Crohn’s disease and ulcerative colitis have become increasingly common in recent years, including in children and young people. Atypical symptoms may occur in both conditions: these include isolated impairment of linear growth or presentation with extra-intestinal manifestations. Inflammatory bowel disease (IBD) is not a frequent cause of bleeding in Cuba and the Caribbean. 15 years ago we published another case of IBD in Cuban infant with Crohn’s disease, Amebiasis and Shigellosis.¹ At that time, our aim was to increase the awareness among pediatricians that CD can affect all age groups. The epidemiology of IBD in the Caribbean has not been well studied and the disease has not been well described in infants and young children. Now we alert pediatricians in the area of the Caribbean and other developing countries to be aware of red flags that suggest IBD such as growth failure or slowed growth, weight loss, bleeding and extra intestinal signs. Another aim is to avoid misdiagnosis in a clinical setting in which intestinal infections are endemic. We also emphasize the need to maintain clinical suspicion and diagnose IBD before complications set in. The patient from Venezuela 2 years ago had a fall and hit himself in the right knee with inflammation of the cartilage that did not improve with orthopedic treatment. He had a progressive loss of his capacity to walk. He had a second fall with a fracture of the right wrist. A biopsy of the right knee and wrist showed synovitis, He started with bloody diarrhea in number of 15 to 20 a day of small volume accompanied with abdominal cramps. He also had pain in the elbows, knees, ankles and hips without local signs of inflammation. Weight 54 Kg. Hemoglobin 11 gr.; Hematocrit 28; Sedimentation rate 110; C-Reactive Protein 35.7; Total protein 70.6 gr/l; Albumin 31 gr/l. At Colonoscopy he had multiple deep ulcers with inflammation at the border. In the biopsy, erosion of the epithelium, branching and distortion of the glands with crypt abscesses. Pediatricians should be aware of the emergence of Crohn’s Disease in the Caribbean population. Failure to make a diagnosis may impact on their growth and development. IBD should be suspected in the presence of red flags. Sometimes is very difficult to classify the disease as CD or UC.

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Background: In spite of early surgical intervention of choledochal cysts to prevent adverse outcomes, a few still develop significant morbidity and mortality. Determining which factors affect outcome will aid in the management and care of patients with choledochal cysts. Objective: This study aims to determine the clinical profile of patients with choledochal cyst and determine the factors affecting its outcome. Methodology: A retrospective cohort study of patients with choledochal cysts 0-18years old was done. Clinical data were correlated with the outcome which include immediate postoperative complications, portal hypertension and mortality. Results: A total of 77 patients with choledochal cyst were studied. Majority were >2-5 years old at 31% (n=24/77). The mean age at onset of symptoms was at 2.75 years old. The most common cyst type was type I at 79% (n=61) followed by 16% type IV (n=12), 3% type III (n=2) and 1% type V (n=1). There was no type II cyst. Age had a significant association with the clinical manifestations with jaundice, abdominal distention and hepatosplenomegaly found in less than 2 years old and abdominal pain in 5-7 years old (P≤0.05). Classic triad was significantly associated with cyst type III (50%) and IV (20%). 91% underwent surgery (n=70/77) with cyst excision and hepaticoenterostomy being the most commonly used (n=51/77, 66%).17% had immediate postoperative complications (n=12/70) with infection (n=7/12) being the most common complication significantly found in less than 2years old (n=5/7). 13% had portal hypertension (n=10/77) significantly found in those whose onset of symptoms was less than 2 years old (n=9/10) and Type I cysts (n=6/10). 6.5% died (n=5/77) and was significantly highest in those whose onset of symptom was less than 2 years old (n=4/5). Conclusions: Particular attention to diagnose, provide timely intervention and anticipatory care of possible complications should be given to infants with choledochal cysts because they were significantly associated with immediate postoperative complication particularly infection, development of portal hypertension and mortality. Recommendations: It is recommended to include a bigger population size and follow-up studies to monitor long-term complications of patients with choledochal cysts.

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Aims: 16 year old boy withrecessive dystrophic epidermolysisbullosa and previous history of esophageal strictures presents with progressive dysphagia and hematemesis. Patient was admitted to hospital to determine cause of hematemesis. Methods: Patient underwent endoscopy using Olympus GIF-XP 160 endoscope. Results: Endoscopy revealed active esophagitis and multiple blood clots. A high-grade esophageal stricture was noted at level 35cm from incisors, in which the endoscope (5.9 mm diameter insertion tube) could not pass. Endoscopy two days later revealed an esophageal diverticulum and bifurcation located 35cm from the incisors. Instilling a small amount of water revealed a blind ended sac on the left side and a lumen leading to the stomach on the right side (see image). The true esophageal lumen was dilated using a 6-7-8mm CRE™ Wire guided Balloon Dilator (Boston Scientific). He was treated with nutritional therapy (TPN, then enteral feedings following gastrostomy placement by interventional radiology), sucalafate, ranitidine, and zinc. Three subsequent endoscopic dilationsincreased the true lumen diameter to 15 mm. Follow-up esophagram revealed a notably smaller esophageal diverticulum and a small amount of mediastinal air, suggesting microscopic esophageal perforation treated conservatively with IV antibiotics. Conclusion: EGD three months later showed no residual esophageal stricture and complete resolution of the esophageal diverticulum. Balloon dilation along with management of nutrition have been shown to be effective and safe methods of treating esophageal strictures in children, and in this case has been effective in managing an esophageal diverticulum.

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Ambulatory pH-metry has long been one of the main diagnostic tools used for the diagnosis of gastroesophageal reflux disease (GERD) in adults and is also increasingly used in children. The aim of this study is to describe the clinical data of children, the indications and results of pH-metry in a Moroccan unit. Methods: Over five years, 78 children underwent pH-metry in our unit. We analyzed their clinical data and their examination results. Results: 78 children underwent pH-metry were included. 48,7% are boys and 51,3% are girls. The mean age is 8.2 years (2-17 years).53 pH-metry (78,2%) were realized in children with respiratory symptoms. Other indications are represented by assessment of GERD in 8 patients, vomiting in 4 patients and ear-nose-throat symptoms in 3 patients. The mean recording time was 23 hours. 28patients (35,9%) were diagnosed with GERD and 49 patients (62,8%) had a normal pH-metry. For patients with GERD, the mean time with reflux was 156,7minutes and average EAO was 9,1%. It was noted a diurnal and nocturnal GERD in 10 cases (35,7%), a diurnal GERD in 10 cases (35,7%) and a nocturnal GERD in 8 cases (28,6%). The respiratory symptoms were the main indication of pH-metry represented in 61 children (78,2%). 34,4% had a pathological GERD with a mean De Meester index of 37,3. Conclusion: Ambulatory esophageal pH monitoring is the “gold standard” for diagnosis of acid GERD. In our series, pH-metry assess the diagnosis of pathological GERD in a third of children with respiratory symptoms.

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Eosinophillic ascites is a severe form of eosinophilic gastroenteritis presenting as unexplained ascites with normal liver function tests. Our patient had a window period of spontaneous remission making the diagnosis difficult during the early stage. Eosinophilic gastroenteritis can present in children as nonspecific gastrointestinal (GI) symptoms such as diarrhoea and abdominal distension, making it clinically indistinguishable from other causes of chronic diarrhoea.

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Objective: In view of the paucity of information in the literature, this article aims at providing a simplified and yet state-of-the-art approach for the management of chronic diarrhea in children in resource-limited settings. Resource and Design: Systematic review of literature supported with our own experience spread over four decades. Salient Features: Etiology of chronic diarrhea, implying diarrhea of 2 weeks or more, usually secondary to a malabsorptive cause, is exhaustive. However, in clinical practice in resource-limited settings, only a few conditions such as malnutrition, intestinal infestations, cow’s milk protein allergy (CMPA), celiac disease, cystic fibrosis and endemic tropical sprue monopolize the situation. Diagnostic evaluation needs to be step-by-step with good history-taking and clinical examination followed by select investigations depending on the individual merits of the cases. High index of suspicion is a forerunner in detecting CMPA. Mild to moderate steatorrhea is usually indicative of malnutrition, iron-deficiency anemia or intestinal parasites (L. giardia, A. duodenale). Gross steatorrhea is due to celiac disease, cystic fibrosis or tropical sprue. In cystic fibrosis, despite significant steatorrhea, D-xylose test is usually normal. Conclusion: A good idea about the pattern of etiology of chronic diarrhea/ malabsorption in different regions together with an individualized approach and an adequate follow-up is likely to resolve a large majority of the diagnostic as well as therapeutic problems. Treatment depends on the etiology of chronic diarrhea.

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Objective: The aim of this study was to determine fecoprevalence of Helicobacter pylori infection and find out association between Helicobacter pylori infection and its determinants among asymptomatic 6 - 12 years old school children. Methods: This study was a school-based cross-sectional analytic study involving 90 asymptomatic 6 -12 years old school children in No. (2) Basic Education High School (BEHS), Chan-Aye-Thar-San township, Mandalay. Age, gender distribution and determinants of Helicobacter pylori infection were studied. Detection of H. pylori stool antigen was performed by using monoclonal stool antigen test kit (SD BIOLINE, Korea). The fecoprevalence of H. pylori infection was enumerated. Association between Helicobacter pylori infection and its determinants was analysed. Results: Overall fecoprevalence of Helicobacter pylori infection among asymptomatic school children was 17.8%. The most prevalent age group was 6-8 years (24.2%) followed by >10-12 years (18.8%) and >8-10 years (8%). There was no significant gender preponderance in all age groups. Higher frequency of fecopositivity in children living in overcrowded houses and those who drink non-purified water were noted (p<0.001). Eleven (28.9%) from low socioeconomic status and 5 (9.6%) from middle socioeconomic status were noted to be fecopositive. There was no significant association between domestic water source and H. pylori infection. Conclusion: Helicobacter pylori infection is prevalent in asymptomatic school children in this study. Low socioeconomic status, overcrowding and drinking non-purified water were significant determinants of H. pylori fecoprevalence. This findings may lead to key insights into the transmission of H. pylori infection in developing countries and method of reducing rates of transmission of infection.

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Rationale: Tuberculosis remains to be one of the major health problems among Filipinos. Abdomen remains to be a major extra pulmonary site and diagnosis is indeed challenging. Knowing the clinical profile on gastrointestinal tuberculosis is important and relevant to further strengthen our fight against tuberculosis. Objectives: The study aims to determine the epidemiologic and clinical profile of gastrointestinal tuberculosis among children aged 0-18 years in a tertiary hospital. This research describe the demographic and clinical characteristics of patients diagnosed with gastrointestinal tuberculosis and identify factors associated with the development of gastrointestinal tuberculosis. Methodology: This is a retrospective study of children 0-18 years old diagnosed and admitted with abdominal tuberculosis in a tertiary hospital from January 2003 to December 2012. Frequencies and percentages of the clinical characteristics of subjects were determined. The measures of central tendency were calculated. Cross tabulation and Chi-square were also performed. Results: Out of the 325 subjects, twenty two subjects (9%) had abdominal tuberculosis. Male:Female ratio was 1:1.2. Nine (41%) subjects were above 15 years of age (12.37 + 5.06). Malnutrition was present in 20 (91%) patients. The most common clinical features were abdominal pain (77%), abdominal distention (54%), fever (45%) and weight loss (45%). Hepatomegaly were seen in 12 patients (54%). Most common site of abdominal TB identified among subjects was the liver (36%). More than half of the patients had anemia and leucocytosis which was seen in 64% and 59% of subjects. Two factors were identified with association with gastrointestinal tuberculosis: absence of Bacillus Calmette-Guerin (BCG) vaccination and positive history of exposure with tuberculosis. Conclusion: Extreme vigilance in suspected abdominal TB is the key to its successful diagnosis. Among patients with TB, nine percent (9%) was diagnosed with gastrointestinal tuberculosis. BCG vaccination and history of exposure were seen to have an association with gastrointestinal tuberculosis. Thus, children who have history of exposure to TB, no history of BCG vaccination, malnourished and presenting with abdominal pain, abdominal distention, and fever with laboratory findings of anemia and leucocytosis should be worked up for gastrointestinal tuberculosis.

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Background: The living donor liver transplantation (LDLT) surgery exposes the healthy donors to the risks associated with a major surgical procedure. The impact that this surgery has on the health-related quality of life (HRQOL) of a donor is an important aspect of outcome. Emerging LDLT centers need to be cognizant of the impact of this major procedure on the donor’s quality of life (QOL). The aim of this review is to summarize the current literature on this aspect of LDLT outcomes. Methods: Pubmed search was performed and relevant articles were retrieved Results: The physical domains of the QOL were significantly worse within first 3 months after surgery but return to baseline at 6 months in the majority of patients. The factors that have consistently been reported to impact the donor QOL include donor age, occurrence of prolonged post-operative complications in the donors, unfavorable recipient outcomes and donation decision made prior to informed consent. The type of allograft does not significantly affect the donor QOL. Despite some degree of financial strain a majority of donors perceived donation as a positive experience with no regrets. Conclusion: Overall the benefits to the LDLT recipients outweigh the risks to the donors. The post donation care for certain.

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It is well accepted, that any effect on the health of mother is going to affect the health of the fetus. The first two years of life and nine months in utero, the so called “1000 days” to prevent child malnutrition are the critical window period. Appropriate nutritional practices play a pivotal role in determining health and development of children. The Kangaroo Mother Care method is a standardize protocol based care system for preterm or LBW infants and is based on skin to skin contact between baby and mother. Breastfeeding was consistently associated with higher performance in intelligence tests, with a pooled increase of intelligence quotient points. It is every child’s basic human right to receive a healthy feeding and thereby undergo a normal growth. It is every adult’s ethical, moral, and legal duty to ensure optimal feeding practices and a normal growth and development for their children. WHA resolutions, endorses the comprehensive implementation plan on maternal, infant and young child nutrition and urges strengthening nutrition policies so that they comprehensively address the double burden of malnutrition. “Protest breastfeeding” seems to be a novel approach or way to promote the breastfeeding and to highlight the Mother and Child right issues in the 21st Century. WHO and UNICEF jointly declared “Where it is not possible for the biological mother to breastfeed, the first alternative, should be the use of human milk from other sources. There is proliferation of sophisticated marketing of unhealthy food to children to continue in the midst of a childhood obesity epidemic.

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Background: Obesity has reached an epidemic proportions world-wide. Its risk factors are poorly studied, especially among children in developing countries such as Morocco. Objectives: The aim of this study was to identify the associations between socioeconomic status, food consumption, dietary diversity score and BMI classes in a sample of preschool children in Kenitra city. Methods: A cross-sectional study was conducted on 338 of preschool children aged 5 to 6 years in urban area of Kenitra, North West Morocco. The weight and height were measured with standard method and the socio economic factors and nutritional data were collected using an appropriate questionnaire completed by parents. Results: It reveal an independence between some factors of the socio-economic status (the level of education of mother; the function of the father and mother; number of children in the family; sibling rank; housing nature, type of habitat) and staturo-ponderal status by gender according to body mass index (BMI) for age (p>0.05), the only associations were found between the father’s educational level and nutritional status among boys (p = 0.033). Conclusions: SES impacts well-being at multiple levels, including both family and children. In our study, a strong relationship between educational level of father’s and childhood obesity specifically among boys was found.

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Aim: Gastric hemangiomas (GHs) are rare vascular tumors representing an extremely uncommon cause of gastrointestinal bleeding in children. Up to now, only few cases have been reported in pediatric literature. Methods: The Authors report the case of a 6-year-old-girl with GH presenting with hypovolemic shock due to acute gastro-intestinal bleeding. Focusing on diagnostic and therapeutic assessment, a detailed systematic review of pediatric literature on GH is provided. Results: In our patient a combination of abdominal ultrasound, endoscopy and CT scan were helpful in reaching a diagnosis. Gastric antrum resection and Billroth’s I gastro-duodenal anastomosis was curative. Conclusions: A not invasive diagnostic work-up, including ultrasound as first line examination should be performed in every previous healthy children presenting acute and/or chronic GI bleeding. Once diagnosis of GH is made the appropriate endoscopical and/or surgical treatment should be accomplished as early as possible to avoid severe and potentially life-threatening complications.

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Ventriculoperitoneal (VP) shunt is one of the most common treatments for diverting the cerebrospinal fluid (CF), but it is accompanied by many complications that protrusion through anus is one of the rare ones, a 5 year old baby girl presents with excessive irritability and anorexia to the outpatient department of surgery department, French Medical Institute for Children, and mother of child was complaining from protrusion of shunt through anus two days ago, after performing laperatomy distal end of shunt found in the sigmoid colon. So total removal of shunt is done for this baby and planed for re-shunting after a month.

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A case of acute liver failure who lost five of his family members due to consumption of some food stuff made at home. Autopsy of viscera of the deceased revealed organophosphorous. Only one member who presented as ALF survived. A 33yr old male presented with reeling of head and vomiting after 8-10 hrs of consuming some home made food. He was treated out side for 1 day and shifted to Apollo Hospital Bhubaneswar due to deterioration of condition. On examination he was conscious but disoriented and icteric, hemodynamics and urine output was normal. Investigations revealed serum billirubin 6.3/2.4mg/dl,ALT-10,225u/l,AST-12,865u/l,PT-13.1/66.1sec, INR-8.89, TLC-5,000/cmm, Creatinine:1.1mg, Serum Ammonia 138mmol/l. Other infective markers for viral hepatitis, dengue, malaria and leptospira were negative. Patient went to encephalopathy within an hour. In view of Jaundice, Coagulopathy and encephalopathy diagnosis of ALF was made and Patient was managed with ICU care, head end elevation, mannitol, Inj N-acetyl cystine, Inj vitamine K, IV fluids, IV antibiotics and other supportive treatment. Possibility of need of liver transplantation was discussed but family expressed inability to afford. The patient was not bleeding hence FFP not given. However with conservative management he started improving after 72 hrs and fully recovered within 10days. Investigations: LFT, Infective markers for viral hepatitis, dengue, malaria and leptospira. Diagnosis: Acute Liver Failure

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