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LETTERS TO THE EDITOR

JPGNutr 2013;57:61926.Schneider B, Emre S, Groszmann R, et al. Expert pediatric opinion on thereport of the Baveno IV consensus workshop on methodology of diag-nosis and therapy in portal hypertension. Pediatr Transplant 2006;10:893907.Superina R, Shneider B, Emre S, et al. Surgical guidelines for themanagement of extra hepatic portal vein obstruction. Pediatr Transplant2006;10:90813.16912005. Berlin: Springer Verlag; 2008:112.Alberti D, Colusso M, Cheli M, et al. Results of a stewise approach toies or resection of dilated segments). The concept of a surgicale was introduced much later, only 50 years ago; in a few decades,changed the life of these children. Contemporary single-step,nsperineal, neonatal interventions cure preemptively these chil-n with no hesitation.

Alberti et al (2) proposed a stepwise approach to extra-atic portal vein obstruction in children. Rex recessus wasnd patent at portography in 24 children and 13 were proposedMeso-Rex bypass (MRB); 3 of the 13 MRBs were doneemptively (elective operation in patients with well-controlledphageal varices) and the authors consider it a violation of theirtocol at that time. Although Alberti et al end their discussionth only 1 word about preemptive cure as an opportunity fore children, the latter message is not clearly delivered toaudience.

Beta-blockers, with their unproven value and repeated endo-pic procedures (254 sclerotherapies or bandings in this report),neither curative nor without risk, although the authors choosese palliative procedures over curative surgery in the vastjority of children with symptoms.

Extrahepatic portal hypertension, caused by portal veinlusion, is a chronic condition carrying multiple risks andociated with many penalties to the child development andll-being; a cure can be proposed to selected children with aorable anatomy (patent Rex recessus) by performing an MRBsimilar operations. This procedure should be proposed earliern later in the disease progression, electively and preemptively4).

Riccardo A. Superina and yJean de Ville de Goyet

epartment of Pediatric Surgery, Childrens Memorial Hospital,Chicago, IL

yDepartment of Pediatric Surgery, Bambino Gesu` ChildrensHospital, Rome, Italy

REFERENCES

Grosfeld JL. Hirschprung disease and allied disorders. In: HolschneiderAM, Puri P (eds). Hirschprung Disease: A Historical Perspective

extra-hepatic portal vein obstruction in children. J Pediatr GastroenterolPreemptive Meso-Rex Bypassfor Children With Idiopathic

Prehepatic Portal Hypertension:Trick or Treat?

o the Editor: Once upon a time, in an era when the physio-pathology of the Hirschsprung disease was still unknown,

ation was on the congenitally dilated colon (1). Patients werelowed with conservative means or palliative operations (colos-right 2014 by ESPGHAN and NASPGHAN. UnauN Volume 58, Number 4, April 2014ong these 44 children, 11 were classified as having severecreatitis and 33 with its mild form, according to the criteriatudy evaluating different scoring systems for acute pancreatitis inREFERENCES

Alberti D, Colusso M, Cheli M, et al. Results of a stepwise approach toextra-hepatic portal vein obstruction in children. J Pediatr GastroenterolNutr 2013;57:61926.Shneider BL, Bosch J, de Franchis R, et al. Portal hypertension inchildren: expert pediatric opinion on the report of the Baveno v Con-sensus Workshop on Methodology of Diagnosis and Therapy in PortalHypertension. Pediatr Transplant 2012;16:42637.

aluation of Serum Lipase as Predictorof Severity of Acute Pancreatitis

in Children

o the Editor: The search for an easy-to-use and accuratepredictor tool for the measurement of severity in acute

creatitis is a never-ending quest. In the June 2013 issue ofJournal of Pediatric Gastroenterology and Nutrition, Coffeyl (1) suggested that serum lipase7 the upper limit of normalLN) is a simple predictor of acute pancreatitis severity. Itssitivity was 85% and specificity 56%. In 2012, we published

ohort of 48 children (2). Because we had the lipase level for 44 ofm, we could test the usefulness of serum lipase in our cohort.We hope that Drs Superina and de Ville will have the chanceproduce similar data on a large, unselected population ofildren presenting with extrahepatic portal vein obstructiond managed prospectively with a protocol considering preemp-e MPB as the first step. We look forward to reading such a studyt could prove that preemptive MPB is superior to MPB carriedt as a second-line treatment (1). Meanwhile, we appreciate themment and we agree with what, at the moment, is an expertinion (2).

Daniele Alberti and yLorenzo DAntiga

aediatric Surgery, University of Brescia, Presidio Ospedale deiBambini, Brescia

aediatric Hepatology, Gastroenterology, and Transplantation,Hospital Papa Giovanni XXIII, Bergamo, Italya, we could certainly not argue in favor of or against differentroaches, although the violations tell that we probably agree withAuthors Response

o the Editor: Our study reports the outcome of children withextrahepatic portal vein obstruction managed prospectively

th the same protocol for 15 years, without any selection. In thistocol, surgery (with priority to meso-portal bypass [MPB]) wasicated only after the failure of medical and endoscopic treat-nts. Accurate methodology suggested considering our latestes, which had a preemptive MPB, as violations. With these

comment made.thorized reproduction of this article is prohibited.e41

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Letters to the Editor JPGN Volume 58, Number 4, April 2014

e4cificity 0.43 (95% CI 0.410.43).Unlike previous studies (2,46), Coffey et al used a modified

sion of the Atlanta symposium, excluding pseudocysts fromere pancreatitis. If we exclude pseudocysts from the analysis, thea under the ROC curve is 0.79 (95% CI 0.581, P 0.038), thesitivity 0.80 (95% CI 0.730.87), and the specificity 0.46 (95%0.450.46). If we count pseudocyst as mild form, the area underROC curve is 0.77 (95%CI 0.560.98, P .049), the sensitivity0 (95% CI 0.730.87), and the specificity 0.41 (95% CI 0.401). In our cohort, the area under the ROC curve of Ranson,Banto, and the Glasgow Coma Scale score was 0.846, 0.699, and74, respectively. Thus, we confirm the good sensitivity ofULN lipase as a predictor of the severity of acute pancreatitis;wever, because of its low specificity, the area under the ROCve did not fare better than the other scoring systems and these-positive rate was 68%. To date, the scoring system for severityacute pancreatitis in children is sailing between Scylla andarybdis, in other words, either a good sensitivity or a goodcificity, but never both. The challenge remains to find a wayassociate both of them.

Alexandre Fabre, yOphelie Boulogne, yJean Gaudart,

zEmmanuel Mas, zJean-Pierre Olives, and Jacques Sarlesrvice de Pediatrie Multidisciplinaire, Hopital des Enfants de la

Timone, AP-HMyAix-Marseille University, UMR912 SESSTIM

(INSERM, IRD, AMU)zUnite de Gastroenterologie, Hepatologie, Nutrition et

Diabetologie, Hopital des Enfants, CHU Toulouse,Toulouse, France

REFERENCES

Coffey MJ, Nightingale S, Ooi CY. Serum lipase as an early predictor ofseverity in pediatric acute pancreatitis. J Pediatr Gastroenterol Nutr2013;56:6028.Fabre A, Petit P, Gaudart J, et al. Severity scores in children with acutepancreatitis. J Pediatr Gastroenterol Nutr 2012;55:2667.Bradley EL 3rd. A clinically based classification system for acute pan-creatitis. Summary of the International Symposium on Acute Pancreatitis,Atlanta, GA, September 11 through 13, 1992.Arch Surg 1993;128:58690.DeBanto JR, Goday PS, Pedroso MR, et al. Acute pancreatitis in children.Am J Gastroenterol 2002;97:172631.Suzuki M, Fujii T, Takahiro K, et al. Scoring system for the severity ofacute pancreatitis in children. Pancreas 2008;37:2223.Lautz TB, Chin AC, Radhakrishnan J. Acute pancreatitis in children:spectrum of disease and predictors of severity. J Pediatr Surg 2011;46:11449.

Authors Response

o the Editor: We thank Dr Fabre and colleagues for theirinterest in our study regarding the use of serum lipase

centrations as an early predictor of severity in pediatric acutecreatitis (AP) (1), and for sharing the results of their analysis inmild pancreatitis. The area under the receiver-operating charac-istic (ROC) curve was 0.69 (confidence interval [CI] 95% 0.47the Atlanta symposium (3). The medianULN of serum lipaseue was 9.36 (standard deviation [SD] 32) for the whole cohort,.83 (SD 19.19) for the severe pancreatitis, and 9.3 (SD 35.36) for

1, P 0.06), the sensitivity 0.72 (95% CI 0.570.87), and theright 2014 by ESPGHAN and NASPGHAN. Unau

2Michael J. Coffey, yScott Nightingale, and Chee Y. Ooi

chool of Womens and Childrens Health, Faculty of Medicine,University of New South Wales, Sydney

epartment of Gastroenterology, John Hunter Childrens Hospitaland Discipline of Paediatrics and Child Health,

chool of Medicine and Public Health, University of Newcastle,Newcastle Australia

REFERENCES

Coffey MJ, Nightingale S, Ooi CY. Serum lipase as an early predictor ofseverity in pediatric acute pancreatitis. J Pediatr Gastroenterol Nutr2013;56:6028.Fabre A, Petit P, Gaudart J, et al. Severity scores in children with acutepancreatitis. J Pediatr Gastroenterol Nutr 2012;55:2667.DeBanto JR, Goday PS, Pedroso MR, et al. Acute pancreatitis in children.Am J Gastroenterol 2002;97:172631.Ranson JHC, Rifkind KM, Roses DF, et al. Prognostic signs and the roleof operative management in acute pancreatitis. Surg Gynecol Obstet1974;139:6981.Blamey SL, Imrie CW, ONeill J, et al. Prognostic factors in acutepancreatitis. Gut 1984;25:13406.

Increased Fecal Fat andProtein Intolerance

o the Editor: I congratulate Moore et al on their articleRelations between feeding intolerance and stress bio-

rkers in preterm infants (1). It is of paramount importanceidentify intolerance to enteral feeding to decrease the risk ofrotizing enterocolitis.

The authors predicted necrotizing enterocolitis usingostatic stress by measuring biomarkers from cord blood, saliva,urine (8-hydroxydeoxyguanosine enzyme immunoassay). Thisroach is, however, expensive and slow, and requires speciallyined staff; consequently, results arrive too late to protect anants health.

The fecal fat test is quick, accurate, and easy to perform.rmal fecal fat content is approximately 5%. Increased fecal fattent is a biomarker of food intolerance in early infancy oncetic fibrosis has been ruled out, and should alert the medical teamhours of presentation, whereas scoring systems such as theBanto (3), Ranson (4), and Glasgow (5) could be applied afterir own patient population. We assume that all levels were per-med within 24 hours of presentation. In particular, their finding ofum lipase7 upper limit of normal (ULN) predicting severeAPchildren is strikingly similar to our own results in a separate patientpulation, further validating this finding. As indicated, when com-red with previously validated severity scores in AP, the sensitivityserum lipase 7ULN within 24 hours of presentation (85% inffey et al (1) and 80% in Fabre et al) was superior to the Ranson,asgow, and DeBanto Scale scores (with sensitivities of 62%, 54%,d 54%, respectively) but with poorer specificity (2).

We agree that to date, an early predictor of severe AP inildren with both high sensitivity and specificity has not yet beenntified. For now, we propose that serum lipase may be used fork stratification (to rule out most cases of severe AP) within

hours to provide adjunctive prognostic information.thorized reproduction of this article is prohibited.

www.jpgn.org

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to switch to a hydrolyzed or elemental formula, decreasing the riskof developing a necrotizing enterocolitis.

At the European Society for Clinical Nutrition and Metab-olism meeting in Gotheburg (2011), we showed that fecal fatcontent can be determined in 2 minutes using near-infraredspectroscopy (2). The technique is accepted by other authors (3,4)and requires no special training. Its cost is well under $1 pertest.

Dare I say that veterans like me believe we are approaching atime when tonsillitis is diagnosed not by looking at the throat but byordering an MRI scan?

Ramon TormoUnitat de Gastroenterologia i Nutricio, Barcelona, Spain

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allostatic mechanisms associated with FI in preterm infants, whichmay progress into necrotizing enterocolitis (NEC). Although theconcept of FI is a phenomenon that is documented in various agesand populations, the mechanisms, presentation, diagnostics, treat-ment plans, and secondary outcomes of FI beyond the neonatalperiod, as discussed by Tormo, differ from those of FI in preterminfants explored in our study. Although Dr Tormo has found successin using the fecal fat test in the population he studied, researchreviews of the etiology for NEC in our population do not includefecal fat content (13).

We understand our results are preliminary and exploratory,and we do not suggest any measurements to use in predicting FI andNEC at this point. Our purpose was to further explore mechanismsassociated with the stress response in the etiology of complicationsof prematurity, such as FI. To use an analogy, the downstreammeasure of the fecal fat test for protein intolerance is akin tomonitoring fever by assessing body temperature: although bodytemphmeenthepe

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JPGN Volume 58, Number 4, April 2014 Letters to the Editor

wwreflectance analysis (NIRA) for the assessment of fecal fat, nitrogenand water. A new approach to malabsorption syndromes. Paper presentedat: Annual Meeting of the American Gastroenterological Association(AGA); May 1013, 1992; San Francisco, CA.

Authors Response

o the Editor: We appreciate the response from Dr Tormo andthe opportunity to participate in scholarly discussions. We

derstand that the primary goal of all scientists and practitioners isimprove patient outcomes.

Dr Tormos letter shared his clinical efforts to identify asitive and specific measurement to diagnose feeding intolerance) in early infancy, with a timely and cost-efficient test. To clarify,r article described research efforts to identify metabolic andfat measurement: comparison with conventional gravimetric and titri-metric methods. Gut 1989;30:13447.Moore TA, Wilson ME, Scmid KK, et al. Relations between feedingintolerance and stress biomarkers in preterm infants. J Pediatr Gastro-enterol Nutr 2013;57:35662.Tormo R, Segurola H, Cardenas G, et al. Benefits of a hydrolysed riceprotein formula in no IgE cows milk protein allergy infants. Clin Nutr2011;6:221.Benini L, Caliari S, Guidi BC, et al. Near infrared spectroscopy for faecal

Stein J, Purschian B, Bieniek U, et al. Validation of near-infra-redright 2014 by ESPGHAN and NASPGHAN. Unau

w.jpgn.orgperature diagnoses the fever, it does not speak to the underlyingysiologic mechanisms producing the fever. The suite of measure-nts used in our study provided additional insights into thedogenous metabolic and allostatic processes that may underliebroader diagnosis of FI in preterm infants during the neonatal

riod.In conclusion, the etiology of FI that may lead to NEC

ains unknown at this time and warrants further study. Wepreciate Dr Tormos suggestion to use the fecal fat test; however,strongly disagree for the reasons listed above that this test is

propriate currently for use in preterm infants.

Tiffany A. Moore, yKendra K. Schmid, zAnn Anderson-Berry,

Jeffrey A. French, and jjAnn M. BergerCollege of Nursing,

yCollege of Public Health,zCollege of Medicine, University of Nebraska Medical Center,

OmahaNeuroscience Program,

jjCollege of Nursing, University of Nebraska at Omaha

REFERENCES

Chu A, Hageman JR, Caplan MS. Necrotizing enterocolitis predictivemarkers and preventive strategies. NeoReviews 2013;14:e11320.Neu J, Walker JA. Necrotizing enterocolitis. N Engl J Med 2011;364:25564.Patel BK, Shah JS. Necrotizing enterocolitis in very low birth weightinfants: a systemic review. ISRN Gastroenterol 2012;2012:56294.REFERENCESthorized reproduction of this article is prohibited.

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Evaluation of Serum Lipase as Predictor of Severity of Acute Pancreatitis inChildrenIncreased Fecal Fat and ProteinIntoleranceAuthorsResponse