Computed Tomography Assessment of Severity of Acute Pancreatitis in Bangladeshi Children.

Purpose: Acute pancreatitis (AP) is common among children in Bangladesh. Its management depends mainly on risk stratification. This study aimed to assess the severity of pediatric AP using computed tomography (CT). Methods: This cross-sectional, descriptive study was conducted in pediatric patients with AP at the Department of Pediatric Gastroenterology and Nutrition, BSMMU, Dhaka, Bangladesh. Results: Altogether, 25 patients with AP were included, of whom 18 (mean age, 10.27±4.0 years) were diagnosed with mild AP, and 7 (mean age, 10.54±4.0 years) with severe AP. Abdominal pain was present in all the patients, and vomiting was present in 88% of the patients. Etiology was not determined. No significant differences in serum lipase, serum amylase, BUN, and CRP levels were observed between the mild and severe AP groups. Total and platelet counts as well as hemoglobin, hematocrit, serum creatinine, random blood sugar, and serum alanine aminotransferase levels (p>0.05) were significantly higher in the mild AP group than in the severe AP group (p=0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of CT severity index (CTSI) were 71.4%, 72.2%, 50%, and 86.7%, respectively. In addition, significant differences in pancreatic appearance and necrosis were observed between the two groups on CT. Conclusion: CT can be used to assess the severity of AP. In the present study, the CTSI effectively assessed the severity of AP in pediatric patients.

Upper gastrointestinal bleeding in Bangladeshi children: Analysis of 100 cases.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is defined as bleeding that occurs proximal to the ligament of Treitz and can sometimes lead to potentially serious and life-threatening clinical situations in children. Globally, the cause of UGIB differs significantly depending on the geographic location, patient population and presence of comorbid conditions. AIM: To observe endoscopic findings of UGIB in children at a tertiary care center of Bangladesh. METHODS: This retrospective study was carried out in the department of Pediatric Gastroenterology and Nutrition of Bangabandhu Shiekh Mujib Medical University, a tertiary care hospital of Bangladesh, between January 2017 and January 2019. Data collected from hospital records of 100 children who were 16 years of age or younger, came with hematemesis, melena or both hematemesis and melena. All patients underwent upper gastrointestinal endoscopy (Olympus CV 1000 upper gastrointestinal video endoscope) after initial stabilization. Necessary investigations to diagnose portal hypertension and chronic liver disease with underlying causes for management purposes were also done. RESULTS: A total of 100 patients were studied. UGIB was common in the age group 5-10 years (42%), followed by above 10 years (37%). Hematemesis was the most common presenting symptom (75%) followed by both hematemesis and melena (25%). UGIB from ruptured esophageal varices was the most common cause (65%) on UGI endoscopy followed by gastric erosion (5%) and prolapsed gastropathy (2%). We observed that 23% of children were normal after endoscopic examination. CONCLUSION: Ruptured esophageal varices were the most common cause of UGIB in children in Bangladesh. Other causes included gastric erosions and prolapsed gastropathy syndrome.

Mutational analysis of exon 8 and exon 14 of ATP7B gene in Bangladeshi children with Wilson disease.

BACKGROUND : Wilson disease (WD) is an autosomal recessive disorder caused by mutation in the Adenosine Triphosphate 7B (ATP7B) gene. The spectrum of ATP7B mutation varies in different populations. The objective of this study was to identify the mutation in exon 8 and exon 14 of ATP7B gene in Bangladeshi children clinically diagnosed as WD. We also aimed to explore the phenotypic presentation. METHODS: It was a cross sectional observational study. The study was conducted at the Department of Paediatric Gastroenterology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2017 to June 2018. A total of 37 patients diagnosed with WD were enrolled for the study. Venous blood (about 3 mL) was drawn aseptically from each patient into tube containing ethyline diamine tetraacetic acid (EDTA) and preserved at -30°C for long-term preservation. The peripheral blood leukocytes of the patients and genomic DNAs were extracted. Exons 14 and 8 of ATP7B and their associated splice-site junctions were amplified by the polymerase chain reaction (PCR). The size and quantity of PCR products were verified by electrophoresis in 1.5% (w/v) agarose gel. 74 (37 × 2) PCR products were sent for Sanger Sequencing. The sequences were analyzed by Chromas version 2.6.6 software and the nucleotide blast was done by National Center for Biotechnology Information (NCBI) nucleoblast. Finally, the sequences were analyzed using AB Applied Bio systems and were matched with the reference sequences using MEGA software. RESULTS: In this study, a single novel homozygous mutation pLeu.1071Val in the exon 14 was found in every (100%) studied child clinically diagnosed with WD. Heterozygous mutation p.Gly1061Glu in exon14 was also found in 6 patients (11%) with WD, which is one of the common mutations in this disease. In exon 8, p.Arg778Leu mutation was detected in one patient (2.7%), which is common in the Chinese and the South Asian populations and was heterozygous. Two novel heterozygous missense mutations p.K785R (2.7%) and p.S744F (2.7%) were also found in two other children in the exon 8. CONCLUSION: We found three novel mutations in Bangladeshi children with WD, one of which may be tagged as founder mutation for Bangladeshi population. This finding indicates the necessity to study the mutation profiles of the whole ATP7B gene in our population for risk prediction. A further large-scale study will help in the development of a Mutational Data Base of Bangladeshi population with WD.

Hepatic Histoplasmosis: An Update.

Histoplasma capsulatum is the most common cause of endemic mycosis in developing countries. It is a self-limited and asymptomatic disease in immunocompetent individuals but remains a frequent cause of opportunistic infection in patients with compromised immune status. Liver involvement as a part of disseminated histoplasmosis is well known. However, liver infection as a primary manifestation of histoplasmosis without evidence of primary lung involvement is rare. In conclusion, clinicians should be aware of isolated histoplasmosis affecting the hepatobiliary system, and careful evaluation is warranted to confirm the diagnosis. Given the appropriate clinical context, histoplasmosis should be considered in both immunocompetent and immunocompromised patients, regardless of pulmonary symptoms, in non endemic as well as endemic areas.

Functional constipation in Bangladeshi school aged children: A hidden misty at community.

BACKGROUND: Constipation is a common problem in children and a frequent cause of hospital visit in both primary & specialized care, which needs proper evaluation & management. Presentation of constipation is variable among children. In Bangladesh there has been no published data regarding constipation in community among school aged children. AIM: To determine the magnitude of functional constipation and its risk factors in community among Bangladeshi school children. METHODS: This descriptive cross sectional study was conducted in different schools of Dhaka division, Bangladesh. All school aged children between 5-16 years of age who attended school were included in this study. Samples were collected randomly. Proper clinical history & physical examinations (without digital rectal examination) & available investigations (if done previously) were recorded. Diagnosis of functional constipation was done by Rome IV criteria and was compared with children without constipation. Children with any red flag sign, known chronic disease or any findings suggestive of organic disease and on treatment of constipation were excluded. Statistical analysis of the results was done by using Windows based software device with Statistical Packages for Social Science 20. For all statistical tests, P value of less than 0.05 was considered as statistically significant. RESULTS: Total study populations were 707 and male was 443 and female 264. Among them, 134 (19%) children had constipation. In constipated children, 78 children fulfilled the Rome IV criteria for functional constipation and it was 11% of total population. Mean age of children having functional constipation was 11.24 ± 3.54 years and Male female ratio was 1:1.78. Anorexia, nausea, abdominal pain, hard stool, blood with hard stool, alternate hard and loose stool and fecal mass in left iliac fossa were analyzed between two group and all were significantly higher in children with functional constipation group. Children of school, where toilet numbers were inadequate had 2.5 times more constipation risk in comparison to children of school with adequate toilet number (OR = 2.493, 95%CI: 1.214-5.120). Children who feel embarrassed to use toilet at school, had 3.6 times higher risk of constipation (OR = 3.552, 95%CI: 1.435-8.794). Here children with H/O affected sibs and parents/grandparents had 4 and 2.6 times more chance of constipation respectively in comparison to children without H/O affected sibs (OR = 3.977, 95%CI: 1.884-8.397) and parents/grandparents (OR = 2.569, 95%CI: 1.172-5.629). Children with inadequate fluid intake had 2 times more risk of constipation in comparison to children with adequate fluid intake (OR = 1.972, 95%CI: 1.135-3.426). Children who passed electronic screen time of > 2 h/d had 2 times more chance of constipation in comparison to children who passed electronic screen time < 2 h (OR = 2.138, 95%CI: 1.063-4.301). CONCLUSION: Constipation is not uncommon in Bangladeshi school aged children. Inadequate toilet number, family history of constipation, inadequate fluid intake, feeling embarrassed to use toilet at school, and electronic screen time for > 2 h/d were found as risk factors in the present study for functional constipation.

Juvenile Polyps in Bangladeshi Children and Their Association with Fecal Calprotectin as a Biomarker.

PURPOSE: Colonoscopy is considered the most reliable method for the diagnosis of juvenile polyps. However, colonoscopic screening is an invasive and expensive procedure. Fecal calprotectin (FCP), a marker of intestinal inflammation, has been shown to be elevated in patients with polyps. Therefore, this study aimed to evaluate FCP as a screening biomarker for the diagnosis of juvenile polyps. METHODS: This cross-sectional, observational study was conducted at the Pediatric Gastroenterology and Nutrition Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. For children with polyps, colonoscopic polypectomy and histopathology were performed. FCP levels were analyzed before and 4 weeks after polypectomy in all patients. Information was recorded in a datasheet and analyzed using the computer-based program SPSS. RESULTS: The age of the children was between 2.5 and 12 years. Approximately 93% of the polyps were found in the rectosigmoid region. Children with juvenile polyps had elevated levels of FCP before polypectomy that subsequently normalized after polypectomy. The mean FCP levels before and after polypectomy were 277±247 µg/g (range, 80-1,000 µg/g) and 48.57±38.23 µg/g (range, 29-140 µg/g) (p<0.001), respectively. The FCP levels were significantly higher in patients with multiple polyps than in those with single polyps. Moreover, mean FCP levels in patients with single and multiple polyps were 207.6±172.4 µg/ g and 515.4±320.5 µg/g (p<0.001), respectively. CONCLUSION: Colonic juvenile polyps were found to be associated with elevated levels of FCP that normalized after polypectomy. Therefore, FCP may be recommended as a noninvasive screening biomarker for diagnosis of colonic juvenile polyps.

Atypical manifestations of acute viral hepatitis A in children in Bangladesh: Are these really uncommon?

BACKGROUND/AIM: The aim of this study was to find out the clinical spectrum of acute viral hepatitis A (AVH-A) infection in children, the relationship between atypical manifestations and laboratory findings and the outcome of patients with typical and atypical hepatitis A virus (HAV) manifestations. METHODS: From January 2018 to September 2019, consecutive children (<18 years of age) with features suggestive of AVH with positive IgM anti-HAV both from inpatient and outpatient services were included in this study. Detailed history, physical findings, and investigations were recorded in the study questionnaire. Patients were followed up weekly until complete recovery. The Statistical Package for the Social Sciences (SPSS) version 22 was used for statistical analysis. RESULT: The mean age of 200 children who were finally included in the study was 8.3±3.5 years with male to female ratio of 134:66. Atypical features were present in 30 (15%) children; prolonged cholestasis (17, 8.5%), ascites (12, 6%), pleural effusion (4, 2%), thrombocytopenia (2, 1%), and hemolysis (1, 0.5%) were observed. Pruritus (p=0.005), higher serum total and direct bilirubin (p=0.00 and 0.001 respectively), and lower serum albumin (p=0.01) levels were statistically significant in children with atypical manifestations. Moreover, this group had prolonged mean duration of jaundice and hospital course (p=0.00 and 0.083 respectively). CONCLUSION: Atypical manifestations such as prolonged cholestasis and ascites are not uncommon in children with AVH-A in developing countries and seen in almost one-sixth of patients.

Omental Cyst - Rare Cause of Abdominal Pain in a 7-Year-Old Child: A Case Report.

INTRODUCTION: Abdominal pain is a common complaint in children. In most cases it may be functional. Among all organic causes, an abdominal cyst of omental or mesenteric origin is an uncommon etiology. CASE PRESENTATION: A 7-year-old girl presented with a short history of abdominal pain for 1 month associated with gradual abdominal distention. Physical examination revealed a large oval palpable firm, non-tender mass extending almost the whole abdomen. Imaging studies were suggestive of an intra-abdominal cyst, and the diagnosis was confirmed after exploratory laparotomy. The patient was managed surgically by enucleation of the cyst. CONCLUSION: Omental cysts are a rare benign condition, but should be considered as a diagnostic hypothesis in children with abdominal pain with or without a mass. It is difficult to diagnose an omental/mesenteric cyst clinically. A proper imaging study can guide the diagnosis. After confirming the diagnosis, the main treatment would be surgical excision.

INTRODUÇÃO: A dor abdominal é um sintoma comum durante a infância, mas na maioria dos casos é funcional. Entre as causas orgânicas potenciais, os quistos abdominais de origem epiplóica ou mesentérica são raros. CASO CLÍNICO: Uma menina de 7 anos de idade desenvolveu um quadro clínico caracterizado por dor e distensão abdominal gradual, com aproximadamente 1 mês de evolução. O exame objetivo revelou uma massa abdominal oval, de grandes dimensões, de consistência firme, mas indolor. Os estudos imagiológicos sugeriram a presença de um quisto intra-abdominal que se confirmou durante uma laparotomia exploradora. O tratamento foi cirúrgico e consistiu na enucleação do quisto. CONCLUSÕES: Os quistos epiplóicos são uma condição benigna rara, mas devem ser considerados no diagnóstico diferencial em crianças com dor abdominal, independentemente da presença de uma massa. O diagnóstico semiológico é difícil, mas um estudo imagiológico adequado pode ser esclarecedor. Após confirmação do diagnóstico a excisão cirúrgica é a modalidade terapêutica de eleição.

A 8- year Bangladeshi girl with disseminated histoplasmosis, presented as chronic liver disease with portal hypertension: a rare case report.

BACKGROUND: Histoplasmosis is a rare infectious condition with mainly pulmonary involvement. Disseminated histoplasmosis may occur in immunocompromised condition. It can present in different ways but jaundice and ascites is very uncommon. CASE PRESENTATION: A 8- year old girl visited to department of pediatric gastroenterology & nutrition, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Child presented with fever, jaundice and abdominal distension for 2 ½ months. There was no history of contact with tuberculosis patient and travelling to kala-azar, malaria endemic zone and no history of previous jaundice, blood or blood product transfusion, history of sib death, family history of jaundice or neuropsychiatric disorder, significant weight loss. On general examination she was fretful, febrile, moderately icteric, mildly pale, vitally stable, severely wasted and moderately stunted, skin survey revealed infected scabies, BCG vaccine mark was absent, generalized lymphadenopathy, hepato-splenomegaly and ascites present. After evaluating the physical findings, several investigations was done including lymphnode biopsy, then the case was finally diagnosed as Disseminated histoplasmosis with portal hypertension. Child was treated with injectable Deoxycholate Amphotericin B for 28 days and improved on follow up. CONCLUSION: We suggest that children presenting with fever, jaundice, lymphadenopathy and hepatosplenomegaly and portal hypertension, disseminated histoplasmosis can be one differential.

Non-endoscopic predictors of esophageal varices in children with chronic liver disease and their utility in resource-constrained countries.

BACKGROUND: Although endoscopy is the standard diagnostic screening test to identify esophageal varices in patients with chronic liver disease (CLD), selective endoscopy in patients who are at higher risk of having varices may be cost-effective in a resource-constrained country. The aim of this prospective study was to identify non-endoscopic parameters that may predict the presence of varices, especially high-risk esophageal varices in children with CLD. METHODS: From January 2016 through March 2018, consecutive children with CLD without a history of variceal bleeding were prospectively included. Esophagogastroduodenoscopy was done in all the children to detect and to grade esophageal varices. Both univariate and multivariate logistic regression analyses were done using SPSS version 22 to identify factors associated with esophageal varices. RESULTS: The mean age of 84 children was 9.7 ± 3.2 years (male 44). Esophageal varices were present in 71.4% of children and 55% of them had large varices. On univariate analysis, low platelet count (< 100,000/mm3) and splenomegaly were found to be associated with the presence of esophageal varices (p = 0.006 and 0.001, respectively) and large varices (p = 0.03 and 0.01, respectively). On multivariate analysis, both low platelet count and splenomegaly were independent predictors for the presence of esophageal varices (respectively, OR 11.21, 95% CI 1.2-96.9; and OR 11.39, 95% CI 3.19-40.59). CONCLUSIONS: Splenomegaly and low platelet count independently predict the presence of any grade of esophageal varices and can be used as screening tests to select children for endoscopy. This strategy may help in relieving medical, social, and economic costs in resource-constrained countries.