Colorectal polyps in children. A study of 34 patients

AIM: To assess the frequency and the clinical features of polyps of the colon and rectum in children. METHODS: A total of 34 patients (20 boys and 14 girls, mean age: 5.4 years) were enrolled in this 14-years retrospective study. Diagnosis was done for almost all patients by colonoscopy (n=8) or recto-sigmoidoscopy (n= 19). After endoscopic polypectomy, polyp's type is determined by histological examination. RESULTS: Minimal and relapsing rectal bleeding was the most frequent finding of polyps of the colon and rectum (85.3%) followed by spontaneous emission of polyp (n=3), rectal prolapses (n=2), chronic constipation (n=1) and abdominal pain (n=1). The polyp was unique in all cases and with a mean size of 12 mm. The majority of polyps were localized in the rectum or sigmoid (97%) and were pediculate (81.2%). Endoscopic polypectomies concerned 26 polyps while two small polyps were left. Most of the polyps corresponded histologically to juvenile polyps (96.2%). The immediate post-op course was uneventful for 26 children. CONCLUSION: Our study suggests that rectal bleeding is the most frequent finding of polyps of the colon and rectum in childhood. Outcome after endoscopic polypectomy is good.     

Gastrointestinal surgery and gastroenterology. IX. Obstipation: etiology and diagnosis

Constipation and disordered defaecation are symptoms, not disease entities. Usually these symptoms are not caused by organic abnormalities, but by disordered motility of the colon and pelvic floor. Both decreased colonic motility (inertia coli) and increased frequency and amplitude of haustrating colonic contractions in the context of an irritable bowel syndrome may lead to constipation. A third important functional cause of constipation is by paradoxical straining of the pelvic floor muscles during (attempts to) defaecate: anismus. In the diagnosis of constipation the primary aim usually is the exclusion of organic disorders. A plain abdominal X-ray and measurement of colonic transit with radiopaque particles will provide information about the severity of the constipation. Defaecography is indicated primarily if disordered faecal expulsion exists. Anorectal manometry is relevant when Hirschsprung's disease is suspected.     

Defecation disorders in children: treatment with colonic irrigation through an appendicostomy

In 3 patients with serious constipation or faecal incontinence the appendix was sewn open-ended into the abdominal wall (Malone-stoma) allowing antegrade bowel washouts. The patients were a 4-year-old boy with Hirschsprung's disease, a 15-year-old boy with chronic functional constipation and encopresis, and a 5.5-year-old boy with incontinence associated with a meningomyelocele. Following the procedure they were free from bowel problems. Faecal incontinence has a major detrimental effect on the psychosocial development of children. Severe constipation and faecal incontinence which do not optimally respond to conventional therapy can be treated by this procedure. Treatment is effective in around three-quarters of these children. Complications occur in an equal number of children, stenosis being the most frequently seen.     

Bowel movement and constipation frequencies and the risk of colorectal cancer among men in the Netherlands Cohort Study on Diet and Cancer

The authors investigated the associations between bowel movement and constipation frequencies and colorectal cancer (CRC) endpoints among men in the Netherlands Cohort Study on Diet and Cancer (n = 58,279) and explored whether dietary fiber intake may modify associations. After 13.3 years (1986-1999), 1,207 CRC cases and 1,753 subcohort members were available for case-cohort analyses. Multivariate analyses showed a significantly increased hazard ratio for CRC overall and rectal cancer in men who reported having a bowel movement 1-2 times per day (second-highest category) as compared with once a day (CRC: hazard ratio (HR) = 1.29, 95% confidence interval (CI): 1.09, 1.53 (P(trend) < 0.001); rectal cancer: HR = 1.50, 95% CI: 1.15, 1.95 (P(trend) = 0.001)). Hazard ratios for CRC overall and rectal cancer were significantly decreased and lowest in men who reported suffering from constipation sometimes or more often versus never (CRC: HR = 0.76, 95% CI: 0.58, 0.98 (P(trend) = 0.02); rectal cancer: HR = 0.57, 95% CI: 0.35, 0.90 (P(trend) = 0.01)). No trends in the associations with proximal or distal colon cancer risk were observed. Interactions with dietary fiber intake were not significant. In this study, frequent bowel movements were associated with an increased risk of rectal cancer in men, and constipation was associated with a decreased risk.     

Histologic response after neoadjuvant therapy in rectal adenocarcinoma: own experience and review of the literature

BACKGROUND: Neoadjuvant therapy has improved outcomes for patients with locally advanced rectal cancer. AIM AUTHORS: We studied the degree of histopathological regression after radiotherapy regimens commonly used in their clinical practice, and its effect on the pathology of by clinically founded T3-T4 rectal cancer. PATIENT AND METHODS: A total of 57 patients were investigated who underwent neoadjuvant radiotherapy or chemoradiotherapy--commonly used at our institute--for biopsy proven primary mid or lower third rectum adenocarcinoma between January and December 2004. The standard surgical treatment was anterior resection sec Dixon, Lloyd-Davies--and Hartmann's procedure, all with total mesorectal excision. RESULTS: The surgical specimens were examined by selected pathologists and a modified pathologic staging system the Rectal Cancer Regression Grade (RCRG) was used. (I) "good" response (n=12, 21%), (II) "median" response (n=25, 44%), (III) "poor" response (n=20, 35%). Significant tumor regression (RCRG I-II.) was seen in 37 patients (65%). Six patients (10.5%) have had complete pathological regression and 6 patients (10.5%) have had only microscopic foci of adenocarcinoma. CONCLUSION: Comparing of pretreatment and pathologic staging revealed that the depth of invasion was significantly downstaged. The authors also reviewed the literature of neoadjuvant therapy, total mesorectal excision, prognostic and predictive factors of rectal cancer.     

Technical aspects and indications of anorectal manometry

Anorectal manometry is an important tool in testing anorectal disorders. Water-filled balloons is the most commonly used. The step-by-step anorectal manometry using a small balloon tube is easy to perform, well standardized and reproducible. Parameters studied by anorectal manometry are the rectoanal inhibitory reflex, anal resting pressure, sustained voluntary contraction of anal canal and rectal sensation. Anorectal manometry is also useful for diagnosis of anismus. The most important indications are anal incontinence, distal constipation and preoperative evaluation before sphincteroplasty or surgical rectocele repair.     

Chronic gastritis in children

BACKGROUND: Active gastritis, atrophic gastritis (AG) and intestinal metaplasia are lesions associated with Helicobacter pylori (H. pylori) infection in adults. AIM: To assess the prevalence of chronic gastritis, its histological characteristics and clinical features in children. METHODS: 345 children (M/F: 151/194, mean age: 8.6 +/- 3.7 years; range: 1-18 years) were enrolled, referred for upper gastrointestinal endoscopy (UGI endo) with clinical manifestations of gastritis, i.e., recurrent abdominal pain (n = 232, 67.2%), upper gastrointestinal bleeding (n = 59, 17.1%) and miscellaneous (n = 53, 15.3%). Four perendoscopic gastric biopsy specimens (antrum: 2, fundus: 2) were taken. Biopsies were assessed and graded according to the updated Sydney system. H. pylori infection was considered if 2 out 3 tests were positive (culture, histology and rapid urease test), whereas 3 concordant negative results identified H. pylori negative children. RESULTS: H. pylori infection and chronic gastritis were detected in 215/345 (62.3%) (M/F: 104/117, sex ratio M/F = 0.89) and 221/345 (64.05%) children, respectively. Recurrent abdominal pain (n = 149, 67.4%) was the main clinical features of chronic gastritis followed by vomiting (n = 43, 19.5%) and upper gastrointestinal bleeding (n = 41, 18.6%). Any clinical features were however found to be specific. UGI endo showed; nodular gastritis (n = 90, 40.72%), congestive gastritis (n = 84, 38%), gastric ulcer (n = 9), bulbar ulcer (n = 5) and normal (n = 47, 21.2%). Chronic gastritis was active in 115 cases (52%) and was significantly associated with nodular gastritis (p < 0.05). Thirty two chronic gastritis (14.4%) exhibited AG (M/F: 16/16, mean age: 9.4 +/- 3.4 years) and 30/32 (93.7%) were H. pylori positive. AG was significantly associated with H. pylori infection (p < 0.0001) and nodular gastritis (p < 0.005). Active, follicular and AG were significantly associated with H. pylori infection (p < 0.00001). Three patients exhibited intestinal metaplasia. CONCLUSION: Chronic gastritis is frequent in children. Any clinical features were found to be specific. It significantly associated H. pylori infection and nodular gastritis. Atrophic gastritis was found in 14.5% of children.     

Efficacy of an herbal dietary supplement (Smooth Move) in the management of constipation in nursing home residents: A randomized, double-blind, placebo-controlled study

OBJECTIVE: To investigate the efficacy and cost effectiveness of an herbal tea, Smooth Move, in nursing home residents with chronic constipation. DESIGN: Double-blind, placebo-controlled, 2-armed, parallel-group clinical trial. SETTING: A 483-bed nursing home in Allentown, Pennsylvania, operated by Lehigh County Government. PARTICIPANTS: A total of 86 nursing home residents with chronic constipation. INTERVENTIONS: Participants (n = 86) were randomly assigned to receive Smooth Move (n = 42) or a placebo (n = 44), once daily, in addition to standard treatment for chronic constipation. The study period was 28 days. MEASUREMENTS: The primary efficacy parameter was the difference in total number of bowel movements. Secondary parameters included the difference in average number of standard treatment doses dispensed, and the difference in total medication costs. RESULTS: Compared to placebo, in the intention to treat (ITT analysis) there was a statistically significant increase in the number of bowel movements in the Smooth Move group. The Smooth Move group (n = 42) compared with the placebo group (n = 44) experienced an average of 4.14 more bowel movements during the 28-day study period versus the 28-day pre-study period (P = .017). CONCLUSION: Smooth Move herbal tea, when added to the standard treatment regimen for nursing home residents with chronic constipation, increased the average number of bowel movements compared to the addition of a placebo tea.     

The prevalence of delta virus infection in chronic liver disease in Egyptian children in comparison with some other countries

BACKGROUND: Hepatitis Delta Virus (HDV) infection has a worldwide distribution. The aim of this study was to establish its prevalence in Egyptian children with chronic liver disease, and its role in the development and progress of hepatic illness. METHODS: A prospective study of 45 Egyptian children who had liver cirrhosis (n = 24) or chronic hepatitis (n = 21) was done. They were consecutively chosen. Their ages ranged from 2-15 years (median = 5). Serological studies were performed to detect the presence of hepatitis B surface antigen (HBs Ag) and HDV infection IgG antibody (IgG anti-HD). RESULTS: Anti-delta antibody (IgG anti-HD) was detected in only four children with hepatic cirrhosis and non of the chronic hepatitis, with an overall prevalence of 8.9% (4/45). Three of them (75%) were hepatitis B surface antigen (HBs Ag) negative. Significant statistical association between delta infection and the state of hepatic illness was detected (p < 0.05). Whereas HBs Ag was detected in 54% (13/24) of liver cirrhosis and 52% (11/21) of chronic hepatitis, with an overall prevalence of 53% (24/45). There was no statistically significant association between HBs Ag positivity and state of hepatic illness. CONCLUSIONS: The prevalence of HDV infection is 8.9% of Egyptian children with chronic liver disease. HDV infection in children is associated with advanced chronic liver disease.     

Primary hyperoxaluria in children in central Tunisia

AIM: The goal of this work is to analyze clinical and therapeutics particularities of primary hyperoxaluria in children in Tunisian centre. METHODS: We studied retrospectively 15 cases of primary hyperoxaluria enrolled during 9 years period (1994-2002). RESULTS: It is about 2 boys and 13 girls (sex - ratio = 4.5) aged 2 month to 13 years (mean age: 4 years). Six patients presented the infantile form and nine the juvenile form of HP. At the moment of diagnosis, renal function was normal in one patient, moderately altered in another and severely altered in the other patients. All patients had nephrocalcinosis and 6 among them radio-opaque renal calculi associated. Diagnosis of HP was established in 11 cases by hyperoxaluria and/or important hyperoxalemia or on the data of the renal biopsy and biochemical analysis of renal calculi in 4 cases. The so-called "maghrebin" mutation (Ile244Thr) sought-after in 9 children, has cannot be identified that in 2 among them. Eight patients died of the continuations of their illness. The seven other patients again in life present a terminal renal insufficiency treated by haemodialysis. No patient could benefit from organ transplantation. CONCLUSION: Primary hyperoxaluria is a very heterogeneous disease on the plan clinic that genetic. In Tunisia where it constitutes a frequent cause of end stage renal failure, prenatal diagnosis of this disease is of a big interest.     

Faecal incontinence: an unrecognised epidemic in rural North Queensland? Results of a hospital‐based outpatient study

OBJECTIVES: We explored the prevalence of faecal incontinence (FI) in a referral hospital outpatient population, to explore suspicions that FI is inadequately studied, underestimated and poorly appreciated in the rural North Queensland (NQ) community. DESIGN: Prospective cross-sectional study using a specifically designed questionnaire. SETTING: The Townsville Hospital, a referral centre serving rural NQ. SUBJECTS: A total of 435 consecutive patients attending the gynaecology (n = 261) and colorectal clinics (n = 174) between 31 January and 12 June 2003 were enrolled (participating proportion 96.5%). MAIN OUTCOME MEASURES: FI prevalence, severity, impact on patients' lives, and risk factors. RESULTS: The prevalence of FI in the study population (median age 53 years) was 20.7%. Amongst affected patients (n = 90) the median duration of FI was 2 years with more than half of those affected soiling themselves at least once a month. Many patients with FI (42%) reported feeling hopeless at least some of the time. Rectal prolapse, chronic constipation, psychiatric problems, colon disease, and urinary incontinence were all significantly associated with FI. A CART analysis revealed that many patients (45%) with urinary incontinence and chronic constipation also experienced FI. CONCLUSIONS: This FI prevalence in a clinical setting in NQ is, apart from nursing home studies, the highest reported in the literature. FI negatively impacted on affected persons' lives. In patients presenting with urinary incontinence and chronic constipation, physicians should specifically enquire whether FI is also present. Definitive community studies to determine the scale of this 'silent epidemic' in northern Australia are now required.     

Surgical treatment of rectal prolapse

Rectal prolapse must be distinguished from anal prolapse or mucosal prolapse since the treatment differs. The only effective treatment for rectal prolapse is surgery. The fact that rectal prolapse causes severe disability and that the morbidity of the current surgical treatment is low justifies surgery even at advanced age. Moreover, the success rate is high. Ventral rectopexy seems to be the surgical technique of choice on the grounds of the anatomical advantages (preservation of rectal innervation and lifting of the middle compartment) and the results (low recurrence rates and reduction of constipation). The laparoscopic approach is just as effective as an open procedure and results in less morbidity, quicker recovery and lower medical costs.     

Infection with HGV in children suffering from chronic hepatitis

HGV was discovered in 1995. It belongs to Flaviviruses and it is found worldwide. At first it was though to cause chronic hepatitis, in fact its pathogenicity is up till now unclear. The aim of this work was to estimate the prevalence of anti-HGV antibodies among children suffering from chronic hepatitis B (CHB), chronic hepatitis C (CHC) and chronic hepatitis B + C (CHB + C) and to compare it with the prevalence in healthy children in the district of Lodz, Poland, and to assess the influence of HGV infection on biochemical and histological parameters of chronic liver disease. PATIENTS AND METHODS. 153 children with chronic hepatitis B and C and 22 healthy children have been investigated. The presence of anti-HGV was assessed by ELISA. In children with chronic hepatitis prior the entrance to the study HCV-RNA, HBsAg, HBeAg, and if HBeAg-negative also HBV-DNA were assessed. Thick needle percutaneous liver biopsy was performed in each case. RESULTS. Of 153 children with chronic hepatitis, 17 (11%) were anti-HGV positive. Anti-HGV positivity was found in 3 (3%) of 94 children with CHB, 12 (25%) of 48 children with CHC, and 2 (18%) of 11 children with CHB + C. Anti-HGV were not found in any of 22 healthy children. Previous HGV infection was associated with CHC (p = 0.0001), history of hospitalization (p = 0.002) or blood transfusion (p = 0.0006) as compared with children with CHB. Serum albumin or gamma globulin concentration as well as ALT level or degree of inflammation and fibrosis in liver biopsy specimen were not correlated with previous HGV infection.     

Chronic constipation in overweight children

BACKGROUND: Obesity and functional constipation seem to share a common biopsychosocial model of causation. Though chronic constipation can significantly affect the quality of life of an overweight child, this association has not been highlighted in the literature. The purpose of this study was to compare the proportion of overweight children among children with chronic constipation with a control group of children with normal bowel habits. METHODS: Retrospective chart review with a control population. One hundred one consecutive children 5-18 years of age referred to the Subspecialty Clinic for functional constipation were the study group. The control group consisted of 100 consecutive children from the general pediatric practice seen for physicals and minor illnesses. Children with a body mass index (BMI) of >85 percentile from the National Institutes of Health (NIH) 2000 chart were classified as overweight. RESULTS: The control and study groups were statistically comparable in mean age (10.97 +/- 3.83 years and 8.07 +/- 2.56 years, respectively) and gender ratio (58 males in each group). Thirty children in the control group and 44 in the study population were overweight (p < .05). Among children with chronic constipation, the group of overweight children was male predominant (70.45% vs 47.36%, p < .05), had increased incidence of psychological/behavioral problems (45.45% vs 22.8%, p < .05), and was more likely to fail treatment (40.9% vs 21.05%, p < .05). There was no significant difference in the clinical profile of constipation, such as mean duration of constipation before presentation, sex ratio, incidence of painful defecation, and soiling and frequency of defecation between these 2 groups. CONCLUSIONS: There appears to be an association between chronic severe constipation and being overweight. Children with constipation are more likely to be overweight when compared with controls. Among children with chronic constipation, overweight individuals seem to constitute a distinct clinical group. This group is male predominant, has increased incidence of psychological/behavioral disorders, and is more likely to fail treatment.     

Fiber intake and childhood appendicitis

In order to investigate the possible role of fiber in the etiology of acute appendicitis, 203 consecutive appendectomized children with histologically proved appendicitis and 1922 controls were studied by the diet history method. Statistics were performed by multivariate analysis of variance, discriminant analysis and chi 2. Appendectomized children had statistically significant lower mean daily intake of fiber (17.4 g versus 20.4 g, P < 0.001) including all fiber fractions: cellulose, uronic acid, pentose, exose and lignin. No statistical difference was found for energy, protein, carbohydrate and fat intake. Discriminant analysis proved that only cellulose and exose are independently correlated to appendicitis and lower fiber intake is thought to be the cause in 70% of the cases. Recurrent abdominal pain, chronic constipation and positive family history of appendectomy were more frequent in appendectomized children (P < 0.001). This study gives evidence that low fiber intake could play an important role in the pathogenesis of appendicitis.     

An epidemiological study of Hirschsprung's disease

All newly diagnosed cases of Hirschsprung's Disease among children born in Baltimore City and County, Maryland and diagnosed within the Baltimore Standard Metropolitan Area during 1969 through 1977 were identified. Using hospital records and death certificates, 33 cases were ascertained. An overall incidence rate of 18.6 per 100 000 livebirths was found, similar to that reported by others. A high male to female ratio (4.32:1) was found; the ratio for non-whites to whites was 1.67:1. Non-white males had the highest rate, 37.6 per 100 000 livebirths. These findings plus the fact that 9% of these children were also diagnosed as having Down's Syndrome, were evidence that the aetiology of Hirschsprung's Disease may be partially genetic. Among environmental factors studied, there was no time trend and no relationship with socioeconomic status found. Among whites, there was a larger percentage of children who were the first births of mothers aged 30 and above, a result previously reported for children with neural tube defects. Very little is known about micro-environmental factors in relation to Hirschsprung's Disease and this would seem to be the area for future emphasis in research.     

Microscopic colitis

AIM: Various case presentations in the literature discussed that frequent watery diarrheas introduce the clinical picture of microscopic colitis and intermittent or continuous diarrhea can remain. On the other hand, numerous cases never suffered from episodes of diarrhea but suffered from chronic constipation definitely. The authors present their first observations in Hungary. METHODS: A cohort of patients with independently confirmed typical histopathological changes was investigated. 53 patients with histologically proved MC (46 with CC, 7 with LC) were included. The existence of diarrhea or constipation and the co-existence of autoimmune diseases also investigated and all data were retrospectively analyzed. RESULTS: In contrast of the literature, about half of the patients had chronic constipation and cca. 50% of MC patients had autoimmune disease and the diagnosis of autoimmune disease was always prior to MC. CONCLUSIONS: Causes of inducing and amplifying the processes of "remodelling" the gut wall are thought to be unknown, but the results are: altered structure (and function?). All useful observations of this study may enrich the practice and can help these patients.     

Children Helicobacter pylori infection: antibiogram results

Helicobacter pylori infection is frequent in children. The eradication rate is variable, it is influenced by resistance of the bacteria to the antibiotics used. The aim of this study was to determine the resistance rate of the most commonly used antibiotics among helicobacter pylori (Hp) strains isolated in infected children. PATIENTS AND METHODS: 60 children (26 males, 34 females), with mean age of 8 years 8 months (3 years and 2 month (2.5-13.5 years) underwent an oesogastroscopy. Forty six of them had helicobacter infection assessed by the presence of Hp on the gastric biopsy and or positivity of urease test. The infected children were treated with three medication; Omeprazole. Clarythromycin, and Amoxicillin. The eradication of Hp was confirmed in 13 patients by the absence of Hp on the gastric biopsy and/or negativation of the urease test; RESULTS: Culture was positive in 13 infected children susceptibility to anti microbial drugs was done in ten children. Nine children had primary metronidazole resistance, three had both clarythromycin and Metronidazole resistance, three had Clarythromycin primary resistance. No case of Amoxicillin primary resistance was detected. Children eradication was achieved in four children among 13 children. This study shows the difficulty of Hp culture. It confirms the absence of Hp resistance to Amoxicilline. the high level of Hp resistance to Metronidazole and the mild level of Clarythromycin resistance. The authors stress the importance of Antibiotic susceptibility assay in helicobacter pylori infections.     

Diabetic ketoacidosis in childhood

Diabetic ketoacidosis is the most serious acute complication of insulin-dependent diabetes mellitus and the most frequent reason for hospital admission of diabetic children. The most frequent cause of death of these patients is also the diabetic ketoacidosis. The mortality rate of the disease has not changed since the seventies (1-2%). In this work, the data of 89 patients with diabetic ketoacidosis were analyzed. These patients were admitted to the 1. Department of Pediatrics of the Semmelweis University of Medicine between 1992-1997. The data (metabolic parameters, the causes of ketoacidosis and the length of hospital stay) of previously known diabetic children was compared with the data of previously unknown diabetic children. Our patients were divided in 2 groups: serious (n = 11), and mild-to-moderate (n = 48) acidosis. Their laboratory findings, their intravenous infusion-, and insulin demand and the length of their hospital stay were compared. The state of consciousness at their hospitalisation and the concomitant complications were also examined. Significant difference was found only in the duration of intravenous insulin administration (with the exception of pH and BE, of course). There was no relationship between the seriousness of the disease and the duration of hospital treatment. It is noteworthy that even the previously known diabetic children with the shortest hospitalization spent more than 7 days at the department.     

School Injury Among Ottawa-Area Children: A Population-Based Study

BACKGROUND:  Injuries are the leading cause of death among Canadian children and are responsible for a substantial proportion of hospitalizations and emergency department visits. This investigation sought to identify the factors associated with the likelihood of sustaining an injury at school among Ottawa-area children.
METHODS:  Children presenting to Ottawa-area hospitals and urgent care clinics from January to December 2002 (n = 24,074) were included for analysis. The frequency of school injuries by sex, age group, type of injury, and hospitalization was analyzed. Multivariate logistic regression was used to assess the factors associated with sustaining an injury at school. The school activities most associated with injury and the most frequent types of school injuries were assessed.
RESULTS:  A total of 4287 Ottawa-area children were injured at school in 2002, representing 18% of all injuries. Children aged 5-9 years and 10-14 years were more likely to have school injuries than older children (aged 15-19 years) (OR = 3.07, 95% CI = 2.77-3.40 and OR = 3.10, 95% CI = 2.83-3.37, respectively). The most frequently encountered school injuries were fractures (n = 1132) and musculoskeletal injury (n = 907). The most frequent mechanisms of school injuries were "playing" (n = 1004) and "informal sports" (n = 1503).
CONCLUSIONS:  Many children get hurt at school, particularly during informal recreation activities. Environmental modification and increased supervision are strategies that may reduce school injuries.