Chronic infl ammatory bowel diseases in children – novelties in the etiology, phenotype, diagnosis and treatment

Kronične upalne bolesti crijeva (IBD) - Crohnova bolest, ulcerozni kolitis i neklasifi cirana upalna bolest crijeva sve se češće dijagnosticiraju u dječjoj i adolescentnoj dobi. Navedeno je posebice važno, jer se klinička slika, proširenost i težina bolesti uvelike razlikuju ako je bolest nastala u pedijatrijskoj populaciji. Štoviše, navedeno je to izraženije što je dob kad se bolest javila mlađa. Baš je porast incidencije ovih bolesti, ali i njihova specifi čnost u dijagnostici i liječenju, dovela do razvoja specifi čnih algoritama za dijagnostiku i liječenje IBD-a u djece. Velik je broj istraživanja koja pokušavaju odgovoriti na pitanje zašto se bolest sve češće javlja, koji su etiopatogenetski mehanizmi njezina nastanka te što je to što čini kliničku sliku i terapijski odgovor različitim u dječjoj dobi. Namjena je stoga ovog preglednog rada prikazati i raspraviti specifi čnosti IBD-a u djece, poglavito u odnosu na epidemiologiju, fenotipska obilježja i specifi čnosti dijagnostičkog i terapijskog pristupa.Chronic infl ammatory bowel diseases (IBD) including Crohn’s disease, ulcerative colitis and IBD unclassifi ed have been ever more frequently diagnosed in childhood and adolescence. This tendency is highly important because the clinical picture, spread and severity of these diseases greatly diff er when occurring in pediatric population. In particular, the younger the age at onset, the more pronounced these characteristics are. The increase in the incidence of these diseases, as well as their diagnostic and therapeutic specifi cities, has led to development of specifi c algorithms for IBD diagnosis and treatment in children. Numerous studies have been conducted in an attempt to identify the cause of the growing prevalence of IBD, the etiopathogenetic mechanisms involved, and what makes the clinical picture and therapeutic response diff erent in children. The aim of this review is to present and discuss the specifi c features of IBD in children, with special reference to the epidemiology, phenotypic characteristics, and specifi cities of diagnostic and therapeutic approach

ENTERAL NUTRITION IN CHRONIC INTESTINAL FAILURE IN CHILDREN

Opće je mišljenje da je enteralna prehrana »Condicio sine qua non« u terapiji kroničnog zatajenja tankog crijeva. Međutim, optimalan režim njezine primjene još nije točno utvrđen te kliničari rabe različite algoritme. Slijedom navedenoga, cilj je ovoga preglednog članka ujediniti trenutačno dostupne dokaze o načinu primjene enteralne prehrane u djece sa zatajenjem crijeva te iznijeti preporuke koje se temelje na tim dokazima. Prema dostupnim podacima enteralno hranjenje treba početi što ranije, kontinuiranom primjenom (sonda/stoma), postupnim povisivanjem količine i koncentracije, uz praćenje kliničkog stanja djeteta. Ako je dostupno, treba davati majčino mlijeko, inače se prednost daje elementarnom pripravku (formuli). Važno je cijelo vrijeme stimulirati peroralni unos. Adekvatnim zbrinjavanjem bolesnika mogu se znatno smanjiti posljedice kroničnog zatajenja crijeva i parenteralne prehrane, ponajprije zatajenje jetre, a enteralna prehrana u tom procesu ima neprijeporno važnu ulogu.Although the importance of enteral nutrition in the treatment of intestinal failure is well recognized, the optimal regime is still a matter of debate and clinicians often use different treatment algorithms. Therefore, the aim of this review was to present an overview of currently available evidence on the role of enteral nutrition in children with intestinal failure and to give evidence-based recommendations for clinical practice. According to the published data, enteral feeding should be initiated early after surgical resection with continuous feeding mode, gradually increasing the amount and concentration of formula based on child’s clinical condition. If available, breast milk should be recommended; otherwise the priority is given to an elemental formula. It is very important to stimulate the oral intake. Optimal care for patients with intestinal failure can significantly reduce complications, primarily severe infections and liver disease, and the role of enteral nutrition in this process is of extreme importance

INFANTILE COLIC – NEWER APPROACH TO AN OLD PROBLEM

Dojenačke su kolike od davnina poznate i jedan su od najčešćih razloga posjeta liječniku u ranoj dojenačkoj dobi. Ipak, uzrok njihova pojavljivanja i njihova patogeneza i danas su nepoznanica. Dijagnoza dojenačkih kolika postavlja se podrobnom anamnezom i kliničkim statusom. Posebnu pozornost valja obratiti na znakove i simptome upozorenja koji bi mogli upućivati na neku drugu tešku bolest. Ako anamneza i klinički pregled ne otkriju druge abnormalnosti osim neutješnog plača, daljnji dijagnostički postupci nisu potrebni. Postoji opsežan spektar predloženih terapijskih mjera, ali sve one imaju uglavnom vrlo malenu znanstveno dokazanu terapijsku učinkovitost. Stoga je cilj ovog rada bio pregledno prikazati znanstvene dokaze za različite oblike liječenja te, naposljetku, predložiti terapijski algoritam za dojenačke kolike.Infantile colic have been known for the long time and are one of the most common reasons for pediatrician’s appointment in early infancy. However, their etiology and pathogenesis are yet to be determined. Diagnosis is based on thorough medical history and physical examination. Special attention should be given to red flags or warning signs which could indicate a presence of serious illness. If no other abnormality is present, except inconsolable crying, there is no need for further diagnostic procedures. There is an extensive range of proposed therapeutic measures; however scientific evidence for all of them is scarce. Therefore, the aim of this review article is to present currently available evidence for the management of infantile colic and to provide a possible therapeutic algorithm

INFANTILE COLIC – NEWER APPROACH TO AN OLD PROBLEM

Dojenačke su kolike od davnina poznate i jedan su od najčešćih razloga posjeta liječniku u ranoj dojenačkoj dobi. Ipak, uzrok njihova pojavljivanja i njihova patogeneza i danas su nepoznanica. Dijagnoza dojenačkih kolika postavlja se podrobnom anamnezom i kliničkim statusom. Posebnu pozornost valja obratiti na znakove i simptome upozorenja koji bi mogli upućivati na neku drugu tešku bolest. Ako anamneza i klinički pregled ne otkriju druge abnormalnosti osim neutješnog plača, daljnji dijagnostički postupci nisu potrebni. Postoji opsežan spektar predloženih terapijskih mjera, ali sve one imaju uglavnom vrlo malenu znanstveno dokazanu terapijsku učinkovitost. Stoga je cilj ovog rada bio pregledno prikazati znanstvene dokaze za različite oblike liječenja te, naposljetku, predložiti terapijski algoritam za dojenačke kolike.Infantile colic have been known for the long time and are one of the most common reasons for pediatrician’s appointment in early infancy. However, their etiology and pathogenesis are yet to be determined. Diagnosis is based on thorough medical history and physical examination. Special attention should be given to red flags or warning signs which could indicate a presence of serious illness. If no other abnormality is present, except inconsolable crying, there is no need for further diagnostic procedures. There is an extensive range of proposed therapeutic measures; however scientific evidence for all of them is scarce. Therefore, the aim of this review article is to present currently available evidence for the management of infantile colic and to provide a possible therapeutic algorithm

Differences in Sexual Functioning Between Patients with Benign and Malignant Breast Tumors

The aim of this study was to compare differences in sexual behavior between patients with benign and malignant breast tumors. A total of 187 patients treated for breast tumors (benign or malignant) at the General Hospital »Po`ega«, Croatia, filled in the questionnaire between January 2001 and May 2003. Patients were asked to fill in the questionnaire one to ten years after treatment of breast tumor, while they were on their regular control visit. Deterioration in sexual life experienced 36.27% of patients with benign tumors and 51.76% of patients with malignant tumor (p<0.01). The main reason of sex life impairment in both groups was distortion of body image perception. Most of partners did not change their behavior toward women with breast tumors (48.72% for benign group and 41.82% or malignant group, p>0.05). A great amount of women in both groups felt certain change in her »body image«, but in greater extent in malignant group (41.18% vs. 25.49%), (p<0.05). From our results we can see that patients in this study do not recognize need for consultation with their physician regarding sex life after treatment of tumor (41.18% for benign and 35.29% in malignant group). It can be concluded that considerable amount of attention should be given to psychological aspects of recovery which can improve prognosis and quality of life in general

Laryngopharyngeal reflux as a cause of respiratory symptoms

Laringofaringealni refl uks je povrat želučanog sadržaja iz želuca kroz jednjak u farinks i larinks. Iako je laringofaringealni refl uks prepoznat kao važan uzrok respiratornih simptoma, dijagnostika laringofaringealnog refl uksa u djece nije jednostavna i izazov je za kliničara. U ovom radu prikazujemo 4,5-godišnjeg dječaka u kojeg je obradom ponavljajućih bronhoopstrukcija i dugotrajnog nadražajnog kašlja postavljena dijagnoza laringofaringealnog refl uksa.Laryngopharyngeal refl ux is the refl ux of gastric content into the larynx and pharynx. Although laryngohparyngeal refl ux has been recognised as an important cause of respiratory symptoms, diagnosing laryngopharyngeal refl ux in children is still challenging. We present a 4.5-year-old boy in whom we found laryngopharyngeal refl ux as a cause of chronic cough and recurrent wheezing episodes

The role of national registry in the care of children suffering from chronic infl ammatory bowel disease

Kroničnim upalnim bolestima crijeva u djece, za razliku od odraslih, svojstven je teži tijek i prošireniji oblik bolesti te negativan utjecaj na rast i razvoj. U posljednjih nekoliko desetljeća zamijećen je trend porasta incidencije kroničnih upalnih bolesti crijeva, najviše na račun Crohnove bolesti. Uzimajući u obzir sve navedeno, ali i činjenicu da se upalne bolesti crijeva u djece pojavljuju u razdoblju njihovog ubrzanog rasta i razvoja, svi pedijatrijski bolesnici iziskuju dugoročno praćenje koje je moguće jedino putem nacionalnog registra. U ovom preglednom članku raspravljamo o ulogama, ciljevima i metodama rada nacionalnih registara, koji imaju za cilj praćenje različitih varijabli u djece s kroničnim upalnim bolestima crijeva, ali naglašavamo i važnost osnivanja takvog registra u Republici Hrvatskoj.Unlike adults, infl ammatory bowel disease in children is marked by more extensive and severe course, aff ecting their future growth and development. In general, there is an increasing trend in the incidence of chronic infl ammatory bowel disease, mostly on the account of Crohn’s disease. Taking all these into consideration, but also the fact that infl ammatory bowel disease in children occurs in a period of rapid growth and development, all pediatric patients require long-term monitoring, which is only possible through national registry. In this review, we discuss the role of national registries, their aims and methods to achieve established goals, with special reference to the importance of establishing such a registry in Croatia

Poremećaji motiliteta želuca i uloga elektrogastrografije u njihovoj procjeni

SAŽETAK Poremećaji motiliteta želuca javljaju se u mnogim gastrointestinalnim bolestima djece te mogu biti dio organskih bolesti, ali i funkcijskih poremećaja. Gastrointestinalni motilitet je rezultat kompleksne interakcije mišića, mijenteričkog pleksusa, perifernoga živčanog sustava i mozga. Kontrakcije želuca su posljedica mioelektrične aktivnosti želuca. Poremećaje motiliteta želuca možemo procijeniti pomoću elektrogastrografije (EGG), neinvazivne metode koja bilježi mioelektričnu aktivnost želuca. U radu govorimo o najčešćim poremećajima motiliteta želuca u djece, indikacijama za primjenu elektrogastrografije i njezinom kliničkom značenju. Promjene EGG-a nisu specifične za određene bolesti, ali odstupanja u nalazu ukazuju na poremećaj motiliteta želuca kao dio patomehanizma nastanka nekih gastrointestinalnih poremećaja. U više studija dokazano je da je poremećaj motiliteta želuca dio patomehanizma nastanka funkcijske dispepsije, kao i da je patološki EGG prisutan i kod drugih funkcijskih tegoba, ali i kod gastroezofagealne refluksne bolesti, cikličkog povraćanja, cistične fibroze itd. Nedostatak metode je niska specifičnost nalaza. Budući da je u većini dosadašnjih studija korištena različita metodologija, potrebna su daljnja strogo standardizirana ispitivanja u djece kako bi se potvrdio klinički značaj EGG-a

THE ROLE OF TRANSITION CLINIC IN THE HEALTH CARE OF ADOLESCENTS WITH CHRONIC INFLAMMATORY BOWEL DISEASE

Upalne bolesti crijeva jesu kronične bolesti probavnog sustava koje se u trećine bolesnika klinički očituju u prvih 18 godina života. Stjecanjem punoljetnosti pedijatrijski bolesnici prelaze u zdravstvenu skrb odraslih, koja od njih zahti­jeva samostalnost i odgovornost. Adolescenti s kroničnim bolestima često nisu spremni samostalno se brinuti za svoje zdravlje. Radi osiguranja kontinuiteta zdravstvene skrbi i premošćivanja dostupnosti specijalističko-konzilijarne skrbi u odrasloj dobi nametnula se potreba za jasno strukturiranim i organiziranim prijelazom koji se naziva tranzicijskom skrbi, gdje nadzor nad bolesnikom istodobno provode liječnici pedijatrijske i internističke struke radi osposobljavanja oboljelih adolescenata za samostalno preuzimanje kontrole, bez nadzora i pomoći roditelja. Takva je skrb organizirana u mnogim razvijenim zemljama za različite kronične bolesti, a ne samo za upalne bolesti crijeva. Namjena je ovoga preglednog članka prikazati dosadašnja iskustva u organizaciji tranzicijske skrbi u razvijenim zemljama Europe te obrazložiti na koji način i zašto se to namjerava učiniti i u Zagrebu.Inflammatory bowel disease (IBD) is a chronic disease of the digestive system that occurs in one third of cases in childhood and adolescence. In the majority of patients IBD persists and relapses more or less frequently during their whole life and therefore pediatric patients, at some point, are transferred to the adult health care where autonomy and ­responsibility are required. However, adolescents with inflammatory bowel disease are mostly insufficiently competent in respect to disease specific knowledge and self-management skills what can lead to poor disease outcome. Therefore, to ­enable adolescent patients continuing healthcare and bridging the gap between pediatric and adult services, gain independence and manage disease without parental assistance, structured and organized transition (transitional care) is required, whereby for a defined period of time health care is provided by both pediatricians and internal medicine specialists. That kind of care is carried out in many developed countries through transition clinics which have been organized for patients with a wide spectrum of chronic diseases, IBD included. The aim of this review is to investigate current organizational aspects of the transition care for adolescents with chronic diseases, namely IBD, and to present the published experience in the developed European countries. The final goal is to justify organization of the transition care for IBD patients in Zagreb and to provide methods of the implementation of this kind of care in Zagreb

Tissue Expression of Proliferative Antigens (PCNA and Ki-67) in Oral Lichen Ruber Related to Clinical Status

The aim of this study was to determine the expression intensity of PCNA and Ki-67 tissue antigens related to pathologically modified oral mucosa in OLR lesions, and to determine the reaction intensity of these antigens in individual clinical forms, i.e. lichen ruber planus (LRP) and lichen ruber erosivus (LRE) comparing the reaction intensity with the inflammation grade and the degree of hyperkeratosis in lesions of 30 patients. Control group included patients (n = 15) with oral leukoplakia simplex. Tissue antigens were observed by immunohistochemical analysis using APAAP and LSAB methods. The reaction on tested tissue antigens was focal positive and of mosaic type. The reaction of the PCNA antigen was intensely high in OLR lesions regardless on the clinical form of the lesion. The reaction intensity positively correlated with the inflammation grade and the degree of hyperkeratosis in lesions. The reaction on Ki-67 tissue antigen ranged from low to moderately high intensity. Intensely high reaction was observed in lesions of lichen ruber erosivus. The reaction positively correlated with the inflammation grade and the degree of hyperkeratosis in lesions. Observed modified reaction of analyzed tissue antigens related with individual clinical forms of OLR might be the indicator of transformed nature of these lesions