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Clinical Vignette Poster Session II Friday, November 13, 2009 12:15Pm – 2:15Pm

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Clinical Vignette Poster Session II Friday, November 13, 2009 12:15Pm – 2:15Pm Clinical Vignette Poster Session II Friday, November 13, 2009 12:15pm – 2:15pm Esophagus/Stomach cv 25 IS THERE A ROLE FOR UPPER ENDOSCOPY IN THE EVALUATION OF FAILURE TO THRIVE? Stuart Berezin, Michael S. Halata, Howard E. Bostwick. Pediatrics, NY Medical College, Valhalla, NY Fifteen patients with poor weight gain, 5 months to 2 years of age, were evaluated for failure to thrive due to inadequate caloric intake based on dietary history. All patients had weight for length less than 5% and experienced a significant decrease in weight percentile on the growth curve. None had gastrointestinal symptoms of vomiting, diarrhea, constipation or dysphagia. Evaluation included CBC, total protein, albumin, ALT, AST, BUN, creatinine, T4, TSH and electrolytes. Patients over 10 months had lab testing for celiac disease. Abdominal ultrasound was performed in eight patients and upper gastrointestinal series in four patients. Evaluations were normal for all patients, except for two with positive celiac disease serology. All patients had an upper endoscopy with biopsies of the duodenum, stomach and esophagus. Seven of fifteen patients were under one year of age. Two had biopsy‐confirmed eosinophilic esophagitis (> 100 eosinophils/high power field (HPF)). Two patients had normal appearing endoscopies, but had histological evidence of reflux esophagitis (5‐7 eosinophils/HPF). One patient had a duodenal bulbar ulcer. Two patients had normal endoscopies. Eight of fifteen were over 1 year of age and also had upper endoscopies. One had eosinophilic esophagitis (> 30 eosinophils/HPF). This patient had previously been treated with omeprazole for 2 months. Two patients had biopsy‐proven celiac disease that confirmed their abnormal celiac serology. Five patients had normal endoscopies. In this young population of failure to thrive patients, upper endoscopic examinations with biopsies were useful in obtaining a diagnosis in more than 50% of those examined. Upper endoscopy is therefore a useful evaluation in children under 2 years of age with failure to thrive due to inadequate caloric intake and who do not exhibit overt gastrointestinal symptoms. In children under 1 year of age eosinophilic and reflux esophagitis were the most common diagnosis; in children over one year of age, celiac disease was the most common diagnosis in this patient population. cv 26 ENDOSCOPIC REMOVAL OF A LARGE GASTRIC TRICHOBEZOAR IN A PEDIATRIC PATIENT Ahmet Aybar, Anca M. Safta. Pediatrics, University of Maryland, Baltimore, MD A trichobezoar is an accumulation of swallowed hair in the stomach that fails to pass through the intestines. The incidence is greater among the mentally retarded or emotionally disturbed children. Endoscopic removal is usually not successful and can cause severe complications. Surgical or laparoscopic removal is the preferred method. Many endoscopic techniques have been described for breaking up the trichobezoar. We report a young patient with a large trichobezoar which was removed using hot biopsy forceps and electrocautery snare. A 5 ½ year‐old girl presented to the Pediatric ED with symptoms of small bowel obstruction. Exploratory laparotomy revealed a trichobezoar in the ileum and was removed with resection of the distal ileum. She had persistent nausea and vomiting with poor appetite for 6 weeks. A follow up CT of the abdomen and UGI study confirmed a large residual trichobezoar in the stomach extending through duodenal bulb. Endoscopic removal was attempted to avoid a second operation. Initially, the retrieval of the intact bezoar through the lower esophageal sphincter failed. Subsequently the bezoar was broken into 13 smaller pieces using hot biopsy forceps and snare via ERBE™ and completely removed. After the procedure, mucosal abrasions and small superficial mucosal burns noted in the greater curvature and treated with a course of lansoprazole and sucralfate. She was symptom‐free at follow up. Trichobezoar is a rare condition in which swallowed hair accumulates in the stomach. It is indigestible and slippery in character, can not be propulsed distally and may cause small bowel obstruction. Surgery is recommended for the removal of large bezoars. Endoscopic removal is very seldom successful due to a distal tail extending into small bowel or imbedding of hair in the gastric mucosa. We describe a safe and successful endoscopic removal of a large gastric trichobezoar without immediate complications. To our knowledge this is the first published report in the English literature removing a large trichobezoar endoscopically by cutting into small pieces using electrocautery. cv 27 RELATIONSHIP BETWEEN BMI AND REFLUX ESOPHAGITIS(GERD) IN CHILDREN Radha Nathan, Nidhi Rawal. Pediatrics, Brookdale University Hospital and Medical Center, Brooklyn, NY BACKGROUND: Obesity is a rising public health concern, because of various co‐morbidities. Studies in adults have shown a positive correlation between obesity and GERD. However, data in children have shown conflicting results. AIM: To evaluate the relationship between BMI and GERD in children. METHODS: In a retrospective case control study, we identified patients between ages 3‐18 years, from Jan’06 to Feb’08, with histological evidence of GERD. Charts were reviewed for age, sex, weight, height and symptoms. BMI was calculated and BMI percentiles were obtained using CDC growth charts. We defined overweight as BMI between the 85th and 95th percentiles and obese as >or equal to the 95th percentile. Exclusion criteria included patients with neurological conditions, IBD, prematurity and age<3years. Pediatric patients seen in the Well Child Clinic with no history of reflux symptoms, served as controls. Cases and controls were age and gender matched. Information was obtained for 47 matched pairs. Demographic data were collected. Analysis was performed with STATA software using logistic regression and t test. RESULTS: About 48.9% of cases (GERD +) were overweight/obese compared to 25.7% of controls (GERD ‐). The percentage of overweight and obese children in the control group corresponded closely to the population norm as per the CDC data. When regressed, GERD correlated well with BMI percentiles (OR=1.97, P=0.008) and female gender (OR=2.3, P value=0.026). No statistically significant relationship was found between GERD and age/simple BMI value. CONCLUSION: We report that children with BMI>85%ile have twice the risk of having GERD, as compared to the normal weight population. Prevalence is significantly higher in females. Variables Cases(47)GERD+ Controls(47)GERD‐ Weight(kg) 15.3‐127.8 10.3‐110 BMI(kg/m2) 12.6‐48 Mean=24.1±8.06 14‐37.9 Mean=22.04±6.3 BMIpercentiles <85th%ile 85‐95th%ile ‐ 24(51.06%) 8(17.02%)P=0.008 ‐ 35(74.4%) 6(12.7%) >95th%ile 15(31.9%) 6(12.7%) cv 28 ARGON PLASMA COAGULATION FOR TREATMENT OF RADIATION‐INDUCED HEMORRHAGIC GASTRITIS KATTAYOUN KORDY, MD, BRADLEY BARTH, MD, MPH UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS, CHILDREN’S MEDICAL CENTER Kattayoun Kordy, Bradley Barth. University of Texas Southwestern Medical Center at Dallas, Children's Medical Center Dallas, Dallas, TX Argon plasma coagulation (APC) is a non‐contact, through the scope, monopolar, electrocoagulation technique that has potential benefit in children requiring endoscopic therapy for GI bleeding. It is especially well suited for patients who are at high risk for perforation or with diffuse lesions, including those undergoing chemotherapy. Case Report: We describe a 4 year old boy with history of biliary rhabdomyoscarcoma who recently completed a 5 week course of radiation therapy. He presented with transfusion dependent upper GI bleeding secondary to severe radiation‐induced hemorrhagic gastritis. Several multimodal endoscopic therapies failed to control his chronic GI bleeding, including epinephrine injections and endoscopic clip placement. Due to the diffuse nature of the lesion, APC was applied to 80%‐90% of circumferential bleeding in the antrum with successful achievement of hemostasis. One week follow‐up endoscopy revealed improved gastritis limited to the antrum with some areas of oozing that was again treated with APC. Subsequent follow‐up endoscopy revealed complete resolution of GI bleeding without evidence of ulceration, and a significant drop in transfusion requirement post‐APC treatment. Discussion: To our knowledge, this is the first reported case of APC in the management of GI bleeding secondary to radiation induced hemorrhagic gastritis in a pediatric patient. Data is limited on APC in children with yet unknown long term effects. However, the non‐contact nature of this therapy, along with minimal depth of penetration make it ideally suited for this indication. REFERENCES 1. Kahn K, Scharzenberg S, Sharp H, Weisdorf‐Schindele S. Argon plasma coagulation: Clinical experience in pediatric patients. Gastrointestinal Endoscopy 2003; 57 (1): 110‐112. 2. Watson J, Bennett M, Griffin S, Matthewson K. The tissue effect of argon plasma coagulation on esophageal and gastric mucosa. Gastrointestinal Endoscopy 2000; 52(3):342‐5. cv 29 GASTRIC ADENOCARCINOMA IN A 14 YEAR‐OLD WITH HISTORY OF GIARDIA AND CMV INFECTIONS. Jeffrey H. Ho, Marvin E. Ament. Division of Pediatric GI, Hepatology and Nutrition, UCLA, Los Angeles, CA We describe a case of a 14 year old male with history of chronic abdominal pain and intermittent vomiting since two years of age. Family history is remarkable for members with gastric adenocarcinoma. At age two, patient began vomiting and was reported to have hypoalbuminemia and protein
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