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Evaluation of a new rapid urease test for Helicobacter pylori in gastric biopsy specimens in pediatric patients
PEDIATRIC ENDOSCOPY ~161
}'163
ENDOSCOPY IN CHILDREN- IS E~IOPSYA MUST? Y. Elitsur and CU. Lehmann, Department of Pediatrics, Div. of Pediatric GL Marshall University Huntington, WV. Endoscopy became the prime diagnostic tool in pediatric gastrointestinal disorders, A d v a n c e d endoscopes and improved physician technical skill increased the usage of endoscopies in pediatric patients. Adult gastroegterologists rely on v i s u a l assessment before mucosal biopsy is performed. There are insufficient guidelines for pediatric endoscopies as to when mucosal biopsies are needed.
THE HISTOLOGIC FEATURES OF SELF-LIMITED COLITIS AND INFLAMMATORY BOWEL DISEASE IN CHILDREN J~L.~ishbein, S. Hammond, L. Heitlinger, B Li, R. Murray, H.J. McClung, R.C. Dumont, C.J. Potter, S. Qualman, Depts of Peds and Pathology. Children's Hospital and Ottio State University, Columbus, OH Differentiating self-limited colitis (SLC) from inflammatory bowel disease (IBD) in children is often problematic. Both these entities may present with bloody diarrhea; and since specific disease markers are lacking, a rectal/colonic biopsy is often performed to make a diagnosis. Distinguishing histologic features for self limited colitis and inflammatory bowel disease have been established in previous studies on an adult population for this purpose. This study reviews the utility of these criteria in children. Methods: Fifty-nine subjects, ages 2-27 yr, presenting with bloody diarrhea from 1973-91 were enrolled. Subjects were considered clinically to have SLC (n=28) with a symptom free interval of at least three years following presentation while off therapeutic agents, and verified via phone contact or recent office visit. Subjects with IBD (Crobn's colitis or ulcerative colitis) whose initial biopsies lacked "pathognomonic" granulomata or giant cells were used as a control group [n=31). Their diagnoses were established by disease chronicity and subsequent diagnostic evaluations. Rectal and colonic biopsies were graded (0,normal to IV, severe) by two experienced pediatric pathologists as unknowns, according to established histologic features used to characterize colitis. Statistical analyses included chi-square analysis. Results: ~ 1BD Duration (wk) 2 8 (0.15-60) (0.5-312)
.A.j m : To compare visual assessment during endoscopical procedures with histological results and to establish the need for mucosal biopsies. 342 pediatric endoscopical procedures (between 1990-1994) were retrospectively reviewed for discrepancies between visual assessment and histological findings. Results are shown in Table. The annual rate of discrepancy cases remained stable during the four years. no. Age(mean) Discrepancy Esophagus Stomach Duodenum
'0pper endoscooy 229 9.8 years 137 (60%) 85 (37%) 64 (28%) 32 (14%)
Lower endoscooy 113 8.3 years 24 (21%) Colon 17(15%) Rectum 07 (06%)
Conclusions: Visual assessment as a sole diagnostic modality in upper endoscopies in children, particularly in the esophagus and stomach, is inadequate. We recommend that biopsy should be performed routinely from all sites irrespective of mucosal appearance.
162
164
ENDOSCOPIC
RETROGRADE
CHOLANGIOPANCREATOGRAPHY
(ERCP) IN CHILDREN AND ADOLESCENTS
A.Farca. O. Alarcrn, (3. Rodrfguez. Endoscopic Hospital General Dr Manuel Gea Gonz',ilez. M~xico ERCP is a technique widely utilized in the population. However, it,s use in children has
Unit City adult been
limited, due to both the low incidence of biliarypancreatic diseases among these patients and t h e limited availability of experienced personnel. We performed ERCP on 25 children and adolescents, ages 3 to 18 years, average 14.3 years, over a period of 57 months. The most frecuent diagnosis on admission
was
acute
or
relapsing
paacreatitis o f
unknown origin, in eig~h patients. The 25 ERCP's Were done with standard e q u i p m e , t and aceesories. ERCP was successful in 24 of the 25 patients (96%). Among other diagnosis we found choledochal cysts in seven patients and biliary or pancreatic duct stenosis in three. We also found choledocholitiasis in six children, successfully performing endoscopic sphincterotomy with complete stone extraction in all of them. Therapy also included endoscopic sphincterotomy in another three patierits ~ and placement of four biliary duct endoprostheses, without major complications. We conclude that ERCP is a safe diagnostic and children and" adolescents endoscopists
336
Stool Cx+ 5/20 0/15 C.rii;eria Chi-squ~__~ Cryptitis/abscess SLC
EVALUATION OF A NEW RAPID UREASE TEST FOR HELICOBACTER PYLORI IN GASTRIC BIOPSY SPECIMENS IN pEDIATRIC PATIENTS. JF u SKF Chong, JM Croffie, JD Rogge, DR Wagner and EA Glowinski. Division of Gastroenterology, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis; Indlanapoli8 Gastroenterology Research Foundation, Beech Grove, IN~ In an ongoing study of the clinical significance of gastric H.pylori infection in children, patients undergoing upper gastrointestinal endoscopy were evaluated with a urease sensitive test strip (PyloriTek TM, Scrim Research} and histology. Paired biopsy specimens were taken from two different sites: the distal antrum (site I), and either the antral lesser curvature near the incisura (site 2}, or the corpus along the greater curvature (site 3). One specimen from each pair was examined by PyloriTek strips while the other was evaluated with histology, unless the patient had a prior history of H.pylori infection and positive serology. Thirty-five patients (17 male, 18 female; mean age I1.~3 years} were examined. Seven (5 male, 2 female) were positive for H.pylori bY histolegy. Six patients were positive for PyloriTek strips for at least one biopsy site. There were no false positives but one false negative with PyloriTek strips. Comparison values of PyioriTek strips to histology are: Sensitivity = 0.86; Specificity = 1.0; Positive Predictive Value = 1.0; Negative Predictive Value = 0.96; Kappa = 0.90. A total of 44 individual sites had both histology and PyloriTek results available. Of these 44 sites, 8 were positive for H.pylori. PyloriTek strips correctly identified 7, with one false negative. There were no false positives. Comparison values of PyloriTek strips to histology for these sites are: Sensitivity = 0.88; Specificity = 1.0; Positive Predictive Value = 1.0; Negative Predictive valu~ ~ 0.97; Kappa = 0.86. The average time to positive for the PyloriTek strip was 15 minutes. These results suggest PyloriTek strips can rapidly and accurately diagnose H.pylori infection in ~ediatric patients. Additionally, multiple individual biopsies can be tested at room temperature on a single PyloriTek strip. This investigation was supported in part by a grant from Scrim Research.
therapeutic technique in when applied by expert
GASTROINTESTINAL ENDOSCOPY
VOLUME 41, NO. 4, 1995
}'163
ENDOSCOPY IN CHILDREN- IS E~IOPSYA MUST? Y. Elitsur and CU. Lehmann, Department of Pediatrics, Div. of Pediatric GL Marshall University Huntington, WV. Endoscopy became the prime diagnostic tool in pediatric gastrointestinal disorders, A d v a n c e d endoscopes and improved physician technical skill increased the usage of endoscopies in pediatric patients. Adult gastroegterologists rely on v i s u a l assessment before mucosal biopsy is performed. There are insufficient guidelines for pediatric endoscopies as to when mucosal biopsies are needed.
THE HISTOLOGIC FEATURES OF SELF-LIMITED COLITIS AND INFLAMMATORY BOWEL DISEASE IN CHILDREN J~L.~ishbein, S. Hammond, L. Heitlinger, B Li, R. Murray, H.J. McClung, R.C. Dumont, C.J. Potter, S. Qualman, Depts of Peds and Pathology. Children's Hospital and Ottio State University, Columbus, OH Differentiating self-limited colitis (SLC) from inflammatory bowel disease (IBD) in children is often problematic. Both these entities may present with bloody diarrhea; and since specific disease markers are lacking, a rectal/colonic biopsy is often performed to make a diagnosis. Distinguishing histologic features for self limited colitis and inflammatory bowel disease have been established in previous studies on an adult population for this purpose. This study reviews the utility of these criteria in children. Methods: Fifty-nine subjects, ages 2-27 yr, presenting with bloody diarrhea from 1973-91 were enrolled. Subjects were considered clinically to have SLC (n=28) with a symptom free interval of at least three years following presentation while off therapeutic agents, and verified via phone contact or recent office visit. Subjects with IBD (Crobn's colitis or ulcerative colitis) whose initial biopsies lacked "pathognomonic" granulomata or giant cells were used as a control group [n=31). Their diagnoses were established by disease chronicity and subsequent diagnostic evaluations. Rectal and colonic biopsies were graded (0,normal to IV, severe) by two experienced pediatric pathologists as unknowns, according to established histologic features used to characterize colitis. Statistical analyses included chi-square analysis. Results: ~ 1BD Duration (wk) 2 8 (0.15-60) (0.5-312)
.A.j m : To compare visual assessment during endoscopical procedures with histological results and to establish the need for mucosal biopsies. 342 pediatric endoscopical procedures (between 1990-1994) were retrospectively reviewed for discrepancies between visual assessment and histological findings. Results are shown in Table. The annual rate of discrepancy cases remained stable during the four years. no. Age(mean) Discrepancy Esophagus Stomach Duodenum
'0pper endoscooy 229 9.8 years 137 (60%) 85 (37%) 64 (28%) 32 (14%)
Lower endoscooy 113 8.3 years 24 (21%) Colon 17(15%) Rectum 07 (06%)
Conclusions: Visual assessment as a sole diagnostic modality in upper endoscopies in children, particularly in the esophagus and stomach, is inadequate. We recommend that biopsy should be performed routinely from all sites irrespective of mucosal appearance.
162
164
ENDOSCOPIC
RETROGRADE
CHOLANGIOPANCREATOGRAPHY
(ERCP) IN CHILDREN AND ADOLESCENTS
A.Farca. O. Alarcrn, (3. Rodrfguez. Endoscopic Hospital General Dr Manuel Gea Gonz',ilez. M~xico ERCP is a technique widely utilized in the population. However, it,s use in children has
Unit City adult been
limited, due to both the low incidence of biliarypancreatic diseases among these patients and t h e limited availability of experienced personnel. We performed ERCP on 25 children and adolescents, ages 3 to 18 years, average 14.3 years, over a period of 57 months. The most frecuent diagnosis on admission
was
acute
or
relapsing
paacreatitis o f
unknown origin, in eig~h patients. The 25 ERCP's Were done with standard e q u i p m e , t and aceesories. ERCP was successful in 24 of the 25 patients (96%). Among other diagnosis we found choledochal cysts in seven patients and biliary or pancreatic duct stenosis in three. We also found choledocholitiasis in six children, successfully performing endoscopic sphincterotomy with complete stone extraction in all of them. Therapy also included endoscopic sphincterotomy in another three patierits ~ and placement of four biliary duct endoprostheses, without major complications. We conclude that ERCP is a safe diagnostic and children and" adolescents endoscopists
336
Stool Cx+ 5/20 0/15 C.rii;eria Chi-squ~__~ Cryptitis/abscess SLC
EVALUATION OF A NEW RAPID UREASE TEST FOR HELICOBACTER PYLORI IN GASTRIC BIOPSY SPECIMENS IN pEDIATRIC PATIENTS. JF u SKF Chong, JM Croffie, JD Rogge, DR Wagner and EA Glowinski. Division of Gastroenterology, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis; Indlanapoli8 Gastroenterology Research Foundation, Beech Grove, IN~ In an ongoing study of the clinical significance of gastric H.pylori infection in children, patients undergoing upper gastrointestinal endoscopy were evaluated with a urease sensitive test strip (PyloriTek TM, Scrim Research} and histology. Paired biopsy specimens were taken from two different sites: the distal antrum (site I), and either the antral lesser curvature near the incisura (site 2}, or the corpus along the greater curvature (site 3). One specimen from each pair was examined by PyloriTek strips while the other was evaluated with histology, unless the patient had a prior history of H.pylori infection and positive serology. Thirty-five patients (17 male, 18 female; mean age I1.~3 years} were examined. Seven (5 male, 2 female) were positive for H.pylori bY histolegy. Six patients were positive for PyloriTek strips for at least one biopsy site. There were no false positives but one false negative with PyloriTek strips. Comparison values of PyioriTek strips to histology are: Sensitivity = 0.86; Specificity = 1.0; Positive Predictive Value = 1.0; Negative Predictive Value = 0.96; Kappa = 0.90. A total of 44 individual sites had both histology and PyloriTek results available. Of these 44 sites, 8 were positive for H.pylori. PyloriTek strips correctly identified 7, with one false negative. There were no false positives. Comparison values of PyloriTek strips to histology for these sites are: Sensitivity = 0.88; Specificity = 1.0; Positive Predictive Value = 1.0; Negative Predictive valu~ ~ 0.97; Kappa = 0.86. The average time to positive for the PyloriTek strip was 15 minutes. These results suggest PyloriTek strips can rapidly and accurately diagnose H.pylori infection in ~ediatric patients. Additionally, multiple individual biopsies can be tested at room temperature on a single PyloriTek strip. This investigation was supported in part by a grant from Scrim Research.
therapeutic technique in when applied by expert
GASTROINTESTINAL ENDOSCOPY
VOLUME 41, NO. 4, 1995