Pandisaccharidase deficiencies in chronic abdominal pain

patients (1 was post-colectomy), 3 of whom had active fistulae. The other 7 had ileocecal (IC)/gastroduodenal (GD) involvement with concurrent active fistulae in 2. There were 10 responders (67%), including five with fistulae, and 1 partial responder with a median followup of 6 rag. All 4 non-responders had refractory CD, and relapsed in <3 mo from the last intUximabinfusion. Elevenwere receivingprednisone1-2 mo/kg at the time infliximab therapy was started. Five (45%) were weaned off while 1 had a 50% reduction in prednisone dose. The meandifference in PCDAIscores pre (26) and post (13.8) treatment was 12.3 [p<0.022]; and the mean change in PCDAi scores for responders (16.3) vs non-responders (2.5) was 15.3 (p = 0.05). Those with IC/GD localization had significantly improved responsecompared to those with colitis (p=O.04). There was no significant difference in response based on duration of disease >2 y (n =7) or <- 2 y (n =8). Conclusions: Children with fistulizing CD and itiseass localized to IC/GD respond significantly heifer to treatment with infiiximah. We confirm that infiiximab is an effective steroid sparing therapy in cases of refractory and fistulizthg pediatric Crohn s disease.

1102 Effect Of Prenatal GlncocodicoidsAnd Postnatal Nitric Oxide Inhalation On Survival Of Newborn Rats With Nitrntun-lnduced Congenital Diaphragmatic Hernia Oliver Mann, Christina Huppertz, Christian Bloechle,Jakob R. Izbicki, Wolfgang Lamhrecht, Dietrich Kluth, Univ Hosp Eppendorf, Hamburg Germany Background: Psthogenesisof congenital diaphragmatichernia (CDH) associatedwith pulmonary hypoplasiais still poorly understood. Pulmonaryhypertensionand pulmonary hypoplesia account for the high mortality associatedwith CDH. In previous studies a significant improvement of survival was demonstratedin animals receivingpostnatal nitric oxide (NO)-inhalatioo. Antenatal glucocorficoids resulted in a batter lung compliance. The objective of this study was to evaluatethe potentialsynergism of prenatalglucocorticoid administrationand postnatal NO-inhalation on survival of newhom rats with nitrofen-induced CDH. Mefheds:CDH was induced in fetal rats by maternal application of a single oral dose (lOOmg) of nthofen on day 11,5 of pregnancy.After spontaneousdelivery animals were exposedto either NO (80 ppm) (groups II + IV) or room air (groups I+ ifi) according to protocol. D e x a m ~ n a (DE)(: O,25mg/kg) was given in group III and IV by intraparitoneal injection on day 18,5 and 19,5 before delivery. Control animals received vehicle alone. Vitality (Rat-Score), sO2and survival were monitored continuously until animals were sacrificed at 12 h of age. Extend of the herniation and histologic damage of the lungs were assessed. Results: In 365 out of 449 (81%) newborn rats CDH were depicted. Animals with bamla sizes > 50% of the thoracic cavity died within 4 h after birth, irrespective of treatment. As clinically relevant bamia size is considereda defect < 50%. In this category, i.e. herniadegree HI, 2 of 16 (12.5%) animals of the control group (group I) survived compared to 7 of 11 (63,6%) animals of the NO treatment group (group I1: p
1115 l " k R e d ~ m l M Imlin-Like Growlb Facter-1 and Linear Growth in a Rat Model of Colitis is ildiMed by the Combined Inhibitory Effects of Interleukin-6 and U n ~ Anne B. Ballinoer, Omiea G. Azooz, Mona Bajaj-EIliott, Michael Farthing, St Barf's and Royal London Sch of Medicine and Dentistry, London United Kingdom Background:Impaired linear growth is a major complication of paediatricIBD. Both undernutrilion and the inflammatory process par se inhibit hepatic production of insulin-like growth factor-1 (IGF-1). Candidate cytokines for suppression of IGF-1 include interieukin-6 (IL-6) and tumour necrosis tactor-~. The aim of this study was to determine the role of these cytoldnas in suppression of IGF-1 in a model of colitis, and to determine their interaction with undemutfition. Methods: 4 groups of prepubartai Wistar rats: healthy controls (n = 14), colrds treated with anti-lL-6 antibodies (IL-6ab, 12), colitis treated with TNFab(8) and colitis treated with non-specific IgG (20). Colitis was induced by intrarectal administration of trinitrobanzenesulphooic acid in ethanol. Food intake and body weight were measured daily and ani,'nalssacrificed on day 5. PlasmaIGF-1 was measuredby RIA and hepatic IGF-1 mRNA by RT-PCR rmrmalissd for p-actin. Linear growth was measured by the change in nose-tail baselength at days 0 and 5. Intestinalinflammation was assessedby measurementof intestinal myeioporoxidaseconcentrations. In subsequent experiments we assessed the effects of ILBab in combination with nutritional supplements (to restore calorie intake to control values) on IGF-1 and linear growth. Results: IL-Bab restored hepatic IGF-1 mRNA to control values and significantly increased plasma IGF-1 and linear growth (Table).lL-6ab had no effect on severity of intestinal inflammation or anorexia. The combination of IL-6ab and nutritional supplements norrnaiissd plasma IGF-1 and linear growth in colitic rats; values were similar to those of healthycontrols. TNFabbad no effect on IGF-1 mRNA or plasma IGF-I. Conclusion: IL-6ai0 and nutritional supplements reverse IGF-1 and growth deficit in experimental colitis.

1103 Loss of PTEN and hMSH3 Protein Expression h'om Familial JuseMle Polyp Epithelium Sherry C. Huang, E Julieta Smith, Antonio Fiorino, Univ of CA, San Diego, CA; Robert O. Newbury, Children's Hosp, San Diego, CA; John M. Carethers, Univ of CA San Diego and San Diego VAMC, San Diego, CA Background&Aims: Patientswith familial juvenile polyposis syndrome (JPS) develop multiple hamartomatous polyps in their intestinal tract, and may have germline mutations in the transforming growth factor/~ signaling protein SMAD4 or the dual function phosphatase PTEN. Patients with JPS have a 12-fold increase risk of coiorectai cancer over the general population, but the mechanism for this is unexplained.We examined histological domains from a familial juvenile polyp to assess for evidence of a second, somatic hit of a mutated germline protein from within the polyp, and tO demonstratea mechanism of potential tumor formation. Methods: We extracted DNA by microdissection from the formalin-fixed, paraffinembeddedjuvenile polyp from a patient that we have previously cbaractanzedwith a oermline PTEN mutation, and amplified the following DNA mono- and dinuclantide microsateilitas: BAT25, BAT26, O2S123, O5S346, D17S250, and D10S1765. We performed immunohlstochemistry on the polyp using antibodiesto PTENand four of the DNAmismatch repair proteins (hMLH1, hMSH2,hMSH6,and hMSH3). Results: In this patientwith a germline PTENmutation, cystic epithelium microdissectedfrom the polyp demonstrated high-freguency microsetellite instability (more than 2 markers with novel alleles) at dinucleotide, but not rnononucleotide repeat markers. Immunohistochemistry of the polyp demonstratedloss of PTENand hMSH3 expression from the cystic epithelium while the lamina proprle expressed both proteins. Expression of hMLH1, hMSH2, and hMSH6 were present in both the cyst epithelium and lamina propria. Conclusions: Somatic inactivation of PTENin a patient with a germline PTEN mutation occurs in the cystic epithelium of the juvenile polyp. Inactivation of the DNA MMR gene hMSH3, which repairs insertion-deletionloops larger than I nucleo~e, is not expressed in the cyst epithelium, the site of dinucleotide hut not mononucleotidemicrosuteilite instability. Our results suggest a mechanism for potential carcinogenesisin the epithelium of familial juvenile polyps, although any interaction of PTEN and the DNA MMR system has not yet been established.

I.~g~ IGFi mRNA IGF.t (ng/ml)

Coetroi

igG-co~s

IL-6ablcoiitis

18~3.7 rnm/5days 7,.~2500 795~152

5.2±2.1, 3 ~ _ 1900, 514±141.1

8.6±3.4* 64~_2300 662±134t

*P--O.O01vs healthyconf~s; "i'P= 0.02vs IL-6ab/colitJs;~LP= 0.04 vs healthycontrol

11N PoedisenaAbddnae Deficiencies In Chronic Abdominal Pain. Wikrom Kamsekul, Carlos Lifschltz, Seiji Kltagawa,Anthony Olive, Xavier Villa, Stephen Avery, Bayior Coil of Medicine, Houston, TX; Erwin E. Sterchi, Degmar Hahn, Ursi Lugenbuehl, Univ of Berne, Berne Switzerland; Dallas M. Swallow, Univ Coil London, London United Kingdom; Buford L. Nichols, 8aylor Coil of Medicine, Houston, TX Background:Congenitallectasedeficiency(CLD) and congenitalsucrase-isomaitasedeficiency (CSID) are well described. Double disaccharidase deficiencies were previously reported in some patients with CLO and CSID. We reported a case of congenital pandisaccharidase deficiency at the World Congressof Pediatric Gastroenterology2000 (first patient, see table). Jejunal biopsiesdemonstratedlow enzymeactivities with normal intestinal histology. Sequencing of maitaseglucoamylase(MGA) cDNArevealedhomozygousmutation of C1673T.However, when expressed in COS 1 cells there was no loss of enzyme activities. No mutation was found in the MGA promoter region. Posttranslatinnalprocessing of all diseccharJdaseswas normal on intestinal organ culture. Cis-regulatory pandisaccharidase deficiencies were deduced. Objective:To determinethe frequency o1 pandisaccharidaeedeficiencies in children with chronic abdominal pain (CCAP). Methods/Results: Forty-one children, (age: 11_+5 yrs), endoscoped for CCAP, were studied. Six had pandisaccbaridaeedeficiencies at a frequency of 14%. All had normal villi and villus-crypt ratio with no increase of epithelial lymphocytes. Conclusion: Sharedcis-dysragulstion of all three disecchandasegenes may play a role in the dietary based symptoms of some patients with CCAP.

1104 The Use of Infliximah in Pediatric Crohn's Disease Seema Khan, Wendy A. Henderson,Children's Hosp of Pittsburgh, Pittsburgh, PA; Samuel A. Kocoshis, Children's Hosp Medical Ctr, Cincinnati, OH; Alka Goyai, Carlo Oi Lorenzo, Children's Hosp of Pittsburgh, Pittsburgh, PA Background: Between30 to 50 % of children with Cmhn s Disease(CD) are either refractory to treatment or steroid dependent. Fistulae develop in 25 to 30 % of cases. As the chronic use of steroids is undesirable in prepubescentpatients, it has become important to assess the efficacy of new steroid sparing therapies. There are limited data regarding infliximab treatment protocols and long term follow-up in children with CD. We report our experience with the use of infliximab in children with refractory and fistulizing CD. Methods: We review our data pertaining to all children, who received infiiximab for the treatment of CD (n=15). We used Pediatric Crohn s DiseaseActivity Index (PCDAI) (n=14), global physician assessment and healing of fistulae as outcome measures. Raspondersare defined as those with healing of fistulae, reduction of ->50% steroid use and/or decreasein PCDAI. Results: Fdtean patients (9 male, median age = 15 y, range = 8.9-20.5) received infliximab infusions. The indications for its use were refractory CD in 7 (47%), fistulizing CD in 3 (20%) and refractory CD with fistulae in 5 (33%). Median duration of diseaseprior to first infusion was 2 y (range = 0.5-10.5). Eleven(73%) had <-3 infusions and the remaining4 (27%) bad >3, with variable intervals in between infusions. Infliximab was indicatedfor moderateto severecolitis in eight

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a pilot survey, families of children and young adults with IBD from three centers of pediatric gastroenterology (Boston, Detroit and London, UK) were enrolled to complete the questionnaire. Results. 206 questionnaires were completed in total (Boston 108, Detroit 37, and London 51). 34% had UC, 57% had Crohn's disease, age range 3.8-23.0 years. London patients reported the highest number of sickness days in the last two weeks (30% had 14/ 14 days of sickness, 12 & 15% in Boston and Detroit respectively). Patients in London had more hospitaladmissionsand days off school. Of the total, 41% usedcomplementarytherapies in addition to conventionaltreatments. Of those using CM, 35% modified their diet, 19% used megavitamintherapy, 17% food supplements,14% herbalmedicine,10% madeenvironmental changes, 6% used acupuncture, homeopathyand probiotics, and 5 % used hypnosis. 49% of patients in Detroit used CM, compared to 41% in London and 38% in Boston. Only 29% of these families consulted a CM practitioner. The most important reasons given for using a CM were; side-effects of prescribed medicines, prescription medicines not working as well as they had hoped,and hoping for a cure. The least important reasonsfor making this choice were; reading about CMs on the Internet, advicefrom friends and family and that CM therapy made more sense. 59% of respondents not taking CM therapy were interested in learning more about them. Only 8% of doctors, hut 24% of patients had initiated a discussion about CM therapies during a previous consultation. Conclusions. Over 40% of children with chronic IBD use complementary medicine. Initial analysis suggests that disease severity may be the most important predictor of CM use. Few physicians are aware of their use by patients. With the rise in interest in these therapies, physicians must seek to identify patients them, as this suggests ongoing dissatisfaction with conventional therapy.

Sevenpatientswith pandisaccharidasedeficiency. Age (years) 0.3 11 8 7 11 0.5 15

Glucoamylas e 46±13" 15 17 22 23 15 28 29

Sucrase

Lactase

Maltase

36±11" 9 14 16 14 13 10 18

14±3" 3 2 3 3 3 5 5

176±90" 38 65 -57 76

* Rangeof normalvalues, IU/gprotein. 1107 Management of Esophageal Strictures in Children with Recessive Dystrophic Epidermolysis Bullosa. Ricardo O. Castillo, Yinka K. Davies, Yuan-Chi Lin, Manuel Garcia, Stanford Univ Medical Ctr, Pain Alto, CA Esophagealstdctures(ES)are knownto occur commonly in children with recessivedystrophic epidermolysis hullosa(RDEB), resulting in dysphagia, limited dietary intake and inability to handle oral secretions.The managementof ES in this clinical setting continuesto be controversial as conventional methods of dilatation (bougienage,endoscopic dilatation, endotracheal intubation) are contraindicated due to excessiveesophagealtrauma, leaving few therapeutic alternatives. We report our current experience with our f[ouroscopically-assisted balloon dilatation technique for ES in children with RDEB that we have been performing for 8 yrs. Stanford Medical Center/PackardChildren's Hospital is the location of the Western Clinical Site of the National EB Registry. 644 patients with EB are followed here, 129 of whom have RDEB. 75 (57%) of these are children (<21 yrs). Procedure: o Endotrachealintubation with uncuffed tube. o Use of small caliber endoscope for stricture localization and guide wire placement,o Use of OTW balloon dilators positionedflouroscopically, o Outpatientprocedure. o Early introduction of feeds. Results: o No. of children undergoing dilatation: 22 o Total number of dilatation's: 105 o Age onset of dysphagia: 48 _+ 35 mos o Interval between dilatation's: 19_+25mos o Complications:1 esophagealintramural tear 1 aspiration of contrast No complications for the past 6 yrs No complications of intubation Conclusion: Flouroscopically-assisted balloon dilatation of RDEB-associatedES appears to be safe and effective in this high-risk population of children. Balloon dilatation should be considered the initial managementtechnique of choice in RDEB children with ES.

1111 Evaluation of the Effect of a Soluble Fiber (Beneliber) Supplemented Comminuted Chicken Based Diet in the Treatment of Persistent Diarrhea in Children Nur Haque Alam, ICDDR, 8:Centre for Health and Population Research, Dhaka Bangladesh; Remy F. Meier, GI-Unit, Lieetat Switzerland; Shafiqul A. Sarker, Pradip K. Bardhan, Georg J. Fuchs, ICDDR, B:Centrefor Health and Population Research,Dhaka Bangladesh; Heinz Schneider, Health Ecom, Basel Switzerland; Klaus K. Gyr, Univ Hosp, Basel Switzerland Background: Partially hydrolyzedguar gum (Benefiber~) when addedto comminuted chicken based diet (children's diet for persistent diarrhoea) is fermented to produce short chain fatty acids (SCFAs), which improve intestinal function including colonic absorption of salt and water. The aim of this study was to evaluatethe effect of Benefiberaddedcomminuted chicken based diet in the treatment of children with persistent diarrhea. Method: A double-blind randomized controlled clinical trial was carried out at ICDDR, B in 116 male children aged 5 to 24 months with a history of watery diarrhea continued for 14 days (persistent diarrhea). After admissionthe children were randomizedto receiveeither: (a) comminuted chicken based diet supplementedwith Benefiber(study diet) or (b) comminuted chicken based diet without Benefiber (control diet). The study period was 7 days. Major outcome variableswere duration of diarrhea after randomization, stoppage of diarrhea within 7 days, stool output daily after randomization. Results: Of 116 children, 57 receivedcomminuted chicken based diet supplemented with Benefiberand 59 receivedchicken baseddiet without Benefiber.Greaternumber of children stopped diarrheawithin 7 days with study diet than with the control diet (Benefiber vs. control, 46 vs. 36, p=O.O09), the difference being statistically significant. The duration of diarrhea (in hours) was also significantly reduced in children who received study diet (mean-+SD, 60_+39 vs. 81 _+48, p = 0.03). The survival analysis for the duration of diarrhea also showed a similar trend toward reduced duration of diarrhea (p=O.02, log rank test). There was also a trend in stool output reduction in children receiving study diet, however the differences were statistically significant from day 4 to day 7 (p=0.041; 0.045; 0.014; 0.022 respectively). Conclusion: The present study demonstratesthat Benefiber, if added to comminuted chicken based diet, enhances recovery of children suffering from persistent diarrhea indicating its therapeutic potential in persistent diarrhea.

1109 Autosomal Oominaut Infant GERD: Exclusion of a 13q14 Locus in 6 WellCharacterized Families Suggests Genetic Heterogeneity. Susan R. Orenstein, Theresa M. Shalaby, Roland H. Pfuetzer, M Michael Barmada, Robert Finch, Suzanne Kosmack, Lara J. Chensny, David C. Whitcomb, Univ of Pittsburgh & Children's Hosp of Pittsburgh, Pittsburgh, PA Background: Gastroesophagealreflux disease (GERD) affects approximately7% of all infants during the first year of life by various incidenceestimates,and causes considerablemorbidity and even mortality. Family clustering and segregationanalysis suggest autosomal dominant inheritance of a predisposing gene in some kindreds. Although agene locus for severe pediatric GERD has been proposed at 13q14 (Hu et al., JAMA 2000, 284(3):325-34), the phenotypic criteria have been questioned, and this locus has not yet been confirmed in independent kindreds. AIM: To test for disease gene linkage in 6 well-characterizedand phenotypedkindreds with infant GERDat 13q14. Methods:After informed consent, an adaptation of the validated Infant GERD Questionnaire(Orenstein, Clin Pediatr 35:607, 1996) was utilized to phenotypicallycharacterize individuals in 6 kindreds with an autosomal dominant pattern of GERD inheritance. Blood was obtained from informative family members for DNA extraction. Polymorphic markers previously reported to define the disease gone locus (D13S218, D13S1288, D13S1253 and D13S263) were analyzedand genetic linkage analysis performed using the VITESSEprogram (0 Connell and Weeks, Nat. Genet. 11:402-8, 1995). Results: Linkageto the defined region of chromosome 13q14 was excludedfor the 6 families combined by 2-point (maximum LOD= -0.821115 at D13S218) and multipoint (maximum LOD between D13S218 and D13S203= -3.48158) linkage analysis using the genetic model used by Hu et al. (autosomal dominant, 70% penetrance).No individual family demonstrated even suggestive positive linkage. Conclusions: Infant GERD is not linked to chromosome 13q14 in any of our 6 well-characterizedand phenotypedfamilies. Thesedata suggest genetic heterogeneity in autosomal dominant forms of GERD.

1112 Jejunoileitis in Crohn's Disease: A Pediatric Cohort Analysis Thomas M. Attard, Kelly Devito, Mark I. Attard, Lisette Stamato, Carmen Cuftari, The Johns Hopkins Children's Ctr. Baltimore, MD Background: Jejunal and proximal ileal Crohn's Diseaseis more common in Pediatrics (15 20%) than in adults (3-7%)(GastroenterologyInternational 1997;10:89-98). The importance of jejunoiteatinvolvement in Crohn's Disease(JICD) is the associatedmorbidity and its effect on patient growth and development. Herein, we have provided a hospital-basedanalysis of the demographic, clinical and nutritional outcomes of children with JICD. METHODS: We performed a 17-year(1983-2000)retrospectivechart and databaseanalysisof patientsfollowed at the John's HopkinsChildren's Center.A total of 135 of 229 patientswithin the IBD Database had CD (59%) and of these, 22(16%), (mean age _+SEM)11.2_+l.1yrs had JICD based on either a smartbowel series, abdominalCT or gadolinium-enhancedMRI. A group of 37 patients (mean age _+SEM)12.2_+0.9yrs who were JICD negativewere randomly selectedas controls for compadson(CT).The demographic, clinical, and biochemical parameterswere compared by blinded investigators.RESULTS:Therewere no significant differences in eitherthe biochemical(serum albumin, total protein, transaminases) or hematological parameters(white blood cell count, hemoglobin, MCV, RDW) betweenthe two groups. Patients with JICD showed an increased use ol corticosteroid therapy as welt as a reliance on parenteral nutrition. There was no difference in the use of 6-Mercaptopurine therapy. The increased use of nutritional therapy in patients with JICD correlatedwith improved growth parameters(Table1). DISCUSSION: JICD is a distinct and relatively common subtype of pediatric CD. Early and aggressive nutritional intervention may significantly impact on patient growth and development. The tendency for increased corticosteroid use in patients with JICD may suggest a role for the early introduction of immunomodulatory therapy.

1110 The Use Of ComplementaryMedicines In Children And Young Adults With Inflammatory Bowel Disease. Robert B. Heuschkel, NadeamAfzal, Ctr of Paedietdc Gastroenterology,Royal Free Hosp, London United Kingdom; Anne Wuerth, Children's Hosp of Michigan, Detroit, MI; David Zurakowski, Kathi Kemper, Children's Hosp, Boston, MA; Vasu Tolia, Children's Hosp of Michigan, Detroit, MI; Athos Bousvaros, Children's Hosp, Boston, MA Background.The use of complementarymedicines(CM) is widespreadin patientswith chronic medical illnesses. In the US more resources are spent on the purchase of complementary therapies every year than on conventionalmedicines.About 50% of adults with IBD use some form of complementarytherapy in addition to their prescribed medications.Aim. We examined the use of CM in children and young adults with IBD and sought to identify predictors of their use. Methods. Following extensivevalidation of a new questionnaireand completion of

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