An update on gastrointestinal disorders
An update on Coeliac disease
Fevronia Kiparissi
Great Ormond Street HospitalUniversity College London Hospital
Practical Paediatric UpdateGastroenterology
Ownership
bull ldquoshare seamlessly and steal shamelesslyrdquo
ICN (ImproveCareNow)
bull PubMed
bull Dr Google
Content
bull Upper GI
ndash Helicobacter pylori guideline
ndash GOR and GORD guideline
bull Mid GIlower GI
ndash Functional abdominal pain and constipation
bull Coeliac disease - Update
Helicobacter pylori
ESPGHAN 2018
bull EuroPedHP registrybull 12013 to 92016 bull 21 centres in 16 European countries bull Anonymous reporting of H pylori infections
Helicobacter pylori
bull 934 included patients
ndash 518 (555) were female
ndash mean age120 years SD 40 range (14 ndash210)
ndash 748 (801) therapy naiumlve patients
ndash 95 (101) had received one
ndash 38 (41) ge 2 treatment courses
ndash previous treatment was unknown for 53 (57)
ESPGHAN 2018
Helicobacter pylori
Symptoms
bull abdominal pain 580 (621)
bull dyspepsia 102 (109)
bull anaemia in 35 (38)
bull bleeding 17 (18)
bull and other causes 200 (214)
Resistance rates
bull Clarithromycin 288 (216751)
bull Metronidazole 286 (214748)
bull Amoxicillin 14 (9628)
ESPGHAN 2018
Helicobacter pylori
Macroscopic findings
bull stomach ndash Nodularity 723 (774)
ndash Erosions 94 (101)
ndash Ulcers 12 (13)
bull duodenum ndash Nodularity 94 (101)
ndash Erosions 42 (45)
ndash Ulcers 41 (44)
ESPGHAN 2018
Helicobacter pylori
Conclusion
bull Gastric or duodenal peptic ulcer disease (PUD) is rare in H pylori infected symptomatic paediatric patients undergoing endoscopy (57)
bull Antibiotic resistance rates to Cla or Met prior to first treatment are high 193 and 16 respectively
ESPGHAN 2018
Methods bull A systematic review of the literature
bull 2009ndash2014
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
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Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
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Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Ownership
bull ldquoshare seamlessly and steal shamelesslyrdquo
ICN (ImproveCareNow)
bull PubMed
bull Dr Google
Content
bull Upper GI
ndash Helicobacter pylori guideline
ndash GOR and GORD guideline
bull Mid GIlower GI
ndash Functional abdominal pain and constipation
bull Coeliac disease - Update
Helicobacter pylori
ESPGHAN 2018
bull EuroPedHP registrybull 12013 to 92016 bull 21 centres in 16 European countries bull Anonymous reporting of H pylori infections
Helicobacter pylori
bull 934 included patients
ndash 518 (555) were female
ndash mean age120 years SD 40 range (14 ndash210)
ndash 748 (801) therapy naiumlve patients
ndash 95 (101) had received one
ndash 38 (41) ge 2 treatment courses
ndash previous treatment was unknown for 53 (57)
ESPGHAN 2018
Helicobacter pylori
Symptoms
bull abdominal pain 580 (621)
bull dyspepsia 102 (109)
bull anaemia in 35 (38)
bull bleeding 17 (18)
bull and other causes 200 (214)
Resistance rates
bull Clarithromycin 288 (216751)
bull Metronidazole 286 (214748)
bull Amoxicillin 14 (9628)
ESPGHAN 2018
Helicobacter pylori
Macroscopic findings
bull stomach ndash Nodularity 723 (774)
ndash Erosions 94 (101)
ndash Ulcers 12 (13)
bull duodenum ndash Nodularity 94 (101)
ndash Erosions 42 (45)
ndash Ulcers 41 (44)
ESPGHAN 2018
Helicobacter pylori
Conclusion
bull Gastric or duodenal peptic ulcer disease (PUD) is rare in H pylori infected symptomatic paediatric patients undergoing endoscopy (57)
bull Antibiotic resistance rates to Cla or Met prior to first treatment are high 193 and 16 respectively
ESPGHAN 2018
Methods bull A systematic review of the literature
bull 2009ndash2014
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
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Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
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Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
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JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
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Algorithm 2
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Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
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Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Content
bull Upper GI
ndash Helicobacter pylori guideline
ndash GOR and GORD guideline
bull Mid GIlower GI
ndash Functional abdominal pain and constipation
bull Coeliac disease - Update
Helicobacter pylori
ESPGHAN 2018
bull EuroPedHP registrybull 12013 to 92016 bull 21 centres in 16 European countries bull Anonymous reporting of H pylori infections
Helicobacter pylori
bull 934 included patients
ndash 518 (555) were female
ndash mean age120 years SD 40 range (14 ndash210)
ndash 748 (801) therapy naiumlve patients
ndash 95 (101) had received one
ndash 38 (41) ge 2 treatment courses
ndash previous treatment was unknown for 53 (57)
ESPGHAN 2018
Helicobacter pylori
Symptoms
bull abdominal pain 580 (621)
bull dyspepsia 102 (109)
bull anaemia in 35 (38)
bull bleeding 17 (18)
bull and other causes 200 (214)
Resistance rates
bull Clarithromycin 288 (216751)
bull Metronidazole 286 (214748)
bull Amoxicillin 14 (9628)
ESPGHAN 2018
Helicobacter pylori
Macroscopic findings
bull stomach ndash Nodularity 723 (774)
ndash Erosions 94 (101)
ndash Ulcers 12 (13)
bull duodenum ndash Nodularity 94 (101)
ndash Erosions 42 (45)
ndash Ulcers 41 (44)
ESPGHAN 2018
Helicobacter pylori
Conclusion
bull Gastric or duodenal peptic ulcer disease (PUD) is rare in H pylori infected symptomatic paediatric patients undergoing endoscopy (57)
bull Antibiotic resistance rates to Cla or Met prior to first treatment are high 193 and 16 respectively
ESPGHAN 2018
Methods bull A systematic review of the literature
bull 2009ndash2014
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Helicobacter pylori
ESPGHAN 2018
bull EuroPedHP registrybull 12013 to 92016 bull 21 centres in 16 European countries bull Anonymous reporting of H pylori infections
Helicobacter pylori
bull 934 included patients
ndash 518 (555) were female
ndash mean age120 years SD 40 range (14 ndash210)
ndash 748 (801) therapy naiumlve patients
ndash 95 (101) had received one
ndash 38 (41) ge 2 treatment courses
ndash previous treatment was unknown for 53 (57)
ESPGHAN 2018
Helicobacter pylori
Symptoms
bull abdominal pain 580 (621)
bull dyspepsia 102 (109)
bull anaemia in 35 (38)
bull bleeding 17 (18)
bull and other causes 200 (214)
Resistance rates
bull Clarithromycin 288 (216751)
bull Metronidazole 286 (214748)
bull Amoxicillin 14 (9628)
ESPGHAN 2018
Helicobacter pylori
Macroscopic findings
bull stomach ndash Nodularity 723 (774)
ndash Erosions 94 (101)
ndash Ulcers 12 (13)
bull duodenum ndash Nodularity 94 (101)
ndash Erosions 42 (45)
ndash Ulcers 41 (44)
ESPGHAN 2018
Helicobacter pylori
Conclusion
bull Gastric or duodenal peptic ulcer disease (PUD) is rare in H pylori infected symptomatic paediatric patients undergoing endoscopy (57)
bull Antibiotic resistance rates to Cla or Met prior to first treatment are high 193 and 16 respectively
ESPGHAN 2018
Methods bull A systematic review of the literature
bull 2009ndash2014
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Helicobacter pylori
bull 934 included patients
ndash 518 (555) were female
ndash mean age120 years SD 40 range (14 ndash210)
ndash 748 (801) therapy naiumlve patients
ndash 95 (101) had received one
ndash 38 (41) ge 2 treatment courses
ndash previous treatment was unknown for 53 (57)
ESPGHAN 2018
Helicobacter pylori
Symptoms
bull abdominal pain 580 (621)
bull dyspepsia 102 (109)
bull anaemia in 35 (38)
bull bleeding 17 (18)
bull and other causes 200 (214)
Resistance rates
bull Clarithromycin 288 (216751)
bull Metronidazole 286 (214748)
bull Amoxicillin 14 (9628)
ESPGHAN 2018
Helicobacter pylori
Macroscopic findings
bull stomach ndash Nodularity 723 (774)
ndash Erosions 94 (101)
ndash Ulcers 12 (13)
bull duodenum ndash Nodularity 94 (101)
ndash Erosions 42 (45)
ndash Ulcers 41 (44)
ESPGHAN 2018
Helicobacter pylori
Conclusion
bull Gastric or duodenal peptic ulcer disease (PUD) is rare in H pylori infected symptomatic paediatric patients undergoing endoscopy (57)
bull Antibiotic resistance rates to Cla or Met prior to first treatment are high 193 and 16 respectively
ESPGHAN 2018
Methods bull A systematic review of the literature
bull 2009ndash2014
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Helicobacter pylori
Symptoms
bull abdominal pain 580 (621)
bull dyspepsia 102 (109)
bull anaemia in 35 (38)
bull bleeding 17 (18)
bull and other causes 200 (214)
Resistance rates
bull Clarithromycin 288 (216751)
bull Metronidazole 286 (214748)
bull Amoxicillin 14 (9628)
ESPGHAN 2018
Helicobacter pylori
Macroscopic findings
bull stomach ndash Nodularity 723 (774)
ndash Erosions 94 (101)
ndash Ulcers 12 (13)
bull duodenum ndash Nodularity 94 (101)
ndash Erosions 42 (45)
ndash Ulcers 41 (44)
ESPGHAN 2018
Helicobacter pylori
Conclusion
bull Gastric or duodenal peptic ulcer disease (PUD) is rare in H pylori infected symptomatic paediatric patients undergoing endoscopy (57)
bull Antibiotic resistance rates to Cla or Met prior to first treatment are high 193 and 16 respectively
ESPGHAN 2018
Methods bull A systematic review of the literature
bull 2009ndash2014
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Helicobacter pylori
Macroscopic findings
bull stomach ndash Nodularity 723 (774)
ndash Erosions 94 (101)
ndash Ulcers 12 (13)
bull duodenum ndash Nodularity 94 (101)
ndash Erosions 42 (45)
ndash Ulcers 41 (44)
ESPGHAN 2018
Helicobacter pylori
Conclusion
bull Gastric or duodenal peptic ulcer disease (PUD) is rare in H pylori infected symptomatic paediatric patients undergoing endoscopy (57)
bull Antibiotic resistance rates to Cla or Met prior to first treatment are high 193 and 16 respectively
ESPGHAN 2018
Methods bull A systematic review of the literature
bull 2009ndash2014
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Helicobacter pylori
Conclusion
bull Gastric or duodenal peptic ulcer disease (PUD) is rare in H pylori infected symptomatic paediatric patients undergoing endoscopy (57)
bull Antibiotic resistance rates to Cla or Met prior to first treatment are high 193 and 16 respectively
ESPGHAN 2018
Methods bull A systematic review of the literature
bull 2009ndash2014
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
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JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Methods bull A systematic review of the literature
bull 2009ndash2014
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendation 1 Primary goal of investigation of gastrointestinal symptoms should be to determine the underlying cause ofthe symptoms and not solely the presence of H pylori infection
Practice Points
1 H pylori infection is not likely to be the cause of the symptoms in non PUC
2 Treatment not expected to cure symptoms3 Discussion about
1 potential risk of developing complications related to infection (PUD gastric cancer) later in life
2 potential risks of treatment (eg treatment failure adverse effects of antibiotic use such as diarrhoea cramps or negative alterations to the gut microbiome)
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendation 2c Against a lsquolsquotest and treatrsquorsquo strategy for H pylori infection in children
Practice Points
Current evidence indicates that H pylori infection does not cause symptoms in the absence of PUD
Performing a non invasive test to detect infection andtreat if the test is positive is not warranted
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendation 3 Testing for H pylori for gastric or duodenal PUD onlyIf H pylori infection is identified then treatment should be administered and eradication confirmed
Practice Points
Eradication of infection prevents ulcer recurrence
Proton pump inhibitor (PPI) monotherapy may be continued after eradication therapy for another 2 to 4 weeks in patients with PUD
Successful H pylori eradication is associated with cure of PUD and very low risk of relapse
Monitoring the success of therapy is mandatory in 4 to 6 weeks after stopping antibiotics and at least 2 weeks after stopping PPI therapy
Intake of acid-suppressive drugs and antibiotics decrease the sensitivity of all biopsy-based tests for H pylori
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
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JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendation 4Against diagnostic testing for H pylori infection in functional abdominal pain disorders
Practice Points
Children with bull recurrent abdominal painbull without any alarm signs or symptoms most likely have functional pain independent of H pylori status
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendation 5aAgainst diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anaemia (IDA)
Recommendation 5bWe suggest that in children with refractory IDA in which other causes have been ruled out testing for H pylori during upper endoscopy may be considered
Practice Points
If upper endoscopy is clinically indicated in the management of IDA refractory to iron therapy biopsies for the diagnosis of H pylori
If H pylori infection is detected in the setting of refractory IDA eradication therapy for H pylori should be combined with iron supplementationNon invasive testing for H pylori in the case of refractory IDA is not recommended
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendation 6We suggest that non invasive diagnostic testing for chronic immune thrombocytopenic purpura (ITP)
Practice Points Non invasive testing to diagnose the presence of infectionIf the non invasive test is depending on the platelet count for upper endoscopy or none before eradication therapy
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendation 8We recommend that before testing for H pylori wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics
Practice Pointsdrug intake during the 4 weeks before testing need to be stopped (invasive and non invasive urea breath test [UBT] stool antigen)
If acid suppressive therapy cannot be discontinued for 2 weeks because of recurrence of symptoms changing to an H2-receptor antagonist with discontinuation of the drug2 days before testing may improve the sensitivity of the diagnostic test
Antibiotics may suppress bacterial growth and may result in false-negative test results in all applied diagnostic methods except serology (which is not recommended)
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
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JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendation 10We recommend against antibody-based tests (immunoglobulin G [IgG] IgA) for H pylori in serum whole blood urine and saliva in the clinical setting
Practice PointsThese antibody-based tests should not be used to detect the presence of active H pylori infection or for use in post-treatment evaluation in children or adolescents
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
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JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Treatment
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
Joint Recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
Rachel Rosen MD MPH1 Yvan Vandenplas MD1 Maartje Singendonk MDdagger Michael Cabana MDsect Carlo Di Lorenzo MDDaggerFredericGottrand MD|| SandeepGupta MDpara MirandaLangendam PhDdagger Annamaria Staiano MD Nikhil Thapar MDdaggerdagger Neelesh TipnisMDDaggerDagger Merit Tabbers MDdagger
JPGN Publish Ahead of Print 2018
bull Systematic literature search was performed from October 2008 bull Embase MEDLINE the Cochrane Database of Systematic Reviews Cochrane Central
Register of Controlled Clinical Trials
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
The Lancet Pathophysiology of gastro-oesophageal reflux disease
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
DefinitionsRegurgitation
the passage of refluxed contents into the pharynx mouth or from he mouth Other terms such as lsquospitting-uprsquo lsquopossetingrsquo and lsquospillingrsquo are considered equivalent to regurgitation
Vomiting a coordinated autonomic and voluntary motor response causing forceful expulsion of gastric contents through the mouth
Rumination effortless regurgitation of recently ingested food into the mouth with subsequent mastication and re-swallowing
Rumination syndrome distinct clinical entity in which rumination follows in minutes after ingestion of a meal does not occur during sleep and does not respond to standard treatment for gastroesophageal reflux
In infant rumination syndrome this involves repetitive contractions of the abdominal wall muscles diaphragm and tongue
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Reflux hypersensitivity patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring but do have evidence that reflux events trigger symptoms
Functional Heartburn patients with oesophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring and do not have evidence that symptoms are triggered by reflux events
Non-erosive reflux disease(NERD) patients with oesophageal symptoms who lack evidence of reflux on endoscopy but do have an abnormal acid burden that may or may not trigger symptoms
Definitions
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Question 1 What is the definition of GERGERD in infants and children 0-18 years
GER the passage of gastric contents into the oesophagus with or without regurgitation and vomiting
GERD when GER leads to troublesome symptoms that affect daily functioning andor complications
Refractory GERD GERD not responding to optimal treatment after eight weeks
Optimal Therapy Maximum pharmacologic andor non-pharmacologic therapy based on the available health-care facilities in the region of practice of the subspecialist
JPGN Publish Ahead of Print 2018
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Question 2 What are the ldquored flagrdquo findings and diagnostic clues to distinguish infants and children with GERD (or conditions other than GERD) from GER
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
JPGN Publish Ahead of Print 2018
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
Recommendations
31 not to use barium contrast studies for the diagnosis of GERD in infants and children
32 to use barium contrast studies to exclude anatomical abnormalities
33 not to use ultrasonography for the diagnosis of GERD in infants and children
34 to use ultrasonography to exclude anatomical abnormalities
JPGN Publish Ahead of Print 2018
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendations
35 not to use oesophago-gastro-duodenoscopy to diagnose GERD in infants and children
36 to use oesophago-gastroduodenoscopy with biopsies to assess complications of GERD in case an underlying mucosal disease is suspected or prior to escalation of therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendations
313 a trial of PPIs should not be used as a diagnostic test for GERD in infants
314 a 4-8 week trial of PPIs for typical symptoms (heartburn retrosternal or epigastric pain) in children as a diagnostic test for GERD
315 a trial of PPIs should not be used as a diagnostic test for GERD in patients presenting with extra oesophageal symptoms
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendations
316 when pH-Impedance is not available to consider to use pH-metry only
1 to correlate persistent troublesome symptoms with acid gastroesophageal reflux events
2 clarify the role of acid reflux in the aetiology of esophagitis and other signs and symptoms suggestive for GERD
3 Determine the efficacy of acid suppression therapy
Question 3 What diagnostic interventions have additional value to history taking and physical examination in infants and children with suspected GERD
JPGN Publish Ahead of Print 2018
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
Recommendations41 to use thickened feed for treating visible regurgitationvomiting in infants with GERD (Algorithm 1)
42 to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD (Algorithm 1)
43 a 2 ndash 4 week trial of formula with extensively hydrolysed protein (or amino-acid based formula) in formula fed infants suspected of GERD after optimal non-pharmacological treatment has failed (Algorithm 1 or see ESPGHAN 2012 CMPA guidelines)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
JPGN Publish Ahead of Print 2018
Algorithm 1
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendations
44 not to use positional therapy (ie head elevation lateral and prone positioning) to treat symptoms of GERD in sleeping infants
45 to consider the use of head elevation or left lateral positioning to treat symptoms of GERD in children
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendations
46 not to use massage therapy to treat infant GERD
47 not to use currently available lifestyle interventions or complementary treatments such as prebiotics probiotics or herbal medications to treat GERD
48 informing caregivers and children that excessive body weight is associated with an increased prevalence of GERD
49 providing patientparental education and support as part of the treatment of GERD (Algorithm 1)
Question 4 What non-pharmacologic treatment options are effective and safe for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
Recommendation
51 not to use antacidsalginates for chronic treatment of infants and children with GERD
52 the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2)
53 to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2)
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Algorithm 2
JPGN Publish Ahead of Print 2018
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Algorithm 2
JPGN Publish Ahead of Print 2018
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendation510 baclofen can be considered prior to surgery in children in whom other pharmacological treatments have failed511 not to use domperidone in the treatment of GERD in infants and children512 not to use metoclopramide in the treatment of GERD in infants and children513 not to use any other prokinetics (ie erythromycin) as first line treatment in infants and children with GERD
Question 5 What are effective and safe pharmacologic treatment options for the reduction of signs and symptoms of GERD
JPGN Publish Ahead of Print 2018
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Recommendations61 antireflux surgery including fundoplication can be considered in infants and children with GERD and
ndash life threatening complications (egcardio respiratory failure) of GERD after failure ofoptimal medical treatment
ndash symptoms refractory to optimal therapy (question 4 5 6) after appropriate evaluation to exclude other underlying diseases
ndash chronic conditions (ie neurologically impaired cystic fibrosis) with a significant risk of GERD-related complications
ndash the need for chronic pharmacotherapy for control of signs andor symptoms of GERD
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
64 the use of trans-pyloricjejunal feedings can be considered in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication
Question 6Which infants and children would benefit from surgical treatment (ie fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies
JPGN Publish Ahead of Print 2018
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Question 7 What is the prognosis of GERD in infants and children and what are prognostic factors
Age of onset of GERD symptoms lt 5 years and the use of acid-suppression at time of initial diagnosis may result in less favourable outcome
Firm conclusions however are limited by the poor quality of the studies
No evidence exists showing an association between gender ethnicity andor family history of GERD or number of visits to the primary care physician
JPGN Publish Ahead of Print 2018
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Question 8 What is the appropriate evaluation of infants and children 0-18 years with GERD refractory to non-pharmacological and pharmacological treatmentRecommendations81 evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 ndash 8 weeks of optimal therapy for GERD
82 refer infants and children with GERD to the paediatric gastroenterologist if
ndash There are alarm signs or symptoms suggesting an underlying gastrointestinal disease (Table 3)
ndash Patients are refractory to optimal treatment (Question 1)
ndash Patients cannot be permanently weaned from pharmacological treatment within 6-12 months (additional evaluation should be considered after 4 - 8 weeks of optimal GERD therapy if clinically indicated)
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
JPGN Publish Ahead of Print 2018
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
JPGN Publish Ahead of Print 2018
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Practical approach to chronic (functional) abdominal pain
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Understanding The Gut Function
bull Unique immune system of the mucosa
ndash Innate immunity
ndash Adaptive immune response
bull Unique mucosal barrier (Innate immune system)
ndash Gastric acid
ndash Mucin glycoproteins on the surface
ndash Inter epithelial tight junctions
ndash IgA secretion
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Gastroenterology 20161501262ndash1279
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
bull Irritable bowel syndrome (IBS)bull Functional Dyspepsia (FD)bull Abdominal migrainebull functional abdominal pain not otherwise
specified(FAPNOS)
Can overlap of more than 1 FAPD in an individual patient
H2 Functional Abdominal Pain Disorders
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
H2a Functional Dyspepsia
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
TreatmentNo double blind placebo-controlled paediatric studies of FD treatment
bull Avoid specific foods Food (eg caffeine spicy fatty)
bull Avoid nonsteroidal anti-inflammatory agents
bull Consider Psychological factors and treat
bull Acid blockade with histamine receptor antagonists and proton pump inhibitors for pain
bull Cure of FD
ndash complete symptomatic relief after 4 weeks of treatment
ndash omeprazole superior to ranitidine
bull low-dose tricyclic antidepressant (amitriptyline and imipramine)
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
bull Nausea bloating early satiety
ndash difficult to treat
ndash prokinetics (cisapride and domperidone) can be offered where available
ndash Cyproheptadine safeeffective for treating dyspeptic symptoms
ndash Gastric electrical stimulation in refractory FD
Treatment
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
H2b Irritable bowel syndrome
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
bull A careful history and physical examination
bull Exclude
ndash infection coeliac disease carbohydrate malabsorption inflammatory bowel disease
bull Alarm symptoms present
bull Faecal calprotectin
H2b Irritable bowel syndrome
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Treatment
Little evidence from trials
bull probiotics
bull peppermint oil
bull Elimination diet reducing intake of fermentable oligosaccharides disaccharides monosaccharides and polyols (low FODMAP)
bull Behavioral treatments
ndash optimizing symptom coping skills
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
bull Explanation in simple language that although the pain is real there is no underlying serious disorder
bull Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences
bull They will ldquoshop aroundrdquo for further opinions
MANAGEMENT
Arch Dis Child 2005 Apr90(4)335-7Consumerism in healthcare can be detrimental to child health lessons from children with functional abdominal painLindley KJ1 Glaser D Milla PJ
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Management of (functional)constipation
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Colonic functions
bull Absorption ofbull waterbull some electrolytesbull bacterial metabolitesbull short chain fatty acids
bull Distal propulsion of contents
bull Storage of faecal matter until defecation is (socially convenient)
Camilleri M Ford MJ Aliment Pharmacol Ther 1998 Scott SM Nurogastroenterol Mot 2003
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Colonic Contractile Patterns in Humans
Segmental activity
Single contractions
Bursts of contractions rhythmic arrhythmic
Propagated activity
Low amplitude propagated contractions (LAPC)
High amplitude propagated contractions (HAPC)
Scott SM Neurogastroenterol Mot 2003
Bassotti G World J Gastroenterol 2005
Camilleri M Neurogastroenterol Mot 2008
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Single contractions
Bursts of contractions rhythmic arrhythmic
Slowly movement of the contents toward the
rectum
Optimal absorbtion of water electrolytes SCFA and bacterial metabolites
Segmental activity
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Low amplitude propagated contractions (LAPC)
movement of fluid contents within the colon
Propagated activity
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
High amplitude propagated contractions (HAPC)
Homogeneous throughout the colon
Associated with defecatory stimulus and or defecation
Constant event in healthy subjects
Propagated activity
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Constipation
bull Slow transit constipationvsbull Rectal outlet obstruction
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
H3 Functional Defecation Disorders
H3a Functional Constipation
H3b Non retentive Faecal Incontinence
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
H3a Functional Constipation
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Clinical Evaluation
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
TreatmentEducation and counselling to recognize withholding behaviours
bull Behavioural interventions
ndash regular toileting
ndash use of diaries to track stooling
ndash reward systems for successful evacuations
bull Normal fibre and fluid intake is recommended
bull Prebiotics and probiotics does not seem to be supported by adequate evidence
Pharmacological approach in 2 steps
ndash Rectal or oral disimpaction
ndash Maintenance therapy to prevent re-accumulation
Polyethylene glycol is first-line therapy for constipated children
ndash superior to lactulose
ndash 15 grKgday for 3-5 days
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Treatment
bull Education regarding
ndash withholding behaviour
ndash Regular toileting
ndash Diaries and reward system
bull Normal fibre and fluid intake
bull No evidence for probiotics
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
H3b Non retentive Faecal Incontinence(NFI)
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Pathophysiology
bull Normal defecation frequenciesbull Normal colonic and anorectal motility parametersbull clinical symptoms
ndash Normal defecation frequencyndash absence of abdominal or rectal palpable massndash normal transit marker study
bull NFI might be a manifestation of an emotional disturbance
bull NFI has been described as a result of sexual abuse in childhood
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Treatment
Behavioural therapy
bull Regular toilet training with rewards
bull Diminishing toilet phobia
bull Biofeedback therapy does not provide additional benefit
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Coeliac disease definition
Permanent
multi-systemic autoimmune
ldquogastrointestinalrdquo disorder
induced by exposure to gluten
(wheat rye and barley proteins)
in genetically susceptible individuals
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
What is newESPGHAN 2018
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Prevent Coeliac disease
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Israel
wwwpreventcdcom
Project PreventCD
17
partners
10
countries
medical
centres
labs
industries
AOECS
wwwpreventcdcom
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
donderdag 7 juni 2018
HLA DQ2DQ8 typingnewborns high risk family
Positive Negative
StopRandomization
Placebo100 mg lactose
100 mg gluten
4-6 Monthsdouble-blind
Coeliac DiseaseRCDBPC family intervention study
Project PreventCD
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Hypothesis
There is a window of opportunity for reducing the risk of
celiac disease by introducing gluten to infants at 4 to 6
months of age
METHODS
- multicentre randomized double-blind placebo-controlled
dietary intervention study
- at least one first-degree relative with celiac disease
- from 16 to 24 weeks of age
- 475 participants received 100 mg of immunologically active
gluten daily
- 469 received placebo
Antindashtransglutaminase type 2 and antigliadin antibodies
measured
The primary outcome was the frequency of
biopsy-confirmed celiac disease at 3 years of age
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
CONCLUSIONS
As compared with placebo the introduction of small quantities of
gluten at 16 to 24 weeks of age did not reduce the risk of
celiac disease by 3 years of age in this group of high-risk
children
No reduced risk of coeliac disease associated with breastfeeding
at time of gluten introduction
Current ESPGHAN guidelines of
breastfeed and introduce gluten not sooner than 4 and
no later than 7 months
Not supported by this study
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
AimTo assess whether children from coeliac families benefit from screening early diagnosis and treatment
Method Data from PreventCD cohort involving 944 new born recruited 2007-2010 prospectively assessed for CD development
Results7 years later 130 children (mean age 91 years range 73-109 598 female) diagnosed with CD at a mean age of 38 years (range 11- 92)71 children (563) were symptomatic at diagnosis878 of the symptomatic children at diagnosis were symptom free after 1-2 years on a GFD
Conclusion Most children from CD families develop CD very early in life half of them have CD-related symptoms that improve significantly after treatment with a GFD Early screening diagnosis and treatment in children from CD families recommended
G-eP-044Children from coeliac families benefit from early diagnosis and treatment an analysis of the Prevent CD cohort
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
G-O-005Gluten intake and risk of celiac disease Preliminary data from an at-risk birth cohort
AimTo determine the association between gluten intake through childhood and CD development
Method Since 1993 the Diabetes Autoimmunity Study in the Young (DAISY) cohort in Denver prospectively assessment of diets of 1758 children genetically at risk for CD
152 identified with CD-autoimmunity (CDA persistent tTGA positivity) 83 fulfilled CD-criteria of biopsy-verified histopathologypersistently high tTGA levels
Using validated food frequency questionnaires gluten intake determined(gramsday) yearly from age 2 years through childhood
Results66 (SD 17) to 182 (42) grams - average of 112 (55) gramsChildren in the highest third of recent gluten intake had a 2-fold greater hazard rate of CDA (aHR 213 95 confidence interval [CI] 118-383) than those in the lowest third
Conclusion Data suggest that the most recently-reported gluten intake level predicts onset of CDA and CD in children at risk for the disease
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
G-O-024Viral infections as triggers of coeliac disease in a longitudinal birth cohort
AimTest whether enterovirus or adenovirus predicted coeliac disease
Method 2001-2007 46939 Norwegian children HLA screening risk of coeliac disease and type 1 diabetes (MIDIA study)(22) monthly stool samples from age 3 to 36 months and blood samples at age 3 6 9 and 12 months and then annuallyDuring 2014-2016 237 children consented to be screened for coeliac disease
ResultsEnterovirus in 385 of 2275 samples (17)
Enterovirus positivity more frequent prior to seroconversion for coeliac disease antibodies compared to matched controlsEnterovirus infections after gluten introduction and after end of breastfeeding were associated with coeliac disease while earlier infections were not
Adenovirus in 274 of 2140 samples (13) similar proportions among children who developed coeliac disease and controlchildren
Conclusion Frequent enteroviruses may contribute to the aetiology of coeliac disease
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
AimAssociation between dispensed prescriptions for systemic antibiotics in the first year of life and diagnosed coeliac disease in two large independent population cohorts from DenmarkNorway
Method Data from administrative registers
ResultsDanish cohort 1 168 656 children Coeliac disease in 1427 children (012)Systemic antibiotics dispensed to 451 196 children without coeliac disease (387) and 622 children with coeliac disease (436)Norwegian cohort 541 036 children Coeliac disease in 1920 children (035) Systemic antibiotics dispensed to 98 821 children without coeliac disease (183) and 391 children with coeliac disease (204)
Conclusion Dose-response relationship between increasing number of dispensed prescriptions and coeliac disease was foundDispensed prescriptions for systemic antibiotics in the first year of life was associated with an increased risk of diagnosed coeliac disease
G-O-040Systemic antibiotics in the first year of life is associated with an increased risk of diagnosed coeliac disease
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
AimGrowing body of neurological disorders (peripheral neuropathy cerebellar ataxia myelopathy myopathy brainstem encephalitis epilepsy and headache)EEG changesMethod 47 children (age 2-17 years) CD diagnosisneurological examination EEG questionnaire The electroencephalogram was repeated in abnormal EEG at the first exam after 6 and 12 GFDResults1647 (34) abnormal EEG findingsAfter 6 months of GFD EEG abnormalities disappeared in 7 children (4375)Conclusion Suggest that gluten diet may play a role inpresence of unexplained EEG abnormalitiesother neurological disorders as headache or sleep disordered breathing
G-eP-048Celiac disease sleeping disorders and neurological symptoms a prospective study in 47 children
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
AimLiver abnormalities in coeliac disease are common To investigate the ratio of the children with coeliac disease with elevated ALT
Method 519 paediatric patients with coeliac disease with raised ALT before diagnosis of coeliac disease
ResultsALT raised in 66 (127)519ALT levels (40-50 Ul) in 50 of the patientsBack to normal on GFDConclusion Coeliac disease should be investigated in patients with very mildly elevatedaminotransferase levels
G-P-016Liver involvement in children with coeliac disease experience of a big tertiary centre in eastern Turkey
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Aimgender differences in coeliac epidemiology in children systematic review of the literature and a meta-analysis
Method MEDLINE Embase Scopus and Cochrane databases
Results4245 articles meta-analysis on 84073 paediatric subjects (age range 0-18 majority primary school aged females 37456 males 46617) The rate of undetected coeliac disease in girls was 087 and in boys was 045 with the pooled prevalence (plt 000001)
Conclusion Coeliac disease is more common in girls than boys
This finding could have clinical implications in higher index of suspicion for coeliac disease in girls
G-P-032Female predominance in children with undetected coeliac disease a systematic review and meta-analysis
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
AimFollowing of ESPGHAN 2012 guidanceMethod Paediatric gastroenterologists in HungaryDiagnosis if coeliac January 2016-April 2017
Results566 were below 18 years of ageBiopsy was performed in 435 children (768)no-biopsy approach in 105 patients (185) EMA 92105 (87) and HLA-DQ 94 (895)HLA-DQ testing did not add to the diagnosis
Conclusion Omitting HLA-DQ testing does not compromise accuracy
This would make the no-biopsy approach more broadly available
G-P-037Nation-wide survey on the utilisation of diagnostic tools for paediatric coeliac disease in 2016- 2017
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
AimTo look at feasibility of withdrawing HLA-DQ2DQ8 testing from the non-biopsy pathway
Method Electronic non-biopsy pathway register data of diagnosed CD patients with EMAtTGHLA
ResultsHLA-DQ2DQ8 results for 96110 patients9596 patients (990) were positive for HLA-DQ2DQ8Of these 9095 (947) were HLA-DQ2 positive 1895 (189) HLA-DQ8 positive 1395 (137) carried both haplotypes
Conclusion Identification of the HLA DQ2DQ8 status did not contribute towards confirming CD
G-P-039HLA-DQ2DQ8 typing for non-biopsy diagnosis - is it necessary
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
Thank you
Vincent van Gogh-Wheat Fields with Reaper at Sunrise
