AIM:To evaluate the clinical presentation, response to prophylactic therapy and outcome of children with cyclic vomiting syndrome (CVS) in Shiraz, Iran. METHODS:During a period of 11 years (March 1994 to March 2005, 181 consecutive children with a final diagnosis of CVS were evaluated, treated and followed in our center. Patients were randomized to receive either amitriptyline or propranolol as prophylactic treatments. RESULTS:There were 88 boys and 93 girls with mean age of onset of symptoms of 4.9 ± 3.3 years (range, neonatal period to 14 years), the mean age at final diagnosis was 6.9 years (range, 1.5 to 14), and the mean duration between the onset of the first attack and the final diagnosis of CVS was 2 ± 1.81 years (range, 1/6 to 8). The mean duration of each attack was 4.26 days (range, from few hours to 10 d) and the mean interval between the attacks was 1.8 mo (range, 1 wk to 12 mo). The time of onset of the attacks was midnight to early morning in about 70% of cases. Amitriptyline was effective in 46 out of 81 (56%) patients (P < 0.001). Propranolol appeared to have a superior action and was effective in 74 out of 83 (92%) patients (P < 0.0001). CONCLUSION:There is a significant lag time between the onset of clinical symptoms and the final diagnosis of CVS in our area. In patients with typical clinical presentations www.wjgnet.com of CVS, who are examined by an experienced physician, invasive workup is not necessary. Propranolol appears more effective than amitriptyline for prophylactic use in children with CVS.

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Background/Aim:Although liver abscess is more prevalent in developing countries than in developed countries, there is scant data about the characteristics of pediatric liver abscess in our region. We aimed to analyze the characteristics of pediatric liver abscess in our region and compare these with those of developed countries.Materials and Methods:The clinical features, laboratory, imaging, microbiologic findings, management strategy, and final outcome were extracted from the patients’ records retrospectively.Results:There were 18 cases of liver abscess including 16 pyogenic liver abscess, one amebic liver abscess and one candida liver abscess. Fever and abdominal pain were the most common clinical findings and leukocytosis was the most common laboratory finding. The most predisposing factors of liver abscesswere immune deficiency, minor thalassemia. Origin of liver abscess was appendicitis in two patients, the rest were considered as cryptogenic. While one patient was treated with antibiotics alone, five cases were taken for open drainage, and 12 cases were treated with percutaneous aspiration. Percutaneous aspiration failed in two patients who were later ttaken for open drainage, with an overall mortality rate of 5.5%. Conclusion: The overall characteristics of liver abscess in children in our society are not so different from developed countries. However, in contradiction to cases reported in developed countries, most cases of liver abscess were seen in healthy patients in our centre. Moreover, liver abscess was reported in our patients at a younger age and was more commonly seen in male children. Mortality rate was similar to that of developed countries.

BACKGROUND Functional gastrointestinal system diseases (FGIDs) are a group of childhood disorders, our knowledge of which is relatively limited. More importantly, the different subgroups among such a disease group are closely interrelated, and their natural courses and interrelations have yet to be fully clarified. Functional constipation and gastroesophageal reflux disease (GERD) are most frequently seen among this group. However, evidence as to whether any relationship exists between them is limited. In this study, we tried to examine the existence or absence of this relationship. METHODS First, patients with functional constipation were identified based on ROME III criteria, which included 205 patients. All patients were classified into two groups of 185 and 20 patients based on their ability to respond to the questions. Then age, sex, duration of constipation, treatment, and symptoms associated with reflux were examined based on the GERD questionnaire (in case group 185) and I-GERD (in case group 20). Score > 11 in the GERD questionnaire and score > 15 in the I-GERD questionnaire were considered as reflux disease. The variables that were evaluated using Chi-square and Fisher exact tests using SPSS software version 19 included age, sex, the onset of constipation, constipation duration, duration of treatment of constipation, ROME III criteria, and symptoms associated with reflux. RESULTS In the current study 205 subjects were included (girls = 49.8%, boys = 50.2%). The mean age of the children was 5.51 ± 3.15 years. Among the Rome III criteria, the most frequent were retentive posturing, painful defecation, history of large stool defecation, defecation less than 2 times per week, stool accumulation in the rectum, and fecal incontinency more than once a week, respectively. The lowest symptom among people with chronic constipation was fecal incontinency. Also, 46.8% of all patients in the study had a positive familial history. In general, there were 29 patients (14.1%) with reflux out of the 205 patients with functional constipation. In the present study, no significant relationship was found between Rome III criteria and reflux. CONCLUSION The frequency of GERD among cases with constipation was 14.1%. There was no significant relationship between Rome III criteria and reflux.

Bowel perforation is one of the causes of mortality after pediatric liver transplantation. The aim of this study was to evaluate the incidence, risk factors, clinical presentations, and outcomes of bowel perforation in pediatric liver recipients. This is a retrospective analysis of all pediatric patients who underwent liver transplantation at a single liver transplant center in Iran between 1999 and 2006. During this period 72 liver transplantations were performed in children <18 yr. Twenty-two children underwent 33 re-explorations after liver transplantation. Five bowel perforations occurred in four children (incidence, 6.9%). One patient required two re-explorations. The median time between liver transplantation and the diagnosis of the bowel perforation was seven days. All patients had abdominal distention before re-exploration. The sites of perforation were jejunum (n = 3) and ileum (n = 2), and simple repair was performed in all cases. Three children had a history of prior Kasai operation. One of them received high dose of methylprednisolone before bowel perforation. Two children expired after bowel perforation (mortality rate, 50%). Bowel perforation is relatively frequent after pediatric liver transplantation. Among risk factors, prior Kasai operation may have a role. We observed that abdominal distention is a sign of bowel perforation and a high index of suspicion is required for rapidly diagnosis of this complication. The outcome of bowel perforation is poor and its mortality is high. Further studies are needed to establish real risk factors for this complication.

INTRODUCTIONSpontaneous bacterial peritonitis (SBP) is defined as an ascitic fluid infection without a demonstrable intraabdominal cause [1] . It is a well known complication of cirrhosis in adults, occurring in 8% to 13% of patients [2][3][4][5] . The diagnosis is established by a positive ascitic fluid bacterial culture and an elevated ascitic fluid absolute polymorphonuclear leukocyte (PMN) count (≥ 2.5 × 10 5 /L). In adults, the organisms of SBP are usually gramnegative bacteria [2][3][4]6] , but they may differ in children [5,7] . The aim of the present study was to deter mine the causative agents of SBP in children with liver disease and ascites in our center. MATERIALS AND METHODSDuring a period of 2.5 years, from September 2003 to March 2006, 63 children with liver disease and ascites were prospectively studied in the Department of Pediatric Gastroenterology in Nemazee Hospital affiliated with Shiraz University of Medical Sciences, the major referral center in Southern Iran. Written consent was obtained from all parents after informing them about this study which was approved by the Ethics Committee of the University.Of the children involved in this study 12 had met the criteria for SBP (polymorphonuclear leukocyte count greater than 2.5 × 10 5 /L and positive ascitic fluid culture). In total 13 episodes of SBP were documented, of which two occurred with one patient, 4 mo apart. The patients and their parents answered a structured questionnaire, which included name, age, sex, clinical history, underlying liver diseases, history of antibiotic and diuretic use, history of previous variceal bleeding and episodes of SBP. All children had undergone a thorough physical examination.Serum albumin and glucose, urinalysis and urine culture were done in all patients. CONCLUSION: S. pneumoniae is the most common cause of SBP in the pediatric age group and we recommend a third generation cephalosporine (e.g., Ceftriaxione or Cefotaxime) for empirical therapy in children with SBP.

Background: Constipation is one of the most common Gastrointestinal (GI) symptoms among children. The present study aimed to identify the demographic and clinical characteristics of the children suffering from constipation. Methods: This descriptive-analytical study was conducted on 987 children with constipation in Fars province from March 2015 to March 2016. The study data were collected in the pediatric GI clinic affiliated to Shiraz University of Medical Sciences and analyzed using descriptive statistics, including frequency, mean, and standard deviation (SD). Results: More than 40% of the cases who referred to the pediatric GI clinic were suffering from constipation. Totally, 987 [495 females (50.2%) and 492 males (49.8%)] out of the 1000 children with constipation met the inclusion criteria. The remaining 13 children were

Among paediatric medical conditions, chronic gastrointestinal complaints and diseases such as chronic constipation, chronic abdominal pain and failure to thrive, along with patients with chronic hepatic diseases such as cirrhosis and hepatic transplant patients, are also disposed to high prevalence of CAM use (11). Use of CAM in these patients has specific considerations such as potential lower toxic doses and different herb and drug interactions in the absence of normal liver metabolism. These facts emphasize the need for more information on CAM use and associated factors in children with hepatic and gastrointestinal diseases. This study aimed to evaluate the prevalence and type of CAM use in patients attending a paediatric