Ra ahi - Europe PMC

12 downloads 0 Views 965KB Size Report
sorption and lactose intolerance in children with .... adults, the sensitivity and specificity of the technique are .... pain in children: lactose and sucrose intolerance.
Ra ahi obervation of gas - fluid levels in the colon of children with abdominal pain and malabsorption of lactose Ronald G. Barr,* MD, CM, FRCPC David C. Kushner,t MD

Gas-fluid levels in the colon observed in radiographs are abnormal and usually indicate serious gastrointestinal disease. Colonic gas-fluid levels associated with concurrent abdominal pain and malabsorption of lactose, documented by lactose breath hydrogen testing, were observed in five children. Incomplete lactose absorption is a relatively benign condition that can be added to the differential diagnosis of gas-fluid levels in the colon and may account for some cases of spontaneous resolution of clinical and radiologic signs in children presenting with acute recurrent abdominal pain. La presence de niveaux liquidiens coliques 'a la radiographie de l'abdomen indique generalement une maladie grave de l'appareil digestif. On les a retrouves chez cinq enfants souffrant de douleur abdominale et d'une malabsorption du lactose demontree par le dosage de l'hydrogene dans l'haleine apres ingestion de lactose. L'insuffisance d'absorption du lactose est un etat relativement b6nin qui pourra figurer dans le diagnostic difffrentiel des niveaux liquidiens coliques. Elle rend compte d'un certain nombre de cas ou l'on assiste a la resolution spontanee de signes cliniques et radiologiques chez des enfants presentant une douleur abdominale aigue recidivante.

Gas-fluid levels in the colon are unusual in the radiographs of children, and their differential diagnosis is somewhat different from that of gas-fluid levels in the jejunum or From *the Department of Pediatrics, Montreal Children's Hospital and the Montreal Children's Hospital-McGill University Research Institute, Montreal, and tthe departments of Medicine and Radiology, Children's Hospital Medical Center, Boston Reprint requests to: Dr. Ronald G. Barr, Montreal Children's Hospital, 2300 Tupper St., Montreal, PQ H3H IP3

118

ileum, which are more frequent. We describe five cases in which gasfluid levels in the colon were associated with concurrent abdominal pain and malabsorption of lactose. Case studies Gas-fluid levels in the colon were first observed in radiographs by chance during a clinical study of the prevalence of incomplete lactose absorption and lactose intolerance in children with recurrent abdominal pain syndrome.' The 12-month study included all 80 children (59 white, 16 black and 5 Hispanic, aged 4 to 15 [mean 9.6] years) seen at a general medical diagnostic clinic at the Children's Hospital Medical Center, Boston, who had presented with a primary complaint of intermittent abdominal pain (more than three episodes in less than 3 months) of unexplained origin that was of sufficient severity to affect activity." 2 Lactose breath hydrogen tests3,4 were performed with each patient, but abdominal radiographs with the patient supine were made selectively, often during the breath hydrogen test. For four patients radiographs were also made with the patient standing, because gaseous distension of the colon was seen on the film made when the patient was supine and having abdominal pain. The four patients (two white and two black) ranged in age from 7 to 12 years. Their histories were similar and typical of recurrent abdominal pain syndrome of childhood,2 which is characterized primarily by intermittent unexplained episodes of periumbilical or epigastric pain. The symptoms in these four patients occurred once every few weeks to three times per week. One patient reported that loose stools occasionally accompanied the pain, and two reported having infrequent and hard stools. One patient was awakened from sleep by the pain. The patients consumed one to three glasses of milk per day. One patient drank milk in an unsuccessful attempt to produce relief. There were no episodes of fever, vomiting, weight loss

CAN MED ASSOC J, VOL. 132, MAY 15, 1985

or blood in the stools, nor, was there any apparent relation between the occurrence of symptoms and the consumption of meals. The parents of two patients suspected "nerves" to be the cause of the pain. The results of physical examinations were normal. Cultures of urine samples yielded no growth, and the results of urinalyses and complete blood counts were normal. The erythrocyte sedimentation rates were normal. A blood sample obtained from one black patient was tested for sickle cell anemia, but the result was negative. The lactose breath hydrogen test was performed with a noninvasive interval breath sampling technique.34 The patients were required to fast for 8 hours before visiting the clinic. A baseline breath sample was taken when they arrived at the clinic. Each patient then ingested 2 g/kg (maximum, 50 g) of an aqueous solution containing 20% lactose and lemon flavouring. Lactose malabsorption was demonstrated by an increase in the peak hydrogen level in breath samples obtained at 90 and 120 minutes to 104 to 229 parts per million (ppm) (normally less than 10 ppm).4 Between 120 and 180 minutes following the ingestion of lactose x-ray films of the abdomen with the patient standing revealed gas-fluid levels in the ascending colon and, occasionally, the transverse colon, with moderate gaseous dilation, in all four patients (Fig. 1). No consistent abnormalities of the small bowel were noted. All the patients reported concurrent moderately severe abdominal cramps. Burping, flatulence and bloating were reported by- two patients, and diarrhea was reported by one patient. The breath hydrogen test was repeated 1 week later in one patient following the ingestion of a mixture of 25 g (140 mmol) of glucose and 25 g (140 mmol) of galactose. No increase in the hydrogen level was detected, no symptoms were reported, and 150 minutes following ingestion of the mixture no gas-fluid levels were noted on radiographs made

The five patients we have described illustrate an association between the radiographic finding of gas-fluid levels in the colon, abdominal pain and malabsorption of lactose. However, the degree to which gas-fluid levels are sensitive or specific for incomplete lactose absorption cannot be determined from the larger series of 80 patients since radiographs with the patients standing were not routinely made at the time of the lactose breath hydrogen test. In addition, the gas-fluid levels and symptoms occurred in response to ingestion of a test dose (50 g) of

lactose. However, the patient who presented to the Emergency Department with acute abdominal pain illustrates that these findings are probably not limited to the test situation. The results of the diet trials suggest that the incomplete absorption of lactose was related to the presenting complaint of pain in the five patients. The presence of unabsorbed disaccharide in the colon is confirmed by markedly elevated breath hydrogen levels.56 It results in large quantities of intraluminal gas, a byproduct of bacterial fermentation, especially in patients with lactase deficiency.7 There is usually no significant production of hydrogen gas in the small intestine, and much smaller quantities are produced with bacterial overgrowth in the small bowel.56 In addition, the amount of colonic fluid is increased because of the net osmotic flow of water and electrolytes into the lumen of the small bowel due to the presence of unabsorbed carbohydrate and because the osmotically active short-chain acids formed as byproducts of bacterial fermentation interfere with reabsorption of colonic fluid.8'9 There appears to be great variability between individuals in their symptomatic tolerance to unabsorbed lactose. Such differences may be related to the marked individual variability in the volume and the rate of production of gas.5 Consequently, it is possible that some patients with lactase deficiency who have no pain will demonstrate the same roentgenographic abnormality

Fig. 1- Abdominal radiographs from 1lO/2-year-old patient standing (left) and supine (right) 150 minutes following ingestion of 50-g lactose solution. Left panel shows mild gaseous distension of colon and gas-fluid levels.

Fig. -Adominal adiograph, with patient standing, 150 minutes following administration of 25 g of glucose and 25 g of galactose, showing no abnormalities.

with the patient standing (Fig. 2). The four patients subsequently participated in a controlled trial in which they ate a lactose-free diet for the first 2 weeks, their usual (lactose-containing) diet for the next 2 weeks and then the lactose-free diet for the final 2 weeks. Throughout the trial they were to record in a daily diary whether they had abdominal pain. The diaries showed that three of the patients had a reduction of 80% or better in the frequency of pain when lactose was eliminated from their diet. The fourth patient dropped out of the trial during the second phase because of exacerbations of pain. Subsequently, one of us (R.G.B.) evaluated a 7-year-old black girl who presented to the Emergency Department complaining of intermittent periumbilical abdominal pain for 2 days with an exacerbation on the evening of the visit. She had been otherwise well except for an upper respiratory tract infection that had been treated with a 10-day course of penicillin starting 3 weeks before presentation. She did not complain of fever, vomiting, diarrhea, a change in stool colour, dysuria or a change in urinary frequency. Her last bowel movement, 7 hours previously, had been normal. She had a 5-year history of unexplained episodes of mild abdominal pain. The results of physical examination were unremarkable except that the bowel sounds were hyperactive and there was tenderness on palpation and slight guarding in the right lower quadrant of the abdo-

men. She was able to jump up and down, but with discomfort. An abdominal roentgenographic series demonstrated gas-fluid levels in the ascending colon and some stomach distension. After 2 hours of observation the pain disappeared and the physical signs were normal. A lactose breath hydrogen test performed 2 weeks later showed incomplete lactose absorption (peak hydrogen level, 102 ppm 90 minutes after ingestion of lactose) associated with mild diarrhea and moderately painful cramps. No abdominal pain or diarrhea was reported during the 2 months in which lactose was eliminated from the diet. At follow-up 5 months later milk had been reintroduced to her diet, but she was limited to two glasses a day; abdominal pain and occasional diarrhea occurred only with lactose "binges" (e.g., when she drank milkshakes). Discussion

CAN MED ASSOC J, VOL. 132, MAY 15, 1985

1159

THE PHARMACEUTICAL ADVERTISING ADVISORY BOARD (PAAB), represents the Canadian pharmaceutical manufacturers, the medical and pharmacy professions, professional health media, consumers and government. The main role is to ensure that pharmaceutical advertising conforms to the prescribed Code. The PAAB invites applications for the position of:

Assistant to the Commissioner Pharmaceutical Advertising Under the direct supervision of the Commissioner, the Assistant will be required to work closely with Canada's pharmaceutical manufacturers in the review, evaluation and clearance of all pharmaceutical advertising and other promotions directed to members of the health professions through health-oriented publications, direct mail, detail and audio-visual aids, tape and video programs and all other promotional systems. The position requires a mature, well-organized, resourceful individual, with a basic knowledge of pharmacology and an appreciation of marketing and promotional practices within the pharmaceutical industry. Experience in drug information services would be a valuable asset. Excellent verbal skills, tact and the ability to work closely and harmoniously with industrial marketing executives, advertising personnel and government officials are of prime importance. A good working knowledge of both English and French is essential. The position offers an interesting and challenging career opportunity to an individual with the necessary qualifications and the willingness to work. Please reply in confidence to Mr. Murray D. Shantz, Commissioner, Pharmaceutical Advertising Advisory Board, 345 Kingston Road, Pickering, Ontario. Ll1V IA1. 1160

during incomplete absorption of lac- References tose. Other investigators have reported 1. Barr RG, Levine MD, Watkins JB: Recurrent abdominal pain of childhood due the use of barium sulfate-lactose to lactose intolerance: a prospective mixtures in the diagnosis of lactose study. N Engl J Med 1979; 300: 1449intolerance.'0-'3 In these studies di1452 lution of contrast medium, dilata- 2. Apley J: The Child with Abdominal tion of the small bowel and rapid Pain, 2nd ed, Blackwell Sci Publ, Oxford, 1975 small-bowel transit were considered radiologic signs of hypolactasia. 3. Perman JA, Barr RG, Watkins JB: Sucrose malabsorption in children: noninvaGas-fluid levels were not usually sive diagnosis by interval breath hydroreported, probably because the pagen determination. J Pediatr 1978; 93: tients were supine during the exami17-22 nation. Although satisfactory in 4. Barr RG, Watkins JB, Perman JA: Muadults, the sensitivity and specificity cosal function and breath hydrogen excretion: comparative studies in the cliniof the technique are poor in chilcal evaluation of children with nonspecifdren."12 ic abdominal complaints. Pediatrics Since lactose malabsorption is 1981; 68: 526-533 easily diagnosed without the use of 5. Levitt MD: Production and excretion of radiation,"'7'4'5 primary roentgenohydrogen gas in man. N Engi J Med graphic attempts to diagnose lactase 1969; 281: 122-127 deficiency are not indicated. On the 6. Bond JH, Levitt MD: Use of pulmonary hydrogen (H2) measurements to quantiother hand, plain abdominal radiotate carbohydrate absorption. J Clin Ingraphs are frequently used in chil1972; 51: 1219-1225 dren to evaluate acute or recurrent 7. vest Levitt MD, Donaldson RM: Use of respiabdominal pain, and the finding of ratory hydrogen (H2) excretion to detect gas-fluid levels in the ascending or carbohydrate malabsorption. J Lab Clin Med 1970; 75: 937-945 transverse colon may be important when the radiograph is made during 8. Christopher NL, Bayless TM: Role of the small bowel and colon in lactoseepisodes of pain. Since gas-fluid induced diarrhea. Gastroenterology levels in the colon are never normal, 1971; 60: 845-852 their presence in a child with acute 9. Bond JH, Levitt MD: Quantitative meapain suggests a potentially serious surement of lactose absorption. Gastrocondition and warrants further inenterology 1976; 70: 1058-1062 vestigation. However, malabsorption 10. Laws JW, Neale G: Radiologic diagnosis of disaccharidase deficiency. Lancet of lactose occurs in approximately 1966; 2:139-143 25% of white children presenting with recurrent abdominal pain syn- 11. Laws JW, Spencer J, Neale G: Radiology in the diagnosis of disaccharidase drome.'"'5 Although the extent to deficiency. Br J Radiol 1967; 40: 594which the syndrome is accounted for 603 by intolerance to the malabsorbed 12. McNeish AS, Sweet EM: Lactose intollactose remains unclear,"'5-'8 finding erance in childhood celiac disease. Arch Dis Child 1968; 43: 433-437 gas-fluid levels during acute presentations of the syndrome, such as 13. Bolin TD, Davis AE, Seah CS et al: Lactose intolerance in Singapore. Gasoccurred in our fifth patient, would troenterology 1970; 59: 76-84 not be unexpected. AD, McGill DB, Thomas PJ Malabsorption of any osmotically 14. etNewcomer al: Prospective comparison of indirect active carbohydrate may account for methods for detecting lactase deficiency. some instances of acute abdominal N EngliJ Med 1975; 293: 1232-1236 pain and colonic gas-fluid levels in 15. Wald A, Chandra R, Fisher SE et al: Lactose malabsorption in recurrent abchildren whose symptoms resolve dominal pain of childhood. J Pediatr spontaneously. Assessment for car1982; 100: 65-68 bohydrate malabsorption is probably 16. Bayless TM, Huang SS: Recurrent abindicated in children with acute or dominal pain due to milk and lactose recurrent abdominal pain who are intolerance in school-aged children. Pedifound to have otherwise unexplained atrics 1971; 47: 1029-1032 gas-fluid levels in the colon. 17. Lebenthal E, Rossi TM, Nord KS et al: We thank Drs. R.L. Siegal and A. Chan for referring their patients to us, and Drs. J.B. Watkins and J.A. Kirkpatrick for reviewing this paper. Dr. Barr received support from the W.T. Grant Faculty Scholar Award.

CAN MED ASSOC J, VOL. 132, MAY 15, 1985

Recurrent abdominal pain and lactose absorption in children. Pediatrics 1981; 67: 828-832 18. Liebman WM: Recurrent abdominal pain in children: lactose and sucrose intolerance. A prospective study. Pediatrics 1979; 64: 43-45