Helicobacter-pylori Negative Gastritis in Children—A New Clinical Enigma

The decrease in the prevalence of Helicobacter pylori (Hp) infection in children in the world gave rise to a new pathological finding termed as Hp-negative gastritis. Unfortunately, the term “Hp-negative gastritis” has not been identified as a pathological process and has the status of a “second cousin”; in most publications it was never mentioned as a subject to be dealt with, but was “left over” data that was never the topic of the manuscripts’ discussions. Only recently has the topic captured the attention of the pathologists who described this phenomenon in adults, yet the pathological and/or clinical spectrum or significance of this phenomenon has not been adequately investigated. In the current manuscript we describe Hp-negative gastritis in children, summarize its clinical prevalence and touch upon the possible etiology, pathology, and/or therapeutic implication. Overall, this review has concluded that Hp-negative gastritis is a pathological phenomenon in children that needs further investigation, and to date, as the title suggests, is a new clinical enigma that needs to be considered

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

Helicobacter pylori serology and the diagnosis of H. pylori infection in children

Serological screening accuracy rate may be dependent on clinical and pathological determinants. The aim of this study was to evaluate the accuracy of Hp serology test (Roche Biomedical Lab., Labcorp), In the diagnosis of Hp infection in 121 children who were seen in the Pediatric Gastoenterology Clinic at the Marshall University Joan C. Edwards School of Medicine In Huntington. Positive serology detected children with Hpassociated gastritis with a sensitivity of 51.6%. Positive serology significantly correlated with the degree of gastric inflammation and density of Hp organisms in the gastric mucosa (ANOVA p \u3c 0.001). The Labcorp. Hp-ELISA test had a poor accuracy rate for the detection of Hp-gastritis in children. Gastric biopsies should always be performed to establish the diagnosis of Hp infection in children

Local immune regulation of mucosal inflammation by tacrolimus

Purpose: Tacrolimus is a potent immunomodulator that is effective in the treatment of inflammatory bowel disease (IBD). However, potential toxicity and systemic effects with oral intake limit its use. Local tacrolimus treatment is effective in a subgrou

Safety of Infliximab in Children with IBD: The Experience of an Academic Center in WV

BACKGROUND: The immune-modulating drug, infliximab, is approved for Inflammatory Bowel Disease (IBD) treatment in children. Chronic therapy with infliximab is associated with the development of early and delayed infusion reactions. We reviewed our experience with infliximab treatment and its side effects in a cohort of children diagnosed with IBD who were treated in our clinic. METHODS: A retrospective analysis of all IBD children treated with infliximab in our center from 2006-2011 was performed. The demographic, chronological and clinical data were recorded. The infliximab infusion was given at 5mg/ kg according to a standard protocol after pre-treatment with low dose steroid and diphenhydramine. RESULTS: Of 30 IBD patients (23 CD/7 UC) receiving 454 infusions (341 CD/113 UC), six (20%) patients experienced early infusion reactions. Two (6.7%) patients had a delayed reaction; of those, both required intestinal resection. CONCLUSION: Our study is the first to address the safety of infliximab infusion reactions in children in the state of WV. Our results lend support to the use and safety of infliximab in children with moderate to severe IBD

Evaluation of invasive and non-invasive methods for the diagnosis of Helicobacter pylori infection in symptomatic children and adolescents

CONTEXT: Multiple diagnostic methods are available for the detection of Helicobacter pylori infection, but at present no single one can be used as the gold standard. OBJECTIVE: The aim of this study was to evaluate the diagnostic accuracy of 3 invasive and 2 non-invasive methods for detection of Helicobacter pylori infection in symptomatic children and adolescents. DESIGN: Prospective cohort study SETTING: Peptic Disease outpatients service, Discipline of Pediatric Gastroenterology, Universidade Federal de São Paulo (UNIFESP) / Escola Paulista de Medicina. PATIENTS: Forty-seven patients who underwent endoscopy because of dyspeptic symptoms. DIAGNOSTIC METHODS: Endoscopy with gastric biopsies for 3 invasive (rapid urease test, histology and culture) and 2 non-invasive methods (a commercial ELISA serology and 13carbon urea breath test - isotope ratio mass spectrometry) for detection of Helicobacter pylori infection. MAIN MEASUREMENTS: Sensitivity, specificity, positive and negative predictive values of each method and agreement and disagreement rates between the methods. RESULTS: Forty-seven patients [mean age, 11y9mo (SD 2y10mo), 27 female and 20 male]; 62% of them were Helicobacter pylori-positive. All methods agreed in 61%, and were negative in 21% and positive in 40%. The greatest concordance between 2 methods occurred between the invasive methods: histology and rapid urease test (89.6%) and histology and culture (87.5%). The greatest sensitivity, considering Helicobacter pylori-positive cases, for any combination of 3 or more tests, was achieved by the rapid urease test (S=100%), followed by histology, serology and 13carbon-urea breath test (S=93.1%) and lastly by culture (S=79.3%). The highest specificity was obtained by histology (100%) and culture (100%), followed by the rapid urease test (84.2%), serology (78.9%) and 13carbon-urea breath test (78.9%). CONCLUSIONS: Our results suggest that among invasive methods, an association between the rapid urease test and histology constituted the best choice for the detection of Helicobacter pylori infection. If results of histology and the rapid urease test are different, serology may be recommended.CONTEXTO: Vários métodos diagnósticos estão disponíveis para a detecção da infecção por Helicobacter pylori (Hp), porém, até o presente momento, não há um teste que possa ser utilizado isoladamente como padrão-ouro. OBJETIVO: Avaliar a acurácia de três métodos invasivos e dois não-invasivos na detecção da infecção por Hp em crianças e adolescentes sintomáticos. TIPO DE ESTUDO: Estudo coorte prospectivo. LOCAL: Ambulatório de Doença Péptica, Disciplina de Gastroenterologia Pediátrica, Universidade Federal de São Paulo (UNIFESP) / Escola Paulista de Medicina. PACIENTES: 47 pacientes sintomáticos que realizaram exame endoscópico devido a sintomas dispépticos. MÉTODOS DIAGNÓSTICOS: Exame endoscópico com biopsias gástricas para três métodos invasivos (teste rápido da urease, histologia e cultura) e dois métodos não-invasivos (teste sorológico ELISA industrializado e teste respiratório com uréia marcada com Carbono13). VARIÁVEIS ESTUDADAS: Sensibilidade, especificidade, valor preditivo positivo e negativo de cada método e taxas de concordância e discordância entre os métodos. RESULTADOS: 47 pacientes [idade média de 11a9m (DP 2a10m), 27 do sexo feminino e 20 do masculino], 62% deles com infecção por Hp. Todos os 5 métodos concordaram em 61%, sendo negativo em 21% e positivo em 40%. As maiores concordâncias entre dois métodos ocorreram entre os métodos invasivos: histologia e teste rápido da urease (89,6%) e entre a histologia e cultura (87,5%). A maior sensibilidade, considerando como Hp positivo, qualquer combinação de 3 ou mais testes, foi encontrada no teste rápido da urease (S=100%), seguido pela histologia, sorologia e o teste respiratório com uréia marcada com Carbono13 (S=93,1%) e por fim a cultura (S=79,3%). A maior especificidade foi obtida pela histologia e cultura (100%), seguidos pelo teste rápido da urease (84,2%), sorologia (78,9%) e teste respiratório com uréia marcada com Carbono13 (78,9%). CONCLUSÕES: Nossos resultados sugerem que, entre os métodos invasivos, a associação do teste rápido da urease e histologia constituem a melhor escolha para a detecção da infecção por Hp. Se os resultados da histologia e do teste rápido da urease forem discordantes é recomendada a sorologia.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Pediatric DepartmentUNIFESP, EPM, Pediatric DepartmentSciEL

Effect of Low-Carbohydrate, Unlimited Calorie Diet on the Treatment of Childhood Obesity: A Prospective Controlled Study

Background: Childhood obesity has been recognized as the new epidemic in developed countries. Caloric restriction with physical activity is the main therapeutic treatment available for these children. We compared two different dietary protocols to assess treatment efficacy. Methods: Obese children from the Pediatric Endocrinology clinic were prospectively recruited for the study. Children and their parents were allowed to choose one of two dietary protocols: (1) carbohydrate restricted diet (\u3c30 g/day), with unlimited calories, protein, and fat (High protein, Low CHO Diet), and (2) calorie restricted diet (Low Cal Diet). Anthropometric data were measured at baseline and at the 2 month follow up appointment. Results: Thirty-seven children completed the study of whom 27 chose High Protein, Low CHO Diet and 10 chose Low Cal diet. No differences in gender ratio, age, or BMI were observed at baseline. At 2 months, children in the High Protein, Low CHO Diet lost an average of 5.21 ± 3.44 kg (p \u3c 0.001) and decreased their BMI by 2.42 ± 1.3 points (p \u3c 0.001), compared to the children in the Low Cal Diet who gained an average of 2.36 ± 2.54 kg and 1.00 point on the BMI value (p \u3c 0.001). Conclusions: A high protein, low carbohydrate, unlimited calorie diet was superior to a restricted calorie protocol for weight loss in obese school age children; moreover, compliance was better

Role of Serum Biomarkers in Early Detection of Non-Alcoholic Steatohepatitis and Fibrosis in West Virginian Children

Background: Obesity, an epidemic among West Virginia children, as well as insulin resistance (IR), is wellestablished contributors to nonalcoholic steatohepatitis (NASH). Progression of NASH can lead to hepatic fibrosis and cirrhosis, making early detection imperative. The standard for diagnosing NASH is histologically via liver biopsy, which is highly invasive and generally contraindicated in children. By studying serum biomarkers associated with NASH, we aim to identify high risk children who can benefit from a less invasive, alternative approach to the early detection of NASH. Methods: Seventy one children were prospectively recruited and divided into 3 groups: normal weight without IR (control), obese without IR, and obese with IR. Serum samples were drawn for each patient and biomarker levels were assessed via ELISA kits. Results:Obese without IR and obese with IR patients had significantly elevated levels of lipid metabolism and accumulation markers (FGF-21, NEFA, FATP5, ApoB), oxidative stress markers (dysfunctional HDL, 8-Isoprostane), inflammatory markers(dysfunctional HDL, CK-18) and apoptosis markers (CK-18) compared to control patients (p\u3c0.02). Conclusion: This study showed a correlation between obesity, IR, and biomarkers associated with NASH in pediatrics patients from West Virginia, with obese with IR patients showing the strongest correlation. These findings support the clinical application of these serum biomarkers as a less invasive method for early detection of NASH and hepatic fibrosis

Sedation under JCI standard

The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents. In Korea, the Ministry of Health and Welfare developed new sedation standards for hospital evaluation, which is similar to the JCI standards. This review intends to help with the understanding of the JCI sedation standard and compare it to the Korean sedation standard

Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents ( Update 2016)

Background: Because of the changing epidemiology of Helicobacter pylori infection and low efficacy of currently recommended therapies, an update of the European Society for Paediatric Gastroenterology Hepatology and Nutrition/North American Society for Pediatric Gastroenterology, Hepatology and Nutrition recommendations for the diagnosis and management of H pylori infection in children and adolescents is required. Methods: Asystematic review of the literature (time period: 2009-2014) was performed. Representatives of both societies evaluated the quality of evidence using GRADE (Grading of Recommendation Assessment, Development, and Evaluation) to formulate recommendations, which were voted upon and finalized using a Delphi process and face-to-face meeting. Results: The consensus group recommended that invasive diagnostic testing for Hpylori be performed only when treatment will be offered if tests are positive. To reach the aim of a 90% eradication rate with initial therapy, antibiotics should be tailored according to susceptibility testing. Therapy should be administered for 14 days, emphasizing strict adherence. Clarithromycin-containing regimens should be restricted to children infected with susceptible strains. When antibiotic susceptibility profiles are not known, high-dose triple therapy with proton pump inhibitor, amoxicillin, and metronidazole for 14 days or bismuth-based quadruple therapy is recommended. Success of therapy should be monitored after 4 to 8 weeks by reliable noninvasive tests. Conclusions: The primary goal of clinical investigation is to identify the cause of upper gastrointestinal symptoms rather than H pylori infection. Therefore, we recommend against a test and treat strategy. Decreasing eradication rates with previously recommended treatments call for changes to first-line therapies and broader availability of culture or molecular-based testing to tailor treatment to the individual child