Pediatr Gastroenterol Nutr Research Articles

Inflammatory Bowel Disease in Pediatric Age

Inflammatory bowel disease in children shows the rising incidence with evidence of more CD than UC. So the clinical field of childhood IBD is evolving. Recognition of the rising incidence and other epidemiologic results will have important implications for diagnosis and management of inflammatory bowel disease in children. The clinical characteristics of IBD developing in pediatric age somewhat differs from that in adult. This review had been summarized that the incidence, clinical manifestations, practical diagnosis, and utilization of non invasive disease activity index of IBD in pediatric age. (Korean J Pediatr Gastroenterol Nutr 2011; 14(Suppl 1): S34∼S41)

A Child with Abdominal Pain, Headache, and Dizziness

Abdominal migraine is a syndrome characterized by recurrent episodes of paroxysmal abdominal pain and nausea or vomiting with wellness between episodes. It is often associated with a positive family history of migraine and no other apparent underlying disease. Abdominal epilepsy is an infrequent syndrome which occurs with gastrointestinal complaints caused by a seizure activity. It is characterized by paroxysmal onset of abdominal pain without visceral disorders, but comes along with the alteration of awareness during the attack and abnormal electroencephalogram findings. Like other epilepsies, this abdominal epilepsy is improved with anticonvulsant medication. (Korean J Pediatr Gastroenterol Nutr 2011; 14(Suppl 1): S19∼S24)

Feasibility of Foley Catheter Prior to Endoscopy for the Removal of Esophageal Coin in Children

Purpose: This study evaluated the efficiency and safety of the Foley catheter for esophageal removal of coins in children, compared to standard endoscopic extraction with respect to success rate, sedation, promptness and cost. Methods: Twenty four children with coin lodgement in esophagus were managed with either a Foley catheter (n=14) or endoscopic extraction (n=10) from January 2007 through August 2010 at Kyungpook National University Hospital. A retrospective review of medical records and radiological findings was performed. Results: Of the 14 patients who underwent Foley catheter extraction, successful and complication-free removal was achieved in 10 cases (71.4%). Of the 10 patients who underwent endoscopic extraction, all cases were successful (p=0.114). Sedation rate in the Foley catheter and endoscopic extraction group was 6/14 and 10/10 (p=0.006). The average wait time before the procedure and average hospital charge (US$) were 2.0±1.1 hours and 18.1±13.7 hours, and $113 and $428 for Foley catheter extraction and endoscopic extraction, respectively. Conclusion: Foley catheter extraction may be tried for the removal of esophageal coins in uncomplicated children. The technique is effective, safe, inexpensive and free of general anesthesia. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 251∼257)

Acute Intermittent Porphyria Presented with Recurrent Abdominal Pain and Hypertension

Acute intermittent porphyria (AIP) is a rare disorder characterized biochemically by the increased excretion of porphyrins and porphyrin precursors, including delta-aminolevulinic acid (ALA) and porphobilinogen (PBG). AIP has variable clinical manifestations, such as acute abdominal pain, vomiting, nausea, constipation, peripheral neuropathy, seizures, tachycardia, and hypertension. A 16-year-old girl presented with recurrent abdominal pain, vomiting, hypertension, seizures, hypercholesterolemia, and red urine. AIP was confirmed by clinical features and increased 24-hour urine ALA and PBG. AIP should be considered in the differential diagnosis of patients who have abdominal pain, hypertension, and seizures when the results of all other tests are normal. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 81∼85)

Waist-to-height Ratio, a Simple and Practical Index for Screening of Adolescent Metabolic Syndrome Aged 17~19 Years

Purpose: To evaluate the validity and usefulness of the waist circumference-to-height ratio (WHtR) in screening for metabolic syndrome in Korean adolescents aged 17∼19 years. Methods: Data (body mass index, waist circumference, and height) and blood samples were obtained from adolescents in A University Hospital in 2011. This study included 554 adolescents (176 boys and 378 girls) aged 17∼19 years. Dependent variables were systolic and diastolic blood pressure, fasting blood glucose (FBS), total cholesterol (TC), triglyceride (TG), high density lipoprotein-cholesterol (HDL-C) and low density lipoprotein-cholesterol (LDL-C). Using the Pearson’s correlation analysis and logistic regression analysis, we measured the WHtR against Body mass index (BMI). Results: An assessment was carried out of the ability of the 2 indexes to 1) account for the variability in each metabolic risk factor and 2) correctly identify adolescents with metabolic risk factors. The results revealed that the predictive abilities of the waist-to-height ratio index were better values. The waistto-height ratio showed superior values in predicting concentrat ions of DBP, FBS, TC, TG and LDL-C. However, BMI showed better values in identifying adolescents with high systolic blood pressure and HDL-C. 3) Normal weight adolescents (BMI: 5 th ≤BMI＜85 th percentiles) were divided by WHtR (obesity cutoff value: ≥0.51 in male, ≥0.49 in female). WHtR was better than the BMI index for signaling metabolic risk in the normal-weight adolescents. Conclusion: The WHtR is a better predictor for finding metabolic risk factors in adolescents aged 17∼19 years with normal BMI. The WHtR is proposed as an alternative, convenient measure of screening metabolic syndrome for adolescents aged 17∼19 years independent of age and sex. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 385∼392)

Assessment of Clinical Nutrition Problems in Korean Adolescents

Nutritional assessment in adolescents is key to detect major health risks at this age, such as obesity and under nutrition, which continue as adult health risks. Recent epidemiological evidence in Korea has shown that obesity is quite prevalent. Scientific protocols assessing nutritional status should be used in various clinical settings, particularly in hospitals and schools. Recent protocols are typically based on growth charts, calorie calculating equations, and Dietary Reference Intakes in Korea which have been developed through extensive studies. Non-communicable chronic diseases, such as type II diabetes mellitus and atherosclerosis could be ameliorated by intervening in behaviors related to nutrition. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 334∼339)

Mutations in Hepatitis B Virus Precore, Core Promoter, and "a" Determinant in Children with Chronic Hepatitis B Virus Infection

Purpose: The aim of this study was to determine the prevalence, types of variants, and clinical significance of mutations in precore, core promoter, and “a” determinant mutations in children with chronic hepatitis B virus infection. Methods: Thirty-one patients with chronic hepatitis B virus infection who visited Seoul National University Children's Hospital in Korea between 2004 and 2005 were enrolled in this study. Serum HBV DNA was amplified by polymerase chain reaction (PCR) and the precore/core promoter and “a” determinant sequences were determined. Results: Precore mutations were found in 11 of 27 patients (40.7%), and appeared more frequently in the HBeAg-negative group (p＜0.05) compared to the HBeAg-positive group. G1896A was detected most frequently (81.8%). BCP mutations were found in 15 of 27 patients (55.6%) and the TA mutation (A1762T/G1764A) was the most common (86.7%). Mutations in the “a” determinant region were detected in 8 of 28 patients (28.6%), and amino acid changes were detected in 6 of 28 patients (21.4%). Of these mutations, substitutions at amino acid position 126 were found most frequently. Conclusion: In children with chronic hepatitis B virus infection, the most common mutations were G1896A in the precore region and TA mutation(A1762T/G1764A) in the core promoter region. Substitutions at amino acid position 126 was the most common mutation in the “a” determinant. Precore mutants were found to be significantly higher in HBeAg-negative patients. The high prevalence of mutations in the “a” determinant and low frequency of G145R were characteristic features. These mutations were not significantly associated with other clinical features except for high aminotransferase concentration in the core promoter variant group. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 279∼285)

Stem Cell in Pediatric Gastrointestinal Tract Disease: Hirschsprung Disease

Stem cell is characterized with self-renewal and mult-potency. Many pediatric gastrointestinal diseases have defect in enterocytes, enteric nervous system, and Interstitial cell of Cajal. Various kinds of stem cell could be applied to these diseases. Here, the author introduces stem cell for pediatric gastrointestinal diseases, particularly Hirschsprung disease. (Korean J Pediatr Gastroenterol Nutr 2011; 14(Suppl 1): S42∼S46)

Early Exclusive Diagnosis of Biliary Atresia among Infants with Cholestasis

The persistence of jaundice beyond the first 2 weeks of life require further investigation and this can be determined if the conjugated bilirubin levels are greater than 1.5 mg/dL or greater than 20% of the total bilirubin level. There is a diverse differential diagnosis for the cause of neonatal cholestasis due to hepatobiliary disease including biliary atresia, which eventually leads to liver cirrhosis if uncorrected before 60∼80 days of life. Long-established initial studies include abdominal ultrasonography, hepatobiliary scintigraphy and liver biopsy, but better diagnostic methods are needed. Promising new options are described including MRCP (magnetic resonance cholangiography), ERCP (endoscopic retrograde cholangiography), and PCC (percutaneous cholecysto-cholangiography). Though no single test can differentiate biliary atresia from other neonatal cholestasis with confidence, a combination of diagnostic methods is usually consistently beneficial. By excluding biliary atresia as early as possible, the risk of unnecessary explolaparotomy with intraoperative cholangiography is decreased. Further evaluation would be required for the diagnosis of neonatal cholestasis after excluding biliary atresia. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 122∼129)

Psychosocial Factors and Psychiatric Disorder in Childhood Chronic Abdominal Pain

Childhood chronic abdominal pain usually doesn’t have an organic etiology. It may cause social impairment and emotional distress in children as well as their families. In view of cognitive and behavioral aspect, passive coping style, maladaptive social modeling, and reinforced secondary gain could contribute to the development and maintenance of pediatric somatization. Integrative etiological model includes biological factors due to the enteric sensitization process, psychosocial factors which encompass family influences, psychodevelomental vulnerability, and life event-related stress. These factors interact with each other and manifest as various psychosomatic symptoms. In the treatment of childhood chronic abdominal pain, multimodal treatment program, which includes cognitive behavioral therapeutic methods, emotional support, family education, selective serotonin reuptake inhibitor, and so on, is known to be most effective. (Korean J Pediatr Gastroenterol Nutr 2011; 14(Suppl 1): S25∼S33)

Usefulness and Pitfall of Abdominal Ultrasonographic Examination by a Pediatrician in Children

National University Hospital were reviewed. The main causes leading to ultrasonographic evaluation were abdominal pain (43.9%), vomiting (17.3%), elevated liver enzymes (11.8%), and jaundice (9.8%). Abnormal ultrasonographic findings accounted for 57.9% of cases. The major abnormal findings were mesenteric lymphadenitis (29.2%), fatty liver (12.1%), hepatitis (6.4%), hepatosplenomegaly (6.2%), and acute appendicitis (4.8%). The major findings in children with abdominal pain were mesenteric lymphadenitis (32.6%), intussusception (2.7%), and acute appendicitis (2.7%). The major findings in children with vomiting were mesenteric lymphadenitis (12.7%), hypertrophic pyloric stenosis (10.4%), acute appendicitis (3.5%). The major ultrasonographic findings in children with urinary tract diseases were hydronephrosis (45.4%), urolithiasis (21.5%) and cystic renal disease (18.1%). Ultrasonography performed by pediatricians is advantageous because pediatricians are able to perform the procedure with clinical information at the right time. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 245∼250)

Clinical Approach to Functional Gastrointestinal Disorders in Children: Revolve Around on Cyclic Vomiting Syndrome and Aerophagia

Functional gastrointestinal disorders (FGIDs) are defined as a chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities. The Rome II pediatric criteria for FGIDs were announced in 1999. The Rome III criteria, update and revise the pediatric criteria, included FGIDs criteria of infant and toddler to child and adolescent (aged 4 to 18 years). The aerophagia was classified into abdominal pain-related FGIDs in the ROME II criteria. However, cyclic vomiting syndrome and aerophagia, both were classified into vomiting and aerophagia part in the ROME III criteria. We describe the clinical features, diagnostic criteria, and treatments of cyclic vomiting syndrome and aerophaiga among pediatric FGIDs. (Korean J Pediatr Gastroenterol Nutr 2011; 14(Suppl 1): S9∼S18)

Tumor Necrosis Factor-α Gene Polymorphisms in Korean Children with Inflammatory Bowel Disease

Purpose: The aim of this study was to investigate the existence of TNF-α polymorphisms in Korean children with Crohn’s disease (CD), ulcerative colitis (UC), as compared to healthy controls. Methods: Blood samples were obtained from 40 patients with CD, 14 patients with UC, and 30 healthy controls. Genotyping for 5 TNF-α polymorphisms (G238A, G308A, C857T, C863A, and T1031C) was performed. The allele frequencies for the inflammatory bowel diseases, CD and UC, were measured in patients with these disease and in healthy controls, and these allele frequencies were compared between the 3 groups. We examined the significant association between polymorphism and disease phenotype, such as location, behavior, perianal disease, and pediatric Crohn’s activity index (PCDAI) in CD. Results: Based on our findings, the TNF-α allele frequencies of G238A, G308A, C857T, C863A, and T1031C were 3.3, 8.3, 16.7, 16.7, 21.7% in healthy control, 2.5%, 7.5%, 18.8%, 20.0%, 22.5% in CD, 7.1%, 7.1%, 7.1%, 21.4%, 28.6% in UC. They were no statistically significant differences between the 3 groups. There were no associations between genotypes and phenotypes in CD, except a statistically significant higher allele frequency of G238A in ileal type (L1) disease (p=0.010). Conclusion: Our results indicate that 5 TNF-α polymorphisms do not seem to be associated with susceptibility to inflammatory bowel disease in Korean pediatric patients even though young patients were anticipated to have a stronger genetic affiliation for these diseases than adult patients. We think that further studies are needed to find those genes associated with susceptibility to CD and UC in Korean pediatric patients with inflammatory bowel disease. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 269∼278)

Helicobacter pyloriInfection and Extraintestinal Manifestations in Children

Helicobacter pylori (H. pylori) may be one of the most common pathogen in gastrointestinal tract. Although several recent articles have reported a decline in the prevalence of H. pylori infection in both children and adults over the last several years, H. pylori infection usually occurs early in life and persists for a long time. The role of H. pylori in some digestive diseases, such as gastritis, ulcer and gastric cancer has been well established. And the possible role of H. pylori as a trigger for some extraintestinal diseases in children and adults has been considered in the last year. H. pylori infection might be associated with refractory iron deficiency anemia, idiopathic thrombocytopenic purpura, growth retardation and obesity etc, directly or indirectly. Most of the studies are classified as epidemiological, clinical researches about effects on extraintestinal manifestations after eradication, or case reports. This review describes the possibility of association with several extraintestinal diseases and H. pylori infection and their possible mechanisms based on reported studies in the world and our several studies, even though there are still many conflicting results about that. (Korean J Pediatr Gastroenterol Nutr 2011; 14(Suppl 1): S1∼S8)

Usefulness of Ultrasonographic Examination by a Pediatrician in Children with Abdominal Pain

Purpose: Ultrasonography (US) is widely used as a screening test in patients with abdominal pain (AP). We investigated the usefulness of US by a pediatrician in children with AP. Methods: We retrospectively analysed the medical records of children with AP who undertook US from December, 2008 to July, 2010. Results: A total of 628 patients (325 male, 303 female) were enrolled in this study. The mean age of patients was 8.08±4.61 years. Duration of AP was acute in 427 and chronic in 201 patients. Localization of AP was diffuse (36.9%), periumbilical (24.4%), epigastric (21.0%), and right lower quadrant (8.1%). On the examination, there were no abnormal findings in 327 patients (52.1%). Abnormal ultrasonographic findings were mesenteric lymphadenitis (27.1%), intestinal mural thickening (10.0%), intussusception (3.0%), appendicitis (2.6%), choledochal cyst (1.6%), and pancreatitis (0.3%). We performed additional imaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) in 39 patients who showed obscure findings on the US. In 33 patients (84.6%), the same results were obtained from CT or MRI. Two cases of appendicitis, one case of pancreatitis and one case of Henoch-Shonlein purpura were diagnosed by the CT examination. However, there were two cases of appendicitis diagnosed by US thathad no evidence of appendicitis on the CT. Diagnostic accuracy of initial US in children with abdominal pain was 99.4%. Conclusion: US by a pediatrician as a screening test in children with AP provides a rapid and accurate diagnostic indication and has non-invasive and radiation-free advantages. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 141∼147)

The Importance of Nutritional Assessment and Dietary Counseling in Infants and Young Children with Common Illnesses

The influence of nutrition during early life on physical growth as well as mental development has been thoroughly discussed in the literature. The physical dimensions of the body are greatly influenced by nutrition, particularly during the period of rapid growth in early childhood. Nutritional status affects every pediatric patient's response toillness. Good nutrition is important for achieving normal growth and development. It is indicated that permanent impairment of the central nervous system may result from dietary restriction of imbalance during certain periods of life. If children under 3 years of age show a good nutritional status, it may be assumed that they are well nourished. Several common diseases of children such as iron deficiency, chronic constipation and atopic dermatitis are known food related diseases. Patients with chronic illness and those at risk of malnutrition should have detailed nutritional assessments done. Components of a complete nutritional assessment include a medical history, nutritional history including dietary intake, physical examination, anthropometrics (weight, length or stature, head circumference, midarm circumference, and triceps skinfold thickness), pubertal staging, skeletal maturity staging, and biochemical tests of nutritional status. The use of age, gender, and disease-specific growth charts is essential in assessing nutritional status and monitoring nutrition interventions. Nutrition assessment and dietary counseling is helpful for the cure of disease, and moreover, the prevention of illness. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 33∼44)

Comparison of the Clinical Manifestations and Prognosis of Henoch-Schonlein Purpura in Children with and without Abdominal Pain

Purpose: We compared the clinical manifestations and prognosis of Henoch-Schonlein Purpura (HSP) in children with and without abdominal pain to investigate the usefulness of endoscopy. Methods: We retrospectively studied 185 HSP inpatients (group A [with abdominal pain] and group N [without abdominal pain]) who had been admitted to the BundangCHA hospital between 2001 and 2010. We compared clinical manifestations, laboratory findings and endoscopic and ultrasonographic findings. Results: Of the 185 children, 112 (60.5%) had abdominal pain and 31 (16.8%) presented with abdominal pain before developing cutaneous purpura. Group A patients were older (6.9±3.5 vs. 5.3±3.3 years), had higher rates of positive results for stool occult blood (53.8%, p＜0.001), and had longer hospital stays (5.2±4.2 vs. 3.6±2.5 days) than group N patients. Group A had a higher frequency of renal involvement than group N on admission (p=0.047). Ultrasonography showed small bowel wall thickening in 31 cases (43.7%) and increased Doppler flow in the bowel wall in 22 cases (31%) in Group A. Upper gastrointestinal endoscopy revealed HSP - related lesions in the stomach (25 cases) and duodenum (19 cases). The second portion of the duodenum was a more common lesion site than the duodenal bulb. Ultrasonography showed abnormalities in 13 of 19 patients with duodenal lesions. Recurrence was more common in Group A. Conclusion: These results suggest that recurrence and renal involvement are more common in HSP patients with abdominal pain. Upper gastrointestinal endoscopy could be a useful diagnostic tool for HSP patients who develop abdominal pain before cutaneous purpura. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 359∼367)

Underweight in Adolescents

There are few studies of underweight in adolescents in Korea and other developed countries. According to the recent surveillance in Korea, prevalence of underweight in adolescents is lower than those in developing countries, and higher than those in developed countries in Northern Europe. This article reviews the problems, diagnosis, and nutritional support of underweight in adolescents. (Korean J Pediatr Gastroenterol Nutr 2011; 14(Suppl 1): S55∼S60)

A Case of Magnet Ingestion in a Child with Autism: Gastro-Colonoscopic Removal without Surgical Complication

With the increasing use of magnets in toys, magnet ingestion is becoming a serious problem in children. Two or more magnets may attract across the gastrointestinal tract leading to pressure necrosis, perforation, fistula, volvulus or obstruction. We report a case of a 12-year-old boy with autism who presented with vomiting during seven days due to ingestion of 14 magnetic rods. Under general anesthesia, 5 of 14 magnets were removed from the second portion of the duodenum using a magnetic probe during endoscopy. The remaining magnets were not visible in the duodenum. A plain radiograph taken the next day revealed that the remaining magnets were impacted in the descending-sigmoid junction. One magnet passed spontaneously. However the other 8 magnets did not pass through the junction for 7 days. Five of 8 impacted magnets were removed by a colonoscopic procedure. After 2 hours of colonoscopy, one by one, the remaining three magnets spontaneously passed. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 299∼304)

Tentative Proposal of Optimal Timing of Kasai Operation for Biliary Atresia Based on Fibroscan Results

Purpose: Based on previous research findings, it is well-known that the timing of surgery is generally considered the most important prognostic factor for a Kasai por toenterostomy, the primary treatment for biliary atresia. This research aimed to identify the optimal timing of a Kasai portoenterostomy and to verify if the proposed optimal timing corresponds to previous studies. All patients were classified by the timing of surgery, and pre- and post-operative fibrotic changes of the liver were measured with the elasticity value from fibroscans. Methods: The stiffness scores of the pre- and post-operative fibroscans in 34 patients who were treated by Kasai portoenterostomy from October 2007 to September 2010 in Severance children's hospital were reviewed. Results: The earlier the patients were treated by Kasai portoenterostomy, the lower the fibroscan scores. When the patients were treated prior to the 8th week, the post-operative scores of the fibroscans were significantly better than those patients who were treated after the 8th week, and some even recovered partially. Moreover, when operated before the 8th week, the differences between each pre- and post- operative fibroscan score also showed statistical relevance (p=0.0002). Conclusion: The earlier the patient was treated by Kasai portoenterostomy, the less liver fibrosis that developed, the lower the level of post-operative fibrosis, and the less the degree of fibrotic progress before and after the operation. Thus, this research proposal reconfirms once more that the 8th week is the optimal timing for a Kasai portoenterostomy. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 74∼80)