Prevalence and histological features of the gastric cardia-type mucosa in children.

BACKGROUND: It has been suggested that the presence of gastric cardia in adults (with or without inflammation or intestinal cells) is a metaplastic condition. The presence of gastric cardia in children would argue against this contention. We examined the presence and determinants of gastric cardia-type mucosa at a normally located z-line in children without underlying gastroesophageal reflux disease (GERD)-predisposing disorders. METHODS: We conducted a prospective study of consecutive pediatric patients undergoing routine upper endoscopy. We excluded patients with coagulopathy or bleeding disorder, prior gastric or esophageal surgery, major congenital disorders, or neurodevelopmental disorders. Biopsies were obtained with the endoscope in the anterograde position within 5 mm below the endoscopic z-line, and were examined for the presence of gastric cardia-type mucosa, defined as both mucous and oxynto-mucous glands. RESULTS: Eighteen (47%) of 38 subjects has gastric cardia mucosa. There were no significant differences in age, gender, or race between patients with and without gastric cardia-type mucosa. There were no differences between the groups in weight and height either at birth or at the time of endoscopy, in the mother's age at childbirth or history of peripartum problems. There were no differences in symptoms suggestive of reflux such as spitting up or difficulty of gaining weight. Neither history of gastroesophageal testing nor histological esophagitis (38% versus 40%) was different between the groups with and without gastric cardia-type mucosa. CONCLUSIONS: Gastric cardia-type mucosa is unlikely to be a metaplastic condition since it is present in a large proportion of children undergoing endoscopy. Neither histological esophagitis nor GERD symptoms are significantly associated with the presence of gastric cardia-type mucosa.

The role of the discriminant factor in the assessment and treatment of alcoholic hepatitis.

GOALS: To evaluate the role of the discriminant factor in predicting mortality and deciding on treatment in acute alcoholic hepatitis. BACKGROUND: Current guidelines on the treatment of alcoholic hepatitis restrict the use of corticosteroids to patients with discriminant factor > 32 (severe disease) because of the toxicity of steroids. Less toxic forms of therapy, such as proxyphylline, may have a role in patients with lower discriminant factor, if mortality without therapy is common. STUDY: We performed a 5-year retrospective analysis comparing the outcomes of patients with mild and severe alcoholic hepatitis. Receiver operator characteristic curves were used to study the accuracy of the discriminant factor to predict short-term mortality. RESULTS: Among the 41 patients with severe alcoholic hepatitis (discriminant factor > 32) and 48 with mild alcoholic hepatitis, 16 (39%) and 8 (16.7%), respectively, died within 28 days of admission. Only 11 (32%) actually received corticosteroid therapy. The sensitivity and specificity of the discriminant factor in predicting mortality was 66.7% and 61.5%, respectively. A receiver operator characteristic curve of the discriminant factor gave the optimal value for the discriminant factor as 33, with the area under the curve being 0.666 (P = 0.0078; 95% CI = 0.531-0.801). CONCLUSIONS: Using the value of around 32 maximizes sensitivity and specificity of the discriminant factor in predicting mortality in alcoholic hepatitis. However, there is a high mortality in patients with alcoholic hepatitis and a discriminant factor less than 32. Alternative effective agents should be considered in patients with milder alcoholic hepatitis.