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Pediatric Gastroenterology in Japan: A Personal Perspective

Yamashiro, Yuichiro M.D.

Section Editor(s): Baker, Robert D. Jr. M.D., Ph.D.; Rosenthal, Philip M.D.; Sherman, Philip M. M.D., F.R.C.P.C.; Finkel, Yigael M.D., Ph.D.

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Journal of Pediatric Gastroenterology and Nutrition: May 2002 - Volume 34 - Issue 5 - p 493-495
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OUR SOCIETY

The Japanese Society for Pediatric Gastroenterology, Hepatology and Nutrition (JSPGHAN) was founded in 1972. We now have about 300 active members most of whom are pediatricians with a special interest in gastroenterology, hepatology and nutrition in children. JSPGHAN will hold its 29th annual scientific meeting on 21 and 22 of September this year. The society will, for the first time, hold a postgraduate course on the day before the meeting and this will henceforth be a regular event in conjunction with the annual meeting. The society is planning to present awards to members every year, including a research grant and a scholarship for study abroad. These industry-supported awards will be presented to excellent young investigators at the annual meeting.

PEDIATRIC GASTROENTEROLOGY PRACTICE

I work for the Department of Pediatrics in a private University Hospital located in the central part of Tokyo, the capital city. The University Hospital was founded in 1838 and is a well-known referral hospital in Japan. There are three gastroenterologists in our group and we see about 450 patients per year. These include patients with acute gastroenteritis who are seen in our outpatient GI clinic. We also see about 150 patients with chronic GI complaints and 30 patients with chronic liver diseases yearly. In Japan, there has never been a reported case of celiac disease, and cystic fibrosis (CF) is also very rare (about 1 in 350,000)(1). Therefore, unlike our Western colleagues, we have neither a celiac clinic nor a CF clinic in our hospital. Indeed, the pediatric gastroenterology clinics in this country are not as busy as those in Europe or the USA. The majority of children seen at our twice-weekly gastroenterology clinic and come because of complaints of abdominal pain, vomiting, chronic diarrhea, bloody or tarry stool, constipation, or failure to thrive. The most common diagnoses made in our clinic are gastroenteritis, peptic ulcer, food allergy, infantile hypertrophic pyloric stenosis, gastroesophageal reflux, Meckel's diverticulum, juvenile colonic polyps, lymphoid proliferative hyperplasia of the colon, and inflammatory bowel disease. We see six to eight new peptic ulcer patients in a year. Of these, about 70% have duodenal and 30% have gastric ulcers. About 80% of the peptic ulcer patients are H. pylori-positive. We have found by DNA analysis of the causative bacteria that the father is as important a source of infection as the mother (2). JSPGHAN will soon publish a guideline on the treatment of children with H. pylori-positive peptic ulcers. One of the current therapies in this country is 0.75 mg/kg of lansoprazole twice daily, 25 mg/kg of amoxicillin twice daily, and 10 mg/kg of clarithromycin twice daily for 7 days (3).

In our center in 2001, we identified four new cases of childhood inflammatory bowel disease (IBD)—two cases of ulcerative colitis (UC) and two of Crohn disease (CD). The mean number of newly diagnosed IBD patients was only 1.0 per year in the 1980s and 1.5 per year in the 1990s. The ratio of UC to CD in our patients is five to one. It is uncertain whether these recent incidence figures indicate that the incidence of IBD in Japanese children is increasing, but the incidence in Japanese adults has increased by about 10% in the last decade according to a governmental survey on IBD (4). The incidence of IBD in Japan nonetheless is still far below that in Europe (UC: 1.95, CD:0.51, per 100,000). We are happy to report that infliximab will be available to Japanese patients with IBD through the national healthcare system starting in May 2002.

Although gastrointestinal endoscopy has been widely used in adults in Japan, endoscopy has not been widely practiced in pediatric patients until recently, because of the low prevalence of pediatric GI diseases in this country. Endoscopies for pediatric patients used to be done by adult gastroenterologists or pediatric surgeons, and only a few pediatricians performed it. JSPGHAN has been encouraging the performance of endoscopies by pediatricians, and the number of pediatric endoscopies has been gradually increasing. In our institute, there are two pediatricians who can perform both upper and lower GI endoscopies.

In the pediatric wards, which we share with pediatric surgical colleagues, we care not only for pediatric GI and hepatology patients, but also for postoperative patients to whom we provide nutritional consultation. We also provide consultation for patients receiving intravenous nutrition.

PEDIATRIC HEPATOLOGY PRACTICE

Hepatitis B

The prevalence of hepatitis B has been declining since the nationwide preventation program for maternal-infant transmission of HBV was instituted in 1985. Every pregnant woman is now screened, and the babies born to HBsAg positive mothers are treated with Hepatitis B immune globulin and HB vaccine. The vaccine escape mutant or vaccine failure has not been a serious problem. Since the introduction of the immunization programs for high-risk neonates, the prevalence of HBsAg positive children has decreased from 2.6 per thousand before screening to .24 per thousand since screening. Acute HBV infection including fulminant hepatitis in infants has been eradicated. It has not yet been defined whether children with chronic hepatitis B are likely to develop severe liver disease including hepatocellular carcinoma in the future. We monitor all children with chronic HBV infection for the possible development of HCC, especially in the anti-HBe positive phase after spontaneous seroconversion or even after IFN treatment. Consensus on aggressive treatment using the IFN and/or lamivudine for chronic hepatitis B in children has not been achieved (5).

Hepatitis C

Since 1989, all donated blood in Japan has been screened for Hepatitis C. As a consequence, vertical transmission is now the most frequent mode of HCV acquisition in the pediatric setting. Most of the many studies have reported that vertical transmission occurs in around 10% of children born to HCV-RNA positive mothers. Around 30% of infected children spontaneously clear the HCV in the first 3 years of life. In Japan, the frequency of co-infection with HIV in pregnant women is very rare. Most treatment studies on children with Hepatitis C infection have involved interferon monotherapy of children with chronic hepatitis C. In general, long-sustained response has been obtained in 30 to 50% of children treated with IFN therapy in a dosage of 0.1 MU/Kg daily for 2 weeks and then 3 times a week for an additional 22 weeks. The efficacy of IFN therapy depends mainly on high baseline ALT levels, low serum HCV-RNA levels, HCV genotype other than 1b, and no underlying malignant disease. Studies of dual therapy with interferon and ribavirin have not been reported (6).

Biliary Atresia

Management of pre and postoperative extra hepatic biliary atresia (BA) patients is a big job for us. We have three to four new BA patients every year. The incidence of BA per year in Japan is 100 and there are 93 institutions that have participated in the Japanese Billiary Atresia Registry (JBAR). Our figure of new patients is higher than the average in this country because our pediatric surgery department (Prof. T. Miyano, chief) is the biggest one in Japan. According to JBAR, which started in 1989, the five-year survival rates of 734 patients registered in 1993 and 1994 were 58.7% and 52.7% without liver transplantation (LTx), and 19.3% and 25.6% with LTx, respectively. Ten-year follow-up results of 108 patients in 1989, showed 52.8% and 13.9% survival in those without and with liver transplant, respectively. The lower survival rate of the transplanted patients probably reflects the fact that patients requiring liver transplantation were those whose Kasai operations were ineffective and who progressed to liver failure quickly. The overall 5- and 10-year survival in all biliary atresia patients was 75.3%(553/734) and 66.7%(72/108), respectively (7).

PEDIATRIC NUTRITION PRACTICE

We are involved in nutritional management of food allergy, obesity, low birth weight infants and patients with TPN, both at the outpatient clinics and in the wards.

Finally, because the prevalence of major pediatric GI diseases is low in this country, as mentioned before, pediatric Gastroenterology may not be a very attractive field in the pediatric subspecialities, and nutrition as well, for Japanese pediatricians. Therefore, JSPGHAN has been trying to attract young pediatricians and trainees to pediatric Gastroenterology including hepatology and nutrition by various strategies, such as presenting awards and holding postgraduate seminars. Endoscopy training seminars are also planned. The Japan Pediatric IBD Research Society was founded as one of the sub-societies of JSPGHAN in February 2001 and the second annual scientific meeting was held this year. I hope that these activities help JSPGHAN to grow into a more active and attractive society for pediatricians in this country.

REFERENCES

1. Yamashiro Y, Shimizu T, Oguchi S, et al. The estimated incidence of Cystic Fibrosis in Japan. J Pediatr Gastroenterol Nutr 1997; 24:544–47.
2. Shimizu Y, Yarita Y, Haruna H, et al. Parent-child transmission of Helicobacter Pylori in the family. Gastro, in press.
3. Shimizu T, Yarita Y, Suzuki R, et al. Detection of Helicobacter Pylori-associated asymptomatic duodenal ulcer in a boy. Pediatr Int, in press.
4. The government report: Ministry of Health, Labour and Welfare. 2002, in press.
5. Fujisawa T, Komatsu H, Inui, A, et al. Long-term outcome of chronic hepatitis B in adolescents of young adults in follow-up from childhood. J Pediatr Gastroenterol Nutr 2000; 30:201–206.
6. Fujisawa T, Komatsu H, Inui A, et al. Spontaneous remission of chromic hepatitis C in children. Eur J Pediatr 1997; 156:773–776.
7. Nio M, Miyano T, Saeki M, et al. Five and 10-year survivals after surgery for biliary atresia in Japan: a report from the Japanese Biliary Atresia Registry, personal communication.
© 2002 Lippincott Williams & Wilkins, Inc.