Predictive score for positive upper endoscopies outcomes in children with upper gastrointestinal bleeding

Background: Upper gastrointestinal bleeding [UGIB] is a common pediatric emergency. Esophago-gastro-duodenoscopy [EGD] is the first line diagnostic procedure to identify the source of bleeding. However etiology of UGIB remains unknown in 20% of cases. Furthermore, emergency endoscopy is unavailable in many hospitals in our country

Aims: Identify clinical predictors of positive upper endoscopy outcomes and develop a clinical prediction rule from these parameters

Methods:Retrospective study of EGDs performed in children with first episode of UGIB, in the endoscopic unit of Children's Hospital of Tunis, during a period of six years. Statistical analysis used SPSS20. Univariate analysis was performed and multivariate logistic regression was then modelled to derive a clinical prediction rule

Results: We collected 655 endoscopies [23.2% normal, 76.8% pathological]. We found that time to EGD within 24 hours from the onset of bleeding [p=0.027; Adj OR: 3.30 [1.14 - 9.53]], rebleeding [p=0.009; Adj OR: 6.01 [1.57 - 23.02]], positive gastric lavage outcome [p=0.001; Adj OR: 4.79 [1.95 - 11.79]] and non steroidal anti-inflammatory drugs intake [p=0.035; Adj OR: 5.66 [1.13 - 28.31]] were predictors of positive upper endoscopy outcomes. By assigning each factor, the adjusted odds ratio [Adj OR], we developed a score with four items, ranging from 4 to 20. Using the receiver operating characteristic [ROC] curve the best cut off >/= 9 was defined [sensitivity 88.2%, specificity 60.6%, positive predictive value 92.7% and negative predictive value 47.6%]. The score discriminated well with a ROC curve area of 0.837 [95% confidence interval [0.769 - 0.905]]

Conclusions: This clinical prediction rule is a simple measure that may identify children who needed emergency endoscopy. A prospective study is required to validate our results and evaluate other clinical features that were insufficient for this analysis

Endoscopic diagnosis in a Tunisian paediatric population with upper gastrointestinal bleeding [UGIB]

Esophagogastroduodenoscopy [EGD] is currently considered the first line diagnostic procedure chosen for Upper Gastrointestinal Bleeding [UGIB] since 1970. However, studies are still limited in our country. Finding out the most common causes of UGIB in children and whether the causes differed according to age in developing and developed countries. A retrospective review of the medical records of children referred to the Paediatric Gastroenterology Department of The Tunis Hospital of Children between January 1998 and December 2006 for upper gastrointestinal bleeding. The children were divided into three groups; G1: neonates; G2: infants; G 3: children and adolescents. The study involved 614 endoscopies. The aetiology was not ascertained in 20.68%of cases. G1 included 125 newborns: 24 with no identified causes, 97 mucosal lesions [isolated or associated]; two ulcers and two tumours. G2 and G3 included respectively 205 infants and 289 children. Toxic drug intake was recorded in 140 out of 489 patients. Endoscopy was normal in 101 cases. Peptic oesophagitis was recorded in 57/205 [27.8%] of G2 infants versus 52/284 [10%] of G3 children [p=0.015]. Gastritis was recorded in 164/284 [55.6%] of G2 infants versus 86/205 [41.9%] of G3 children [p

[Pediatric Crohn's disease in Tunisia]

Crohn's disease occur mainly in adults. However, pediatric onset forms are not rare and have many characteristics.To study clinical, diagnostic, therapeutic and evolutive characteristics of crohn's disease in tunisian children. Retrospective multicenter study conducted in 10 pediatric departments on a period of 10 years [2000-2008]. 43 children were included. The sex-ratio was 1.68. The mean age at the onset of the symptoms was 11 +/- 2.3 years [5-16 years]. The age of onset was inferior to 10 years in 25% of the children. The delay before management was superior to 1 year in 25% of cases. The initial symptoms were dominated by diarrhea [95%]. Perineal manifestations were present at diagnosis in 30% of children and extra-digestive manifestations in 53%. Ileocolonic localization was the most frequent [46%]. The initial disease flare was moderate in 83% of cases. The treatment was medical in 77% of cases, nutritional and medical in 18.5%. Maintenance therapy was instituted in 86% of cases and consisted essentiallay in azathioprin [62%]. The mean follow-up was 3 years and 4 months. 60% of the children had at least one acute flare. During evolution, 7% of children had anoperineal surgery and 11% an intestinal resection. Crohn's disease seems rare in Tunisia. The time of diagnosis is often delayed. The management is based on immunosuppressive therapy and nutritional support

[Web site of "La Tunisie Medicale" was created two years ago]

La Tunisie M‚dicale, official journal of Tunisian Society for Medical Sciences and Tunisian Medical Organization, born in 1903 with ISSN number 0041-4131and INIST code 4691 of French Pascal database, had since September 2009 its website: www.latunisiemedicale.com. To assess the editorial policy of "La Tunisie M‚dicale". A descriptive analysis was performed to evaluate different categories of articles and number of papers written with English language. mdweb society, which created the website site www.latunisiemedicale.com, planned to have instantaneously a descriptive analysis concerning the number of consultants per article. The site www.scopus.com helped us to have the number of articles citations which was useful to calculate Impact Factor [IF]. National Center for Biotechnology Information [NCBI] of National Library of Medicine provided monthly number of hits. Number of published articles increased regularly to reach 250 and 300 between 2009 and 2011. Beside original articles, cases report, overviews, continuing medical education and editorials, we introduced systematic reviews of literature, letters to editors, historical notes, section reserved for images in clinical practice, point of view, technical novelty and section for " Pro and Cons" in which readers could present their opinions with reply of authors. Articles written in English have increased to reach the number of 60 between 2010 and 2011. Visitors number of "la Tunisie M‚dicale" website, from 195 countries, was 465 596 between January 1st 2011 and December 22nd 2011. Half of consultants [51.06%] came from several sources such as "Google/organic" and "ncbi.nlm.nih.gov/ referral". Number of visits from NCBI was about 3000 per month from June 2010 to December 2011. The ten first visited articles concerned sexual organ and tuberculosis. Articles citations of "laTunisie M‚dicale" are in constant progress and Impact Factor, increased from 0.054 in 2004 to 0.277 in 2011. We succeeded to increase the number of articles written in English. Results are interesting Impact Factor of 2011 is 0,277; however we should be modest because we still have a very long way, we should help authors to perform systematic reviews with a sound methodology

Nodular gastritis: an endoscopic indicator of helicobacter pylori infection in children

Helicobacter pylori [Hp] infection is a common and universally distributed bacterial infection. It is predominantly acquired in childhood. To assess the relationship between endoscopic nodular gastritis and Hp infection. A retrospective study was conducted in children who underwent upper gastrointestinal endoscopy for chronic abdominal pain. All children who had five gastric biopsies for histologic analysis, urease test and Hp culture were included in the study. The Sensitivity and sensibility of nodular gastritis were determined and different parameters were studied according the presence or not of nodular gastritis[age, gender, Hp status, gastritis score and lymphoid follicles]. 49 children, mean age 6.9 +/- 3 years [range 1-12 years] were eligible for the analysis. Hp Infection was diagnosed in 35 out of the 49 children [71.5%]. Nodular gastritis was recorded in 16 out of 49 children and in 14 infected children and 2 out of 14 non infected children [p=0.07], 40% sensitivity, 85.7% specificity, 87.5% positive predictive value, and 36,4% negative predictive value. The parameters associated significantly to the presence of nodular gastritis were older age: [p=0.04], Hp infection: [p=0.01], chronic gastritis: [p=0.05], active gastritis: [p=0.02], follicular gastritis: [p=0.005], higher gastritis score: [p=0.005]. Completely normal gastric mucosal histology was never found in infected children with antral nodularity. Among all infected children, the gastritis score was significantly higher when there was a nodular gastritis and follicular gastritis was significantly associated to nodular gastritis. The endoscopic pattern of antral nodularity identifies children with Hp infection, and active chronic follicular gastritis

C6771 polymorphism of MTHFR and G80A polymorphism of RFC genes and their relation with homocysteine levels in obese tunisian children

To investigate the frequencies of C677T polymorphism in MTHFR gene and G80A polymorphism in RFC gene in obese and no obese Tunisian children and to assess their relation with homocysteine [tHcy], folate and vitamin B12 levels. We have studied 31 obese compared to 22 no obese children. tHcy was assessed by fluorescence-immunoassay ; folate and vitamin B12 by radioimmunoassay. C677T and G80A mutations were detected using pyrosequencing. There were no differences in tHcy levels between obese and no obese, [10,34 +/- 4,86micro moll/l vs11,00 +/- 4,26micro moll/l]. We found no difference for the allelic frequencies of the C677T polymorphism [29.03% vs 30.95%] and of the G80A polymorphism [64.52% vs 59.52%]. Mean levels of tHcy, folic acid and vitamin B12 were not significantly different according to MTHFR and RFC genotypes. We demonstrated no difference in tHcy, folates, vitamin B12 levels and allelic frequencies of C677T and G80A polymorphisms in MTHFR and RFC genes between obese and no obese Tunisian children. These two polymorphisms don't seem to have any impact on homocysteine, folate and vitamin B12 status in the two populations

[Interventional endoscopy in the gastrointestinal tract in children]

Interventional endoscopic procedures involving the gastrointestinal [GI] tract in children are very common. Over the last several years the number of procedures in this area has steadily increased. To study indications and results of GI interventional endoscopies performed in a Pediatric GI unit. Retrospective study over a period of 10 years [1999- 2008]. Data were collected from endoscopic files. All procedures were performed endoscopically under general anesthesia. 185 interventional endoscopic procedures were done during this period in 96 patients [58 boys] median age: 4.9 +/- 4.7 years [1 month-13 years]. Indications were as follows: esophageal stenosis [n= 46; 47.9%], rectal polyp resection [n=21; 19.8%], esophageal varices ligation [n=19; 19.7%], foreign body extractions [n= 8; 8.3%] and percutaneous endoscopic gastrostomy [n= 2; 2.1%]. One hundred and thirteen esophageal dilations [61.1% of procedures] were performed in 46 patients: caustic stenosis [n=22; 22.9%], peptic stenosis [n=13; 13.5%] and anastomotic stenosis [n= 11; 11.4%]. The main indication of interventional GI endoscopy in this series was oesophageal stenosis followed by rectal polyp resection, esophageal varices ligation and foreign body extractions

[Value of procalcitonin measurement in materno foetal infection]

Materno foetal infection [MFI] remains one of the major causes of neonatal morbidity and mortality. Early detection of neonatal sepsis can be difficult, because the first signs of the disease may be unspecific and similar to symptoms of other non-infectious processes. We aimed to investigate the role of procalcitonin [PCT] in the diagnosis of fetal infection [MFI], and to compare it with those of the C-reactive protein [CRP]. We have conducted a prospective study during 20 months; which concerned 25 new-borns suspected of MFI and admitted before 12 hours of life. All newborn had anamnestic and / or physical signs of possible infection. MFI was confirmed in newborns with positive bacterial analysis. CRP and PCT were determined in the sera at H12, H24, H36 and H48. Newborns were divided into: patients with recognized MFI [group 1], patients with possible MFI [group 2] and non infected newborns [group 3]: The specificity of PCT was 80% versus 27% for the CRP. Negative predictive value of PCT was 85% versus 66% for the CRP. The mean values, at H12, H24, H36 and H48, of PCT for newborn who had MFI were statistically grater than those for no infused group [p <0.05]. No statistical difference was observed concerning CRP values. PCT may a useful tool in early diagnosing of MFI; it has better specificity and negative predictive value than CRP

[Study [knowledge, behaviour practices] of 116 mothers on vitamin D supplementation]

In our country, the prevention of rickets is based on daily vitamin D intake from birth to eighteen months .This vitamin D intake has decreased according to our hospital practice. To assess vitamin D supplementation prevalence and to study mother knowledge, attitude and practices about vitamin D and factors that influenced them and to define target population who needs further education. A predefined questionnaire was submitted to 116 mother's child who was aged from two months to three years and were hospitalised for acute disease in Tunis children hospital. The questionnaire was filled by the paediatrician. He included as well questions on vitamin D supplementation and questions on socio- demographics characteristics. 68% of the infants had received vitamin D. The various significant factors who influenced the knowledge about vitamin D were father and mother out of work, low education level, and the living in a deserited area, The factors that influenced significantly the practices were the one parity and the living far away, up to five kilometer, from a primary health care. Given that the supplementation of vitamin D is recommended for all infants the study show that supplementation prevalence is unsatisfactorily low. Various risks factors were identified. In view of the new evidence emerging on additional preventive properties of vitamin D and the resurgence of rickets, its promotion must be discussed anew

[Thrombocytopenic idiopathic purpura: predictive factors for chronic disease]

The aim of this study is to determine factors predicting development of chronic thrombocytopenic idiopathic purpura. It was a retrospective study, regarding the cases of PTI diagnosed in "service de medicine infantile C H"pital d'Enfants de Tunis" during 11 years. Acomparison was done between two groups: the first including acute PTI and the second including chronic and recurrent PTI. Factors predicting development of chronic disease were searched by the Fisher test which was significant when p < 0, 05. 33 cases of PTI were diagnosed. The ratio sex was 1.06. The mean age was five years and a half. The disease onset was insidious in three cases; all of them have had a chronic course. An haemorrhagic personnel background was present in three cases. Counselling cause was always petechies and ecchymoses. The mean platelets rate was 14555, 5/mm3. Therapeutics abstinence was carried out in five cases. 20 infants received an initial corticotherapy. The immunoglobulins were prescribed in nine cases, witch six associated to Corticotherapy. Three modes of outcome were discerned: acute PTI [n=23], recurrent PTI [n=4] and chronic PTI [n=6]. Factors predicting development of chronic disease were: haemorrhagic personnel background, an insidious disease onset and the failure of an initial therapeutic abstinence. Acute PTI is the most common. The disease had a chronic or recurrent outcome in 1/3 of cases. The search after factors predicting chronic disease allows an early prognosis. Thus, a best management of the disease can be achieved

[Diagnosis of hyper transaminasemia in childhood]

Elevated serum levels of transaminases must always be considered as an abnormal finding in children. Drugs and toxins must be eliminated first as possible hepatotoxic agents or co-factors. Antiviral hepatitis A immunoglobulin M serology is the first test to perform. However, others viruses with spontaneous benign courses are the most frequent cause. Only if initial presentation is severe or if liver tests remain abnormal after several weeks, other rare diseases can be sought. Aetiologies of persistent cytolysis associated to cholestasis are different in infancy and childhood. Metabolic, auto immune, genetic, muscular, endocrine disorders and obesity may cause isolated persistent hyper transaminasemia. Early diagnosis and management is essential, Isolated elevation of serum amino transferases in healthy looking children with negative investigations is mostly a benign condition that usually resolves within a year. Liver biopsy does not contribute much to diagnosis and is probably unnecessary

[Aetiologies and outcome of bronchiectasis in children: a study of 41 patients]

Bronchiectasis remains an important cause of chronic suppurative lung disease in the developing world. This study is to describe the epidemiological characteristics, clinical features, underlying aetiologies and Outcome of bronchiectasis in the paediatric hospital of Tunis. A retrospective study of 41 children with bronchiectasis was conducted between January 1994 and December 2006. Diagnosis was made in patients with clinical suspicion of bronchiectasis associated with abnormalities on chest X ray [n=37] and/or on high resolution computed tomography [HRCT] [n=36]. Mean age at diagnosis was 5 years 9 months; [range: 6 months-14 years]. Persistent cough and bronchorhea were the most common symptoms. Fourteen patients [34%] had dyspnoea on first presentation, 11 of them [26.8%] had chest deformation and/or finger clubbing. Haemoptysis was noted in only two cases. Mean time to diagnosis from symptom onset was 2.7 years [range: 2 months- 4 years]. The underlying aetiologies were identified in 52% of patients. Cystic fibrosis [17%], previous pneumonic illness [9.7%], primary ciliary dyskinesia [9.7%] and immunodeficiency [9.7%] were the most common causes. After a mean follow-up of 6.6 years, the annual lower respiratory infection rate decreased from 7.2 +/- 3 to 3.1 +/- 2.6 [p<0.05], Twenty one point nine per cent of patients had chronic respiratory failure and five patients required surgery. Delays diagnosis of bronchiectasis remains important in our country. Congenital and indeterminate aetiologies are the most common forms. Prognosis is poor with a high prevalence of chronic respiratory failure

[Cholestasis in infant: a study of the children's hospital of Tunis]

Cholestasis in infant constitutes an heterogeneous group of disease; diagnosis and management are often difficult. The Aim of the study is to describe clinical, paraclinical characteristics and outcome of infants hospitalized for cholestasis in children's Hospital of Tunis. A retrospective study of 94 infants with cholestasis was conducted. Patients were hospitalized in four departments of paediatrics of our hospital between January 1995 and December 2005. Cholestasis complicating severe sepsis and visceral leishmaniasis were excluded. Incidence of cholestasis was 8.5 cases/year which represented 0.72% of the hospitalizations. Sex ratio was 1.08 and mean age at diagnosis was 105 days [extremes: 1 day- 24 months]. Biliary atresia was the most common cause of extra hepatic cholestasis [13.8%]. Normal A GT cholestasis [11.7%], benign neonatal cholestasis [11.7%] and bile duct hypoplasia [9.5%] represented the most common aetiologies of intra hepatic cholestasis. Aetiology remained unknown in 12.7% of cases. Only three infants with biliary atresia had Kasai operation. After a mean follow-up of 6 years, 18% of patients had portal hypertension, 14.8% had hepatic failure and mortality rate was 14.8%. Cholestasis of unknown aetiologies are frequent in our hospital. Poor prognosis, in our study, is due to delay to diagnosis and difficulties in medical and surgical management

[Chronic gastritis in children]

Active gastritis, atrophic gastritis [AG] and intestinal metaplasia are lesions associated with Helicobacter pylon [H. pylon] infection in adults. To assess the prevalence of chronic gastritis, its histological characteristics and clinical features in children. 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 per-endoscopic gastric biopsy specimens [antrum: 2, fundua: 2] were taken. Biopsies were assessed and graded according to the updated Sydney system. H. pylon infection was considered if 2 out 3 tests were positive [culture, histology and rapid unease teat], whereas 3 concordant negative results identified H. pylon negative children. H. pylon infection and chronic gastritis were detected in 215/345 [62.3%] [M/F. 104/1 17, 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=4l, 18.6%]. Any clinical features were however found to be specific. UGI endo showed; nodular gastritis [n=90, 40.72%], congestive gastnitis [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 gastnitis [14.4%] exhibited AG [M/F: 16/16, mean age: 9.4 +/- 3.4 years] and 30/32 [93.7%] were H. pylon positive. AG was significantly associated with H. pylon infection [p<0.0001] and nodular gastritis [p<0.005]. Active, follicular and AG were significantly associated with H. pylon infection [p <0.00001]. Three patients exhibited intestinal metaplasia. Chronic gastnitis is frequent in children. Any clinical features were found to be specific. It significantly associated H. pylon infection and nodular gastnitis. Atrophic gastnitis was found in 145%of children

[Congenital hepatic fibrosis in children: about 9 cases and review of the literature]

Congenital hepatic fibrosis is a recessive autosomic disease with two major risks: gastrointestinal haemorrhage caused by portal hypertension and cholangitis related to bacterial infection of dilated intrahepatic bile ducts. The aim of our study is to define epidemiological features, the presenting symptoms, the diagnosis, the evolution and the management of this disease. Between January 1990 and December 2000, we reported the cases of nine children with this disease at children hospital of Tunis.Three were male and six female. The mild age was three years and six months. Consanguinity was present in five cases and similar cases were found in six cases. The FHC was revealed by portal hypertension in five cases, angiocholitis in one case and by portal hypertension and angiocholitis in three cases. Liver biopsy was done in seven children. Ultrasound examination of the liver and kidney revealed caroli syndrome in five cases and polykystose renal in two cases The intravenous pyelography was performed in four cases showing precalicial canalicular ectasia in four cases. Eosophageal endoscopy had shown oesophageal varices in six patients. The follow up had shown that three patients had gastrointestinal bleeding, three had angiocholitis. One patient died with multivisceral failure. The treatment of acute bleeding has needed blood transfusion in four cases. Primary prevention of bleeding was done by endoscopic sclerosis alone in one case and associated to betablokers in two cases. Secondary prevention of varices bleeding was done by sclerotherapic in two cases, by beta blokers alone in one case and by betablokers associated to elastic ligation of oesophageal varices in one case

[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. 60 children [26 males, 34 females], with mean age of 8 years 8 months [3years and 2 month[2.5-13.5years] 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 medications 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. 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