups of children are among those most at risk for developing severe GE reflux disease in the first place. Close examination of surgical reports also raises some questions about the indications for surgery in some children, specifically whether the presence of severe GE reflux disease had been established before surgery and whether a trial of appropriate medical management had been given. Failure of medical management has always been an accepted indication for surgery. However, in the past the medical management that was available for children was ineffective because drug dosages were not optimized (H2-receptor antagonists), the drugs had side effects precluding their use long term or in high doses (bethanechol, metoclopramide), or they were simply insufficiently potent to treat severe GE reflux disease (all the above drugs plus cisapride). Thus, in the past, failure of medical management did not mean failure of very much. In contrast, the proton pump inhibitor omeprazole has recently been shown to be effective and safe for the treatment of severe childhood GE reflux disease refractory to other medical treatments and where antireflux surgery has failed. The issues of why certain groups of children are at highest risk for severe GE reflux disease are discussed as are the outcomes and roles of surgical and medical treatment for all groups of children with severe GE reflux disease. The options of antireflux surgery or omeprazole should be reserved for those children with severe GE reflux disease, e.g., GE reflux accompanied by a complication.
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As an alternative to surgical splenectomy, partial splenic embolization was performed in seven children for hypersplenism manifested by splenomegaly, thrombocytopenia, leukopenia, and erythrocyte hemolysis. Within a few days, platelet and leukocyte counts rose significantly in all patients and were maintained in six of seven patients during a follow-up period of 9 to 69 months. Spleen size and abdominal distention also decreased significantly in all children. There were no infectious complications.
The purpose of this study was to collect prospective data regarding the quality, extent, and duration of pediatric pancolonoscopy performed by pediatric gastroenterology attending physicians and a fellow in training. Over 7 months, data were prospectively collected on 40 colonoscopic procedures. The cecum was reached in 37 cases (92.5%) and the terminal ileum in 35 cases (87.5%). When cases of stricture and equipment failure were excluded, these completion rates were 97 and 95%, respectively. The overall average duration for pancolonoscopy, ileoscopy, multiple biopsies, and polypectomy (where necessary) was 38 min. When attending physicians performed the procedure, the duration was 31 min; the duration was 37 min when the fellow completed the procedure and 45 min when the fellow required the attending physician to complete it. The average time taken to reach the cecum by the attending physician was 19 min (range, 8-32); by the fellow it was 25 min (range, 17-32), and by the combination it was 37 min (range, 11-59). The average time from cecum to terminal ileum was 3 min for all, with ranges of 1-12 min for the attending physician and 1-23 min for the fellow. The fellow initiated 24 procedures, of which the attending physician was required to complete 12, including all five procedures performed in the initial 2 months of the study, 7 of 13 in the next 3 months, and none of the six procedures in the last 2 months. Of the 40 examinations, the colon was normal in five (12.5%), and a specific diagnosis was made in 35.(ABSTRACT TRUNCATED AT 250 WORDS)
The nonsurgical management of portal hypertension in infants and children has undergone dramatic changes with the advent of endoscopic injection sclerotherapy and variceal ligation. Additional newer therapeutic interventions include radiographic transhepatic obliteration of vessels and angiographic portosystemic shunts. Adjunctive drug therapy is helpful in selected cases. Physicians managing infants and children with varices must understand the nature of portal hypertension in younger patients and the limitations of the therapeutic modalities.