Plasma oxytocin in children with recurrent abdominal pain

OBJECTIVE: The main objective of this work was to study plasma oxytocin concentration of children with psychosomatic recurrent abdominal pain and children with organic abdominal disease producing pain. Another objective was to study plasma oxytocin in children with psychosomatic recurrent pain over time and its relationship to other associated symptoms such as somatic pains and appetite. DESIGN: The concentration of oxytocin in plasma (fasting morning sample) was measured by radioimmunoassay in 48 children with abdominal pain, 32 of whom had psychosomatic recurrent abdominal pain according to previously defined criteria. Oxytocin levels were assessed in a separate group of 15 children with inflammatory bowel disease with abdominal pain and in a control group of 79 healthy school children. RESULTS: Plasma oxytocin concentration was significantly lower in children with recurrent abdominal pain of psychosomatic origin (P < 0.0001) and in the group of children with inflammatory bowel disease (P < 0.001) compared to controls. There was no difference between oxytocin levels of children with psychosomatic abdominal pain and those with inflammatory bowel disease. When repeated after one year, children with psychosomatic abdominal pain had an increase in mean plasma oxytocin level (P < 0.05). No relationship was found between specific symptoms and plasma oxytocin. CONCLUSIONS: Plasma oxytocin level is low in patients with abdominal pain of psychosomatic origin and inflammatory bowel disease. Measurement of plasma oxytocin may be of some help in the differential diagnosis of recurrent abdominal pain, but does not differentiate between psychosomatic abdominal pain and pain associated with inflammatory bowel disease.     

Giant inflammatory polyposis coli as a manifestation of Crohn's disease in patients with coexistent cystic fibrosis.

Crohn's disease (CD) arising in children with cystic fibrosis (CF) is well recognized. Indeed, reports suggest that CD is significantly more common in patients with CF than in the general population. Giant inflammatory polyposis is a rare manifestation of idiopathic inflammatory bowel disease and may complicate both ulcerative colitis and CD. Giant inflammatory polyposis has not been specifically reported in patients with coexistent CF and CD. Herein, we report the occurrence of giant inflammatory polyposis in 2 boys attending a tertiary care hospital, with an established diagnosis of CF who subsequently developed CD. Both boys required surgical treatment for CD. In addition to classical features of CD, both colonic resection specimens showed giant inflammatory polyposis. The appearances were modified by the presence of a layer of thick mucus. It is suggested that the coexistence of CF in patients with CD may predispose to the development of giant inflammatory polyposis. In addition to contributing to their development, it also appears that there is a propensity for CF to alter the morphological appearance of giant inflammatory polyposis. This may lead to diagnostic confusion when examining endoscopic biopsies.     

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??The incidence and prevalence of inflammatory bowel disease ??IBD?? in children are increasing worldwide. Abdominal pain is one of important symptoms of IBD?? and has certain clinical characteristics. The pathogenesis of abdominal pain in IBD is extremely complex?? there are a number of factors and mechanisms involved in the pathogenesis of IBD. Clinically?? the management of abdominal pain in IBD should be individualized.     

Colonic hamartomatous polyposis associated with hypertrophic osteoarthropathy

A 7-year-old girl with an unremarkable family history was admitted with complaints of diarrhea containing mucus and blood, abdominal pain, weight loss and fever for 10 months. Although her symptoms, physical examination and laboratory results were highly suggestive of inflammatory bowel disease, radiologic studies and colonoscopy demonstrated multiple colonic polyps. A bilateral and symmetric lamellar periosteal reaction and osteopenia were present on her extremity radiographs. The chest radiograph and thoracic CT scan were normal. The histologic nature of the polyps was determined as hamartoma. One month after subtotal colectomy, the patient's symptoms resolved and she gained 7kg in weight. The association of generalized juvenile polyposis and hypertrophic osteoarthropathy has previously been described in five cases; arteriovenous malformations were present in four of them. In our case the polyps were hamartomatous and localized in the colon, without associated arteriovenous malformation.     

Chronic nonspecific inflammatory bowel disease of the cecum and proximal colon in children with grossly normal-appearing colonic mucosa: diagnosis by colonoscopic biopsies

The diagnosis of inflammatory bowel disease rests on radiologic, endoscopic, and histologic criteria. Five patients, 2 to 17 years of age, sought medical attention because of chronic abdominal pain, diarrhea, and heme-positive stools. Rectal biopsies, visual inspection of colonic mucosa through the colonoscope, and contrast radiographs of the large and small intestine yielded nonspecific results. Serial endoscopic biopsies demonstrated a gradient of inflammatory changes diminishing in severity distally from the ileocecal valve and cecum. The disease process was most evident in specimens from the cecum, whereas biopsies distal to the transverse colon had a normal histologic appearance in all five patients. Biopsies from the proximal colon may provide evidence of inflammatory bowel disease not detectable using standard techniques. The combination of chronic abdominal pain, diarrhea, and heme-positive stools associated with inflammatory changes in biopsy specimens obtained from the proximal colon, but normal findings on radiologic, colonoscopic, and rectal biopsy examinations, may represent an early stage in the evolution of chronic nonspecific inflammatory bowel disease, including ulcerative colitis or regional enteritis (Crohn disease).     

Nephrolithiasis in childhood inflammatory bowel disease

Six children with inflammatory bowel disease and nephrolithiasis are reported. Their mean age at the passage of the first stone was 12.5 years and the mean duration of active inflammatory bowel disease was 34.5 months. Four had ulcerative colitis and two had Crohn's disease. In three patients, the onset of stone disease was associated with a flare in the bowel disease. Stone passage in four patients was accompanied by an increase in abdominal pain; three experienced gross hematuria. Stones from four of the patients were composed primarily of calcium phosphate; stones from the remaining patients contained uric acid and/or calcium oxalate. The pathogenesis of nephrolithiasis as it relates to inflammatory bowel disease is considered and an approach to therapy offered.     

Approach to a Child with Functional Abdominal Pain

Functional abdominal pain (FAP) is one of the most common functional gastrointestinal disorders (FGIDs) of childhood. Only a minority of patients with FAP seek medical attention, often presenting to the primary care physician while symptoms are still evolving. The bio-psychosocial model of treatment not only aims to alleviate the illness symptoms but also identifies and remedies the psychological comorbidities and social factors that contribute to illness behavior. Many patients with a mild illness can be managed in the primary care setting. However those with chronic, severe, frequently relapsing, and disabling illness usually are referred to a pediatric gastroenterologist. One of the reason for referral is to exclude organic disorders such as peptic ulcer disease, celiac disease or inflammatory bowel disease which can present with chronic abdominal pain. Recent data suggest that psychological therapy is very effective in alleviating symptoms, a subset of patients may require dietary modification and medications as an adjunct to psychological treatment.     

Idiopathic colitis following cardiac transplantation: three pediatric cases

Colitis can cause significant morbidity in pediatric solid organ transplant recipients. In many cases, despite intensive evaluation, a specific infectious, inflammatory, or immunologic etiology is not identified, and idiopathic colitis may be the ultimate diagnosis. We defined idiopathic colitis as the presence of gastrointestinal symptoms (vomiting, diarrhea, abdominal pain) with inflammatory changes seen on intestinal biopsy in the absence of identifiable bowel disease. We describe three cases of idiopathic colitis following cardiac transplantation. In each case, the post-transplant course was complicated by persistent abdominal pain, diarrhea, and in two cases, vomiting. All three patients' post-transplant courses were marked by multiple graft rejection episodes, and all received intensified immune therapy in addition to usual maintenance immunosuppression. Differential diagnosis of the patients' gastrointestinal symptoms included drug side effect, indolent opportunistic infections, inflammatory bowel disease, post-transplant lymphoproliferative disease, and microvascular ischemic colitis. Continued symptoms led these patients to extensive evaluation including imaging studies, endoscopy and tissue biopsy, and stool, blood and tissue cultures for viral, bacterial and parasitic pathogens. Definitive differentiation presented significant diagnostic challenge, and once identifiable etiologies were excluded, the diagnosis of idiopathic colitis was assigned. We conclude that idiopathic colitis following pediatric cardiac transplantation can be a cause of significant morbidity. Endoscopic evaluation of patients who present with gastrointestinal symptoms after transplant is warranted to identify the presence of idiopathic colitis once common causes are ruled out. Further study is needed to identify its incidence, etiology, therapeutic options and prognosis.     

Pathology mimicking distal intestinal obstruction syndrome in cystic fibrosis.

Eight patients with cystic fibrosis had chronic abdominal pain and the other features of distal intestinal obstruction syndrome. Coexistent abdominal pathology was shown in six patients. Two had a small bowel volvulus, and the others had Crohn''s disease, a small bowel fistula, appendix abscess, and an ovarian dermoid. Opiate abuse exacerbated symptoms in two other patients.     

Growth Failure as the Presenting Symptom of Crohn's Disease

Short stature is a common symptom of Crohn's disease in children, but it is rarely the chief complaint. We have encountered 5 pati?nts whose major complaint was stunted growth and poor weight gain. Only one patient had moderately severe diarrhea, abdominal pain and weight loss, while the remaining patients exhibited mild abdominal symptoms elicited only by probing questions. Bone age was retarded in all. Sedimentation rate was elevated in 3 patients, and 4 had anemia. Small bowel series revealed typical findings of Crohn's disease in all. Two patients had surgical treatment, and 3 received nutritional supplement and steroid therapy. It is concluded that in the patient with stunted growth, careful history taking is essential. A work-up to rule out inflammatory bowel disease is indicated, especially if an elevated sedimentation rate and/or anemia are present, even in the absence of clear-cut abdominal compliants.     

Challenges in management of irritable bowel syndrome in children

Irritable bowel syndrome (IBS) is a common cause of recurrent abdominal pain (RAP) in children and can be a debilitating experience for both child and family. Organic causes of RAP symptoms such as celiac and inflammatory bowel diseases should be excluded before a diagnosis of IBS is made. Treatment consists of dietary manipulation, drugs, and stress management. Newer therapies may offer better control of symptoms with minimal side-effects. This article discusses the challenges faced by pediatricians in managing IBS and reviews management in the context of children from the Indian subcontinent.     

Red Flags of Organic Recurrent Abdominal Pain in Children: Study on 100 Subjects

Objective

A variety of sign, symptoms and laboratory findings are more common in children with organic abdominal pains. This study was performed to evaluate the prevalence of organic and functional abdominal pains and relation of red flags to organic pains in 100 children with recurrent abdominal pain (RAP).

Methods

One hundred consecutive patients with RAP were enrolled in the study. A complete interview and physical examination was made for each patient, accompanied by a series of laboratory, clinical and para-clinical examinations. The data were recorded and analyzed. Logistic regression analysis was used to model and formulize correlations between sign, symptoms, and laboratory findings with organic and functional abdominal pain.

Findings

Among 100 patients (52% male, 48% female, Age: 9.29±3.17) diagnostic works up revealed organic pain for 57 patients. The most common symptoms of the patients included constipation, diarrhea, chest pain, cough, headache, vomiting, hematuria, and dysuria. Fecal incontinence, delayed puberty, organomegaly, jaundice, and family history of inflammatory bowel disease were reported in none of the patients with RAP. Fever, pain not located in periumbilical area, nocturnal pain, elevated erythrocyte sedimentation rate, weight loss, growth disorder, and abdominal tenderness were among the red flags which revealed diagnosis of organic pain in this study.

Conclusion

A series of red flags could increase likelihood of finding organic pain in children with RAP.     

Colorectal cancer in two pre-teenage siblings with familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is an autosomal dominant disorder that characteristically presents with colon cancer in early adult life. We describe a Pakistani FAP family in which two sons had an unusually early manifestation of colorectal cancer. The index patient presented at 11 years of age with abdominal pain, rectal bleeding and iron deficiency anaemia. Colonoscopy showed that the colon was carpeted with a myriad of polyps. Oesophago-gastric and duodenal endoscopy revealed that polyps had also developed in the duodenum. Multiple biopsies indicated neoplastic lesions. The patient underwent a proctocolectomy and endoscopic duodenal mucosectomy. The diagnosis of an adenocarcinoma of the colon and further adenomatous polyps with low-grade and high-grade dysplasia was confirmed by histology. Family screening including a blood test for anaemia and bowel examination revealed that his 12-year-old brother was also affected. Conclusion:Children with familial adenomatous polyposis are at risk for colon cancer and emphasise the need for early tumour recognition. Gastrointestinal symptoms in children should be thoroughly evaluated and standard screening for colonic polyposis should be performed in all individuals with a positive family history and/or known mutations in cancer-associated genes, particularly in children who are under 10 years of age.     

Crohn's disease in children and adolescents

93 children and adolescents with Crohn's disease have been studied. Terminal ileum (25.8%) and ileum and colon (61.3%) were the most common sites of involvement as determined by X-ray examination. The mean age at the time of diagnosis was 13.2 years. A familial incidence of chronic inflammatory bowel disease was found in 12 patients (12.9%). The most common symptoms were: abdominal pain, anorexia, lassitude, diarrhea, loss of weight. Weight below the third percentile, pain on abdominal palpation, anal lesions, mouth ulcers and clubbing of the fingers were the most common clinical signs at the time of diagnosis. Growth retardation (below the third percentile) was present in 22 of 79 children (27.8%) with a mean follow-up of 40 months. 16 patients out of 75 had initial rectal biopsies with histologic changes characteristic of Crohn's disease. 27 patients had surgical treatment; six of them experienced a relapse within a mean period of 26.7 months. Lastly, the authors show that continuous elemental enteral alimentation (CEEA) during 3 weeks induces a remission. CEEA on a longer period is specially targetted to the treatment of growth retardation.     

Castleman's disease of the mesentery in a child: A case of seven years' duration without typical x-ray findings

This report describes a 9-year-old boy with intermediate variant type of giant lymph node hyperplasia or Castleman's disease (CD) originating from the mesentery. He had symptoms and signs related to the disease for seven years before the final diagnosis. The patient's general condition remained good, except for periods of fever and abdominal pain. Pallor and slow growth were the only abnormal findings on physical examination during the follow-up. Laboratory measurements showed worsening microcylic anemia, low serum iron level, and low iron stores in bone marrow samples. The erythrocyte sedimentation rate (ESR) increased to 110 mm/h, and the serum levels of C-reactive protein varied between 80 and 120 mg/l. The level of serum albumin was low, 25–28 g/l, and serum immunoglobulin G was somewhat elevated, varying between 17–13 g/l. The radiologic examination of intestine gave pathological results suggesting a small bowel disease, but no tumor was detected. The abnormal laboratory values and symptoms of the patient resolved completely after surgical removal of the mass. Med. Pediatr. Oncol. 28:362–365, 1997. © 1997 Wiley-Liss, Inc.     

Small bowel intussusception in childhood

BACKGROUND: Intussusception is the most common cause of abdominal emergency in early childhood. The majority of cases are ileocolic type of intussusception. Only few reports concerning small bowel intussusception have been reported. PATIENTS AND METHOD: We retrospectively reviewed the clinical records and imaging findings of all patients with the diagnosis of intussusception (comparing small bowel intussusception with ileocolic type of intussusception), which were documented by ultrasound in the period April 1997 to January 2001. The routine ultrasound scans included an evaluation of the entire abdomen using sector and linear transducers of high frequency (5 - 7.5 MHz) and power doppler ultrasound. RESULTS: A total of 22 patients with small bowel intussusception (9 female, 13 male) and 29 patients diagnosed to suffer from ileocolic intussusception (10 female, 19 male) were identified and treated. Children with small bowel intussusception were significant older in comparison to children with ileocolic type of intussusception (median age 50 vs. 11 months). In our series the presenting symptoms of patients with small bowel intussusception consisted of abdominal pain (86 %) and vomiting (36 %). The initial clinical symptoms of patients with ileocolic intussusception were abdominal pain (100 %), vomiting (72 %) and/or rectal fresh blood (35 %). Small bowel intussusception was an incidental finding in 3 asymptomatic patients (14 %). Hydrostatic reduction was attempted in 14 % of children with small bowel intussusception (vs. 93 % of children with ileocolic intussusception), one patient needed operative treatment (vs. 21 %). Outcome in all patients was favorable. CONCLUSION: The high percentage of patients with small bowel intussusception observed may relate to increased use of abdominal ultrasound in children presenting with abdominal pain and improvements in resolution and quality of the images. Small bowel intussusceptions in our series were in the majority of cases short-segmented, self-limited and without a lead point. In comparison to patients with ileocolic intussusception the presenting symptoms of small bowel intussusception are less acute.     

Diagnostic problems in a 17-year-old patient with gastrointestinal manifestations of Fabry disease

Fabry disease is a rare X-linked recessive lysosomal storage disorder caused by deficiency of lysosomal enzyme alpha-galactosidase, which leads to accumulation of globotriasylceramides (GL-3) in visceral tissues and vascular endothelium, causing multi-organ failure. We presenta case of Fabry disease in a 17-year-old patient with mainly gastrointestinal manifestations, diagnosed 10 years after the manifestation of first symptoms. Significant and progressive weight loss with abdominal pain and vomiting, leading to cachexia, were observed in early childhood. The patient was investigated for non-inflammatory bowel diseases, Raynaud syndrome, polimyositis, mitochondrial cytopathies, intestinal lypodystrophies and others. The symptoms of intenstinal pseudo-obstruction syndrome were observed and surgical treatment was instituted because of necrosis of the colon. There was progressive cachexia and parenteral nutrition had to be instituted. Finally, plasma alpha-galactosidase was measured, and its deficit confirmed Fabry disease. In conclusion gastrointestinal symptoms in the course of Fabry disease can obscure other characteristic symptoms, may be prodromal and leading. Heart and renal failure may not occur in children. Unexplained abdominal pain and malnutrition may be gastrointestinal manifestations of metabolic disorders.     

Lower abdominal inflammatory myofibroblastic tumor -an unusual presentation- a case report and brief literature review

A 9-year-old girl presented with lethargy, malaise & chest pain. Her blood counts confirmed hypochromic microcytic anemia. She was prescribed iron supplements. Subsequently she was admitted to our hospital with fever and increasing chest and abdominal pain. She was treated with antibiotics, and a diagnosis of “early chest infection” was made. Over the following 2 weeks she failed to improve, and her anemia worsened. She was readmitted, and found to have a mass in her lower abdomen with pressure symptoms on her bowel and bladder. A white-cell scan showed increased uptake in right lower quadrant. An ultrasound and a CT scan confirmed a mass adjacent to her bladder. Needle biopsy showed it to be an unusual localization of an inflammatory myofibroblastic tumor (IMT) of cecum. A presentation with chest pain, fever, anemia and pressure symptoms was highly unusual of a lower abdominal IMT mass. She had a successful excision of the tumor, with resolution of her symptoms.     

Celiac disease and cardiomyopathy in an adolescent with occult cirrhosis

Patients with celiac disease commonly present with gastrointestinal symptoms including abdominal pain, bloating, constipation or diarrhea. Extraintestinal manifestations of this small bowel disease are increasingly recognized, and greater numbers of patients are being diagnosed after presenting solely with nongastrointestinal symptoms. The present report describes a case involving a 16-year-old girl with oligomenorrhea who was found to have celiac disease and liver cirrhosis of unknown etiology. Subsequent evaluation revealed cardiac dysfunction consistent with cirrhotic cardiomyopathy, a rare finding in the paediatric population. This patient’s unusual presentation permits an exploration of several conditions uncommonly reported in conjunction with celiac disease.     

Reizdarmsyndrom

Irritable bowel syndrome (IBS) is a common medical condition with altered bowel habits in association with abdominal pain or discomfort. Recently, the Rome criteria, a classification system of functional gastrointestinal disorders, have been updated; by definition, no mechanical, biochemical, or overt inflammatory condition can explain the patient’s symptoms. IBS is one of the most commonly diagnosed gastrointestinal disorders, with a prevalence (estimated from population-based studies) of about 5–15%. IBS accounts for a significant number of visits to primary care physicians and is, after the common cold, the second most common cause of work absenteeism in the United States. The direct and indirect costs of IBS have been estimated to exceed 20 billion U.S. dollars yearly. Aetiology and pathogenesis are unknown, but altered gastrointestinal motility and visceral hypersensitivity might play a role. A few basic investigations are sufficient to rule out organic disease in the absence of alarming symptoms and chronic diarrhoea. Treatment is symptomatic and based on the predominant symptoms of the individual.