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Esophagitis in infants with gastroesophageal reflux and irritability
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TWO-SITE BIOPSY FOR THE ASSESSMENT OF GASTRITIS IN CHILDREN: HISTOPATHOLOGICAL AND ENDOSCOPIC CORRELATES, C Vaquero Solans, S Mitsudo and RE Sockolew. Departments of Pediatrics and Surgical Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. Esophagogastroduodenosoopy (EGD) is often performed in pediatric patients for the evaluation of gastrointestinal symptoms. It is well known that the endoscopic findings tend to overestimate the histopathologic abnormalities. Therefore, antral biopsies are frequently performed. However, there are no formal recommendations in terms of the number and site of biopsies to be obtained during an EGD in children. To evaluate the importance of fundie biopsies in EGD, we compared the histopathology of antral and fundic samples obtained in 51 consecutive pediatric patients (ages 1.4 to 22.2, median 14.83 yr; 33 males) undergoing diagnostic EGD. Biopsies of the antrum and fundus were systematically obtained for light microscopy and stained with H&E. Additionally, the histological findings were correlated with the corresponding description of the endoscopic appearance (n 24). Our results showed that 39/51 subjects had histopathology consistent with gastritis as defined by the Sydney criteria. Lymphoplasmoeytie infiltrates of the superficial mucosa was the morphologie change most fi'equently documented, followed by stromal eosinophilie and polymorphonudear infiltrates, lymphocytic infiltrates of the glandular isthmus and hyperplastie lymphoid aggregates. These abnormalities were found in both biopsy sites. However, 11/39 patients, (28 %) had at least one histopathologie finding in the fundus that was graded as more prominent than in the antrum. The histopathology of the antrum was in general less severe than what was suggested by the endoscopy. However, the histopathology of the fundas showed more severe changes than expected by the endoscopic appearance. We oonclude that, in contrast with the results found in the antrum, the endoscopic appearance of the fundas underestimates its histopathological findings. Therefore, systematic fundie biopsies should be added to the usual antral studies for a comprehensive evaluation of the gastric mucosa.
ESOPHAGITIS IN INFANTS WITH GASTROESOPHAGEAL REFLUX AND IRRITABILITY TA Weinstein, BH Kessler, IJ Levine, DM Gold, MJ Pettei. Dept of Pediatric GI/Nutrition, Albert Einstein College of Medicine, Schneider Children's Hosp, Long Island Jewish Medical Center, New Hyde Park, NY Regurgitation/vomiting (R/V) is a common clinical problem in infants and typically represents physiologic gastroosophageal reflux (GER). Patients with R/V are considered for further evaluation when they demonstrate a possible complication of GER such as symptoms suggestive of esophagitis, failure to thrive (FTT), or respiratory disease. When R/V occurs in association with irritability, the complication of reflux-induced esophagitis is entertained. Alternatively, R/V and irritability in an infant may represent a functional problem such as colic. We reviewed the medical history, endoscopic and pathologic findings in patients < 12 months of age who underwent esophagogastroduodenoscopy (EGD) from 1990-1994 for symptoms of reflux esophagitis. Indications for EGD were R/V _+_irritability, FTT, hematemesis, bronchospasm, pneumonia or anemia. Those infants with caustic ingestion, esophageal varices, or tracheoesophageal fistula were excluded. A total of 93 patients met the criteria. 50.5% (47/93) had histologic markers for esophagitis defined as intraepithelial eosinophilia, intraepithelial lymphocytes, and/or elongation of the papillae. 10/93 infants presented with R/V alone and 50.0% (5/10) had esophagitis. 17/93 presented with R/V and irritability and 29.4% (5/17) had esophagitis. 22/93 presented with R/V, irritability, and another indication for EGD and 54.5% (12/22) had esophagitis. 44/93 presented with R/V without irritability but with another indication for EGD and 56.8% (25/44) had esophagitis. Conclusion: Infants with the combination of R/V and irritability as presenting signs of GER had a lower yield on EGD for esophagitis than infants with any other indication for EGD including R/V alone. R/V in combination with irritability alone is a poor predictor of esophagitis. Isolated irritability in infants with R/V should not be used as an indicator to perform EGD for esophagitis.
194
t196
COLONIC MALAKOPLAKIA, A PEDIATRIC CASE REPORT. Vargas JH., Bahar R., I_~win K.,Martin M & Ament MI~'."Dept. of Pediatrics. UCLA School of Med. Los Angeles CA. A 12 yo male guatemalan who migrated 4 years before presented with a history of bloody diarrhea and tenemus. Past medical history was remarkable for iron defficiency anemia and swelling of a knee. Review of systems revealed I~rharps some photophobia. Initial colonoscopy described erosions and superficial ulcerations but biopsies were nonspecific.With a diagnosis of Ulcerative Colitis treatment with prednisone and azulfadine is started at adequate doses but no improvement is observed and the patient looses 20-30 lbs. Endoscopic reevaluation in Our center reveals "cobblestoning", pseudopolyps, erosions and superficial ulcerations throughout the colon with normal ileum. Biopsies show raised appearence of mucosa due to infiltrate with histiocytes which have eosinophilic granular cytoplasm and small round basophilic PAS/ GMST negative inclusions. EM reveals inclusions to be bacterial debris. Diagnosis established and treatment with antibiotics initially IV, subsequently oral, improves nutritional status and diarrhea. Malakoplakia is a rare cause of colitis in children but described primarily in this group when not associated with malignancy or para-neoplastic syndrome. Characteristic endoscopic and histologic features should evoke the diagnosis but electron microscopy establishes nature of inclusions. Pathophysiology and causes remain obscure.
HISTOLOGIC FINDINGS IN CHILDREN UNDERGOING UPPER ENDOSCOPY FOR EVALUATION OF ABDOMINAL PAIN. B,Weissell3erg, H. Shashidhar, J.A.Morelli, K.A. Caleoda. Div of Pediatric Gastroenterology and Nutrition, Floating Hospital for Children, New England Med Ctr, Tufts Univ School of Medicine, Boston, MA. The prevalence of chronic abdominal pain among school age children peaks around ages 10-12 yrs. Prior studies suggested that the majority of pts with this complaint lacked objective evidence of organic etiology for the pain. However, recent studies (JPGN 1993;16:273, Seand J Gastroenterol 1991;26:95) indicated a higher prevalence of organic disorders than previously recognized, with gastritis in 60% and H. pylori disease in up to 58% of affected children. Aim: The aim of the present study was to investigate current experience in a large New England referral population, and to characterize the pathological features accompanying abdominal pain in pediatric pts. Patients: The histological appearance of biopsies obtained during upper gastrointestinal endoscopy were retrospectively reviewed in 82 consecutive children (62% F, ages 2-18y, mean 1ly) with abdominal pain (with/withoutnausea or vomiting) who otherwise had normal physical examination, growth and laboratory studies. Additional clinical findings included constipation in 12 pts, hiatal hernia in 3, and lactose intolerance in 7. Multiple biopsies were taken from the duodenum, antrum and esophagus and reviewed by one pathologist. Results: Histological changes were found in 24 (29.2 %) pts: 8 (9.7%) had chronic duodenitis (one of them with Giardia), 7 (8.5%) had esophagitis, 5 (6%) had H. pylori infection, 3 (3.6%) had gastritis with no evidence of H. pylori, and 1 0.2%) had eosinophilic gastroenteritis. One pt with duodenitis underwent a colonoscopy that revealed Crohn's disease. Histological findings were not dependent upon the age of the pts. Males had a significantly higher prevalence of abnormal histological features than females (45% vs 19.6% respectively, p < 0.05). Conclusions: 1) 29% of pts with abdominal pain had histological abnormalities found during upper endoscopy; 2) Most common were duodenitis, esophagitis and H. pylori; 3) The prevalence ofH. pylori was markedly lower than previously reported in conjunction with abdominal pain; 4) In general, abnormal histological findings were less prevalent than those reported in other studies.
344
GASTROINTESTINAL
ENDOSCOPY
V O L U M E 41, NO. 4, 1995
~:195
TWO-SITE BIOPSY FOR THE ASSESSMENT OF GASTRITIS IN CHILDREN: HISTOPATHOLOGICAL AND ENDOSCOPIC CORRELATES, C Vaquero Solans, S Mitsudo and RE Sockolew. Departments of Pediatrics and Surgical Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. Esophagogastroduodenosoopy (EGD) is often performed in pediatric patients for the evaluation of gastrointestinal symptoms. It is well known that the endoscopic findings tend to overestimate the histopathologic abnormalities. Therefore, antral biopsies are frequently performed. However, there are no formal recommendations in terms of the number and site of biopsies to be obtained during an EGD in children. To evaluate the importance of fundie biopsies in EGD, we compared the histopathology of antral and fundic samples obtained in 51 consecutive pediatric patients (ages 1.4 to 22.2, median 14.83 yr; 33 males) undergoing diagnostic EGD. Biopsies of the antrum and fundus were systematically obtained for light microscopy and stained with H&E. Additionally, the histological findings were correlated with the corresponding description of the endoscopic appearance (n 24). Our results showed that 39/51 subjects had histopathology consistent with gastritis as defined by the Sydney criteria. Lymphoplasmoeytie infiltrates of the superficial mucosa was the morphologie change most fi'equently documented, followed by stromal eosinophilie and polymorphonudear infiltrates, lymphocytic infiltrates of the glandular isthmus and hyperplastie lymphoid aggregates. These abnormalities were found in both biopsy sites. However, 11/39 patients, (28 %) had at least one histopathologie finding in the fundus that was graded as more prominent than in the antrum. The histopathology of the antrum was in general less severe than what was suggested by the endoscopy. However, the histopathology of the fundas showed more severe changes than expected by the endoscopic appearance. We oonclude that, in contrast with the results found in the antrum, the endoscopic appearance of the fundas underestimates its histopathological findings. Therefore, systematic fundie biopsies should be added to the usual antral studies for a comprehensive evaluation of the gastric mucosa.
ESOPHAGITIS IN INFANTS WITH GASTROESOPHAGEAL REFLUX AND IRRITABILITY TA Weinstein, BH Kessler, IJ Levine, DM Gold, MJ Pettei. Dept of Pediatric GI/Nutrition, Albert Einstein College of Medicine, Schneider Children's Hosp, Long Island Jewish Medical Center, New Hyde Park, NY Regurgitation/vomiting (R/V) is a common clinical problem in infants and typically represents physiologic gastroosophageal reflux (GER). Patients with R/V are considered for further evaluation when they demonstrate a possible complication of GER such as symptoms suggestive of esophagitis, failure to thrive (FTT), or respiratory disease. When R/V occurs in association with irritability, the complication of reflux-induced esophagitis is entertained. Alternatively, R/V and irritability in an infant may represent a functional problem such as colic. We reviewed the medical history, endoscopic and pathologic findings in patients < 12 months of age who underwent esophagogastroduodenoscopy (EGD) from 1990-1994 for symptoms of reflux esophagitis. Indications for EGD were R/V _+_irritability, FTT, hematemesis, bronchospasm, pneumonia or anemia. Those infants with caustic ingestion, esophageal varices, or tracheoesophageal fistula were excluded. A total of 93 patients met the criteria. 50.5% (47/93) had histologic markers for esophagitis defined as intraepithelial eosinophilia, intraepithelial lymphocytes, and/or elongation of the papillae. 10/93 infants presented with R/V alone and 50.0% (5/10) had esophagitis. 17/93 presented with R/V and irritability and 29.4% (5/17) had esophagitis. 22/93 presented with R/V, irritability, and another indication for EGD and 54.5% (12/22) had esophagitis. 44/93 presented with R/V without irritability but with another indication for EGD and 56.8% (25/44) had esophagitis. Conclusion: Infants with the combination of R/V and irritability as presenting signs of GER had a lower yield on EGD for esophagitis than infants with any other indication for EGD including R/V alone. R/V in combination with irritability alone is a poor predictor of esophagitis. Isolated irritability in infants with R/V should not be used as an indicator to perform EGD for esophagitis.
194
t196
COLONIC MALAKOPLAKIA, A PEDIATRIC CASE REPORT. Vargas JH., Bahar R., I_~win K.,Martin M & Ament MI~'."Dept. of Pediatrics. UCLA School of Med. Los Angeles CA. A 12 yo male guatemalan who migrated 4 years before presented with a history of bloody diarrhea and tenemus. Past medical history was remarkable for iron defficiency anemia and swelling of a knee. Review of systems revealed I~rharps some photophobia. Initial colonoscopy described erosions and superficial ulcerations but biopsies were nonspecific.With a diagnosis of Ulcerative Colitis treatment with prednisone and azulfadine is started at adequate doses but no improvement is observed and the patient looses 20-30 lbs. Endoscopic reevaluation in Our center reveals "cobblestoning", pseudopolyps, erosions and superficial ulcerations throughout the colon with normal ileum. Biopsies show raised appearence of mucosa due to infiltrate with histiocytes which have eosinophilic granular cytoplasm and small round basophilic PAS/ GMST negative inclusions. EM reveals inclusions to be bacterial debris. Diagnosis established and treatment with antibiotics initially IV, subsequently oral, improves nutritional status and diarrhea. Malakoplakia is a rare cause of colitis in children but described primarily in this group when not associated with malignancy or para-neoplastic syndrome. Characteristic endoscopic and histologic features should evoke the diagnosis but electron microscopy establishes nature of inclusions. Pathophysiology and causes remain obscure.
HISTOLOGIC FINDINGS IN CHILDREN UNDERGOING UPPER ENDOSCOPY FOR EVALUATION OF ABDOMINAL PAIN. B,Weissell3erg, H. Shashidhar, J.A.Morelli, K.A. Caleoda. Div of Pediatric Gastroenterology and Nutrition, Floating Hospital for Children, New England Med Ctr, Tufts Univ School of Medicine, Boston, MA. The prevalence of chronic abdominal pain among school age children peaks around ages 10-12 yrs. Prior studies suggested that the majority of pts with this complaint lacked objective evidence of organic etiology for the pain. However, recent studies (JPGN 1993;16:273, Seand J Gastroenterol 1991;26:95) indicated a higher prevalence of organic disorders than previously recognized, with gastritis in 60% and H. pylori disease in up to 58% of affected children. Aim: The aim of the present study was to investigate current experience in a large New England referral population, and to characterize the pathological features accompanying abdominal pain in pediatric pts. Patients: The histological appearance of biopsies obtained during upper gastrointestinal endoscopy were retrospectively reviewed in 82 consecutive children (62% F, ages 2-18y, mean 1ly) with abdominal pain (with/withoutnausea or vomiting) who otherwise had normal physical examination, growth and laboratory studies. Additional clinical findings included constipation in 12 pts, hiatal hernia in 3, and lactose intolerance in 7. Multiple biopsies were taken from the duodenum, antrum and esophagus and reviewed by one pathologist. Results: Histological changes were found in 24 (29.2 %) pts: 8 (9.7%) had chronic duodenitis (one of them with Giardia), 7 (8.5%) had esophagitis, 5 (6%) had H. pylori infection, 3 (3.6%) had gastritis with no evidence of H. pylori, and 1 0.2%) had eosinophilic gastroenteritis. One pt with duodenitis underwent a colonoscopy that revealed Crohn's disease. Histological findings were not dependent upon the age of the pts. Males had a significantly higher prevalence of abnormal histological features than females (45% vs 19.6% respectively, p < 0.05). Conclusions: 1) 29% of pts with abdominal pain had histological abnormalities found during upper endoscopy; 2) Most common were duodenitis, esophagitis and H. pylori; 3) The prevalence ofH. pylori was markedly lower than previously reported in conjunction with abdominal pain; 4) In general, abnormal histological findings were less prevalent than those reported in other studies.
344
GASTROINTESTINAL
ENDOSCOPY
V O L U M E 41, NO. 4, 1995