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Indian Pediatr 2019;56: 518 |
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Clippings
Theme: Gastroenterology
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Vyom Aggarwal
Email:
[email protected]
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Appendicitis in children with ventriculo-peritoneal shunt (Arch
Dis Child. 2019;104:607-9)
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Whether to remove or leave the ventriculo-peritoneal (VP) shunt in
situ, in a child with acute appendicitis, is often a perplexing
issue. In this review of 6 reports, the authors tried to find the best
strategy in cases with perforated and non-perforated acute appendicitis
in children with VP shunt. Out of 12 children with perforated
appendicitis, in whom the shunt was left in situ, complications
were encountered in 6 cases (3 required externalization, two required
conversion to ventriculo-atrial (VA) shunt and one had shunt
discontinued). In group of 16 children with non-perforated appendicitis,
complications necessitated externalization in one, conversion to VA
shunt in one, and only antibiotic therapy in one subject with fluid in
pouch of Douglas. These data suggest that the risk of ascending shunt
infection is low in non-perforated appendicitis while in cases of
perforated appendicitis, the risk of shunt infection and other
complications appears higher. In the case of perforated appendicitis,
the risk of developing a shunt infection secondary to peritonitis must
also be balanced against the risk of revising the shunt. The limited
data in these studies suggest shunt removal may not be mandatory in
patients with appendicitis, particularly if the appendix is not
perforated, but needs careful consideration based on the clinical and
microbiological findings.
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Fecal microbiota transplant in recurrent
Clostridium difficile infections (J Pediatr
Gastroenterol Nutr. 2019;68:343-7)
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Fecal microbiota transplant (FMT) is known to be curative in up to 91%
cases of recurrent Clostridium difficile infection in
non-inflammatory bowel disease patients. However, the same beneficial
effect has yet not been demonstrated in children with inflammatory bowel
disease (IBD). This retrospective review involved 8 children with IBD
(all on vancomycin) in association with recurrent C. difficile
disease, who underwent fecal microbiota transplant by colonoscopy. Two
children had recurrence by 2 months while another 3 had recurrence
between 2 and 6 months. The median time of recurrence was 101 days. With
a cure rate of 75% at 60 days, FMT administered for the treatment of
recurrent C. difficile disease was thus proposed to be an
effective short-term treatment option in pediatric IBD. However, there
appears to be a significant rate of late recurrence of C difficile
infection after 60 days in these patients, signifying need for
developing more effective and optimal management strategy for these
children.
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Does Dientamoeba fragilis cause
abdominal pain or diarrhea in children? (Arch Dis Child.
2019 Feb 23. doi:10.1136/archdischild-2018-316383 [Epub ahead of
print])
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Dientamoeba fragilis, a flagellate protozoan parasite, has often
been linked to several gastrointestinal symptoms, including diarrhea and
abdominal pain. However, conclusive evidence for its role in causation
of gastrointestinal pathologies is yet elusive. This study aimed at
comparing the prevalence of D. fragilis (detected by real-time
PCR) in stools of 200 children with chronic abdominal pain and diarrhea
with that in 122 reference children from healthy community. The
concentration of fecal calprotectin (a marker of intestinal
inflammation) was compared in the two groups to demonstrate if presence
of D. fragilis was causally associated with intestinal
inflammation. D. fragilis was detected in 45% of patients and in
71% of healthy children. Median (IQR) concentrations of calprotectin in
patients and healthy children with a positive PCR result were not
different from those with a negative PCR result (40 (40-55)
mg/g vs. 40
(40-75) mg/g,
respectively). Authors concluded that D. fragilis colonization is
very much prevalent in healthy children, and is not associated with an
increase in faecal calprotectin concentration, supporting the inference
that it is not a pathogenic parasite. Routine testing for D. fragilis
in children with chronic abdominal pain should therefore not be
encouraged at all.
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Anal intrasphincteric botulinum toxin
injection in Hirschsprung disease (J Pediatr
Gastroenterol Nutr 2019;68:527-32)
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In Hirschsprung disease (HD), despite successful surgical treatment, 50%
of children continue to experience chronic functional obstructive
symptoms, attributable to a nonrelaxing anal sphincter complex. This
study aimed at determining the efficacy of intrasphincteric botulinum
toxin (BT) injection in relieving these distressing symptoms. Fifteen
patients (median age 4 y) with HD and postoperative functional
intestinal obstructive symptoms received neurostimulation-guided
intrasphincteric BT injections, for specific delivery of BT to muscular
fibers of the nonrelaxing anal sphincter complex. The Bristol stool form
scale was used to assess stool consistency, and the Jorge-Wexner (JW)
score to assess fecal continence. In the short-term, a significant
improvement in stool consistency was noted in 12 of 14 patients, and JW
score significantly decreased for 14 of 15 patients. In the medium-term,
JW score significantly decreased for all patients, with an improvement
of 50% or more for 10 patients. In the long-term, 83.3% of patients had
normal stool consistency and JW score was <3 for all. Recurrent
enterocolitis decreased from 86.7% to 8.3%. A complete resolution of all
symptoms without further medication was observed in 66.7% of patients in
the long-term. Authors concluded that the intrasphincteric BT injection
is a safe, effective, and durable option for the management of
postoperative functional intestinal obstructive symptoms in Hirschsprung
disease.
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