Gastrooesophageal reflux in infants and children in north India.

OBJECTIVES: To assess the prevalence of gastrooesophageal reflux disease (GERD) as suggested by the symptom profile in babies ranging in age from 1 month to 2 years. METHODS: Six hundred and two babies were recruited from the well baby clinic for hospital delivered babies and from the childrens OPD of a tertiary care hospital. Children with acute severe illness needing hospitalization were excluded from the study. The primary care taker of each baby was interviewed using a questionnaire (IGERQ) designed by Orenstein et al and the I-GERD score obtained was used to assess for likelyhood of GERD. Upper gastrointestinal (GI) endoscopy was carried out and an oesophageal biopsy was taken in clinically suspected cases of GERD (IGERD > 5). RESULTS: Sixty one (10%) of the 602 subjects had an I-GERD score of > 5 suggestive of GERD. Regurgitation was present in 56 of these 61 subjects and also in 106 of the 541 normal subjects. 112 of 205 infants aged 1-6 months had regurgitation and 25 (22.2%) of these regurgitant infants had a score suggestive of GERD. Only 30 of the 202 infants aged 6-12 months and 20 of the 195 babies aged 12-24 months had regurgitation, however 14 of the 30 (46.5%) and 17 of the 20 (85%) regurgitant babies had an I-GERD score suggestive of GERD. Upper GI endoscopy was carried out in 31 babies with a score > 5 and endoscopic oesophagitis was detected in 16 (51.6%). Oesophageal biopsies were taken in 25 of these cases and showed histological evidence of reflux oesophagitis in 23 (92%). CONCLUSION: GERD is fairly common under 2 years of age as observed by symptom evaluation using the I-GERD score. Regurgitation when present beyond 6 months of age with no other identifiable cause needs evaluation. Upper GI endoscopy and oesophageal biopsy is a useful means of demonstrating reflux oesophagitis in babies with a symptom profile suggestive of GERD.

Management of celiac disease.

Celiac disease (CD), perceived as a rare cause of chronic diarrhea three decades ago, was diagnosed as a cause of diarrhea in 60 (7.5%) post weaned children among 800 cases of chronic diarrhea. The diagnosis was established on the basis of a detailed clinical history, histopathological studies on small bowel mucosa and a complete recovery on gluten free diets. Thirty four children were followed up for a period of 0.3 to 8.2 years (mean 3.45 +/- 2.28). Catch up growth was seen in all. A rapid gain in height and weight was observed in first year following exclusion of gluten from the diet. However, on subsequent follow up, flattening of growth curve was seen in 9 subjects which was attributed to non-compliance of gluten free diets and dietary inadequacies. Strict dietary compliance is difficult to adhere to with wheat being a staple cereal in India. Other factors affecting compliance include lack of awareness and non availability of gluten free diets as well as contamination of other items with wheat at grocery shops. A few cases may present as celiac crisis which is a medical emergency requiring aggressive management including use of corticosteroids to improve survival in this otherwise life threatening situation. Effective management of CD requires intense family cooperation as well as concerted national efforts to provide these patients easy access to gluten free diets. The evolution of Celiac Societies, and widespread dissemination of knowledge through all available media will greatly help in management of patients with this chronic disease.

Aetiology of chronic diarrhoea in tropical children.

AIM: We studied the causes and presentations of chronic diarrhoea in post-weaned children. METHODS: Forty seven children (6 months to 12 years) with diarrhoea of more than 2 weeks duration were recruited and subjected to detailed clinical examination and investigations. RESULTS: Primarily on the basis of history, clinical examination and duodenal biopsy, children could be classified into 5 groups namely tropical enteropathy (46.8%), irritable bowel syndrome (10.6%), giardiasis (14.8%), celiac disease (6.8%) and non specific diarrhoea (21.8%). Children with tropical enteropathy improved with broad spectrum antimicrobial therapy, those with irritable bowel syndrome and non specific chronic diarrhoea with dietary interventions while children with celiac disease required definite withdrawal of gluten from diet.

Determinants of symptomatic giardiasis in childhood.

Giardia has been frequently implicated as a causative agent for acute as well as chronic diarrheal diseases in children. The present study was aimed at exploring the determinants of manifestations of Giardiasis in childhood, in relation to various host and parasite related factors. A total of 200 children with acute (100), chronic (50) or without (50) diarrhea in last 15 days were recruited for the study and evaluated with regards to nutritional status, serum immunoglobulins, secretory IgA levels, presence of Giardia in stool/duodenal aspirate/duodenal biopsy specimen and for associated infections. Lysates from acute giardiasis cases were further studied for zymodeme (banding) pattern. After correlation of all investigations, humoral immune defect in the host was found to be the major determinant of whether the Giardial infestation would be symptomatic or not, while associated bacterial infections and zymodeme patterns were not found to be important in determining the pathogenicity or presentation of giardiasis.

Diagnostic upper GI endoscopy for hemetemesis in children: experience from a pediatric gastroenterology centre in north India.

Upper GI endoscopies were done in 236 children (upto 12 years of age) presenting with history of hemetemesis. Varices were the commonest lesions (in 39.41%) followed by esophagitis (23.73%). Gastritis, gastric ulcer, duodenal ulcer and oesophageal ulcers were identified in 7.20%, 1.27%, 0.42% and 0.42% cases respectively. Cause of bleeding could not be ascertained in 27.54% cases. No significant premedication or procedure related complications were observed. Upper GI endoscopy is thus a safe and useful mode of investigation in cases of hemetemesis in children.

Chronic diarrhea in children of tropics.

Syndrome of prolonged diarrhea is quite frequent in tropical children. Careful clinical appraisal can help in separating these children into distinct clinical entities which have different underlying etiological factors. In most cases diagnosis is possible on clinical grounds supplemented by simple investigations. A step by step approach as outlined is extremely helpful in planning a rational management.