Persistent diarrhea: 15 years experience at a tertiary care hospital.

OBJECTIVE: To determine the risk factors, causative enteric pathogens, final diagnosis and treatment outcomes of persistent diarrhea in children. MATERIAL AND METHOD: A retrospective study of the patients who had diarrheal symptoms for at least 14 days diagnosed as persistent diarrhea (PD) and admitted at QSNICH during January 1997 and December 2011. Demographic data, risk factors, causative enteric pathogens, management and outcome were reviewed. RESULTS: The review included 79 PD patients. Excluded were patients who were HIV seropositive, had GI anomalies and/or other underlying immune deficiencies. The demographic data showed mean age 11.42 months and male:female 56:23 (2.43:1). Feeding with infant formula before admission was 43% compared to exclusive breastfeeding that was only 10%. Normal nutritional status was found in half of the cases (52.1%) and protein energy malnutrition (PEM) was present in 42.3%. Stool for enteropathogens was positive only in 49.4% and the most common being mixed enteropathogens. Secondary lactase deficiency was the cause of PD in half (50%) of the patients. Management consisted of rehydration, intravenous antibiotics 53%, and other adjuvant therapies such as cholestyramine, zinc and probiotics. Along with rehydration, all patients received aggressive nutritional management upon admission. The diarrhea subsided in less than 7 days in about 70% of the patients. CONCLUSION: The present study supports that important risk factors for PD are very young age group (especially under 1 year old), lack of breastfeeding and malnutrition. Enteropathogens were found in only about half of the patients and the most common cause of PD was secondary lactase deficiency. Most of the diarrhea subsided in less than 7 days of admission with proper management and aggressive nutrition upon admission.

Eosinophilic gastrointestinal disease: analysis of sixteen cases from ten years experience in Thailand.

OBJECTIVE: To study eosinophilic gastrointestinal disease (EGIDs) in children concerning the clinical presentations, diagnostic methods and results of treatment. MATERIAL AND METHOD: A retrospective study of EGIDs was done from January 2000 to December 2009. All patients diagnosed as EGIDs according to gastrointestinal symptoms combined with eosinophilic infiltration in mucosal, muscular or serosal layer of involvement. Exclusion of extraintestinal eosinophilic involvement and parasitic infestations were done. Analysis of clinical presentations, diagnostic methods and results of treatment were reviewed. RESULTS: Sixteen children fulfilled criteria of EGIDs. Mucosal type was the most common finding type (12 out of 16 cases) (75%). Muscular and serosal type was found in equal numbers (2 of each in 16 cases) (12.5% each). Ages ranged from 6 months to 13 years. The male: female ratio was 1: 1.2. Abdominal pain was the most common presenting symptom followed by diarrhea. Allergic history was detected in 68.75% of all patients. Peripheral eosinophilia was found in only 37.5% of all cases. Radiographic findings showed non-specific findings. Endoscopy was performed in 14 out of 16 cases (87.5%). Lymphoid hyperplasia was the most common endoscopic finding especially in mucosal type. Eosinophil (more than 20 per high power field) was found from biopsied tissues obtained from the esophagus, stomach, colon or from ascitic fluid. Prednisolone was used in 13 out of 16 cases with satisfactory results in 11 cases. The two resisted cases responded to ketotifen in one and the other in combination with montelukast. One out of 16 cases subsided with only proton pump inhibitor The last two cases improved by allergic food elimination. CONCLUSION: Eosinophilic gastrointestinal disease in children presents with varieties of gastrointestinal symptoms. Biopsied tissues or ascitic fluid are required to demonstrate significant eosinophilic infiltration or presence of eosinophil. Allergic history seems to play an important role in more than half of the patients. Specific dietary elimination is the most important treatment in allergic cases. Corticosteroid is the treatment of choice in the non-allergic group or for those who did not improve with food elimination.

Hepatocellular carcinoma in children presents with massive upper gastrointestinal bleeding: a case report.

Hepatocellular carcinoma (HCC) is a very rare pediatric tumor. The incidence is 0.5-1.0 cases per million children. The most common clinical sign is abdominal mass. HCC often develops in the presence of underlying liver disease and cirrhosis, especially viral hepatitis. The authors hereby report a 9-year-old girl with hepatocellular carcinoma associated with positive hepatitis B surface antigen at Queen Sirikit National Institute of Child Health. She was admitted because of massive upper gastrointestinal bleeding (UGIB) due to esophageal varices. Multiple sessions of esophagogastroscopy with sclerotherapy banding ligation and glue injection of esophageal varices were performed but she still had massive UGIB. Sengstaken-Blakemore tube was used, after which she developed a ruptured esophagus. Finally she passed away. Liver necropsy was performed and diagnosed as HCC.

Clinical features of gastrointestinal salmonellosis in children in Bangkok, Thailand.

This retrospective descriptive study was conducted at Queen Sirikit National Institute of Child Health (QSNICH), Bangkok, Thailand to describe the clinical features of gastrointestinal salmonellosis in children. The medical records of 134 patients admitted to QSNICH in 2009 who had a positive stool culture for Salmonella spp were reviewed. Demographic, clinical, laboratory, treatment, culture and antimicrobial sensitivity data were collected and analyzed. The mean age of the patients was 22.9 months (range 0.5 to 158 months); 76.9% were < 2 years old. The male to female ratio was 1.5:1. Salmonella B was most commonly found serogroup (47%). The common clinical manifestations included diarrhea (99.3%), fever (93.3%), dehydration (64.9%) and nausea/vomiting (48.5%). Most of the Salmonella isolates were sensitive to a fluoroquinolone and many were sensitive to Cotrimoxazole, but few were sensitive to ampicillin. There were no significant differences in the clinical manifestations and drug sensitivities of the different Salmonella serogroups, except convulsions were more common in Salmonella E infected patients (p = 0.04) and more Salmonella C isolates were sensitive to ampicillin (p = 0.04). There was no significant correlation between clinical course and antimicrobial treatment, except the duration of diarrhea was significantly longer in patients who received antimicrobial treatment (mean 6.1, SD 4.7 days vs mean 4.2, SD 2.1 days) (p = 0.03). Three patients had Salmonella bacteremia. Three patients died but not directly due to Salmonella infection.

Gastrointestinal manifestations in severe strongyloidiasis: report of 3 cases and literature review.

We report here three cases of severe strongyloidiasis in normal and immunocompromised hosts. The first was a patient with a normal immune system who presented with acute severe abdominal pain. The second and third patients were immunocompromised due to steroid and chemotherapy treatment of underlying diseases. Both presented with obstructive symptoms. In all three cases, Strongyloides stercoralis larvae were detected in stool concentration samples, and in biopsied specimens from the duodenum in the first and second cases.