RELATION BETWEEN CAGA EXPRESSION AND PERSISTENT HELICOBACTER PYLORI INFECTION AMONG CHILDREN AND ADOLESCENTS
James R Rick, Cristina Semino-Mora, Eugenia Reuda-Pedraza, Carolyn A Sullivan, Andre Dubois, Pediatrics, Walter Reed Army Medical Center, Washington, DC; Medicine, USUHS, Bethesda, MD; Pathology, Walter Reed Army Medical Center, Washington, DC
BACKGROUND & AIM.
Decreased eradication of Helicobacter pylori among children with CagA+ infection has been reported. Therefore, we examined the relationship between H. pylori 16S rRNA and cagA gene expression measured by fluorescent in situ hybridization (FISH) with H. pylori eradication among infected children and adolescents.
7 children with H. pylori infection underwent follow up endoscopy with biopsies. The initial endoscopic findings were nodularity in 3 and duodenal ulcer (DU) in 4. After standard triple treatment, indication for endoscopy was persistent symptoms in 3 and follow up of DU in 4. Serial 4 micron sections of the initial and post therapy antral biopsy were stained by H&E and Genta. Unstained sections were prepared for FISH. Assessment of histology was by the Updated Sydney System. FISH was performed with specific primers for H. pylori 16S rRNA and cagA. Morphometric quantification of gene expression was performed using an intraocular grid.
H. pylori infection persisted in 3 of the 7. The persistently H. pylori infected children tended to be older (16.3 ± 0.7 vs 11.3 ± 2.3 yr) than the cured children. In the group with persistent infection, the initial biopsy had increased chronic (3.0 ± 0 vs. 2.0 ± 0.4) and active inflammation (2.7 ± 0.3 vs 1.0 ± 0.4), H. pylori colonization by both Genta (15.8 ±± 2.4) and H. pylori 16S rRNA expression (13.6 ± 1.4 vs 7.9 ± 2.0), cagA expression (10.1 ± 1.6 vs 4.7 ± 2.3) and ratio of cagA + bacteria (0.74 ± 0.04 vs. 0.52 ± 0.1) when compared to the cured group. No active inflammation and decreases in chronic inflammation (1.3 ± 0.3), H. pylori colonization by Genta (3.7 ± 0.9) and H. pylori 16S rRNA expression (2.5 ± 0.5), cagA expression (1.1 ± 0.2), and ratio of cagA + bacteria (0.43 ± 0.03) were seen after treatment in those with persistent infection.
Persistent H. pylori infection is associated with increased expression of cagA and ratio of cagA + bacteria among children and adolescents. cagA may play a role in the treatment failure of H. pylori infected children and adolescents.
CONTINUOUS REAL-TIME 13C UREA BREATH ANALYSIS FOR EVALUATION OF HELICOBACTER PYLORI IN CHILDREN
Arie Levine, Orit Shevah, Yaron Niv, Yona Avni, Haim Shirin, Pediatric Gastroenterology Service, E.Wolfson Medical Center, Holon, Israel; Institute of Gastroenterology, E.Wolfson Medical Center, Holon, Israel
Carbon labeled urea breath tests are commonly used as a non invasive method to evaluate the presence of Helicobacter pylori infection. These usually entail 2 point sampling and necessitate mass spectrometry for analysis. A novel new office based methodology for 13C urea breath test utilizes passive continuous real time sampling with molecular correlation spectrometry analysis, and gives an immediate printout of the result. We evaluated this technology in a pediatric cohort, and compared it to conventional techniques.
A prospective controlled study in which consecutive children and adolescents ages 5–18, underwent 13C urea breath testing using both conventional mass spectrometry based two point sampling and office based continuous real time sampling with a citrate based test meal (BreathID, Oridion Medical Ltd.).
Seventy -one breath tests, using both techniques, were performed in 67 children with a mean age of 13 ± 3.6 years.Twenty three children also performed endoscopy with gastric biopsies. Helicobacter pylori was present in 45% of children. Continuous real time sampling 13C breath tests were well tolerated, and gave a final result within 10 minutes in 96% of patients. Concordance between this test, conventional breath testing and endoscopic diagnosis was 100%.
13C urea breath using the continuous real time sampling technique is efficient, patient friendly, rapid and accurate. This methodology may prove especially useful in the pediatric population.
PREVALENCE OF H. PYLORI INFECTION IN THE PEDIATRIC POPULATION IN THE SOUTHERN AREA OF PUERTO RICO
Emilia Talamas, Marta I Delgado, Jose D Santiago, Pediatrics, Saint Luke's Episcopal Hospital, Ponce, PR, Puerto Rico
Determine the prevalence of H. pylori infection in different age and sex groups of the pediatric population in the southern area of Puerto Rico from 1996 to 2001.
Review of 650 medical records of children with abdominal pain from 1996 to 2001.
Variables: sex, age, residence location, year of diagnosis, method of screening and presence or absense of H. pylori infection.
Chi square and T test study of data.
Inclusion criteria: Age range: 1–18 years
History of abdominal pain
No previous treatment for H. pylori infection
Residence location: Southern area of Puerto Rico
Screening methods: Serum H. pylori IgG, urea breath test and gastric biopsy.
431 children were screened with serum H. pylori IgG, 213 children with urea breath test and 46 children with gastric biopsy. Of these patients, 40 were screened with two methods: 27 with serum H. pylori IgG and urea breath test, 10 with serum H. pylori IgG and gastric biopsy and 3 with urea breath test and gastric biopsy. The infection rate was 53.7% seropositive female and 46.3% seropositive males. The mean age of diagnosis was 9.29 years old (p < 0.05).
There was a statistically significant linear trend in the prevalence of H. pylori in our study sample through the 6 year period, taking as reference the patients that were seropositive for H. pylori IgG (p < 0.05). No statistically significant difference was noted between the two genders ( p>0.05).
CHILDHOOD MENETRIER'S DISEASE(MD) IN A THREE YEAR OLD CHILD ASSOCIATED WITH ACTIVE CMV INFECTION
George Yanni, Alexandra Clark, Khiet DT Ngo, Pediatric Gastroenterology, Loma Linda University Children's Hospital, Loma Linda, CA
Childhood MD is a rare disease entity with approximately fifty reported cases characterized by hypertrophic gastropathy with protein losing enteropathy. In contrast with adults, the disease in children is typically self-limited with a good prognosis.
We aim to describe our clinical experience with a child diagnosed with MD.
Our patient was a previously well three year old female who presented with a ten day history of progressive anasarca. Her physical examination was remarkable for moderate facial edema and abdominal distension, and significant pitting edema of the lower extremities. Laboratory evaluation revealed hypoalbuminemia, hypoproteinemia, and elevated fecal alpha-1-antitrypsin levels. Initially a malignant process was considered. A CT scan of the chest, abdomen, and pelvis revealed evidence of hypertrophic gastric rugae, large pleural effusions, and ascites. Protein losing enteropathy was suspected. Upper and lower gastrointestinal endoscopies were performed. Findings on the colonoscopy were normal. The upper endoscopy showed marked gastric mucosal erythema and hypertrophy. The biopsies from the gastric mucosa showed foveolar hyperplasia and CMV inclusion bodies with subsequent tissue viral cultures positive for CMV. A urine culture for CMV was also positive. Because of the severity of her anasarca, pleural effusions requiring chest tubes, and hypoalbuminemia she was treated with albumin infusions, and a course of gancyclovir. She was discharged after eleven days of stay with full clinical recovery.
The etiologic agent and mechanism of pathology in MD are not well defined. CMV, enterovirus, echovirus, and H pylori infections have been reported in association with MD. However, CMV accounts for the majority or approximately 30% of cases. Although a rare and self limited disease, MD should be considered in children presenting with edema, hypoalbuminemia, and/or protein losing enteropathy.
ENDOSCOPIC PYLORIC BALLOON DILATATION IN PEDIATRIC PATIENTS WITH DELAYED GASTRIC EMPTYING
Nick Ogunmola, Marsha Kay, Robert Wyllie, Vera Hupertz, Department of Pediatric Gastroenterology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH
To determine the outcome of endoscopic pyloric balloon dilatation in pediatric patients with delayed gastric emptying at our institution. We sought to determine the rate of success of the procedure and if there were patient characteristics or technical aspects of the procedure that influenced the procedure outcome.
We performed a retrospective chart review of 18 pediatric patients who underwent endoscopic pyloric balloon dilatation at our institution between January 2000-May 2002. Serial balloon dilation was performed across the pylorus with controlled radial diameter through the scope (TTS) balloons under direct endoscopic visualization.We reviewed each patients symptoms and physical findings, results of gastric emptying tests, serologic evidence of recent viral illnesses, biopsy findings at the time of endoscopy, number of dilatation procedures, technique of dilatation and outcome following the procedure.
There were 8 boys and 10 girls with a mean age of 13.7 years. The patients were followed for a mean of 17 weeks. The mean duration of symptoms prior to the first balloon dilation was 23.9 months. 17% had preceeding viral illnesses. The indications for the procedure were delayed gastric emptying due to idiopathic causes (33%), Crohns disease (6%), cyclical vomiting (6%), and GERD (55%). 15 of 18 patients had a gastric emptying test prior to the procedure. 93% of patients had an abnormal gastric emptying time. 39% of patients had more than one dilatation procedure. The mean number of dilatation procedures per patient was 1.5, with a mean inflation pressure of 59 psi. The mean duration of each inflation was 87.6 sec and the mean number of inflations at each procedure was 3.2. Follow-up was available for 15 patients. No complications were seen. Resolution of symptoms was seen in 27% and improvement of symptoms was seen in an additional 53% of patients.
Endoscopic pyloric balloon dilation with TTS balloons is a safe, minimally invasive procedure with an excellent outcome in pediatric patients with many different types of gastric outlet obstruction This technique may be especially well suited to children who develop a transient post viral gastroparesis with severe symptoms as an alternative to pyloromyotomy.