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

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

[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

[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

[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

[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

[Helicobacter pylori infection in childhood revealed by hematemesis endoscopic and pathologic patterns]

Helicobacter pylon infection frequency in hematemesis was scarcely studied. To asses the frequency of this infection in children with upper gastrointestinal bleeding and to study the endoscopic and histological features. It is a retrospective study including 180 children who underwent an endoscopy for upper gastrointestinal bleeding. Our population was divided in two groups. The group 1 [n=95] has performed gastric biopsy. The group 2 [n=95] has performed gastric biopsy. For each group, we studied the personal and familial history of gastroenterologic disease, the hospital where they come from, the importance of bleeding, the gastro-agressif drugs intake, the endoscopic and histological features. The helicobacter pylon infection was present in 48%of the children. The mean age of these children was 99.8 +/- 42.1 months versus 95.7 +/- 44 months [p=0.13]. The comparison of the two groups according to Hp infection, and the others parameters don't found any differences. All the infected children have chronic gastritis 40/40 versusl3/44 in the non infected children [p>10-6]. The frequency of Hp infection was high in this group of patients with upper gastrointestinal bleeding. It was probably underestimated because the investigation was not complete. We emphasize that Hp infection has to be investigated and systematically eradicated whenever there were severe symptoms like hematemesis indicating therefore organic disease

[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

[Upper gastrointestinal endoscopy in Neonates -experience of pediatric gastroenterology unit]

The aim of our study was to assess the frequency of the dif-ferent lesions occurring as well as to precise indications of upper gastrointestinal endoscopy in neonates

Method: We have achieved a retrospective study about 128 neonatal gastrointestinal endoscopies. Three groups were constituted according to macroscopic findings:- Group I: normal aspect [n=1]- Group II: isolated esophagitis [n=19]- Group III: esogastritis or gastroduodenitis or esogastroduo-denitis [n=92

Results: The neonates undergoing endoscopy for malaise were more frequent in group I than in group II and III, respectively 36.5% versus 15.8% and 9.8% [P = 0.04]. Digestive hemorrhage [hematemesis and/or melena] was more frequent in group III than in group II and I, respectively 90.2% versus 78.9% and 63.6% [P = 0.03], Digestive hemorrhage was in our study the main indication of upper gastrointestinal endoscopy in neonates [85.9%] which showed a macroscopic lesion in 93.5% of cases

Conclusion: Hematemesis and suspicion of esophagitis are good indications for upper gastrointestinal endoscopy in neonates

[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

Analyse des modalites therapeutiques et evolutives des oesophagites caustiques severes chez l'enfant traites par les bolus de methyl prednisolone experience d'une unite d'endoscopie digestive

We reviewed the case histories of 28 children seen at children hospital from 31 December 1991 to 31 December 2001. These children has second and 'third degree oesophageal burns and they were treated by systemic Methylprednisolone [1000mg/1,73/m2SC]. We divided the 26 children in four groups according to the time we began the steroids [before or, beyond the 24th hours of the accident and according the number of steroids's bolus [less or more than 21 bolus].we analysed the number and the treatment of stricture in each group. High doses of methyl prednisolone seem to decrease the risk of oesophageal stricture. We found no difference between the children treated before the 24th hours and those treated after the 24 hours and those treated with less than 21 bolus and those with more than 21 bolus