OBJECTIVEHirschsprung's disease (HD), one of the most common causes resulting in lower intestinal obstruction in children, is prone to be misdiagnosed or to be missed from diagnosis because of its atypical clinical symptoms and inconspicuous morphological findings by barium enema X-ray. Recently, this situation has been largely ameliorated by increased comprehension of anorectal kinetics and improvement of instrument for measurement of anorectal pressure. By now, anorectal manometry (ARMM) has been regarded as a routine means for functional assessment and diagnosis for anorectal disease. Nevertheless, the accuracy rate of diagnosis of HD in neonate by ARMM remains to be elucidated. In this study the clinical evaluation of anorectal manometry as an early diagnostic method for neonates with Hirschsprung's disease was appraised.

METHODSForty-two HD patients defined by pathological study of rectal tissue obtained via rectal mucous membrane biopsy or operation were recruited in this study. ARMM was performed in liquid transmission using PC polygraph high rate gastrointestinal dynamical detection system (PC Polygraf HR, CTD-synectics, Sweden), with 4-lumen catheter with which a small 5-cm-long balloon was connected at the terminus. All children were positioned on their left side or back during the procedure and the pressure transducers were placed in the mid-axillary line level. The results of ARMM performed before operation or biopsy were compared with the results of barium enema X-ray testing. The decrease of internal anal sphincter pressure as rectoanal inhibitory reflex (RAIR) was measured based on the fluctuation curve of pressure detected. HD was defined when no decrease of anal catheter pressure was detected after insufflation (RAIR positive), and suspected HD state was assessed with the presentation of incomplete relaxation or positive/negative results coexisted (RAIR abnormal) in canal.

RESULTSThirty patients (71.43%) were diagnosed as HD by ARMM including 18 patients who showed negative response to RAIR and 12 patients whose response was abnormal. While barium enema examinations were carried out in all the 45 patients, the results showed 5 HD patients and 14 suspected HD patients, giving an overall diagnostic accuracy of 45.24%. There were also 16 patients with positive ARMM response and negative barium enema findings together, and 5 patients with negative ARMM results and positive barium enema findings at the same time. There was a significant difference between the two diagnostic methods (chi(m)(2) = 4.76, P < 0.05).

CONCLUSIONAnorectal manometry seems to be a more reliable method for diagnosis of Hirschsprung's disease in neonate than barium enema X-ray. Because ARMM is a simple, safe and non-invasive method, it can be used as a screening test of choice in neonates with clinically suspected HD. But for final diagnosis, it is reasonable to combine ARMM with other diagnostic methods in HD patients.

Anal Canal ; physiopathology ; Barium Sulfate ; Enema ; Hirschsprung Disease ; diagnosis ; Humans ; Infant, Newborn ; Manometry ; Rectum ; pathology ; physiopathology

OBJECTIVETo evaluate the benefits of biofeedback therapy in children with functional constipation caused by pelvic floor dysfunction (PFD).

METHODAnorectal manometry (PC Polygraf HR, Medtronic) was performed in children with functional constipation according to the diagnostic criteria of Rome III. Among them, 47 cases with PFD were trained with biofeedback therapy (PC Polygraf HR, Medtronic) according to the degree of cooperation. They received the treatment twice every week, and those in whom the therapy was performed at least three times were enrolled to evaluate the efficacy in this study.

RESULTA total of 27 cases (20 male and 7 female) in whom the procedure was performed at least three times were eligible for inclusion into this study. The mean age of them was (6.7 + or - 2.2) years (range 4 to 12 years), and the mean duration of symptoms was (3.0 + or - 2.3) years with a range of 6 months to 8 years. Among them, 16 cases received the biofeedback training more than 5 times, while 8 cases more than 7 times. The rectal maximum contraction pressure during defecation was increased significantly with the number of biofeedback training before treatment and after 3, 5, and 7 times of treatment was (36.2 + or - 10.4), (45.1 + or - 9.5), (47.6 + or - 9.1), and (47.8 + or - 8.8) mm Hg (1 mm Hg = 0.133 kPa) respectively (P < 0.01). The potential of electromyography of external anal sphincter decreased progressively, but had not reached significance. Follow-up continued for 3 to 12 months by telephone, the clinical response to biofeedback treatment was evaluated as excellent (complete resolution of constipation), good (improvement of constipation), partial or poor (no improvement of constipation). The response was excellent in 13 cases (48.1%), good in 8 (29.6%), partial in 3 (11.1%), and 2 (7.5%) cases had no improvement, and 1 case was lost to follow-up, and the rate of success was 88.9% (24/27).

CONCLUSIONBiofeedback therapy is a safe and effective treatment option for functional constipation due to PFD in children probably by increasing the rectal maximum contraction pressure during defecation.

Biofeedback, Psychology ; Child ; Child, Preschool ; Constipation ; therapy ; Female ; Humans ; Male ; Treatment Outcome

OBJECTIVEIt has been proposed that aberrant immunity of local bowel mucosa may cause ulcerative colitis (UC) and the tumor necrosis factor-alpha (TNF-alpha) and nuclear factor-kappa B (NF-kappa B) may play a role in the development of this disease. To investigate the role of TNF-alpha and NF-kappa B in childhood UC, the expression of TNF-alpha and NF-kappa B in the bowel mucosa and their relationship were studied.

METHODSUsing anti-CD68, anti-TNF-alpha and anti-NF-kappa Bp65 antibodies, the cytokine immunoreactivities in the bowel mucosa of 39 cases of childhood UC (active UC: n = 21, non-active UC: n = 18) were detected by immunohistochemistry. The control specimens of normal bowel mucosa were collected from 7 cases with colorectal polyp or abdominal pain by sigmoidoscopy.

RESULTSThe numbers (median: interquartile range) of CD68(+) cells, TNF-alpha(+) cells and NF-kappa Bp65(+) cells were 44.0 (31.5 - 48.2), 42.7 (19.5 - 65.0) and 50.7 (30.0 - 58.0) in the active UC mucosa, and were 9.2 (7.9 - 16.6), 5.5 (2.5 - 9.1) and 4.2 (3.0 - 8.4) in non-active UC mucosa, and 5.3 (4.3 - 8.7), 3.0 (0.0 - 6.3) and 3.3 (0.0 - 4.0) in the control mucosa, respectively. The levels of CD68, TNF-alpha and NF-kappa Bp65 expressions in the active UC were significantly higher than those in the non-active UC (P < 0.001) and the controls (P < 0.001). The expression level of CD68 in non-active UC was much higher than that in the controls (P = 0.008). Using the correlation analysis, a positive correlation between TNF-alpha and NF-kappa B activation was found (r = 0.885, P < 0.001).

CONCLUSIONSMacrophages TNF-alpha and NF-kappa B may play an important role in the pathophysiologic mechanism of childhood active UC. The activation of NF-kappa B may be associated with the release of TNF-alpha.

Adolescent ; Antigens, CD ; analysis ; Antigens, Differentiation, Myelomonocytic ; analysis ; Child ; Child, Preschool ; Colitis, Ulcerative ; metabolism ; pathology ; Female ; Humans ; Immunohistochemistry ; Infant ; Male ; NF-kappa B ; analysis ; Tumor Necrosis Factor-alpha ; analysis

OBJECTIVEDuodenal salami ulcer is a common disease found on routine endoscopic examination in children. The purpose of the study was to explore the characteristics and the clinicopathological features of duodenal salami ulcer in children and to deepen the understanding of duodenal salami ulcer.

METHODSThe endoscopic results of 117 cases with the duodenal salami ulcer were analyzed. The specimens of gastric antrum and duodenal bulb were subjected to HE and Giemsa staining and were examined for any alteration in histopathology and infection with Helicobacter pylori (Hp). The duodenal mucosa was stained with AB (pH 2.5)/PAS in order to diagnose the duodenal metaplasia.

RESULTSThe major endoscopic finding was a kind of hoarfrost, which was dotty or flaky, covered on the hyperemic and edematous mucosa. The detection rate of this change was 2.29% (117/5 106) of all the endoscopic examinations in children and the rate among cases with duodenal ulcer was 49.2% (117/238). The histopathology was characterized by a heavy infiltration of mainly lymphocytes, plasmocytes and neutrophilic granulocytes, frequently accompanied by superficial erosion. Sixty-one cases were pathologically diagnosed as chronic active duodenitis, superficial erosion in 45; chronic duodenitis in 50; eosinophilic duodenitis in 6. Detection rate of Hp in gastric antrum was 58% (68/117) of all cases. Detection rate of Hp infection and gastric epithelium metaplasia in duodenal bulb was 11.1% (13/117) and 31.1% (37/117), respectively. However, detection rate of Hp in gastric antrum was 25.0% (1 203/4 810) in 4 810 cases of normal duodenal bulb and chronic duodenitis in the same period. Detection rate of Hp in duodenal bulb was 0% and the detection rate of gastric epithelium metaplasia in duodenal bulb was 2.7% (128/4 810). All these detection rates were much higher than those of the specimens collected during the same period with normal duodenal bulb and chronic duodenitis (P < 0.001). Twenty-one cases were reexamined by endoscopy after having been treated with antacids or antacids and antimicrobial agents for 4 weeks. The lesions were healed up and no scars were found.

CONCLUSIONDuodenal salami ulcer in children had a special manifestation of duodenal inflammation or erosion but not a real ulcer. It was caused by the Hp infection in gastric antrum or duodenal bulb and the increase of gastric acids. The therapeutic principles were antacid and antimicrobial agents. The prognosis was good.

Adolescent ; Child ; Duodenal Ulcer ; complications ; pathology ; Duodenum ; pathology ; Female ; Helicobacter Infections ; complications ; Humans ; Male ; Pyloric Antrum ; pathology

OBJECTIVEHelicobacter pylori (Hp) infection presents high prevalence in the world, but there are few pediatric assays evaluating antimicrobial treatment using a short regimen of triple therapy. To evaluate the eradication rate and long term therapeutic effect of a triple therapy consisted of omeperazole, clarithromycin (CLA) and amoxycillin (AMO) on Hp infection, the authors explored the alternative therapeutic programs and their effects after first therapeutic failure.

METHODSA total of 192 children with Hp infection were divided into two groups: 157 children were given the triple therapy for one week (CLA group); 35 children were given another triple therapy composed of omeperazole, metronidazole (MET) and AMO for two weeks (MET group). All of the children were followed up for 1 - 36 months after the therapies ended. Twenty-two children in whom Hp was eradicated with CLA triple therapy were followed up for 3 years. The children of the two groups who had therapeutic failure were given re-treatment as follows. CLA triple therapy was given for one week to the children who had failure after MET triple therapy; increased doses of CLA with longer treatment course was given to the children who had failure after CLA triple therapy. A tetra therapy consisted of omeperazole, colloidal bismuth subcitrate (CBS), furazolidone (FUR) and AMO was given to the children in whom the re-treatment failed.

RESULTSThe Hp eradication and ulcer recovery rate of CLA group was 90.4% (142/157) and 96.9% (32/33), respectively; the Hp eradication rate of MET group was 77% (27/35). There was significant difference between eradication rates of the two groups (chi(2) = 4.69, P < 0.05). The recurrence rate of 22 Hp eradicated children treated with CLA triple therapy was 4.5% (1/22) during the 3-year follow-up. The eradication rate of the three re-treatment programs for 29 children was 75% (6/8), 77% (11/15) and 100% (6/6), respectively.

CONCLUSION(1) Omeperazole, CLA and AMO triple therapy for one week was the best to eradicate Hp infection with high eradication rate, few side effects, short period of treatment, good compliance and low recurrence rate. (2) Proper increase of CLA dose and longer therapeutic course may increase the eradication rate. Omeperazole, CBA, FUR and AMO tetra therapeutic program may be used as an alternative treatment in patients who develop resistance to CLA triple therapy.

Adolescent ; Amoxicillin ; administration & dosage ; therapeutic use ; Anti-Ulcer Agents ; administration & dosage ; therapeutic use ; Child ; Child, Preschool ; Clarithromycin ; administration & dosage ; therapeutic use ; Drug Therapy, Combination ; administration & dosage ; therapeutic use ; Female ; Follow-Up Studies ; Helicobacter Infections ; drug therapy ; Helicobacter pylori ; drug effects ; Humans ; Male ; Metronidazole ; administration & dosage ; therapeutic use ; Omeprazole ; administration & dosage ; therapeutic use ; Recurrence ; Time Factors ; Treatment Outcome

OBJECTIVETo evaluate the significance of gastric acid reflux in children with reflux esophagitis (RE).

METHODSTwenty-four-hour esophageal pH monitoring and gastroscopy were performed in 180 children suffered from vomiting. The relationship between RE, non-esophagitis (NE), non-erosive reflux disease (NERD) and gastroesophageal reflux (GER) was analyzed.

RESULTSSixty-five of the 180 patients were confirmed as having RE by endoscopy. Among them, the number of cases with grades I, II and III RE according to the diagnostic criteria by endoscopy was 37, 19 and 9 cases, respectively, while the other 115 cases were diagnosed as NE. The positive rate of acid reflux in RE group was 58.5% (38/65), while it was 42.6% (49/115) in NE group (chi(2) = 4.179, P < 0.05). All parameters of acid reflux in RE group except for the episode of reflux and the number of reflux longer than 5 min were significantly higher than those in NE group. None of the parameters of acid reflux except for Boix-Ochoa score in grade III RE patients was significantly higher than that in both grade II and grade I RE cases. However, the difference in acid reflux parameter between grade I and grade II RE patients had not reached statistical significance. The results also showed that the positive rate of pathological acid reflux was 48.3% (87/180). Among them, 38 cases were RE, while other 49 cases were NERD. The difference in acid reflux between these two groups was not significant.

CONCLUSIONSGastric acid reflux may play a major role in the development of RE in children, but may not be a sole pathogenic factor. The degree of acid reflux is not closely correspondent to the severity of RE. Acid reflux may not completely contribute to RE. Gastroscopy is very important for patients with reflux symptom.

Adolescent ; Child ; Child, Preschool ; China ; Esophageal pH Monitoring ; Esophagitis, Peptic ; diagnosis ; etiology ; pathology ; physiopathology ; Esophagoscopy ; Female ; Gastric Acid ; secretion ; Gastroesophageal Reflux ; complications ; Humans ; Hydrogen-Ion Concentration ; Infant ; Male ; Severity of Illness Index

OBJECTIVETo evaluate the roles of enteric nervous system neurotransmitters, nitric oxide (NO), substance P (SP) and vasoactive intestinal polypeptide (VIP), and interstitial cells of Cajal (ICC) in the colon in slow transit constipation in rats.

METHODSThirty-two healthy Wistar rats were randomly assigned to control and constipated groups. In the constipated group, the rats were daily administered with diphenoxylate (8 mg/kg) to develop slow transit constipation, while the control rats were fed with water. The number and the weight of fecal granule and the body weight of rats were recorded every 5 days for 90 days. Transit functions of intestinal movement were examined by an activated charcoal suspension pushing test one week after stopping the administration of diphenoxylate. The levels of NO and SP in the colonic mucosa were measured by nitrate reductase methods and ELISA respectively. The distribution of VIP and ICC positive cells confirmed with symbolic c-kit+ cells in the colonic wall were observed by immunohistochemical methods.

RESULTSThe daily number of fecal granule in the constipated group was significantly less than that in the control group (P<0.01). The mean weight of each fecal granule in the constipated group was significantly higher than that in the control group (P<0.01). The discharge time of the first granule of black faeces in the constipated group (430.2+/- 132.1 min) was significantly longer than that in the control group (337.2+/- 74.7 min; P<0.05). There were no significant differences in NO and SP levels and the density of VIP positive cells in the distal colonic segment between the two groups. The number of c-kit+ cells in the distal colonic wall in the constipated group was significantly reduced compared with that in the control group (P<0.05).

CONCLUSIONSThe reduction of ICC number in the distal colon may be contributed to the pathogenesis of slow transit constipation in rats.

Animals ; Body Weight ; Coiled Bodies ; Colon ; cytology ; innervation ; Constipation ; etiology ; Male ; Neurotransmitter Agents ; physiology ; Nitric Oxide ; analysis ; physiology ; Proto-Oncogene Proteins c-kit ; analysis ; Rats ; Rats, Wistar ; Substance P ; analysis ; physiology ; Vasoactive Intestinal Peptide ; analysis ; physiology