Quantitative apparent diffusion coefficient (ADC) values as an imaging biomarker for fibrosis in pediatric Crohn's disease: preliminary experience.

PURPOSE: To compare histopathology with ADC values in strictured bowel segments in pediatric patients with known Crohn's disease and surgical bowel resection. METHODS: Magnetic resonance enterography (MRE) images of 14 subjects with Crohn's disease who had surgical bowel resection for strictures were retrospectively reviewed. Five of 14 subjects had DWI (b=0, 500, 1000) sequences included in the MRE study. ADC measurements were made by placing ROI's in the strictured bowel wall and compared to full-thickness histologic analysis of resected specimens. ADC values were also compared to control ADC measurements (in normal and inflamed-nonstenotic bowel segments) as well as the mean ADC values of Crohn's patients published in the literature. RESULTS: All five subjects had transmural fibrosis. The mean ADC value with b = 500 was 0.92 ± 0.10 × 10(-3) mm(2)/s and with b = 1000 was 0.8 ± 0.05 × 10(-3) mm(2)/s. There was a significant difference in ADC values between strictures and inflamed-nonstenotic segments (p=0.0143) and between normal and diseased bowel segments (p=0.009-0.0143). CONCLUSIONS: Quantitative ADC measures of transmural fibrosis are lower compared to the reported values of inflammation in Crohn's disease. To our knowledge, this is the first pediatric pilot study to investigate the correlation of quantitative DWI with histology of surgical specimens in pediatric patients with Crohn's disease. Our results are comparable to a recently published study in adult Crohn's patients showing a significant correlation between a decrease in ADC values and fibrosis.

A primary care approach to pediatric gastroesophageal reflux.

Gastroesophageal reflux is a common problem that occurs in the pediatric population. Gastroesophageal reflux refers to the retrograde passage of gastric contents into the esophagus. Current thinking implicates transient lower esophageal sphincter relaxations as a major cause for reflux. Infants generally present with symptoms of regurgitation, whereas symptoms of esophagitis are more common in older children. When there are dangerous consequences secondary to gastroesophageal reflux, it is termed gastroesophageal reflux disease (GERD). GERD has been shown to manifest with respiratory symptoms and a pathologic process. A variety of diagnostic procedures are available for the assessment of GERD which include barium swallow, pH probe, scintigraphy, and endoscopy with esophageal biopsy. Medical management of GERD primarily involves prokinetic agents and acid suppression therapy. Surgical therapy, albeit less common, now still has its role in the treatment of GERD.

The relationship between insurance class and severity of presentation of inflammatory bowel disease in children.

OBJECTIVE: To determine whether there is an association between insurance class and the severity of presentation of inflammatory bowel disease in children. METHODS: Twenty underinsured (either no insurance or Medicaid) children were computer-matched with 20 children with private insurance with regard to diagnosis and age but without regard to severity of disease from a pool of 63 patients (20 underinsured patients and 43 insured patients). We compared four patient-reported parameters and eight laboratory values. RESULTS: There were 22 patients with Crohn's disease (11 underinsured and 11 insured) and 18 patients with ulcerative colitis (nine underinsured and nine insured), with a mean age at diagnosis of 13.7 +/- 4.2 yr in the underinsured and 13.4 +/- 3.8 yr in the privately insured patients. Patients in the underinsured category had more than 2.5 times the weight loss of the privately insured patients (20.0 +/- 13.9 vs. 7.8 +/- 8.6, p < 0.005) and longer delay in months (10.3 +/- 10.9 vs. 2.7 +/- 2.6, p < 0.005) before the diagnosis was made. Laboratory data in the underinsured children indicated that they were more ill at time of presentation than the insured patients. The underinsured patients had significantly lower hemoglobins (10.5 +/- 2.4 vs. 12.5 +/- 2.1, p < 0.01), a higher erythrocyte sedimentation rate (59 +/- 35 vs. 21 +/- 24, p < 0.005), and higher platelet counts (536 +/- 205 x 10(3) vs. 418 +/- 140 x 10(3), p < 0.05) compared to the insured group. Alkaline phosphatase levels, normally elevated in children during osseous growth, were significantly depressed in the underinsured group when compared with the insured group (117 +/- 42 vs. 155 +/- 71, p = 0.05). CONCLUSION: Underinsured children have clinical and laboratory parameters that indicate that their disease is more severe at presentation than privately insured patients. We postulate that this is partly related to the fact that underinsured patients have inferior access to quality healthcare when compared to privately insured patients.