1.

1                     Carlo JT, DeMarco D, Smith BA, Livingston S, Wiser K, Kuhn JA, Lamont JP. The utility of capsule endoscopy and its role for diagnosing pathology in the gastrointestinal tract.  Am J Surg. 2005 Dec;190(6):886-90.

Department of Surgery and Gastroenterology, University Medical Center, 3409 Worth Street, Suite 420, Dallas, TX 75246, USA.

BACKGROUND: Capsule endoscopy (CE) is a new device that enables visualization of areas of the small bowel that were previously inaccessible through other noninvasive procedures. The purpose of this study is to evaluate this new diagnostic tool and its efficacy in finding occult GI tract pathology. METHODS: A single-institution retrospective review was completed on patients undergoing CE from January 2002 to September 2004. Data evaluated included indications for CE, results of previous studies, CE findings, and complications of the CE study. RESULTS: A total of 702 CE studies in 652 patients were performed during the study period. Suspicious GI bleeding presenting as anemia, guaiac positive stools, or history of gross bleeding were the most common reasons to perform CE (75.8%). Other indications included abdominal pain (11.5%), diarrhea (3.1%), or others (9.5%). In studies performed for GI bleeding (N = 532), a source was found in 49.3% of CE studies. Arteriovenous malformation (AVM) was the most common reported finding (43.9%), followed by ulcer (24.1%), colon or gastric pathology (14.1%), mass/tumor (9.1%), and stricture (6.9%). Patients with abdominal pain (n = 81) had findings 46.9% of the time including edema/ulcer (47.4%), stricture (10.5%), mass/tumor (26.3%), gastric pathology (10.5%), AVM (2.6%), or sprue (2.6%). Patients with diarrhea (n = 22) had findings 45.5% of the time including edema/ulcer (75%), mass/tumor (12.5%), or sprue (12.5%). A total of 66 patients underwent operative exploration after a CE study at this institution either because of the observed findings or for other reasons. There were 12 (1.7%) CE studies in which the capsule was retained and required surgical removal. Pathology at the retention site included benign strictures or adhesions (n = 9, 75%), Crohn's stricture (n = 1, 8.3%) carcinoid tumor (n = 1, 8.3%), and villous adenoma (n = 1, 8.3%). CONCLUSIONS: CE is an accurate study to locate abnormalities in the GI tract that may have either been missed by previous diagnostic studies or cannot be observed through other non-invasive means. When used for diagnostic challenges such as GI bleeding with no apparent source, CE can be helpful in guiding surgical decisions in patients and thus should be integrated as part of the diagnostic workup.

2.

1                     Gadewar S, Fasano A. Current concepts in the evaluation, diagnosis and management of acute infectious diarrhea. Curr Opin Pharmacol. 2005 Dec;5(6):559-65.

Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Maryland School of Medicine, 22 S. Greene St. N5W70, Baltimore, Maryland 21201-1595, USA.

Despite recent advances in our understanding of the pathogenesis of enteric diseases, acute infectious diarrhea remains a major cause of morbidity and mortality worldwide. Infection is the most common cause of acute diarrhea. Some causes of infectious diarrhea also result in serious long-term sequelae such as hemolytic uremic syndrome, Guillain-Barre syndrome and malnutrition. A better understanding of bacterial pathogenesis has grown increasingly important because of the emergence of new pathogens and the growing problems of resistance among enteric pathogens and other enteric flora. Non-antimicrobial approaches to therapy have become increasingly important with the emergence of serious antimicrobial resistance, such as vancomycin-resistant enterococcal colonization of the gastrointestinal tract. Finally, new understanding of how intestinal bacteria cause disease is revealing that enteric infections might trigger damage to epithelial cells or the intestinal barrier, or disrupt intestinal barrier and absorptive function (without necessarily causing overt diarrhea); thus, enteric infections might be far more important as emerging causes of malnutrition than has been previously appreciated. Therefore, diarrhea is both a cause and an effect of malnutrition. Treatment in most cases of bacterial and viral diseases consists of correcting fluid loss and electrolyte imbalance by oral or parenteral rehydration. Prevention of enteric illness by virtue of improved hygiene and provision of sanitation and water treatment is impractical in most developing countries, where morbidity and mortality rates are highest. For this reason, development of vaccines against the most important gastrointestinal infections remains a high priority.

3.                   Juca CA, Rey LC, Martins CV. Comparison between normal saline and a polyelectrolyte solution for fluid resuscitation in severely dehydrated infants with acute diarrhoea. Ann Trop Paediatr. 2005 Dec;25(4):253-60.

Emergency Unit, Hospital Infantil Albert Sabin, Fortaleza, Brazil.

The optimal intravenous solution for rehydration of infants and children with severe dehydration is debated. AIM: The aim was to compare the efficacy of a polyelectrolyte solution (group PS) with sodium chloride 0.9% solution (group NS) in rapid parenteral rehydration of severely dehydrated infants with acute diarrhoea. METHODS: Primary outcomes were volume and time to hydration. Secondary outcomes were urea, creatinine, electrolytes, glucose, arterial pH and bicarbonate levels. Patients were assigned randomly and openly to one of the two treatment groups. Severe dehydration was defined as one or more of the following associated with any other sign of dehydration: depressed consciousness, a weak or absent pulse or capillary refill time > 10 sec. Peripheral blood samples for chemical pathology were collected before and after rapid fluid therapy. The mean age of the 36 enrolled infants was 9.1 mths. All had depressed consciousness or severe hypotension/shock. The fluid infusion rate was 50 ml/kg/hr until haemodynamic stability was restored (absence of severe hypotension and two urine emissions). Fluid volume, time to rehydration and weight before and after rehydration were recorded. RESULTS: All infants recovered full pulse within 1 hr; most had a better level of consciousness or capillary refill <3 sec. Group NS (15 infants) showed (before and after treatment, respectively) a decrease of plasma potassium (3.4 to 3.1 mmol/L, p=0.07), bicarbonate (13.3 to 12.2 mmol/L, p=0.01) and glucose (8.2 to 5.8 mmol/L, p<0.01). Group PS (21 infants) showed a decrease of potassium (4.4 to 3.2 mmol/L, p<0.01) but an increase in bicarbonate (11.6 to 13.3 mmol/L, p<0.01) and glucose (11.4 to 14.8 mmol/L, p=0.08). CONCLUSION: Polyelectrolyte solution was as effective as normal saline on volume expansion and better for correcting acidosis.

3.                   Shamir R, Makhoul IR, Etzioni A, Shehadeh N. Evaluation of a diet containing probiotics and zinc for the treatment of mild diarrheal illness in children younger than one year of age. J Am Coll Nutr. 2005 Oct;24(5):370-5.

Division of Pediatric Gastroenterology and Nutrition, Meyer Children's Hospital of Haifa, Israel. shamirr@netvision.net.il

OBJECTIVES: Supplementation of probiotics and supplementation of zinc during acute gastroenteritis in children have been shown to exert positive effects on diarrhea duration and severity. Our aim was to evaluate a new diet enriched with zinc and probiotic bacteria in the treatment of acute gastroenteritis in young children. METHODS: In a double blind prospective study, 65 children aged 6-12 months were randomized to receive 6 x 10(9) colony forming units of Streptococcus thermophilus, Bifidobacterium lactis, Lactobacillus acidophilus (2 x 10(9) of each strain), 10 mg of zinc/day, and 0.3 grams of fructo-oligosaccharides in the supplemented group (n = 33) or placebo (n = 32), given in a soy protein based rice cereal. For each child, age, sex, weight, degree of dehydration, the presence of fever or vomiting, stool frequency and consistency were recorded daily until diarrhea resolution. RESULTS: Diarrhea resolution occurred after 1.43 +/- 0.71 days in the supplemented group vs. 1.96 +/- 1.24 in the control group (p = 0.017). In the subset of children who presented with vomiting, time to vomiting resolution was 0.27 +/- 0.59 vs. 0.81 +/- 0.91 days in the supplemented and control groups, respectively (p = 0.06). On day 3, there was only 1 child with watery stools in the supplemented group versus 10 children in the control group (p = 0.02). CONCLUSIONS: In our series, the feeding of a cereal containing Streptococcus thermophilus, Bifidobacterium lactis, Lactobacillus acidophilus and zinc, reduced the severity and duration of acute gastroenteritis in young children. However, whether this combination is better than either the addition of probiotics or zinc alone is yet to be determined.