Comparison of esophageal pH and multichannel intraluminal impedance testing in pediatric patients with suspected gastroesophageal reflux.

BACKGROUND: Multichannel intraluminal impedance (MII) is a pH-independent method of assessing gastroesophageal reflux. AIM: To evaluate the diagnostic accuracy of MII-pH as compared with conventional pH monitoring in detecting reflux events (REs) and symptom association in different age groups. METHODS: : A prospective direct comparison of 2 diagnostic techniques on 291 consecutive patients referred for suspected gastroesophageal reflux disease. Sensitivity and diagnostic accuracy of MII-pH versus pH monitoring and symptom association were measured. RESULTS: MII-pH detected 13631 REs, 6260 (46%) of which were nonacid. The prevalence of weakly acid refluxes in the 24 hours and postprandial period as well as the proximal extension of refluxate were significantly greater in infants as compared with children (P < 0.001, P < 0.001, and P < 0.01, respectively). The diagnostic accuracy of combined MII-pH in revealing all RE and acid RE were significantly higher in infants as compared with children (92% vs 82%, P < 0.01 and 83% vs 76%, P < 0.04, respectively). The addition of MII to conventional pH monitoring significantly increases the diagnostic yield of symptom association analysis in revealing an association between atypical symptoms and refluxes irrespective of age, whereas in studying typical symptoms it was true only for infants. CONCLUSIONS: Addition of MII to conventional pH monitoring significantly increases the diagnostic yield in detecting REs, prevalently in infants, and in revealing an association between refluxes and symptoms, prevalently respiratory ones and in infants group.

Immune thrombocytopenic purpura as a complication of Bartonella henselae infection.

Immune thrombocytopenic purpura is an infrequent yet well-recognized complication of viral infections, such as mumps, rubella, varicella, cytomegalovirus, parvovirus and infectious monunucleosis by Epstein-Barr virus. Some recent studies have described a possible association between Henoch-Schonlein purpura, a non-thrombocytopenic purpura, and seropositivity for Bartonella henselae, but in the literature only sporadic case reports have described a severe immune thrombocytopenic purpura as a complication of Bartonella henselae infection. We report a case of an immunocompetent child with clinical and serological evidence of Bartonella henselae infection presenting with purpura and cervical lymphoadenopathy and treated with intravenous immunoglobulin. The patient obtained a rapid and persistent increase in platelet count and a complete regression of purpura.

[Perforated jejunal diverticulum. A case report]. / Diverticolo digiunale perforato. Caso clinico.

The Authors report on a case of a 69 years old woman with an acute peritonitis secondary to a perforated jejunal diverticulum, treated by laparotomy and intestinal resection with end-to-end anastomosis in one layer. The patient was dismissed after seven days, in good general conditions. Jejunal diverticula occur in around 1% of general population. They are usually asymptomatic; sometimes they give origin to dyspepsia or acute manifestations. These are due to complications at the site of the diverticulum like bleeding, occlusion and acute infection with perforation and peritonitis, as occurred in our patient. The main risk in diverticular complications is to prolong the interval between admission of the patient and surgical treatment, favouring the initiation of hypovolemic or septic shock. For these reasons, in most recent years, C.T. and, in case of bleeding, capsule endoscopy, were used in the diagnostic pre-operative work-up. The surgical technique is jejunal resection with direct anastomosis, leaving percutaneous drainage only for patients with an abscess, in poor general conditions for a narcosis.

[The treatment of blunt abdominal trauma. Personal experience]. / Il trattamento dei traumi addominali chiusi. Nostra esperienza.

BACKGROUND: Aim of the study is to work out diagnostic and therapeutic guidelines in blunt abdominal trauma, considering our modern diagnostic tools and actual international propensity for non-operative treatment. METHODS: Seventy five patients observed during the last three years at Emergency Surgery Unit of "Vittorio Emanuele" Hospital in Catania, Italy. All patient underwent, after blood tests, abdominal ultrasound and/or CT showing one or more abdominal lesions in 52 (69.3%) of them. Out of these 52 patients with organ injuries, 29 (55.8%) underwent surgery, while 23 (44.2%) non-operative treatment: the most injured organs were spleen (34 cases), liver (18 cases) and kidneys (4 cases). On the basis of haemodynamic conditions of the patients and of the results of abdominal ultrasound and/or CT the Authors decided between surgical or non-surgical treatment, working out in the meantime their diagnostic-therapeutic guidelines. In Authors' experience, while for splenic injuries the majority of patients was operated (splenectomy), for hepatic injuries non-operative treatment was preferred, as well as for all renal injuries. RESULTS: Two patients (2.6%) died because of hypovolemic shock secondary to an high-grade hepatic trauma associated with d.i.c.; both patients reported other major lesions of, respectively, chest and brain. Other 4 patients developed postoperative complications: 1 patient a pleuritis and 3 patients a wound infection. All these patients recovered with antibiotics and, where necessary, repeated change of medical dressing. The other 69 patients recovered completely, without any significant complication. CONCLUSIONS: The study of personal experience of the last three years on abdominal blunt trauma (75 patients) has allowed the Authors to work out diagnostic-therapeutic guidelines, which are based mainly on patients' haemodynamic conditions and on sonographic and CT results. The applications of this protocol has allowed the Authors during last 12 months to practice more frequently the non-operative treatment, avoiding unnecessary surgical operations, sparing the patient organic deficit and possible intra and post-operative complications.

[Crohn's disease in the elderly]. / La malattia di Crohn nell'anziano.

AIM OF THE STUDY: To define the characteristics of Crohn's disease in the elderly, basing on our own and other Authors' experience. CASISTIC: During last 10 years, 46 patients affected by Crohn's disease were observed at Emergency Surgery Unit of "Vittorio Emanuele" Hospital in Catania (Italy). Of these patients, 4 (8,6%) were old: 3 with an ileal location and 1 with a colic location of the disease. This latter patient was cured only by medical treatment because of the paucity of clinical manifestations of the disease. The other 3 patients underwent surgical treatment (2 ileocecal resections and 1 ileal resection). RESULTS: Up to date all 4 patients are alive and in good general conditions. Only one patient had recurrence of disease, but recovered after medical treatment. DISCUSSION: Crohns disease in the elderly, although usually similar to the adult form, differs for some aspects. Concerning pathology, in the old patient fibro-sclerotic and ulcerative aspects predominate and the colic location is more frequent; clinically, in the elderly the occlusive (two out of our four cases) and haemorrhagic complications are seen more than in young-adults; sometimes the symptoms are poor so that a diagnostic delay occurs, with a possible worsening of prognosis. Regarding the treatment of Crohn's disease it, especially in old patients, must be medical, excluding peculiar situations which need surgical treatment (acute complications, unresponsiveness to drugs). Most frequent operations are segmentary ileal resections and ileocecal resections, as it happened in our experience. Post-operative morbidity and mortality are higher in the elderly, comparing to adult rates, because of more frequent cardiac and respiratory complications, due usually to pre-existing conditions. CONCLUSIONS: Crohn's disease affects old patients in 10-15% of cases. In this age-group it is mandatory to suspect the presence of this disease even if the clinical exam is poor, so that specific diagnostic investigations are carried out in order to avoid lost of time, which can be responsible of an unsuccessful treatment. The treatment is essentially medical; surgery, if necessary, must be as most conservative as possible.

Improved efficacy of 10-Day sequential treatment for Helicobacter pylori eradication in children: a randomized trial.

BACKGROUND & AIMS: The currently recommended first-line eradication treatment of Helicobacter pylori in children is usually successful in about 75%. Recently, in adults, a novel 10-day sequential treatment has achieved an eradication rate of 95%. The aim of the study was to assess the H pylori eradication rate of the sequential treatment regimen compared with conventional triple therapy in children. METHODS: Seventy-eight consecutive children with H pylori infection were randomized to receive either sequential treatment (omeprazole plus amoxicillin for 5 days, followed by omeprazole plus clarithromycin plus tinidazole for another 5 days) (n = 38; 15 boys [39.5%]; median age, 11.0 years [range, 3.3-16 years]) or triple therapy (omeprazole, amoxicillin, and metronidazole) for 1 week (n = 37; 15 boys [40.5%]; median age, 9.9 years [range, 4.3-16 years]). H pylori infection was based on 2 out of 3 positive tests results: 13C-urea breath test, rapid urease test, and histologic analysis. Eradication was assessed by 13C-urea breath test 8 weeks after therapy. RESULTS: Seventy-four patients completed the study. H pylori eradication was achieved in 36 children receiving sequential treatment (97.3%; 95% confidence interval, 86.2-99.5) and 28 children receiving triple therapy (75.7%; 95% confidence interval, 59.8-86.7) (P < .02). Compliance with therapy was good (>95%) in all. CONCLUSIONS: Our study shows, for the first time in children, that 10-day sequential treatment achieves a higher eradication rate than standard triple therapy, which is consistent with the results of adult studies.