Pediatric Gastroenterology Research Articles

Prevalence of delivery mode in an Italian nationwide cohort with celiac disease: a SIGENP multicenter retrospective study (the CD-deliver-IT)

BackgroundStudies have indicated an association between cesarean section (CS), especially elective CS, and an increased risk of celiac disease (CD), but the conclusions of other studies are contradictory. The primary aim of this study (CD-deliver-IT) was to evaluate the rate of CS in a large population of CD patients throughout Italy. MethodsThis national multicenter retrospective study was conducted between December 2020 and November 2021. The coordinating center was the Pediatric Gastroenterology and Liver Unit of Policlinico Umberto I, Sapienza, University of Rome, Lazio, Italy. Eleven other referral centers for CD have participated to the study. Each center has collected data on mode of delivery and perinatal period of all CD patients referring to the center in the last 40 years.ResultsOut of 3,259 CD patients recruited in different Italian regions, data on the mode of delivery were obtained from 3,234. One thousand nine hundred forty-one (1,941) patients (60%) were born vaginally and 1,293 (40%) by CS (8.3% emergency CS, 30.1% planned CS, 1.5% undefined CS). A statistically significant difference was found comparing median age at time of CD diagnosis of patients who were born by emergency CS (4 years, CI 95% 3.40–4.59), planned CS (7 years, CI 95% 6.02–7.97) and vaginal delivery (6 years, CI 95% 5.62–6.37) (log rank p < 0.0001).ConclusionsThis is the first Italian multicenter study aiming at evaluating the rate of CS in a large population of CD patients through Italy. The CS rate found in our CD patients is higher than rates reported in the general population over the last 40 years and emergency CS seems to be associated with an earlier onset of CD compared to vaginal delivery or elective CS in our large nationwide retrospective cohort. This suggests a potential role of the mode of delivery on the risk of developing CD and on its age of onset, but it is more likely that it works in concert with other perinatal factors. Further prospective studies on other perinatal factors potentially influencing gut microbiota are awaited in order to address heavy conflicting evidence reaming in this research field.

Worldwide burden of liver cancer across childhood and adolescence, 2000–2021: a systematic analysis of the Global Burden of Disease Study 2021

Liver cancer is a significant contributor to the global disease burden, of which hepatoblastomas are the most common liver tumors in children, with 90% of cases occurring within the first 5 years of life. It is important for pediatricians and subspecialists in pediatric gastroenterology and hepatology to have knowledge of the epidemiology and incidence trends of pediatric hepatic cancer, despite its rarity. In the present study, we first provide estimates of the incidence and mortality burden of hepatoblastoma and liver cancer from 2000 to 2021 in the childhood and adolescence. Liver cancer burden and its attributable risk factors were estimated using data from the Global Burden of Disease Study (GBD) 2021. Percentage change was estimated to show the trend of liver cancer estimates from 2000 to 2021. The age-standardized rate (ASR) and estimated annual percentage change (EAPC) were utilized for measuring hepatoblastomas incidence and deaths rate trends. In accordance with the GBD framework, 95% uncertainty intervals (UIs) for all estimates by averaging the data from 1000 draws, with the lower and upper bounds of the 95% UIs. Globally, from 2000 to 2021 in the age 5-19 years group, the incidence cases and deaths cases due to liver cancer decreased from 2449.2 (95% UI: 2235.9-2689.8) to 1692.9 (95% UI: 1482.0-1992.5) and 2248.5 (95% UI: 2053.7-2474.9) to 1516.6 (95% UI: 1322.1-1797.9), respectively. Meanwhile, from 2000 to 2021 in the age 20-24 years group, the incidence cases and deaths cases due to liver cancer decreased from 1453.5 (95% UI: 1327.8-1609.4) to 1285.1 (95% UI: 1159.2-1447.2) and 1432.3 (95% UI: 1307.6-1585.7) to 1195.5 (95% UI: 1066.1-1355.2), respectively. In addition, the prevalence of liver cancer decreased from 41.9% (95% UI: 18.7%-64.7%) to 26.4% (95% UI: 14.2%-39.1%) in the age 5-19 years group, and 46.6% (95% UI: 42.8%-51.5%) to 36.5% (95% UI: 33.1%-40.9%) in the age 20-24 years. From 2000 to 2021, in the age group of 5-19 years, the proportion of liver cancer incidence due to hepatitis B has decreased from 42.2% to 37.9%, while the proportion due to hepatitis C has increased from 1.1% to 1.6%. Additionally, there has been an increase in the proportion of NASH-induced liver cancer incidence from 5.2% to 9.4%, and alcohol use induced liver cancer incidence has also increased from 0.5% to 0.7% over the same period. Globally, from 2000 to 2021, the incidence cases and deaths cases due to hepatoblastoma decreased from 6131.8 (95%UI: 5234.8-6961.9) to 4045.6 (95% UI: 3250-4995.8) and 4059.2 (95% UI: 3494.5-4621.2) to 2416 (95% UI: 1940.2-3022.5), respectively. There was some variation in age-related sex-specific patterns, the highest number of hepatoblastoma incidence cases occurred in children between 2 and 4 years old and females in the age range of 12 months to 9 years had a higher number of new cases. Importantly, the incidence of hepatoblastoma was started to increase sharply after the age of 1 month. The results of the present study are significant for liver health policy and practice in childhood and adolescence. Differentiated intervention and outreach strategies based on age and gender would be necessary to reduce the impact of liver cancer. Early screening and interventions for hepatoblastoma is important especially in the population of under 9 years old. This study was supported by the National Key R&D Program of China (grant numbers 2023YFC2307000), National Natural Science Foundation of China [grant numbers 82170571 and 81974068], China Postdoctoral Science Foundation (grant numbers 2023M741283).

Meta-analysis: High pooled positive predictive value of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition no-biopsy approach for coeliac disease testing in children.

The European Society of Paediatric Gastroenterology, Hepatology and Nutrition established guidelines in 2012 for a no-biopsy approach to diagnose coeliac disease in children. This guideline required symptoms suggestive of coeliac disease, positive human leukocyte antigen (HLA) DQ2/DQ8 haplotypes, tissue transglutaminase type-2 immunoglobulin A antibody titre at levels greater than 10 times the upper limit of normal, and positive endomysial immune-globulin A antibody test. An updated 2020 guideline excluded the need for symptoms and positive HLA. To assess the pooled positive predictive value (PPV) of the no-biopsy approach with small bowel biopsy (SBB) data as the reference standard for comparison. Database searches (October 2023) provided data that we combined using a random-effects meta-analysis to provide a pooled PPV, representing the probability that a positive test result means that an individual truly has the condition. We included 23 studies. Study sample sizes totalled 23,769 but only 3007 children had comparative SBB. The proportion of coeliac disease confirmed by the no-biopsy approach and SBB ranged from 79.2% to 100%, with an overall pooled PPV of 97.4% (95% confidence interval 96.0, 98.6). Sensitivity analysis showed higher PPV for the criteria that included HLA (98.5% vs. 96.8%; p = 0.017). Both no-biopsy criteria exhibit high PPV when compared to the reference standard. These results provide a consistent message of accuracy and feasibility to inform change and improve outcomes.

Exploring the Influence of Concurrent Nutritional Therapy on Children with Spinal Muscular Atrophy Receiving Nusinersen Treatment.

Background This study examines spinal muscular atrophy (SMA), a neuromuscular disease associated with malnutrition. Our goals are to assess how effectively screening tools can detect malnutrition and evaluate the impact of nutritional interventions on neurological outcomes, particularly motor functions. Methods Thirty-seven genetically diagnosed SMA patients (types 1, 2, and 3) under nusinersen therapy were included in the study. The nutritional status of these patients was assessed by using anthropometric measurements, including height for age (HFA), weight for height (WFH), and body mass index (BMI) before and after the study. Additionally, the risk of malnutrition was determined using screening tools, namely the Pediatric Yorkhill Malnutrition Score (PYMS) and the Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP). Nutritional counseling followed the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines and considered the patients' dietary history, including content and administration method. Motor functions were assessed by validated tests: the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) and the Hammersmith Functional Motor Scale-Expanded (HFMSE). Result The study showed an improvement in HFA, by a change from -0.95 to -0.65 (p = 0.015). Conversely, BMI scores decreased from 0.08 to -0.54 (p = 0.015), while WFH and MUAC showed no significant alterations (p = 0.135, p = 0.307). Following nutritional interventions, HFMSE demonstrated a median increase from 29.5 to 30.5 (p = 0.023). Patients identified as being at high risk for malnutrition based on PYMS and STAMP belonged to the moderate-to-severe malnutrition group (BMI Z-score ≤ -2, p = 0.001). Conclusions Use of screening tools in SMA patients is highly beneficial for the early detection of malnutrition. Future research should highlight the importance of combining nutritional management with nusinersen therapy to potentially alter the disease trajectory, especially in motor and neurological functions.

Electronic medical record clinical workload metrics from 10,210 gastroenterologists in North America.

In the United States, clinical work had been primarily compensated via a relative value unit (RVU)system reliant on professional surveys estimating the value of clinical care events. However, with the advent of time-based billing in 2021, time accounting has become an important work compensation metric. The Signal functionality within Epic, the most widely used electronic medical record(EMR) system in North America, tracks clinician time within the system. We extracted Epic Signal data from 10,200 gastroenterologists at 356 North American institutions for analysis. Workload metrics were reported as group median (interquartile range) per month and comparisons were performed using nonparametric testing. Gastroenterologists exhibit different EMR time patterns based on clientele and practice arenas. Compared with counterparts, pediatric and academic gastroenterologists spend more time at each encounter which had not been compensated under prior RVU valuations. Clinical compensation benchmarks should be driven by time-based workload metrics to ensure appropriate compensation.

From the kitchen to the medicine cabinet: Examples of food products and supplements used for therapeutic intent.

"Food as medicine" has existed for centuries as the foundation of health for many cultures around the globe. It is a practice built on the knowledge that food and diet play important roles in disease prevention and management. Foods that claim to have therapeutic properties are often referred to as functional foods. These foods contain a number of nutritional and nonnutritional compounds that can interact with pharmacologically relevant receptors, either directly or indirectly via their metabolites, to regulate cellular biochemical processes. Although opinions are changing, the concept of food as a therapeutic intervention goes against conventional Western medicine. To provide guidance to clinicians interested in using these products, members of the Food as Medicine working group of the Nutrition Committee NASPGHAN,as part of a two-part review series, have created summaries of several frequently used nutritional products for therapeutic intent (i.e., fermented foods, fiber, and long-chain omega-3 fatty acids) that includes indications, doses, and caveats. Gaps in their use in pediatric patients are discussed. Evidence supporting their use for management of gastrointestinal conditions, especially in the pediatric population, isprovided when available.

Technical evaluation and fecal continence of laparoscopic-assisted procedures for total colonic aganglionosis

Total colonic aganglionosis (TCA), defined as aganglionosis extending from the anus up to the distal ileum, is a rare variant of Hirschsprung's disease. Surgery for TCA aims to remove the aganglionic colon and reconstruct the intestinal tract by bringing the normally innervated ileum down to the anus while preserving normal sphincter function. Laparoscopy with surgeries including laparoscopic-assisted Duhamel-like and Soave-like pull-through procedures have been progressively applied to the treatment of TCA over the past two decades and may become the dominant treatment for TCA in the future. Postoperative fecal continence, involving issues such as normal defecation, Hirschsprung-associated enterocolitis (HAEC), frequent stool and perianal erosion (perineal rash), soiling/fecal incontinence and constipation/obstructive symptoms, is very important to patients. These complications require nutritional support and comprehensive postoperative gastroenterological care and even require permanent ileostomy and redo pull-through. Some patients have previously seen a psychologist for frequent complaints of diarrhea and other physical symptoms. Patients with TCA postoperatively must be evaluated regularly by pediatric surgeons, enterostoma therapists, gastroenterologists, dieticians and psychologists to achieve a good nutritional status and psychological health.

A Clinician's Guide To Effectively Transitioning and Transferring Care For Pediatric Patients With Inflammatory Bowel Diseases From The Pediatric To Adult Gastroenterologist.

Transition of care for pediatric patients with inflammatory bowel diseases (IBD) is a continuous, dynamic process that takes place over several years with a coordinated approach executed by a multidisciplinary team. We review the concepts, tools, and research in effective transitioning and transfer of care for adolescent/young adult patients with IBD. Given the constraints within the healthcare system, effective transitioning can be challenging to implement in everyday clinical practice. Different barriers include resources and expertise in effective transitioning by pediatric and adult gastroenterology healthcare providers and the impact of non-gastrointestinal issues facing young adult patients who are learning to manage and coordinate all aspects of their medical care and health maintenance. Factors that facilitate successful care transitioning and transfer include structured transitioning programs, utilization of validated transition checklists, and IBD medical summaries. Proactive transitioning by pediatric gastroenterologists in partnership with their emerging young adult patients with IBD leads to better clinical and psychosocial outcomes and ultimately, effective transfer of care to adult gastroenterology. By utilizing utilize comprehensive transition assessment tools and medical summaries in partnership with their patients, pediatric and adult gastroenterology teams can better prepare patients as they transfer to independent care and health maintenance.

Publications by Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition Members in PubMed-indexed Journals (28th March to 30th May 2024)

Publications by Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition Members in PubMed-indexed Journals (28th March to 30th May 2024)

Modern View on Very Early Onset and Early Onset Inflammatory Bowel Diseases in Children

Nowadays, an urgent problem of pediatric gastroenterology is the study of inflammatory bowel diseases with very early onset (VEO-IBD), which have unique genetic, clinical, immunological, morphological, and laboratory sings. Early VEO-IBD is usually considered as monogenic disease, especially in combination with congenital immune defects, which leads to difficulties in diagnosis and management this pathology. Despite this, systematization of information about this group of nosological forms of IBD is practically not carried out. This article presents a review of the available information on etiological factors, course variants, and therapeutic options for VEO-IBD.

Consenso mexicano de tirosinemia tipo 1

Tyrosinemia type 1 is a rare disease with autosomal recessive inheritance, featuring various clinical manifestations. These may encompass acute neonatal liver failure, neonatal cholestatic syndrome, chronic hepatitis, cirrhosis, hepatocellular carcinoma, and, alternatively, kidney disorders like renal tubular acidosis, Fanconi syndrome, hypophosphatemic rickets, among other alterations. Diagnosis relies on detecting toxic metabolites in the blood and urine, ideally confirmed through molecular testing. A consensus was reached with experts in the field of inborn errors of metabolism (EIM), including eight pediatric gastroenterologists, two EIM specialists, two geneticists, three pediatric nutritionists specialized in EIM, and a pediatric surgeon specializing in transplants. Six working groups were tasked with formulating statements and justifications, and 32 statements were anonymously voted on using the Likert scale and the Delphi method. The first virtual vote achieved an 80% consensus, with the remaining 20% determined in person. The statements were categorized into epidemiology, clinical presentation, diagnosis, nutritional and medical treatment, and genetic counseling. This consensus serves as a valuable tool for primary care physicians, pediatricians, and pediatric gastroenterologists, aiding in the prompt diagnosis and treatment of this disease. Its impact on the morbidity and mortality of patients with tyrosinemia type 1 is substantial.

Navigating the Cow’s Milk Allergy Journey: From Diagnosis to Nutritional Optimisation

Cow’s milk allergy (CMA) currently ranks as one of the most common infant food allergies and requires timely diagnosis and appropriate management to mitigate the impact on growth and developmental outcomes and minimise patient/parent distress. During this symposium, chaired by Yvan Vandenplas, Emeritus at KidZ Health Castle, University Hospital Brussels, Belgium, leading experts in paediatric gastroenterology, allergy, and nutrition, discussed how best to navigate the CMA journey in clinical practice, from accurate differential diagnosis to nutritional optimisation. Annamaria Staiano, Professor of Paediatrics and Chief of the Department of Translational Medical Sciences at the University of Naples ‘Federico II’, Italy, discussed the complexities of differentiating disorders of gut–brain interaction (DGBI), previously known as functional gastrointestinal disorders, from CMA, and considered the potential role of the Cow’s Milk Related Symptom Score (CoMiSSTM) in ensuring infants follow the correct diagnostic pathway. Ralf Heine, Paediatric Gastroenterologist, Allergist, and Honorary Research Fellow at the Murdoch Children’s Research Institute in Melbourne, Australia, explored the immune-modulating effects of human milk oligosaccharides (HMO) and lactose on the gastrointestinal (GI) microbiota in infants, highlighting the importance of the early-life microbiome during the nutritional management of CMA. Rosan Meyer, Paediatric Dietitian and visiting Professor at both KU Leuven, Belgium, and the University of Winchester, UK, focused on the final phase of CMA management, the reintroduction of cow’s milk protein, and also examined new evidence to support the optimal timing and strategy for this key step in clinical practice.

From the kitchen to the medicine cabinet: Examples of functional herbs and spices.

In many cultures, "food as medicine" has existed for centuries as the foundation of health. It is a practice built on the knowledge that food and diet play important roles in disease prevention and management. Foods possessing therapeutic properties are often referred to as functional foods. Many herbs and spices contain numerous nutritional and non-nutritional components that can interact with pharmacologically relevant receptors, either directly or indirectly via their metabolites, to regulate cellular biochemical processes. Although opinions are changing, the concept of food as a therapeutic intervention goes against conventional Western medicine. To provide guidance to clinicians interested in using these products, members of the Food as Medicine working group of the Nutrition Committee NASPGHAN, as part of a two-part review series, have identified frequently used foods, supplements, herbs, and spices that are utilized for therapeutic intent and have created summaries of commonly used indications, doses, and caveats. In this review, the focus is the use of select herbs and spices for medicinal purposes. Gaps in our knowledge in how to effectively use these agents in pediatric patients are discussed. Evidence supporting their use for management of gastrointestinal conditions, especially in the pediatric population, is provided when available. Circumstances in clinical settings and patient indications may require actions different from those recommended in this review and professional judgment should prevail.

Beyond diagnosis: exploring coeliac disease incidence alongside clinical and laboratory characteristics of newly diagnosed children in Slovenia.

Coeliac disease is characterized by a wide array of clinical presentations. The focus of our study was to comprehensively assess the clinical manifestations of coeliac disease in newly diagnosed children in Slovenia. Our objectives include estimating the incidence of the disease in children in 2022. In this prospective study, Slovenian paediatric gastroenterologists were invited to provide patient data using medical records of children under 19 diagnosed with coeliac disease from March 2021 to October 2023. Patient data were collected through a dedicated web-based form adapted from the CD SKILLS project, including data on clinical manifestations and laboratory results. Furthermore, the study included an estimation of the incidence of coeliac disease in children and adolescents in Slovenia in 2022. Analysis involved data from 160 children and adolescents (median age: 8 years; 61.9% female). Overall, 16.9% were asymptomatic at diagnosis and 29.4% belonged to a high-risk group for coeliac disease. Among symptomatic cases ( N = 133), abdominal pain was the leading symptom (44.4%), followed by anaemia (12.0%) and diarrhoea (10.5%). Malabsorption symptoms were more prevalent in very young children. Anaemia was found in 22.8 and 10.7% had abnormal alanine aminotransferase levels. The estimated incidence of coeliac disease in Slovene children in 2022 was 17.5/100 000. Abdominal pain emerged as the primary symptom of coeliac disease in children and adolescents, except in very young children where malabsorption symptoms were predominant. Our observation of a lower prevalence of abnormal liver function tests suggests subclinical coeliac disease may be less common in children. Moreover, the calculated coeliac disease incidence in Slovenia aligns with existing data.

Association between Autoimmune Hepatitis and Celiac Disease among Egyptian Children and Adolescents

Abstract Background Celiac disease (CD) is an immune-mediated intolerance to gluten .CD has been recognized as a multisystem disorder which may affect other extra intestinal organs, such as the skin, thyroid, heart, nervous system, pancreas and liver. Individuals with CD are at increased risk of liver disease namely cryptogenic liver disorder and autoimmune liver disorder. However, until now, it remains unknown whether these two forms of liver disease are really different entities or only different severities of the same disorder. Objective To evaluate the association of CD with autoimmune hepatitis in pediatrics. Subjects and Methods This was a cross-sectional study that was conducted at the Pediatric Hepatology Clinic and Pediatric Gastroenterology Clinic, Children’s Hospital, Ain Shams University. The study included 2 groups of patients each comprised 20 children and adolescents as follow: Group I: Patients with established diagnosis of autoimmune hepatitis (AIH). All patients were receiving corticosteroids and azathioprine Group II: Patients with established diagnosis of CD. In group I patients with AIH, CD was screened for using anti-tissue transglutaminase (tTG) IgA in addition to measuring serum IgA to determine the need to measure anti-tTG IgG. Immunological markers (ANA, anti-smooth muscle antibody (ASMA) and liver and kidney microsomal (LKM) antibodies in addition to protein electrophoresis were done for group II patients with CD to screen for AIH. Results All patients in group I with AIH had normal serum IgA levels and were found negative for anti-tTG IgA. Also, group II patients with CD were negative for ANA, ASMA and LKM antibodies with normal protein electrophoresis. Conclusion The current study showed that CD does not seem to have significant association with AIH, however, the small sample size is a study limitation. Further wider scale studies are needed to evaluate the risk of AIH in CD.

Diagnostic Yield of Same Setting Oesophago-Gastro-Duodenoscopy (OGD)and Colonoscopy for Pediatric Patients with Chronic Diarrhea

Abstract Background In patients with unexplained chronic diarrhea colonoscopy and upper GI endoscopy are helpful in the diagnosis. It is the routine practice in Ain Shams University pediatric endoscopy unit to perform both procedures at same setting for patients with unexplained chronic diarrhea. Aim of the Work To find out whether doing Oesophago-gastro-duodenoscopy (OGD) and colonoscopy in patients with chronic diarrhea in one setting is essential for the diagnosis of all cases. Patients and Methods Fifty patients presenting with chronic unexplained diarrhea (&amp;gt;4 weeks duration) in Paediatric Gastroenterology Unit, Children’s Hospital, Ain-Shams University were enrolled. After full history taking, physical examination, both endoscopies were performed biopsy taken and histopathological recording for each sample. Results Of 50 patients with chronic diarrhea included in our study; 23 (46%) had positive endoscopic findings in the OGD. Most common findings in esophagus and stomach were inflammation and erythema. while most common findings in duodenum were edema and flattened mucosa. Colonoscopy findings were positive in 50% of patients including inflammation, nodularity, and edema mostly in the ileum. 50% of endoscopied patients reached final diagnosis based on endoscopy and histopathology. Definitive diagnosis reached through EGD alone in (12%) of cases, through colonoscopy alone in (28%) and through both techniques in (60%). There was no statistical significant agreement between endoscopy findings and predominant gastrointestinal manifestations including different types of diarrhea, fecal calprotectin with p-value =0.150, and 0.833 respectively. There was no statistical significant agreement between final diagnosis and suspected GIT part involvement on initial clinical evaluation with p- value=0.805. Conclusion Endoscopy for upper gastrointestinal tract and colonoscopy at same day may be helpful in diagnosis of cases with chronic diarrhea as we can't decide which one to perform based on clinical presentation.

Applications of culinary medicine in the pediatric gastroenterology, hepatology, and nutrition field.

Key points Culinary medicine can enhance a provider's ability to counsel patients using “food as medicine” to treat disease‐specific areas. Applying culinary medicine in pediatric gastroenterology is a practical way to empower patients to better manage their condition, minimize gastrointestinal symptoms, and promote a healthier relationship with food.

Reliability of pediatric Rome IV criteria for the diagnosis of disorders of gut-brain interaction.

The diagnosis of disorders of gut-brain interaction (DGBI) in children is exclusively based on clinical criteria called the Rome criteria. The inter-rater reliability (IRR) measures how well two raters agree with a diagnosis using the same diagnostic tool. Previous versions of the Rome criteria showed only fair to moderate IRR. There have been no studies assessing the IRR of the current edition of the pediatric Rome criteria (Rome IV). This study sought to investigate the IRR of the pediatric Rome IV criteria and compare its reliability with the previous versions of the Rome criteria. We hypothesized that changes made to Rome IV would result in higher IRR than previous versions. This study used the same methodology as the previous studies on Rome II and III, including identical clinical vignettes, number of raters, and levels of expertise. Participants included 10 pediatric gastroenterology fellows and 10 pediatric gastroenterology specialists. IRR was assessed using the percentage of agreement and Cohen's kappa coefficient to account for possible agreement by chance. The average IRR percentage of agreement using the Rome IV criteria was 55% for pediatric gastroenterologists and 48.5% for fellows, indicating moderate agreement (k = 0.54 for specialists, k = 0.47 for fellows). The results demonstrated higher percentages of agreement and kappa coefficients compared to the Rome II and III criteria. The findings demonstrate improved reliability in Rome IV compared to Rome II and III, suggesting that the changes incorporated into the Rome IV criteria have enhanced diagnostic consistency. Despite the advancements, the reliability is still moderate, indicating the need for further refinement of future versions of the Rome criteria.

Issue Information

On the Cover: “Physician workload and practice management in pediatric gastroenterology” Chien et al 10‐17

Testing in functional constipation-What's new and what works.

Constipation is among the most common symptoms prompting a consultation with a paediatric gastroenterologist. While most patients will respond to lifestyle and dietary changes and conventional therapy, some may require diagnostic studies. To review the diagnostics studies used to evaluate children with functional constipation. There is no evidence to support the routine use of abdominal X-rays in the evaluation of paediatric constipation. Colon transit by radiopaque markers (ROM) should be indicated when medical history does not match clinical findings, to guide colon manometry (CM) performance and to discriminate between faecal incontinence from functional constipation and non-retentive faecal incontinence. Colon scintigraphy may be useful as an alternative to ROM. Lumbar spine MRI may be indicated to evaluate for spinal abnormalities. The role of defecography has not been properly evaluated in children. Anorectal manometry in children is indicated primarily to evaluate anal resting pressure, presence and quality of the recto-anal inhibitory reflex and simulated defecation manoeuvres. The CM is indicated to guide surgical interventions after failing medical therapy. The goal of these studies is to identify treatable causes of constipation. Most of these studies are designed to evaluate anatomy, transit and/or colon/rectum motility function and are primarily indicated in those who fail to respond to conventional therapy.