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Joseph F Fitzgerald

Publications and source records attributed to Joseph F Fitzgerald.

At least 19 recordsLinked to original sources
PubMed2006

Clinical presentation of patients with eosinophilic inflammation of the esophagus.

BACKGROUND: Allergic eosinophilic esophagitis (AEE) is defined by a dense infiltrate of eosinophils within the esophageal mucosa and the absence of pathological gastroesophageal reflux. OBJECTIVE: To characterize a pediatric population with AEE to determine if AEE can be diagnosed based on history; to compare patients with varying degrees of esophageal eosinophilic inflammation to determine if moderate esophageal inflammation is part of a continuum of AEE. DESIGN: Medical records of 112 patients with eosinophils on esophageal biopsy specimens were reviewed. Patients were grouped according to eosinophils per high power field (eos/hpf): group 1 (1-5 eos/hpf, n = 31), group 2 (6-14 eos/hpf, n = 13), and group 3 (> or =15 eos/hpf, n = 68) and compared. SETTING: University Children's Hospital. PATIENTS: Children and adolescents with eosinophils on esophageal mucosal biopsy specimens. INTERVENTIONS: Analysis of clinical information. MAIN OUTCOME MEASUREMENTS: Clinical characterization of patients with esophageal eosinophilia. RESULTS: There was no significant difference in patient demographics. Patients in groups 2 and 3 had multiple food allergens identified. Patients in group 3 with a positive type I allergic response were significantly younger than those with a negative response (mean, 4.6 years old vs mean, 8.5 years old; P = .0065). In group 2, 3 of 13 patients responded histologically to acid-suppressive therapy, whereas 6 patients had improved histology with corticosteroids; 4 of these 6 patients had not responded histologically to acid-suppression. LIMITATIONS: Retrospective study. CONCLUSIONS: History and clinical presentation were not useful in predicting the severity of histologic esophageal inflammation in this cohort. Patients with moderate esophageal eosinophilia (group 2) exhibited a variable response to medical therapy.

Adolescent↗
PubMed2006

Cytokine expression in normal and inflamed esophageal mucosa: a study into the pathogenesis of allergic eosinophilic esophagitis.

OBJECTIVES: We studied the expression of cytokines and inflammatory cells in normal and inflamed esophageal mucosa of children with the aim of furthering our understanding of the pathophysiology of allergic eosinophilic esophagitis (AEE). METHODS: Controls and AEE patients (>or=15 eosinophils/high-power field on esophageal mucosal biopsies) between the ages of 1 and 18 years were recruited. Esophageal biopsies were obtained for histologic examination, immunohistochemical studies, and cytokine analysis. RESULTS: Eight controls (4 males; mean age 9.99 years) and 11 AEE patients (8 males; mean age 7.15 years) were studied. mRNA expression of interferon (IFN)-gamma, interleukin (IL)-4, IL-5, IL-13, eotaxin-1, eotaxin-2, eotaxin-3, and RANTES was studied. IFN-gamma and IL-5 expressions were significantly up-regulated in AEE patients compared with controls. Expressions of IL-4 and IL-13 were similar between AEE patients and controls. Eotaxin-1 expression was significantly up-regulated in AEE patients, whereas eotaxin-2 was up-regulated in controls. Expression of RANTES and eotaxin-3 was similar between the two groups. There was increased staining for mast cells in AEE patients compared with controls. CONCLUSIONS: Our data suggests that AEE is primarily an IL-5 selective TH2 response, with a possible TH1 component, and a differential role of eosinophilic chemoattractants. The role of mast cells in the pathogenesis of AEE needs additional study.

Adolescent↗
PubMed2006

Nocturnal acid breakthrough in children with reflux esophagitis taking proton pump inhibitors.

OBJECTIVES: We aimed to determine if nocturnal acid breakthrough occurs in children receiving proton pump inhibitors for reflux esophagitis, and to compare the healing of esophagitis in children with nocturnal acid breakthrough receiving proton pump inhibitors +/- ranitidine. METHODS: This is a prospective, double-blind study. Endoscopic and histologic esophagitis were scored 0-4 and 0-3, respectively. Patients were treated with a proton pump inhibitor twice daily and esophagogastric pH monitoring was performed at week 3. Patients with nocturnal acid breakthrough were randomized. One group received ranitidine and the other received placebo at bedtime in addition to proton pump inhibitor therapy. Endoscopy was performed on all patients (with pH monitoring on patients with nocturnal acid breakthrough) during the 17th week of therapy. RESULTS: We enrolled 18 patients, ages 1 to 13 years (mean = 10.3 years). Mean baseline endoscopic and histologic scores were 3.1 +/- 1.4 and 1.8 +/- 0.7, respectively. Mean dose of proton pump inhibitor was 1.3 mg/kg +/- 0.6. Nocturnal acid breakthrough was documented in 16/18 (89%) patients. Seven patients received ranitidine and 9 received placebo. The reflux index improved: mean of 14.3 at baseline, 2.0 at week 3 (P = 0.0001), and 5.1 at week 17 (P = 0.09). Nocturnal acid breakthrough persisted in 9/12 (75%) patients, 3 of whom received ranitidine at bedtime. Esophagitis improved in all patients following therapy: mean endoscopy and histology scores were 1.6 +/- 1.8 (P = 0.0020) and 0.8 +/- 0.9 (P = 0.0013), respectively. Symptoms significantly improved from a mean score of 2.0 at baseline to 0.4 at week 17 (P = 0.0001). CONCLUSIONS: Nocturnal acid breakthrough is common in pediatric patients treated with proton pump inhibitors. Reflux index remains normal in spite of nocturnal acid breakthrough. Symptoms and esophagitis continued to improve during therapy in spite of nocturnal acid breakthrough. There appears to be no additional benefit to supplementation with ranitidine at bedtime.

Adolescent↗
PubMed2006

Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis.

OBJECTIVES: Basal cell hyperplasia of the esophageal epithelium is a frequent finding in children with histological evidence of esophagitis. The aim of this study was to compare the severity of basal cell hyperplasia in gastroesophageal reflux vs eosinophilic esophagitis. METHODS: A cohort of pediatric patients who underwent same-day endoscopy with esophageal biopsy and 24-hour esophageal pH monitoring was divided into groups based on endoscopic and pH monitoring findings. Basal cell hyperplasia was defined as normal (< or = 25% of esophageal epithelial height), mild (26%-50%), moderate (51%-75%) or severe (> 75%). The severity of basal cell hyperplasia in patients with abnormal pH monitoring studies, both with and without endoscopic abnormalities of the esophagus, was compared with the severity in patients with eosinophilic esophagitis. RESULTS: Twenty-seven children with abnormal pH monitoring were identified. Of these 27 children, 11 had endoscopic findings consistent with reflux esophagitis. Thirty patients with eosinophilic esophagitis were identified. Patients with eosinophilic esophagitis had significantly increased severity (P < 0.001) of basal cell hyperplasia (87% severe, 3% moderate, 3% mild, 7%, normal) than patients with abnormal esophageal pH monitoring alone (11% severe, 4% moderate, 15% mild, 70% normal) or in combination with endoscopic abnormalities (18% severe, 9% moderate, 18% mild, 55% normal). CONCLUSIONS: Basal cell hyperplasia is more severe in children with eosinophilic esophagitis than in those with reflux esophagitis. The finding of basal cell hyperplasia is a powerful clue into the underlying etiology of pediatric esophagitis and, along with epithelial eosinophil count, can be used as information to guide therapy.

Child↗
PubMed2006

Patient-reported symptoms after pediatric outpatient colonoscopy or flexible sigmoidoscopy under general anesthesia.

OBJECTIVES: Endoscopic examination of the colon is indicated in children with diarrhea, hematochezia and suspected inflammatory bowel disease. The aim of this study was to determine the rate of patient-reported symptoms after colonoscopy and flexible sigmoidoscopy under general anesthesia in children. PATIENTS AND METHODS: This prospective study included patients 18 years of age and younger who underwent colonoscopy or flexible sigmoidoscopy during a 1-year period. At least 30 days after the endoscopy, an interview was conducted regarding symptoms after colonoscopy or flexible sigmoidoscopy. RESULTS: Eighty-eight children were eligible, and 68 (77%) were available for follow-up. Ten (15%) reported symptoms after their endoscopy. The most common symptoms reported were diarrhea, excessive gas and sore throat. The frequency of reported symptoms was similar between colonoscopy and flexible sigmoidoscopy. The frequency of symptoms was not affected by intubation of terminal ileum, polypectomy or the number of prior colonoscopies or flexible sigmoidoscopies. CONCLUSIONS: Outpatient colonoscopy and flexible sigmoidoscopy under general anesthesia are well tolerated by children. A minority of children reports mild symptoms that spontaneously resolve.

Adolescent↗
PubMed2006

Cysteinyl leukotriene levels in esophageal mucosal biopsies of children with eosinophilic inflammation: are they all the same?

OBJECTIVES: Allergic eosinophilic esophagitis (AEE) is characterized by intense eosinophilic inflammation of the esophageal mucosa. Cysteinyl leukotrienes (CysLT) are eosinophil chemoattractants. We studied CysLT levels in esophageal mucosa of children with AEE and controls. METHODS: CysLT levels (pg CysLT/microg protein) were quantified by Enzyme-linked Immunosorbent Assay (ELISA) on endoscopically obtained esophageal mucosal biopsies. RESULTS: Twelve children with AEE (eight boys, mean age 6.6 yr, range 1.0-14.5 yr) and 10 controls (six boys, mean age 9.56 yr, range 1.08-15.08 yr) were enrolled. None were on anti-LT or corticosteroid therapy. All controls had histologically normal mucosal biopsies of the esophagus, stomach, and duodenum. Patients with AEE had intense eosinophilic inflammation of the esophageal mucosa (mean 39 eosinophils/hpf, range 15-70 eosinophils/hpf) and a normal 24-h pH probe study. CysLT levels were similar between the two groups: mean levels were 12.44 (median 10.87, range 2.54-28.29) in AEE patients and 9.52 (median 9.26, range 1.71-21.64) in controls. CysLT levels did not correlate with the degree of esophageal eosinophilic inflammation. Incidentally, five patients with eosinophilic gastroduodenitis, in addition to esophagitis, were enrolled; their CysLT levels were statistically higher than those of controls. CONCLUSIONS: This is the first study to examine CysLT levels in esophageal mucosal biopsies of children with AEE and normal children. CysLT levels in AEE patients are similar to those in controls, and independent of the severity of inflammation. While this would argue against the use of CysLT antagonists in the treatment of AEE, further studies into the expression of the CysLT receptor itself are needed.

Adolescent↗
PubMed2005

Gastrointestinal factors in autistic disorder: a critical review.

Interest in the gastrointestinal (GI) factors of autistic disorder (autism) has developed from descriptions of symptoms such as constipation and diarrhea in autistic children and advanced towards more detailed studies of GI histopathology and treatment modalities. This review attempts to critically and comprehensively analyze the literature as it applies to all aspects of GI factors in autism, including discussion of symptoms, pathology, nutrition, and treatment. While much literature is available on this topic, a dearth of rigorous study was found to validate GI factors specific to children with autism.

Autistic Disorder↗
PubMed2005

Esophageal diverticulum: a complication of histoplasmosis in children.

We report three boys, ages 8 to 14 years, who experienced dysphagia or chest pain while eating. In each patient, contrast esophagrams or esophagogastroduodenoscopy (EGD) demonstrated mid-esophageal traction diverticula, and serologic findings were compatible with acute or recent histoplasmosis. Diverticula appear to result from esophageal traction induced by inflammatory changes in adjacent infected lymph nodes. Antifungal and anti-inflammatory therapies were individualized in each case; all patients recovered fully.

Adolescent↗
PubMed2005

Clinical quiz.

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Adolescent↗
PubMed2005

Age-specific questionnaires distinguish GERD symptom frequency and severity in infants and young children: development and initial validation.

Two gastroesophageal reflux disease (GERD) symptom questionnaires were developed and tested prospectively in a pilot study conducted in infants (1 through 11 months) and young children (1 through 4 years) with and without a clinical diagnosis of GERD. A pediatric gastroenterologist made the clinical diagnosis of GERD. Parents or guardians at 4 study sites completed the questionnaires, providing information on the frequency and severity of symptoms appropriate to the 2 age cohorts. In infants, symptoms assessed were back arching, choking or gagging, hiccups, irritability, refusal to feed and vomiting or regurgitation. In young children, symptoms assessed were abdominal pain, burping or belching, choking when eating, difficulty swallowing, refusal to eat and vomiting or regurgitation. Respondents were asked to describe additional symptoms. Symptom frequency was the number of occurrences of each symptom in the 7 days before completion of the questionnaire. Symptom severity was rated from 1 (not at all severe) to 7 (most severe). An individual symptom score was calculated as the product of symptom frequency and severity scores. The composite symptom score was the sum of the individual symptom scores. The mean composite symptom and individual symptom scores were higher in infants (P<0.001 and P<0.05, respectively) and young children (P<0.001 and P<0.05, respectively) with GERD than controls. Vomiting/regurgitation was particularly prevalent in infants with GERD (90%). Both groups with GERD were more likely to experience greater severity of symptoms. We found the GERD Symptom Questionnaire useful in distinguishing infants and young children with symptomatic GERD from healthy children.

Age Factors↗
PubMed2005

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography in children: a large series report.

OBJECTIVES: Our goal is to evaluate the indications, findings, therapies, safety, and technical success of endoscopic retrograde cholangiopancreatography (ERCP) in children. METHODS: Our database was searched for patients 17 years of age or younger undergoing ERCP between January 1994 and March 2003. Additional information was obtained by chart review. The safety and technical success of ERCP were examined. Complications were classified by the consensus criteria. RESULTS: A total of 245 patients (95 M, 150 F; mean age 12.3 years) underwent 329 examinations. Indications included biliary pathology (n = 93), pancreatic pathology (n = 111), and chronic abdominal pain of suspected biliary or pancreatic origin (n = 41). The ERCP findings were bile duct stone(s) (n = 29), benign biliary stricture (n = 19), primary sclerosing cholangitis (n = 7), anomalous pancreaticobiliary union (n = 8), choledochal cyst (n = 5), bile duct leak (n = 6), malignant biliary stricture (n = 2), biliary atresia (n = 1), chronic pancreatitis (n = 44), pancreas divisum (n = 26), pancreatic duct stricture with (n = 6) or without (n = 9) leak, pancreatic tumor (n = 1), periampullary adenoma (n = 2), and sphincter of Oddi dysfunction (n = 65). Endoscopic therapies were performed in 71% of the procedures and included sphincterotomy, stone extraction, stricture dilation, endoprosthesis placement, snare papillectomy, and cystoduodenostomy. Thirty-two (9.7%) post-ERCP complications occurred and included cholangitis in 1 patient and pancreatitis in 31. The pancreatitis was graded mild in 24, moderate in 5, and severe in 2. No mortality related to ERCP occurred. CONCLUSIONS: Diagnostic and therapeutic ERCP results are similar in children and adults except for a lower incidence of malignant disease in children. Technical success rates are high. However, ERCP-related pancreatitis is not uncommon, and the risk and benefits should be carefully reviewed before proceeding. Outcome data are necessary and is currently being accumulated at our institution.

Adolescent↗
PubMed2004

White specks in the esophageal mucosa: An endoscopic manifestation of non-reflux eosinophilic esophagitis in children.

BACKGROUND: White specks in the esophageal mucosa have been observed in children with eosinophilic esophagitis. The aim of this study was to determine the relationship between white specks in the esophageal mucosa and allergic (non-reflux) eosinophilic esophagitis. METHODS: Endoscopic data, pH probe results, and histopathology reports for children with esophageal endoscopic abnormalities seen during a 17-month period were reviewed. Eosinophilic esophagitis was grouped according to the number of eosinophils per high power field (non-allergic, <15 eosinophils/high power field; allergic, > or =15 eosinophils/high power field). RESULTS: Of 1041 endoscopies performed during the study period, 153 revealed evidence of eosinophilic esophagitis. Of these 153, 61 had fewer than 15 eosinophils/high power field and 92 had 15 or more eosinophils/high power field. At 31 of the 153 procedures, white specks were noted in the esophageal mucosa. The sensitivity of white specks in the esophageal mucosa for allergic eosinophilic esophagitis was only 30%, but the specificity was 95%. pH probe testing was performed in 21 patients with white specks and was normal in all. CONCLUSIONS: This report describes a new endoscopic finding associated with allergic eosinophilic esophagitis in children. Eosinophilic esophagitis tends to be severe when white specks are present (> or =15 eosinophils/high power field) and is not associated with pathologic gastroesophageal reflux, as demonstrated by pH probe testing.

Adolescent↗
PubMed2004

Impact of sedation and anesthesia on the rectoanal inhibitory reflex in children.

OBJECTIVE: The study objective was to determine whether the rectoanal inhibitory reflex (RAIR) can be elicited during limited anorectal manometry (ARM) performed under general anesthesia (GA). METHODS: In this retrospective study, patients with intractable constipation who underwent ARM under GA from November 1999 to March 2002 were evaluated. Rectal biopsy specimens were examined for the presence of ganglion cells. RESULTS: Eighty consecutive patients aged 5 months to 16 years were evaluated. Three patients with Hirschsprung disease were excluded from analysis. Ganglion cells were found in rectal biopsy specimens from 76 patients. RAIR was positive in 69 (90%) and negative in 8 (10%). Forty-five patients received preoperative medications: midazolam (n = 36), midazolam + atropine (n = 3), atropine (n = 1), midazolam + glycopyrrolate (n = 3), and glycopyrrolate (n = 2). Different combinations of general anesthetic medications were used. Ten patients received neuromuscular blockers. The use of preoperative midazolam or atropine did not affect the presence or absence of RAIR; however, the proportion of patients with negative RAIR was higher in those receiving glycopyrrolate (P = 0.007) than in those receiving other medications. There was no significant difference in the effect of the general anesthetic agents or neuromuscular blockers used on the presence or absence of RAIR. CONCLUSIONS: The rectoanal inhibitory reflex in children can be elicited even when anorectal manometry is performed under general anesthesia. Glycopyrrolate, an anticholinergic, appears to inhibit the demonstration of the RAIR.

Adjuvants, Anesthesia↗
PubMed2004

Comparison of serological markers of inflammatory bowel disease with clinical diagnosis in children.

BACKGROUND: Our purpose was to study the concordance of serological tests for inflammatory bowel disease with clinical diagnosis established by traditional testing in children. METHODS: All children seen in our division who had IBD Diagnostic System (ie, pANCA, ASCA IgA, and ASCA IgG) performed over a 21-month period (June 1998 to February 2000) were identified. Their medical records were reviewed for basic demographics, test results (endoscopy, histology, and radiology), IBD Diagnostic System results, and patient symptoms/medications. Results of the IBD Diagnostic System were compared with several patient characteristics including age, sex, absence/presence of symptoms, medication use, disease activity and duration. RESULTS: One hundred seven patients were divided into 6 groups based on clinical diagnosis and IBD Diagnostic System results. The sensitivity, specificity and +/- predictive values of the IBD Diagnostic System for ulcerative colitis were 69.2, 95.1, 90.0, and 87.1%, respectively, and for Crohn's disease were 54.1, 96.8, 90.9, and 80.8%, respectively. Overall, the results of the IBD Diagnostic System were concordant with the clinical diagnosis in 76 of the 107 (71%) patients. CONCLUSIONS: In our experience, the specificity of IBD Diagnostic System is better than the sensitivity; the sensitivity is better for ulcerative colitis than Crohn's disease (69.2% vs 54.1%). The low sensitivity, especially for Crohn's disease, precludes the possibility that the IBD Diagnostic System can replace traditional studies when evaluating for inflammatory bowel disease. Though we do not exclude inflammatory bowel disease solely by IBD Diagnostic System results, it is reassuring to note that all patients without clinical evidence of inflammatory bowel disease also had negative IBD Diagnostic System results.

Adolescent↗
PubMed2004

Correlation between number of eosinophils and reflux index on same day esophageal biopsy and 24 hour esophageal pH monitoring.

OBJECTIVES: The presence of eosinophils on esophageal biopsy is a marker of esophagitis in children. Eosinophilic inflammation without evidence of gastroesophageal reflux has led to the new diagnosis of eosinophilic, or allergic, esophagitis. The aim of this study was to correlate the number of eosinophils with the reflux index on same day esophageal biopsy and 24 h esophageal pH monitoring. METHODS: A retrospective analysis of data collected from children who underwent same day endoscopy with esophageal biopsies and 24 h esophageal pH monitoring over a 3-yr period was performed. The patients were divided into five groups: Group 1: 0 eosinophils/hpf and no histologic change, Group 2: 0 eosinophils/hpf but histologic changes, Group 3: 1-5 eosinophils/hpf, Group 4: 6-20 eosinophils/hpf, and Group 5: >20 eosinophils/hpf. Reflux indices were analyzed within each group. RESULTS: A total of 305 patients met the inclusion criteria. The mean reflux indices +/- standard error within each group were Group 1 (n = 171): 2.14 +/- 0.18%, Group 2 (n = 40): 3.93 +/- 1.24%, Group 3 (n = 42): 5.96 +/- 1.53%, Group 4 (n = 21): 4.18 +/- 1.27%, and Group 5 (n = 31): 2.02 +/- 0.53%. The mean reflux index in Group 3 was significantly greater than Groups 1 and 5. CONCLUSIONS: The presence of denser infiltrates of eosinophils does not correlate with increased gastroesophageal reflux. The finding of more than 20 eosinophils/hpf is likely associated with a normal reflux index and a nonacid-related cause of esophagitis.

Adolescent↗