Background: With first liver transplantation in 1963 and first heart transplant in 1967, the first combined liver and heart transplantation (CHLT) took another 21 years to occur. Since then these remain rare events. During last 12 years, this set of procedures has been used more frequently as therapeutic modality. This study was taken to critically review the various aspects of this clinical condition. With the technical innovation to undertake liver transplantation during transient heart failure has made CHLT possible. Methods/Results: We performed a thorough research of Pubmed/Medline, gathering data regarding situations where CHLT have been performed over last 25 years. This data were discussed to build to better understanding and build consensus about indications for this procedure in this era of organ scarcity. Conclusions: Combined heart liver transplantation is a viable therapy for patients with end stage heart and liver failure. This is specially so in patients with end stage liver disease who are unable to tolerate orthotopic liver transplant(OLT) post operatively due to cardiac dysfunction. Answer to the question that can giving two organs to a single individual in CHLT is justified? As evident from literature among all who received one thoracic one abdominal organ simultaneously, only CHLT recipients have shown greater survival benefits. CHLT is a safe and effective procedure, with combined graft survival rates similar to isolated heart and isolated liver transplantation. National organ donation registry of a country should formulate its own individual criteria for wait listing and prioritization; as technical expertise and resources vary from one nation to other; so do the organ availability and the statutes of law.

In many cystic fibrosis (CF) centers, consultation from gastroenterologist, are not routinely taken. Yet the original name ‘cystic fibrosis of the pancreas’ illustrates the importance of the digestive system in this disease. Nutritional status, occurrence of CF related diabetes, liver involvement, morbidity and mortality are largely associated with pancreatic function. Treatment depends on treating associated conditions as well. Knowledge of exocrine pancreatic function, sufficiency or insufficiency, is therefore paramount from diagnosis on. At present the best test for this purpose is determination of fecal elastase-1, which should therefore be used in clinical practice as the compulsory companion of a positive sweat test.

Aim: The aim of the study is to review the state of Helicobacter pylori (H. pylori) infection and its consequences in Asian population with focus on related Asian enigma. Methods: Review of literature on the subject and critical analysis of the matter. Results: It is revealed in the review that the prevalence of H. pylori in most Asian countries including South East Asia (Bangladesh, India, Thailand and Pakistan) is relatively higher. As the countries concerned are marching towards a developed status, the prevalence is slowly decreasing. However in these countries the corresponding rate of gastric cancer is low. Conclusion: With a better understanding the molecular epidemiology of H. pylori infection, it is now possible to explain partially the basis of so called “Asian Enigma” with sero-prevalence and gastric cancer prevalence rates. Vaccines against H. pylori may change the future epidemiological scenario of particular type of gastric malignancy.

Organ transplantation center, Tokyo Japan reviews the experience of liver transplantation in young children. Based on 27 years experience, since the living donor liver transplantation was first performed in Japan, some of the newer developments necessity by paucity of organs and desire for decreasing mortality and morbidity are presented in this paper. From one transplant in 1989 the number has stabilized around average of 400+ every year. Children have formed significant number of these cases (Adults >18 Yr. n=4992; Children<18 Yr.= 2751). Indications for which these cases were performed are listed. The indications of pediatric liver transplantation have been refined and those are now followed in National Center for Child Health and Development. Technical refinements especially those decrease the parenchymal cell injury to liver meant for transplantation in children weighing less <5 kg receiving adult liver (large for size grafts) are illustrated in step wise manner. The modified left lateral segment reduction by which transplant could be done in very small infants. An algorithm proposed by our experience which takes into account factors like graft thickness and abdominal AP diameter is introduced. In our opinion further refinement of this algorithm is needed.

In the last years the literature related to persistent diarrhea (PD) has decreased in a very alarming way. The WHO has called attention to the lack of information on the protracted episodes of diarrhea, and has invited all researchers to obtain and provide information on this problem. PD is one of the diseases that frequently affects morbidity and mortality of children in the world. There are approximately 3 million diarrhea related deaths per year of children less than 5 years old. Forty five percent of these deaths are due to episodes that last more than 14 days. PD represents an important health problem because its magnitude, significance and long duration. A review of the main risk factors for PD is reviewed in this article. Research to identify risk factors for PD is a priority. The identification of such risk factors is basic for the understanding of the pathogenesis and epidemiology of PD. Knowledge of these risk factors in any country is of vital importance for the strategy to prevent and control PD. This strategy must be comprehensive and effective to reduce the rate of mortality related to diarrheal diseases in general and infant mortality in particular. Risk factors for PD are of two kinds: a) Environmental social and b) Host. The most important host related risk factors for PD are: i. age, ii. previous episodes of acute and PD, iii. malnutrition, iv. early introduction of animal milk, v. the use of metronidazol and antibiotics during the acute phase of the disease, and vi. the identification of enteric pathogens.

Objective: To put in perspectives the scattered information in the literature with inputs from our 2 decades of experience on antibiotic-associated diarrhea (AAD)- a by and large neglected condition. Resource and Design: Systematic review of literature together with our own experience spread over 2 decades. Salient Features: AAD is defined as the diarrhea that has no known cause other than an antibiotic therapy given concurrently or discontinued at the most 4 weeks preceding it. By and large, each and every antibiotic, though some are decidedly high-risk, is capable of causing diarrhea. No doubt, C. difficile is responsible for most cases of severe AID (i.e. colitis), in some cases S. aureus and C. perfringens may well be the causative agents. Diagnosis is by and large clinical. Most important first-aid measure in AAD is withdrawal of the offending antibiotic and offering supportive measures to maintain fluid and electrolyte balance and nutrition. As a therapeutic measure (as and when considered warranted), metronidazole (preferably oral) should be considered the drug of first choice.Alternatively, ornidazole or nitazoxanide may be given. The somewhat superior in efficacy, though expensive, alternative is vancomycin. At times, the two drugs may be given simultaneously. Good food and water hygiene, meticulous hand-washing, and proper environmental cleaning are helpful. Incorporation of probiotics may have both a preventive and therapeutic role. Conclusion: Judicious use of antibiotics is the most important preventive measure in AAD. Treatment modalities include withdrawal of the offending agent and administration of metronidazole, ornidazole or nitazoxanide. In case of poor response, vancomycin yieds gratifying response. Administration of probiotics may be helpful. A vaccine against C. difficile may well be around the corner.

Introduction: The technique is limited to benign conditions in children. The esophageal replacement includes intestinal interposition, gastric tube-Graviliu, and gastric transposition. Pulling stomach to neck as an esophagus has been accepted widely because of its stretch ability and the rich submucosal vasculature. Conditions such as esophageal atresia, caustic ingestion with persistent stricture, persistent peptic stricture, tumors, foreign body injury (battery) and Achalasia could affect the development and function of esophagus. Objectives: This research basically emphasizes on the procedure of gastric transposition and its indications, planning, and outcomes; therefore this study is aimed to determine the Gastric transposition for esophageal replacement outcomes among children. Methodology: Study was conducted in all the patients who underwent gastric transposition for esophageal replacement from 2012 to 2015. A total of 11 patients were included, 5 males and 6 females, age ranged from 4 days - 7 year old. Out of 11 patients 3 had type-1 esophageal atresia, 7 had persistent stricture due to caustic ingestion and 1 had foreign body injury. Results: No major complications during the surgery. The last patient has been followed for one year. Only 3 out of 11 patients underwent esophageal dilatation twice, therefore, the technique was accomplished successfully with excellent long-term outcome. Conclusion: With the relative high frequency of esophageal conditions, and the high mortality with late diagnosis, there is inherent importance in understanding the condition in pediatrics surgery practice in Afghanistan so as to improve survival.

The study aimed to evaluate the effectiveness of the supplementation of VIAMINOKID (a product enriched with amino acids and micronutrients) on stunted children 12-47 months old in 2 communes (Bac Giang Provine) with following objective: To evaluate the effectiveness of VIAMINOKID on anthropometric índices, values of Hemoglobin, Ferritin, zinc, IGF-I, and IgA of stunted children 1 to 3 years old after 9 months of intervention (T9) and 6 months after the intervention completed (T15). A community-based randomized controlled intervention trial was conducted in 180 stunted children from 12 to 47 months living in 2 communes of Luc Ngan district, Bac Giang province. The intervention last for 9 consecutive months; In the trial, the intervention group received 2 sachets of VIAMINOKID a day for 9 months. The results showed that the supplementation of VIAMINOKID had improved anthropometric indices of stunted children. Stunting rate reduced significantly in intervention group compared to the control (p<0.01): 40% reduction in intervention group and 20% reduction in control group. The supplementation of VIAMINOKID had positive results on several blood and biochemical indicators of stunted children: anemia prevalence reduced significantly (reduced by 31.3 %; p<0.05) in intervention group compared to the baseline and the control group. Zinc deficiency prevalence reduced by 46.2 % in intervention group compared to 12.5 % of control group (p<0.05). VIAMINOKID enriched with amino acids, vitamins and minerals is an effective product for the improvement of nutritional status, anemia rate, iron and zinc deficiency; growth and immune indices; reduction of infectious diseases. Therefore, VIAMINOKID is recommended for malnourished children in general and for stunted children in particular.

Aim: Cyclical Vomiting Syndrome (CVS) is a functional disorder in childhood which is increasingly being recognized. The pathogenesis of CVS remains unknown but there appears to be a link between CVS and migraine, suggestive of a central aetiology. We aimed to determine the utility of electroencephalograms (EEG) in the diagnostic algorithm of a child suspected to have CVS. Methods: We conducted a retrospective review of children who have been diagnosed with CVS in our unit since 1999 when EEGs were performed as part of the diagnostic evaluation. Results: There were 48 children with recurrent vomiting in whom the clinical diagnosis of CVS was entertained. Median age of onset was 4 years (6 months-12 years). Of the 48 patients, 27received a final diagnosis of CVS/abdominal migraine, following normal investigations which included abdominal x-ray, barium study, abdominal ultrasound and screen for inborn errors of metabolism (IEM); 21 received other diagnosis which included, non-specific abdominal colic (12), hiatal hernia (1), epilepsy (3) and IEM (1). Of the 27 with CVS/abdominal migraine, 21 had EEG features consistent with mild encephalopathy during an acute attack. Twelve of them had a repeat EEG when clinically well, and all but 1 showed normalization. Conclusions: In our series, 78% demonstrated transient electrographic changes of acute encephalopathy during the acute attacks. The use of EEG in the appropriate clinical context may provide additional evidence to support the diagnosis of CVS in patients without other aetiologies for mild acute encephalopathy.

We review the physiology of gastric acid secretion and main clinical complications of hypochloridria in childhood. It has become a common practice to treat infants and children who have suspected gastroesophageal reflux disease by using acid-suppressive medications empirically. Multiple studies in adult patients indicate an increase in risk of infection, nutritional impairment and imunological complications literature update is revisited in order to summarize acid-suppressive medications adverse effects in infants and children on long-term use.

We review the physiology of gastric acid secretion and main clinical complications of hypochloridria in childhood. It has become a common practice to treat infants and children who have suspected gastroesophageal reflux disease by using acid-suppressive medications empirically. Multiple studies in adult patients indicate an increase in risk of infection, nutritional impairment and imunological complications literature update is revisited in order to summarize acid-suppressive medications adverse effects in infants and children on long-term use.

Ascites is the pathologic fluid accumulation within the peritoneal cavity. Ascitic fluid represents a state of total-body sodium and water excess. Its Etiology includes-gastrointestinal, genitourinary, cardiac and metabolic disorders, infections, haematologic and chromosomal abnormalities. Causes neonatal ascites are different from infants and children group. Most cases of ascites are due to liver disease or due to some precipitating factors deteriorating liver functions. History of abdominal distension, increasing weight, respiratory embarrassment, and associated pedal edema associated with it. Ascites needs to be differentiated from abdominal distension due to other causes like gross obesity, gaseous distension, bowel obstruction, abdominal cysts or masses. Investigations should be directed to rule out the cause of ascites. Ascitic fluid drainage is a useful procedure to made a diagnosis and decide the line of treatment accordingly. Umbilical Hernia, Hydrothorax, Spontaneous Bacterial Peritonitis are some dreadful complications of Ascites and its underlying etiology. Its management includes non pharmacological and medical treatment. Various advanced medication and surgeries like TIPSS, Peritoneovenous Shunt, Portosystemic Shunting and Liver Transplantation will promise a better outcome.