Esophageal polyps in pediatric patients undergoing routine diagnostic upper gastrointestinal endoscopy: a multicenter study.

Esophageal polyps are uncommon findings in pediatric patients, and reports have been limited to case reports. Esophageal polyps have been previously ascribed to esophagitis secondary to gastroesophageal reflux, medications, infections and recurrent vomiting. They have been associated with underlying conditions such as hiatal hernia, Barrett's esophagus, eosinophilic esophagitis and Crohn's disease. Presenting complaints of children with esophageal polyps have included vomiting, dysphagia, hematemesis and abdominal pain. The aim of this paper is to characterize the incidence, clinical presentation and progression, histologic subtypes and associated mucosal abnormalities in children with esophageal polyps. A retrospective multicenter study was performed at four institutions identifying diagnosis of esophageal polyps in pediatric patients (<21 years). Information was obtained from patient charts, endoscopy reports and histopathology reports. Specimens and slides were examined by experienced pediatric pathologists for all included cases. Esophageal polyps were identified in 13 patients (9 M) from 9438 esophagogastroduodenoscopies (0.14%). Mean age of subjects was 9.2 years. Vomiting was the most common indication for endoscopy. Polyp location was at the gastroesophageal junction in 7 of the 13 cases. Most polyps were inflammatory (n = 7). Esophagitis was noted in 69% of those with esophageal polyps. Repeat endoscopies in six patients at a mean interval of 8 months noted persistence of polyps in all six patients. This paper is the first to characterize esophageal polyps in pediatrics. These polyps are rare in children and often are associated with esophagitis. Presenting complaints seem to vary by age. Polyps did not consistently change with either time or acid suppression. The optimal management strategy has yet to be defined and likely depends on the underlying pathophysiologic process.

Pediatric jejunoileitis: a severe Crohn's disease phenotype that requires intensive nutritional management.

BACKGROUND: Jejunoileitis (JI) is an unusual manifestation of Crohn's disease (CD) that has been associated with high morbidity and the frequent need for surgical intervention. Although the disease has been well-described in adults, the true prevalence and clinical phenotype in children is unknown. AIM: To compare the clinical course and nutritional impact of CD in children with and without proximal small bowel involvement. METHODS: Patients with either Crohn's jejunitis or JI with or without colonic involvement were identified through a clinical database (1996--2002). All radiologic studies were reviewed by an experienced radiologist blinded to the clinical diagnosis. Thirty-six patients with CD without histologic or radiologic signs of proximal small bowel involvement were used for comparison. All medical, surgical, and hematologic parameters were compared in both disease groups. RESULTS: Among the 134 patients with CD, 23 (17%) had radiologic signs of JI, including intestinal fold thickening (57%), luminal narrowing (31%), and skip lesions (13%). Enteric fistula (6%) and strictures (6%) were less common. Patients with JI were likely to be stunted at the time of diagnosis, require surgical intervention (P < 0.03) and nutritional therapy in the form of nasogastric tube feeds (P < 0.03). Nutritional therapy was also associated with an improvement in height in patients with proximal small bowel disease (OR:5.87). DISCUSSION: JI is a relatively common disease phenotype in children with CD that requires aggressive nutritional and surgical intervention. Future studies are required to determine if the early detection and use of immune modulators may lessen the morbidity associated with proximal small bowel disease.

The clinical spectrum of duodenal polyps in pediatrics.

OBJECTIVES: The aim of this retrospective study was to determine the prevalence, clinical presentation, and histologic subclassification of duodenal polyps identified on endoscopy (EGD) in pediatric patients. METHODS: We performed an 18-year retrospective study of all pediatric patients (< 21 years) with duodenal polyps diagnosed between 1983 and 2001 at The Johns Hopkins Children's Center. Our analysis includes a formal histologic evaluation of duodenal polyps either biopsied using cold-forceps or removed by snare cautery. RESULTS: Duodenal polyps were reported in 22 of 5766 EGDs (0.4%) performed in 16 (M:F; 1:1) patients with a mean (SD) age of 14.1 (5.1) years. Polyps were equal in both the Caucasian and African American population (adjusted ratio 1.2:1). The histologic subtypes included Adenomatous (42%), Brunner's gland hyperplastic (33%), hamartomatous (17%), and heterotopic gastric gland polyps (8%). The most frequent indication for EGD was surveillance in patients with polyposis syndromes; most of these patients were asymptomatic at the time of their EGD. In comparison, the most frequent indication for an EGD in patients without polyposis syndromes was abdominal pain and vomiting. CONCLUSIONS: Duodenal polyps are most frequently encountered in children with polyposis syndromes, most of whom are asymptomatic. In nonsyndromic patients, the most common histologic subtype is Brunner's gland hyperplastic polyp and presenting symptoms include abdominal pain and vomiting.

Gastric polyps in pediatrics: an 18-year hospital-based analysis.

OBJECTIVE: Gastric polyps are recognized as either an incidental finding on routine gastroscopy or a frequent occurrence in patients with polyposis syndromes. The aim of this study is to determine the prevalence, clinical presentation, and histological subclassification of gastric polyps identified on esophagogastroduodenoscopy in pediatric patients. METHODS: We performed an 18-yr retrospective study of all pediatric (<21 yr) patients with gastric polyps diagnosed between 1983 and 2000 at The Johns Hopkins Children's Center. The histology slides were all evaluated at the time of the study according to the accepted histological classification of gastric polyps. RESULTS: Gastric polyps were reported in 40 procedures (0.7%) [corrected] performed in 35 (male:female 1.3:1) patients with a mean (SEM) age at diagnosis of 14.4 (0.9) yr. Polyps were more frequent in white than in black patients (adjusted ratio 1.4:1). The histological subtypes included hyperplastic-inflammatory (42%), fundic gland (40%), hamartomatous (10%), adenomatous (5%), and heterotopic polyps (3%). Fundic gland polyps were frequently encountered in patients with familial adenomatous polyposis (81%). These patients tended to be asymptomatic at the time of their surveillance esophagogastroduodenoscopy, and frequently harbored histological changes of either dysplasia (31%) or indeterminate of dysplasia (19%). CONCLUSIONS: Hyperplastic polyps are the most frequently identified gastric polyps in our pediatric population. Fundic gland polyps are common in patients with familial adenomatous polyposis wherein they tend to harbor histological changes of dysplasia. Future longitudinal studies are needed to evaluate the temporal progression of dysplasia to gastric cancer in patients with fundic gland polyps, and to establish esophagogastroduodenoscopy surveillance guidelines.

Use of disodium pamidronate in children with hypercalcemia awaiting liver transplantation.

We report four children with advanced liver disease awaiting liver transplantation who developed moderately severe hypercalcemia (range: 1.65-2.40 mmol/L) while receiving total parenteral nutrition. Hypercalcemia had been unresponsive to cessation of calcium intake and therapy with loop diuretics and calcitonin. One or two intravenous doses of disodium pamidronate (35-50 mg/m2) resulted in normalization of plasma calcium concentration within 2-4 d in all four children. Pamidronate may be useful for children with hypercalcemia associated with liver disease.