- Email: [email protected]
Diagnostic duodenal bulb biopsy in children with celiac disease
Abstracts / Digestive and Liver Disease 40 (2008) A41–A118
A73
Methods. Multicenter nationwide study in which a questionnaire was sent to a referent of paediatricians working in the private and MUs with more than 1000 births/year. Physicians were asked to describe their usual dietary advices for at risk infants. The paediatricians included in this study had not received any prior specific information nor training about guidelines. Results. 22 MUs participated to the study. The allergic risk (AR) factor was not usually searched in 12/22 MUs (54%). The newborn was considered at AR in the presence of an allergic affected parent or sibling in 11/22 MUs (50%); or in the presence of biparental familiarity 4/22 MUs (18%). In the newborns with AR not receiving maternal milk, an extensively or partially hydrolysed formula was prescribed in only 5/22 MUs (23%) for the first 5–6◦ months of life. Conclusions. The dietary recommendations for primary prevention of FA in at risk infants are not followed on a daily basis in our country. Our data suggest the importance to improve the information about preventive measures for FA in paediatric clinical practice.
optic nerves. Total blood work-up showed an undetectable selenium level. We immediately started Se supplement both intravenously and orally with progressive disappearance of his symptoms and restoring of his visual capacities. Repeated blood tests showed normal Se serum levels. A repeated RM scan of his brain showed an unchanged pattern of atrophy, either because was not due to Se deficiency, or because was not the cause of his symptoms. Despite we do not routinely add Se in our PN preparations and have been following more than 200 patients on PN since 1988 we never experienced Se deficiency in any of our patients. This could be because all our patient tolerated a minimum of enteral or oral nutrition that naturally contain Se. Our patient in the last 3 years has never been able to tolerate either enteral or oral feeds so he remained on total PN and this led to Se deficiency. Our case show the importance of monitoring trace elements including Se in all patients on PN since supplementation could be inadequate and that Se deficiency symptoms are reversible after appropriate Se supplementation.
doi:10.1016/j.dld.2008.07.228
doi:10.1016/j.dld.2008.07.229
PP44 SELENIUM DEFICIENCY IN A PATIENTS WITH CHRONIC INTESTINAL PSEUDO-OBSTRUCTION ON TOTAL PARENTERAL NUTRITION
PP45 DIAGNOSTIC DUODENAL BULB BIOPSY IN CHILDREN WITH CELIAC DISEASE
D. Knafelz, A. Diamanti, F. Ferretti, B. Papadatou, M. Gambarara, F. Bracci, M.S. Basso, C. Noto, M. Castro U.O.C. Gastroenterologia, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy Selenium (Se) is one of the essential trace elements for human beings. In the human body, Se is a component of at least 35 selenoproteins, some of which have important enzymatic functions. Se deficiency can results in systemic symptoms, including myocardial disorders, skeletal muscle disorders, erythrocytes macrocytosis, finger nail abnormalities, pseudo albinism, permanent visual loss and progressive and irreversible encephalopathy. Se deficiency can occur in patients with long term parenteral nutrition (PN) that do not receive adequate Se supplementation. We describe a 17 years old boy with chronic intestinal pseudo-obstruction PN dependent since birth. He tolerated on and off enteral nutrition as supplement of his PN up ‘till the age of 14, when recurrent episodes of obstruction imposed its suspension. At the age of 16 he started to develop profound muscle weakness with difficulties in walking, whitening of the nail beds, erythrocytes macrocytosis with normal levels of vitamin B12 and folates, and disturbances of his vision. An ophthalmic evaluation revealed a visual loss of 9/10 bilaterally that occurred in a period of one month (a previous ophthalmic evaluation performed one month before revealed normal vision). A magnetic resonance of his brain revealed signs of cerebral atrophy more prominent in the calcarin area with normal
B. Parma a , B. Mangiavillano d , L. Albarello c , M.F. Brambillasca a , G. Tronconi a , P. Corsin a , E. Masci b , G. Barera a , P.A. Testoni b a
Department of Paediatrics; Scientific Institute H. San Raffaele, Vita-Salute University, Milan, Italy b Division of Gastroenterology & Gastrointestinal Endoscopy Scientific Institute H. San Raffaele, Vita-Salute University, Milan, Italy c Division of Surgical Pathology. Scientific Institute H. San Raffaele, Vita-Salute University, Milan, Italy d Department of Gastrointestinal Endoscopy, IRCCS San Paolo Hospital, Milan, Italy Background. The gold standard of Celiac Disease (CD) diagnosis is up to now based on characteristic histological features, according to Marsh criteria modified by Oberhuber (M/O). The biopsies are usually performed in descending duodenum, 1 for each quadrant (Seattle’s criteria). Only few papers focused on the role of duodenal biopsies in diagnosis of CD. Aim. To assess the role of duodenal biopsy in a selected population of paediatric patients undergone oesophagogastroduodenoscopy (OGD) for suspected CD, because of gluten-autoantibodies positivity. Patients and methods. We prospectively enrolled 21 paediatric patients (6 M, 15 F; age: 7.4 ± 10.6 years) with positive titres of IgA and IgG anti-tissue transglutaminase (tTGAb), referred to our Gastroenterology Paediatric Service. All patients underwent to OGD for histological diagnosis. During the OGD we took 4 mucosal biopsies from the duodenal
A74
Abstracts / Digestive and Liver Disease 40 (2008) A41–A118
bulb and 4 in the descending duodenum (1/quadrant). The histological specimens were fixed in 10% formalin and stained with hematoxylin and eosin (H&E). The pathologist reported blindly the histological M/O diagnosis of the bulb and of the descending duodenum. The diagnosis of CD was confirmed according to the revised ESPGHAN criteria. Results. Of the 21 paediatric enrolled patients: - 15 subjects (71%) had the same histology in bulb and descending duodenum: 3 pts had IIIa M/O (20%); 3 pts had IIIb M/O (20%); 9 pts had IIIc M/O (60%). - 5 subjects (23%) had a major histological atrophy grade of the bulb than in the duodenum, and in two of these the descending duodenal biopsies were negative for CD (0 M/O) (Table 1). - 1 subject (6%) presented the duodenal histological atrophy grade major than the bulb (bulb = IIIa and descending duodenum = IIIb). Table 1 Patients
1 2 3 4 5
Bulb histology (Marsh-Oberhuber grade)
Duodenal histology (Marsh-Oberhuber grade)
II IIIa IIIa IIIb IIIb
0 II II 0 IIIa
Methods. Prospective, multicenter study involving VLBW newborns with a gestational age <32 weeks. Serum Clp was measured in subjects presenting clinical and radiological diagnostic criteria for NEC (Bell stage >II), while healthy newborns served as controls. Serum Clp values was determined by an ELISA technique (Calprest® , Trieste, Italy) at similar postnatal age for subjects with NEC and controls. Results. During an observational period of 24 months 78 newborns were enrolled: 7 received diagnosis of NEC (male 4; birth weight 913 ± 248 g; gestational age 27.8 ± 1.8 wks; postnatal age 15.8 ± 5.0 d), and 71 subjects were classified as healthy controls (male 47; birth weight 1098 ± 239 g; gestational age 28.7 ± 2.8 wks; postnatal age 13.9 ± 3.7 d). The mean serum Clp concentrations resulted higher in patients with NEC (3.98 ± 0.69 g/ml) compared to healthy controls (0.70 ± 0.37 g/ml) (p < 0.0001). Conclusions. Determination of serum Clp concentration could be considered an additional diagnostic marker for identification of NEC. doi:10.1016/j.dld.2008.07.231 PP47 RACECADOTRIL DIRECTLY INDUCES ION ABSORPTION UNDER BASAL CONDITION AND INHIBITS ROTAVIRUS CHLORIDE SECRETION IN HUMAN ENTEROCYTES
Conclusion. In conclusion this study suggests that the routinely esecution of biopsies in addition to descending duodenum could improve the diagnostic sensitivity of the bioptic procedure.
C. Armellino, V. Buccigrossi, M. Penza, I. Bracale, M. Oliva, A. Giannattasio, G. Polito, A. Guarino
doi:10.1016/j.dld.2008.07.230
Background. Racecadotril is a potent inhibitor of enkephalinase [1]. Enkephalinase is an enzyme abundant in the gastrointestinal tract that inhibits the enkephalins, neurotransmitters produced by the enteric nervous system (ENS) that possess an antisecretory effect on transepithelial ion transport. Racecadotril reduces ion secretion triggered by cholera toxin and prostaglandins, and is effective in acute diarrhoea in in-vivo studies. Rotavirus (RV) is the major cause of gastroenteritis in infants. A putative mechanism of RV diarrhoea is related to the activation of ENS. However we have previously reported that RV exerts a double pathogenic effect in human enterocytes: an early chloride secretion and a subsequent intestinal epithelial damage. Aim. We tested the hypothesis that Racecadotril directly interacts with the enterocytes stimulating ion absorption in basal conditions and reducing chloride secretion induced by RV. Since MAPKs ERK1/2 and p38 are involved in the regulation of transepithelial ion transport, we also tested the hypothesis that either or both may be involved in the antagonist effects to RV induced by Racecadotril on intestinal ion transport. Materials and methods. Short-circuit current (Isc), an electrical parameter of chloride secretion, was measured in Caco-2 cell monolayers infected with RV strain SA-
PP46 MEASUREMENT OF SERUM CALPROTECTIN LEVEL FOR DIAGNOSIS OF NECROTIZING ENTEROCOLITIS G. Terrin a,b , A. Passariello a , L. Rapacciuolo a , F. Messina b , G. Salvia b , R. Berni Canani a a
Department of Pediatrics University of Naples Federico II, Naples, Italy b Neonatal Intensive Care Unit, Hospital Villa Betania, Naples, Italy Background. Necrotizing enterocolitis (NEC) is a major cause of morbility and mortality in very low birth weight (VLBW) neonates. Although NEC onset is often inconspicuous, with minimal, subtle and non-specific signs, the clinical course may be fulminating. Thus, a prompt diagnosis to initiate an appropriate therapy is crucial. Faecal calprotectin has been proposed for diagnosis of NEC, however a wide overlapping between normal and pathological data in neonatal age limit their diagnostic use. Aim. To investigate whether serum Clp determination could be useful for the diagnosis of NEC.
Department of Pediatrics, University of Naples “Federico II”, Naples, Italy
A73
Methods. Multicenter nationwide study in which a questionnaire was sent to a referent of paediatricians working in the private and MUs with more than 1000 births/year. Physicians were asked to describe their usual dietary advices for at risk infants. The paediatricians included in this study had not received any prior specific information nor training about guidelines. Results. 22 MUs participated to the study. The allergic risk (AR) factor was not usually searched in 12/22 MUs (54%). The newborn was considered at AR in the presence of an allergic affected parent or sibling in 11/22 MUs (50%); or in the presence of biparental familiarity 4/22 MUs (18%). In the newborns with AR not receiving maternal milk, an extensively or partially hydrolysed formula was prescribed in only 5/22 MUs (23%) for the first 5–6◦ months of life. Conclusions. The dietary recommendations for primary prevention of FA in at risk infants are not followed on a daily basis in our country. Our data suggest the importance to improve the information about preventive measures for FA in paediatric clinical practice.
optic nerves. Total blood work-up showed an undetectable selenium level. We immediately started Se supplement both intravenously and orally with progressive disappearance of his symptoms and restoring of his visual capacities. Repeated blood tests showed normal Se serum levels. A repeated RM scan of his brain showed an unchanged pattern of atrophy, either because was not due to Se deficiency, or because was not the cause of his symptoms. Despite we do not routinely add Se in our PN preparations and have been following more than 200 patients on PN since 1988 we never experienced Se deficiency in any of our patients. This could be because all our patient tolerated a minimum of enteral or oral nutrition that naturally contain Se. Our patient in the last 3 years has never been able to tolerate either enteral or oral feeds so he remained on total PN and this led to Se deficiency. Our case show the importance of monitoring trace elements including Se in all patients on PN since supplementation could be inadequate and that Se deficiency symptoms are reversible after appropriate Se supplementation.
doi:10.1016/j.dld.2008.07.228
doi:10.1016/j.dld.2008.07.229
PP44 SELENIUM DEFICIENCY IN A PATIENTS WITH CHRONIC INTESTINAL PSEUDO-OBSTRUCTION ON TOTAL PARENTERAL NUTRITION
PP45 DIAGNOSTIC DUODENAL BULB BIOPSY IN CHILDREN WITH CELIAC DISEASE
D. Knafelz, A. Diamanti, F. Ferretti, B. Papadatou, M. Gambarara, F. Bracci, M.S. Basso, C. Noto, M. Castro U.O.C. Gastroenterologia, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy Selenium (Se) is one of the essential trace elements for human beings. In the human body, Se is a component of at least 35 selenoproteins, some of which have important enzymatic functions. Se deficiency can results in systemic symptoms, including myocardial disorders, skeletal muscle disorders, erythrocytes macrocytosis, finger nail abnormalities, pseudo albinism, permanent visual loss and progressive and irreversible encephalopathy. Se deficiency can occur in patients with long term parenteral nutrition (PN) that do not receive adequate Se supplementation. We describe a 17 years old boy with chronic intestinal pseudo-obstruction PN dependent since birth. He tolerated on and off enteral nutrition as supplement of his PN up ‘till the age of 14, when recurrent episodes of obstruction imposed its suspension. At the age of 16 he started to develop profound muscle weakness with difficulties in walking, whitening of the nail beds, erythrocytes macrocytosis with normal levels of vitamin B12 and folates, and disturbances of his vision. An ophthalmic evaluation revealed a visual loss of 9/10 bilaterally that occurred in a period of one month (a previous ophthalmic evaluation performed one month before revealed normal vision). A magnetic resonance of his brain revealed signs of cerebral atrophy more prominent in the calcarin area with normal
B. Parma a , B. Mangiavillano d , L. Albarello c , M.F. Brambillasca a , G. Tronconi a , P. Corsin a , E. Masci b , G. Barera a , P.A. Testoni b a
Department of Paediatrics; Scientific Institute H. San Raffaele, Vita-Salute University, Milan, Italy b Division of Gastroenterology & Gastrointestinal Endoscopy Scientific Institute H. San Raffaele, Vita-Salute University, Milan, Italy c Division of Surgical Pathology. Scientific Institute H. San Raffaele, Vita-Salute University, Milan, Italy d Department of Gastrointestinal Endoscopy, IRCCS San Paolo Hospital, Milan, Italy Background. The gold standard of Celiac Disease (CD) diagnosis is up to now based on characteristic histological features, according to Marsh criteria modified by Oberhuber (M/O). The biopsies are usually performed in descending duodenum, 1 for each quadrant (Seattle’s criteria). Only few papers focused on the role of duodenal biopsies in diagnosis of CD. Aim. To assess the role of duodenal biopsy in a selected population of paediatric patients undergone oesophagogastroduodenoscopy (OGD) for suspected CD, because of gluten-autoantibodies positivity. Patients and methods. We prospectively enrolled 21 paediatric patients (6 M, 15 F; age: 7.4 ± 10.6 years) with positive titres of IgA and IgG anti-tissue transglutaminase (tTGAb), referred to our Gastroenterology Paediatric Service. All patients underwent to OGD for histological diagnosis. During the OGD we took 4 mucosal biopsies from the duodenal
A74
Abstracts / Digestive and Liver Disease 40 (2008) A41–A118
bulb and 4 in the descending duodenum (1/quadrant). The histological specimens were fixed in 10% formalin and stained with hematoxylin and eosin (H&E). The pathologist reported blindly the histological M/O diagnosis of the bulb and of the descending duodenum. The diagnosis of CD was confirmed according to the revised ESPGHAN criteria. Results. Of the 21 paediatric enrolled patients: - 15 subjects (71%) had the same histology in bulb and descending duodenum: 3 pts had IIIa M/O (20%); 3 pts had IIIb M/O (20%); 9 pts had IIIc M/O (60%). - 5 subjects (23%) had a major histological atrophy grade of the bulb than in the duodenum, and in two of these the descending duodenal biopsies were negative for CD (0 M/O) (Table 1). - 1 subject (6%) presented the duodenal histological atrophy grade major than the bulb (bulb = IIIa and descending duodenum = IIIb). Table 1 Patients
1 2 3 4 5
Bulb histology (Marsh-Oberhuber grade)
Duodenal histology (Marsh-Oberhuber grade)
II IIIa IIIa IIIb IIIb
0 II II 0 IIIa
Methods. Prospective, multicenter study involving VLBW newborns with a gestational age <32 weeks. Serum Clp was measured in subjects presenting clinical and radiological diagnostic criteria for NEC (Bell stage >II), while healthy newborns served as controls. Serum Clp values was determined by an ELISA technique (Calprest® , Trieste, Italy) at similar postnatal age for subjects with NEC and controls. Results. During an observational period of 24 months 78 newborns were enrolled: 7 received diagnosis of NEC (male 4; birth weight 913 ± 248 g; gestational age 27.8 ± 1.8 wks; postnatal age 15.8 ± 5.0 d), and 71 subjects were classified as healthy controls (male 47; birth weight 1098 ± 239 g; gestational age 28.7 ± 2.8 wks; postnatal age 13.9 ± 3.7 d). The mean serum Clp concentrations resulted higher in patients with NEC (3.98 ± 0.69 g/ml) compared to healthy controls (0.70 ± 0.37 g/ml) (p < 0.0001). Conclusions. Determination of serum Clp concentration could be considered an additional diagnostic marker for identification of NEC. doi:10.1016/j.dld.2008.07.231 PP47 RACECADOTRIL DIRECTLY INDUCES ION ABSORPTION UNDER BASAL CONDITION AND INHIBITS ROTAVIRUS CHLORIDE SECRETION IN HUMAN ENTEROCYTES
Conclusion. In conclusion this study suggests that the routinely esecution of biopsies in addition to descending duodenum could improve the diagnostic sensitivity of the bioptic procedure.
C. Armellino, V. Buccigrossi, M. Penza, I. Bracale, M. Oliva, A. Giannattasio, G. Polito, A. Guarino
doi:10.1016/j.dld.2008.07.230
Background. Racecadotril is a potent inhibitor of enkephalinase [1]. Enkephalinase is an enzyme abundant in the gastrointestinal tract that inhibits the enkephalins, neurotransmitters produced by the enteric nervous system (ENS) that possess an antisecretory effect on transepithelial ion transport. Racecadotril reduces ion secretion triggered by cholera toxin and prostaglandins, and is effective in acute diarrhoea in in-vivo studies. Rotavirus (RV) is the major cause of gastroenteritis in infants. A putative mechanism of RV diarrhoea is related to the activation of ENS. However we have previously reported that RV exerts a double pathogenic effect in human enterocytes: an early chloride secretion and a subsequent intestinal epithelial damage. Aim. We tested the hypothesis that Racecadotril directly interacts with the enterocytes stimulating ion absorption in basal conditions and reducing chloride secretion induced by RV. Since MAPKs ERK1/2 and p38 are involved in the regulation of transepithelial ion transport, we also tested the hypothesis that either or both may be involved in the antagonist effects to RV induced by Racecadotril on intestinal ion transport. Materials and methods. Short-circuit current (Isc), an electrical parameter of chloride secretion, was measured in Caco-2 cell monolayers infected with RV strain SA-
PP46 MEASUREMENT OF SERUM CALPROTECTIN LEVEL FOR DIAGNOSIS OF NECROTIZING ENTEROCOLITIS G. Terrin a,b , A. Passariello a , L. Rapacciuolo a , F. Messina b , G. Salvia b , R. Berni Canani a a
Department of Pediatrics University of Naples Federico II, Naples, Italy b Neonatal Intensive Care Unit, Hospital Villa Betania, Naples, Italy Background. Necrotizing enterocolitis (NEC) is a major cause of morbility and mortality in very low birth weight (VLBW) neonates. Although NEC onset is often inconspicuous, with minimal, subtle and non-specific signs, the clinical course may be fulminating. Thus, a prompt diagnosis to initiate an appropriate therapy is crucial. Faecal calprotectin has been proposed for diagnosis of NEC, however a wide overlapping between normal and pathological data in neonatal age limit their diagnostic use. Aim. To investigate whether serum Clp determination could be useful for the diagnosis of NEC.
Department of Pediatrics, University of Naples “Federico II”, Naples, Italy