Recent advances in the pediatric Gastroenterology

Pediatric gastroenterology is described as a sub-specialty of gastroenterology and Pediatrics. It is agitated with treating the gastrointestinal tract, liver and pancreas of children from infancy till age eighteen. The main diseases concerned with it are, persistent vomiting, acute diarrhea, gastritis and problems with the development of the gastric tract.

The treatments by pediatric gastroenterologists are chronic or incurable, and impact not just during the child's initial years but throughout their adult life as well. Management strategies for these conditions need to encompass broad multidisciplinary approaches, with an emphasis upon optimal care in the short-term and enhanced outcomes in the long-term. Whilst providing consistent high-quality, child and family-focused care is important, the introduction of new treatments and the promise of future cure provide on-going challenges. The inflammatory bowel diseases are examples of such conditions.

The inflammatory bowel diseases comprise Crohn disease (CD) and ulcerative colitis (UC), Increasing rates of IBD have been seen in many areas of the world. In recent years it has been increased up to 10-fold in rates of CD and UC. High rates have been seen in individuals migrating from the Indian subcontinent to industrialized countries, such as Canada.

Pathogenesis of coeliac disease, it has become clear that there are a number of potential strategies by which these pathways could be interrupted. One very promising example is the development of vaccine-based treatment currently undergoing clinical trials in several countries. This novel immune-based strategy promises to lead to a new approach to the treatment of coeliac disease. Namely, the introduction of a vaccine will mean that individuals diagnosed with coeliac disease who are then treated with the vaccine, will subsequently be able to tolerate a gluten-containing diet, without need for gluten-free diet. This promise of a cure for coeliac disease could transform the limitations of coeliac disease, and make huge differences in the lives of many children and families. However, this approach is still the “ambulance at the bottom of the cliff.” The development of effective and safe preventative strategies may be even more important and have greater impact. One example of such an approach is the timing of introduction of gluten-containing foods in infancy.

Higher rates of childhood obesity have led to increased rates of non-alcoholic fatty liver disease. These changes have significant implications during childhood and also for future adult years. This condition has become an increasingly common indication for liver transplant, which consequently leads to a further set of long-term health issues.

The development and assessment of new diagnostic tools and markers would ensure optimization of initial assessment and on-going management, Furthermore; other endeavors should focus on advancing our understanding of the pathogenesis of specific conditions, providing impetus to finding cures.

Gastrointestinal physiology and digestive disorders in sleep

Digestive system and sleep is an excellent example of brain-body interaction. New advances in measuring techniques provide an opportunity to evaluate physiology that is dependent upon the sleep/wake state or circadian rhythm and potentially differentiate between normal and pathological conditions.

It has been demonstrated that sleep and circadian factors influence appetite, nutrient absorption, and metabolism. Disruption of sleep and circadian rhythms may increase vulnerability to digestive disorders, including reflux, ulcers, inflammatory bowel issues, irritable bowel disease, and gastrointestinal cancer.

Sleep deprivation and impaired sleep quality have been associated with poor health outcomes. Many patients experience sleep disturbances, which can increase the risk of medical conditions such as hypertension, obesity, stroke, and heart disease as well as increase overall mortality.

Proinflammatory cytokines, such as tumor necrosis factor, interleukin-1, and interleukin-6, have been associated with sleep dysfunction. Alterations in these cytokines have been seen in certain gastrointestinal diseases, such as gastroesophageal reflux disease, inflammatory bowel disease, liver disorders, and colorectal cancer. Sleep disorders have been linked to neurocognitive effects such as slower response time, impaired attention, and increased likelihood of falling asleep at work. Most studies suggest that the daily sleep requirement for adults is 7 to 9 hours per night.

The connection between the brain and the gastrointestinal system is imperative to the regulation of the digestive tract and maintenance of the gut immune system.

The gut-brain axis works through mechanisms that involve immune activation, intestinal permeability, and enteroendocrine signaling. This bidirectional network involves the central nervous system (CNS), autonomic nervous system, and enteric nervous system (ENS). The network incorporates sympathetic and parasympathetic activity, which drive afferent signals through enteric and vagal pathways to the CNS and efferent signals from the CNS to the intestine. There are neural and hormonal influences that allow the brain to modulate the activity of intestinal cells such as interstitial cells of Cajal, enterochromaffin cells, and smooth muscle cells. This dynamic relationship between the brain and the gastrointestinal system involves feedback loops, which also influence the circadian rhythm and sleep regulation pathways. This suggests that there is a relationship between sleep disturbances and physiologic changes of the gastrointestinal tract.

Obesity plays a significant role in multiple gastrointestinal disease processes, such as GERD, hepatic steatosis, and potentially colon cancer. Obesity is a major risk factor for sleep apnea, resulting in poor sleep, which can, in turn, lead to gastrointestinal disease. A strong focus on weight reduction can improve existing symptoms in patients with underlying gastrointestinal conditions. Furthermore, weight reduction can potentially reduce the risk of a patient developing certain disease states.

Pediatric inflammatory bowel disease (IBD): A concern for the Future

The etiology of IBD is unclear. There are several theories but most agree that IBD is multifactorial. It is believed that a complex interaction of environmental, genetic, and immune factors lead to the development of IBD. Approximately 20% of all inflammatory bowel disease (IBD) first presents in childhood or adolescence, and approximately 10% of the estimated children with IBD are under age 17.

As with adults, the clinical presentation of IBD depends on the site and extent of mucosal inflammation. IBD is an important cause of gastrointestinal pathology in children and adolescents. The incidence of pediatric inflammatory bowel disease is increasing; therefore, it is important for the clinician to be aware of the presentation of this disease in the pediatric population.

The detection is cumbersome for the pediatric IBD at presentation due to atypical symptoms or extraintestinal manifestations (e.g., chronic anaemia, short stature, unexplained fever, arthritis, mouth ulcers).Laboratory tests, radiology studies, and endoscopic procedures are helpful in diagnosing IBD and differentiating between Crohn’s disease and ulcerative colitis.

Serologic testing in pediatric patients includes traditional IBD serologic markers such as anti–Saccharomyces cerevisiae antibodies and perinuclear antineutrophil cytoplasmic antibody, as well as newer antimicrobial antibodies, including antibodies to outer membrane.

Once diagnosed, the goal of medical management is to induce remission of disease while minimizing the side effects of the medication. Specific attention needs to be paid to achieving normal growth in this susceptible population. Surgical management is usually indicated for failure of medical management, complication, or malignancy.

In the last coming years more treatment, medicines and drugs option have become available including antibiotics, 5-aminosalicylate, corticosteroids, immunomodulators and biological agents. When anti-tumor necrosis factor (TNF)-α became available to patients with IBD, the risk for surgery is less in comparison to earlier, with the use of anti-TNF-α treatment the risk of surgery has decreased significantly.

It should be appreciated that in children as well as in adults Crohn’s diseases encompasses a varied range of disease phenotypes and severities and therefore optimal patient selection, timing and therapy helps in proper clinical judgment.