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Endoscopic Findings in Children Who Present with Food Refusal
Abstracts AB105
J ALLERGY CLIN IMMUNOL VOLUME 127, NUMBER 2
Angioedema Induced By Angiotensin-converting Enzyme Inhibitors: Two Cases Of Successful Treatment With A Novel B2 Bradykinin Antagonist D. V. Perez, S. Infante, G. Marco, J. M. Zubeldia; Hospital General Universitario Gregorio Mara~non, Madrid, SPAIN. RATIONALE: The angiotensin converting enzyme inhibitors (ACEi) can induce angioedema (AE). These drugs block the angiotensin I to angiotensin II leading to an increase in Bradykinin levels. Icatibant is a new Bradykinin beta-2 receptor antagonist currently accepted for the treatment of hereditary angioedema (HAE) in Europe. RESULTS: Case 1: A 65 year-old woman with isquemic cardiophaty and hypertension was on lisinopril for 9 years. she developed erythema evolving to lower lip, tongue and uvular angioedema, swallowing difficulties and dysphonia. In the emergency room was treated with methylprednisone and dexclorfeniramine without response in 2 hours and shore throat and dyspnoea progressed. Icatibant was administrated slowly disappear in 30 minutes. Case 2: An 81 year-old old man with previous diagnosis of ACEi induced angioedema, received by mistake a lisinopril pill. He developed important lip and tongue angioedema. In emergency room the laryngoscope showed uvular angioedema and upper airway compromise. After 2 hours, with subcutaneous icatibant, the angioedema had disappeared. CONCLUSIONS: Successful treatment with single doses of Icatibant in a 2 cases of ACEi induced laryngeal angioedema is reported. It clinical use is restricted to HAE. More clinical studies are necessary to extend and learn more about clinical uses of Icatibant.
394
Angiotensin-converting Enzyme Inhibitor And Angiotensin II Receptor Blocker-Induced Angioedema: Overuse of Ineffective Treatment M. Nasir, G. Sharma; UTMB-Galveston, Galveston, TX. RATIONALE: To describe the treatment administered to patients who presented to our hospital with angioedema (AE) secondary to angiotensin-coverting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) use. METHODS: A retrospective chart review was conducted of all adult patients admitted to UTMB between 2003 and 2007 with a diagnosis of AE (ICD-9 code 995.1). Patients with a history of hereditary angioedema, acquired angioedema or who were not taking an ACEI or ARB were excluded. RESULTS: A total of 38 patients were identified. The mean age was 58 years and over half (63%) were African-American. The majority (80%) had no documented drug allergy and 23.7% were atopic. The most commonly implicated ACEI was enalapril. Majority of the patients received steroids (81.6%) and H1-blockers (84.2%). Additional treatments received included H2-blockers (55.3%) and epinephrine (21.1%). Fourteen (36.8%) required intubation. The mean length of stay was 5.6 days. Upon discharge the majority of patients (89.5%) went home. Two went to a skilled nursing facility and one to a long-term acute care facility. One patient died in the hospital. CONCLUSION: Despite the lack of evidence for their use, the vast majority of patients at our institution received treatment with steroids, antihistamines and epinephrine. Current guidelines for ACEI-induced AE call for discontinuing the medication and supportive care. Recent reports have shown benefits of FFP and icatibant in the treatment of ACEI-AE. Future randomized controlled trials should explore their efficacy further.
395
Endoscopic Findings in Children Who Present with Food Refusal P. B. M. Jhaveri1,2, P. N. Jhaveri3, A. Darbari3; 1Penn State Hershey Medical Center, Hershey, PA, 2Kennedy Krieger Institute, Baltimore, MD, 3 Johns Hopkins University, Division of Pediatric Gastroenterology, Baltimore, MD. RATIONALE: Food allergies can manifest as a GI disorder through IgE and non-IgE mediated responses, and often translate to feeding difficulties in the pediatric population. An estimated 25-50% of all infants experience feeding problems, leading to further investigations, such as esophagogastroduodenoscopy (EGD) with biopsy, to rule out organic etiologies . Our objective is to identify eosinophilic gastroenteropathy as an etiology for feeding issues as recognized by endoscopic evaluation. METHODS: Between January 2008 and April 2009, an initial evaluation for feeding difficulties was performed in 327 children, ranging from 1 to 13 years old. 36% (118 patients) were recommended for EGD. Of these, 41% (48 patients) underwent EGD at our institution. After IRB approval, histological findings were reviewed for the presence of abnormalities by a surgical pathologist, and the final report was reviewed retrospectively. RESULTS: Eosinophilic esophagitis, defined as greater than 15 eosinophils per high power field, was found in 10% (n55) of children newly evaluated for feeding difficulties who underwent endoscopy at our institution. In 90% (n543) of the patients who underwent endoscopy at our institution, at least one histological diagnosis was found: mild reactive epithelial changes (10%), reactive epithelial changes (50%), H. pylori (4%), duodenitis (27%), gastritis (40%), celiac disease (4%). More than one histological diagnosis was found in 24% of patients. CONCLUSIONS: There are many causes for food refusal in the pediatric population. Eosinophilic esophagitis is a possible etiology for food refusal in children, and should be considered in the evaluation of children with failure to thrive, atopic history, or feeding difficulties.
396
Common Features of Feeding Difficulties (FD) Encountered in Children with Eosinophilic Gastrointestinal Diseases (EGIDs) N. C. Maune1, G. T. Furuta1,2, D. Atkins1,2, M. Henry1, Z. Pan1, A. M. Haas1; 1The Children’s Hospital, Aurora Colorado, Aurora, CO, 2National Jewish Health, Denver, CO. RATIONALE: Previous reports identified FD as a presenting complaint of children with EGIDs but few determined the prevalence or characterized the exact symptoms of FD associated with EGIDs. The aim of this study was to identify key features of FD identified in a specific population of children with EGIDs. METHODS: An IRB approved self-administered caregiver questionnaire focusing on key features of FD was administered to consenting participants at the American Partnership of Eosinophilic Disorders (APFED) patient symposium on July 16-18, 2010. RESULTS: Questionnaires were completed by 33% of caregivers who enrolled in the symposium. Results from the questionnaire described experiences of 56 children (55% male, 45% female, ages 1-16 years of age). FD was reported as the primary presenting complaint in 58.9% of all children. Allergists were the first health care providers to evaluate 38% of children for symptoms that ultimately led to a diagnosis of EGIDs. Most commonly reported features of FD were vomiting (83.9%), low variety of intake (79.6%), and inconsistent patterns of eating (75%). Gastrostomy tube feedings were required in 34% of the children. Of 18 factors queried, use of a feeding tube correlated with low volume of intake (p<0.007), food refusal (p<.067), low variety of intake (p<.073), and difficulty swallowing (p<.078). CONCLUSIONS: Allergists are often the first health care provider to encounter children with EGIDs, with FD identified as an initial symptom. This study identifies an emerging profile of common, but subtle symptoms of FD in children with EGIDs that provide clinical cues for earlier disease recognition.
SUNDAY
393
J ALLERGY CLIN IMMUNOL VOLUME 127, NUMBER 2
Angioedema Induced By Angiotensin-converting Enzyme Inhibitors: Two Cases Of Successful Treatment With A Novel B2 Bradykinin Antagonist D. V. Perez, S. Infante, G. Marco, J. M. Zubeldia; Hospital General Universitario Gregorio Mara~non, Madrid, SPAIN. RATIONALE: The angiotensin converting enzyme inhibitors (ACEi) can induce angioedema (AE). These drugs block the angiotensin I to angiotensin II leading to an increase in Bradykinin levels. Icatibant is a new Bradykinin beta-2 receptor antagonist currently accepted for the treatment of hereditary angioedema (HAE) in Europe. RESULTS: Case 1: A 65 year-old woman with isquemic cardiophaty and hypertension was on lisinopril for 9 years. she developed erythema evolving to lower lip, tongue and uvular angioedema, swallowing difficulties and dysphonia. In the emergency room was treated with methylprednisone and dexclorfeniramine without response in 2 hours and shore throat and dyspnoea progressed. Icatibant was administrated slowly disappear in 30 minutes. Case 2: An 81 year-old old man with previous diagnosis of ACEi induced angioedema, received by mistake a lisinopril pill. He developed important lip and tongue angioedema. In emergency room the laryngoscope showed uvular angioedema and upper airway compromise. After 2 hours, with subcutaneous icatibant, the angioedema had disappeared. CONCLUSIONS: Successful treatment with single doses of Icatibant in a 2 cases of ACEi induced laryngeal angioedema is reported. It clinical use is restricted to HAE. More clinical studies are necessary to extend and learn more about clinical uses of Icatibant.
394
Angiotensin-converting Enzyme Inhibitor And Angiotensin II Receptor Blocker-Induced Angioedema: Overuse of Ineffective Treatment M. Nasir, G. Sharma; UTMB-Galveston, Galveston, TX. RATIONALE: To describe the treatment administered to patients who presented to our hospital with angioedema (AE) secondary to angiotensin-coverting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) use. METHODS: A retrospective chart review was conducted of all adult patients admitted to UTMB between 2003 and 2007 with a diagnosis of AE (ICD-9 code 995.1). Patients with a history of hereditary angioedema, acquired angioedema or who were not taking an ACEI or ARB were excluded. RESULTS: A total of 38 patients were identified. The mean age was 58 years and over half (63%) were African-American. The majority (80%) had no documented drug allergy and 23.7% were atopic. The most commonly implicated ACEI was enalapril. Majority of the patients received steroids (81.6%) and H1-blockers (84.2%). Additional treatments received included H2-blockers (55.3%) and epinephrine (21.1%). Fourteen (36.8%) required intubation. The mean length of stay was 5.6 days. Upon discharge the majority of patients (89.5%) went home. Two went to a skilled nursing facility and one to a long-term acute care facility. One patient died in the hospital. CONCLUSION: Despite the lack of evidence for their use, the vast majority of patients at our institution received treatment with steroids, antihistamines and epinephrine. Current guidelines for ACEI-induced AE call for discontinuing the medication and supportive care. Recent reports have shown benefits of FFP and icatibant in the treatment of ACEI-AE. Future randomized controlled trials should explore their efficacy further.
395
Endoscopic Findings in Children Who Present with Food Refusal P. B. M. Jhaveri1,2, P. N. Jhaveri3, A. Darbari3; 1Penn State Hershey Medical Center, Hershey, PA, 2Kennedy Krieger Institute, Baltimore, MD, 3 Johns Hopkins University, Division of Pediatric Gastroenterology, Baltimore, MD. RATIONALE: Food allergies can manifest as a GI disorder through IgE and non-IgE mediated responses, and often translate to feeding difficulties in the pediatric population. An estimated 25-50% of all infants experience feeding problems, leading to further investigations, such as esophagogastroduodenoscopy (EGD) with biopsy, to rule out organic etiologies . Our objective is to identify eosinophilic gastroenteropathy as an etiology for feeding issues as recognized by endoscopic evaluation. METHODS: Between January 2008 and April 2009, an initial evaluation for feeding difficulties was performed in 327 children, ranging from 1 to 13 years old. 36% (118 patients) were recommended for EGD. Of these, 41% (48 patients) underwent EGD at our institution. After IRB approval, histological findings were reviewed for the presence of abnormalities by a surgical pathologist, and the final report was reviewed retrospectively. RESULTS: Eosinophilic esophagitis, defined as greater than 15 eosinophils per high power field, was found in 10% (n55) of children newly evaluated for feeding difficulties who underwent endoscopy at our institution. In 90% (n543) of the patients who underwent endoscopy at our institution, at least one histological diagnosis was found: mild reactive epithelial changes (10%), reactive epithelial changes (50%), H. pylori (4%), duodenitis (27%), gastritis (40%), celiac disease (4%). More than one histological diagnosis was found in 24% of patients. CONCLUSIONS: There are many causes for food refusal in the pediatric population. Eosinophilic esophagitis is a possible etiology for food refusal in children, and should be considered in the evaluation of children with failure to thrive, atopic history, or feeding difficulties.
396
Common Features of Feeding Difficulties (FD) Encountered in Children with Eosinophilic Gastrointestinal Diseases (EGIDs) N. C. Maune1, G. T. Furuta1,2, D. Atkins1,2, M. Henry1, Z. Pan1, A. M. Haas1; 1The Children’s Hospital, Aurora Colorado, Aurora, CO, 2National Jewish Health, Denver, CO. RATIONALE: Previous reports identified FD as a presenting complaint of children with EGIDs but few determined the prevalence or characterized the exact symptoms of FD associated with EGIDs. The aim of this study was to identify key features of FD identified in a specific population of children with EGIDs. METHODS: An IRB approved self-administered caregiver questionnaire focusing on key features of FD was administered to consenting participants at the American Partnership of Eosinophilic Disorders (APFED) patient symposium on July 16-18, 2010. RESULTS: Questionnaires were completed by 33% of caregivers who enrolled in the symposium. Results from the questionnaire described experiences of 56 children (55% male, 45% female, ages 1-16 years of age). FD was reported as the primary presenting complaint in 58.9% of all children. Allergists were the first health care providers to evaluate 38% of children for symptoms that ultimately led to a diagnosis of EGIDs. Most commonly reported features of FD were vomiting (83.9%), low variety of intake (79.6%), and inconsistent patterns of eating (75%). Gastrostomy tube feedings were required in 34% of the children. Of 18 factors queried, use of a feeding tube correlated with low volume of intake (p<0.007), food refusal (p<.067), low variety of intake (p<.073), and difficulty swallowing (p<.078). CONCLUSIONS: Allergists are often the first health care provider to encounter children with EGIDs, with FD identified as an initial symptom. This study identifies an emerging profile of common, but subtle symptoms of FD in children with EGIDs that provide clinical cues for earlier disease recognition.
SUNDAY
393