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Food protein-induced allergic proctocolitis (FPIAP) is a condition characterized by inflammatory changes in the distal colon in response to one or more foreign food proteins because of immune-mediated reactions. FPIAP prevalence estimates range widely from 0.16% in healthy children and 64% in patients with blood in stools. In clinical practice, FPIAP is diagnosed when patients respond positively to the elimination of a suspected triggering food allergen. Nevertheless, significant proportions of infants get misdiagnosed with IgE mediated allergy and undergo unnecessary dietary changes. Diagnosis is based on clinical symptoms, a good response to an allergen-free diet and the recurrence of symptoms during the "allergy challenge test". Sometimes clinical features may be non-specific and the etiology of rectal bleeding in childhood may be heterogeneous. Therefore, it is crucial to exclude a variety of other possible causes of rectal bleeding in the pediatric age group, including infection, anal fissure, intestinal intussusception and, in infants, necrotizing enterocolitis and very early onset inflammatory bowel disease. The diagnostic workup includes in those cases invasive procedures such as sigmoidoscopy and colonoscopy with biopsies. The high prevalence of FPIAP contrasts with the lack of known information about the pathogenesis of this condition. For this reason and due to the absence of a review of the evidence, a literature review appears necessary to clarify some aspects of allergic colitis. The aim of the review is to fill this gap and to lay the foundations for a subsequent evidence-based approach to the condition.

AIM To investigate the impact of fecal microbiota transplantation (FMT) treatment on allergic colitis (AC) and gut microbiota (GM). METHODS We selected a total of 19 AC infants, who suffered from severe diarrhea/hematochezia, did not relieve completely after routine therapy or cannot adhere to the therapy, and were free from organ congenital malformations and other contraindications for FMT. Qualified donor-derived stools were collected and injected to the AC infants via a rectal tube. Clinical outcomes and follow-up observations were noted. Stools were collected from ten AC infants before and after FMT, and GM composition was assessed for infants and donors using 16S rDNA sequencing analysis. RESULTS After FMT treatment, AC symptoms in 17 infants were relieved within 2 d, and no relapse was observed in the next 15 mo. Clinical improvement was also detected in the other two AC infants who were lost to follow-up. During follow-up, one AC infant suffered from mild eczema and recovered shortly after hormone therapy. Based on the 16S rDNA analysis in ten AC infants, most of them (n = 6) had greater GM diversity after FMT. As a result, Proteobacteria decreased (n = 6) and Firmicutes increased (n = 10) in post-FMT AC infants. Moreover, Firmicutes accounted for the greatest proportion of GM in the patients. At the genus level, Bacteroides (n = 6), Escherichia (n = 8), and Lactobacillus (n = 4) were enriched in some AC infants after FMT treatment, but the relative abundances of Clostridium (n = 5), Veillonella (n = 7), Streptococcus (n = 6), and Klebsiella (n = 8) decreased dramatically. CONCLUSION FMT is a safe and effective method for treating pediatric patients with AC and restoring GM balance.

Inflammatory causes of bloody diarrhea during infancy include necrotizing enterocolitis and allergic colitis, often due to cow's milk protein. We report this case of cow's milk protein allergy, managed successfully with elimination of dietary antigen, to highlight the unusual finding of pneumatosis intestinalis on abdominal x-ray, a radiographic hallmark associated with necrotizing enterocolitis. Detailed patient's history, clinical presentation, and physical examinations are discussed for cow's milk protein allergy and necrotizing enterocolitis.

Introducción: La proctocolitis eosinofílica está inducida por antígenos presentes en las proteínas de leche de vaca contenidas en las fórmulas o en la leche humana y, en los últimos años, se describen cada vez más casos en lactantes pequeños alimentados exclusivamente con la leche materna. Pacientes y métodos: Se presenta un estudio retrospectivo de los 13 casos de colitis alérgica diagnosticados en nuestra unidad entre enero de 1997 y enero de 2004, todos ellos lactantes que estaban recibiendo exclusivamente leche materna. Resultados: La sintomatología de inicio fue siempre la digestive (12 debutaron con heces con moco y hebras de sangre) y en el 77 % de los casos apareció entre los 0 y los 3 meses de edad. Los datos analíticos del componente alérgico fueron negativos. Las lesiones se localizaron, principalmente (75 %), en las zonas descendente y sigma del colon. La anatomía patológica demostró datos inflamatorios agudos, con infiltración por polimorfonucleares y aumento de eosinófilos. En todos los pacientes se inició tratamiento excluyendo la leche de vaca y sus derivados en la dieta de la madre. En 10/13 no se evidenció mejoría, por lo que requirieron administración exclusiva de hidrolizado extenso de proteínas. En 3 niños se mantuvo lactancia mixta (sin proteínas vacunas + hidrolizado). Conclusiones: El diagnóstico exige exclusión de otras causas de colitis específica y hallazgos endoscópicos y anatomopatológicos característicos; además, se debe demostrar respuesta adecuada al tratamiento dietético. Se debe pensar en esta patología al afrontar el diagnóstico de lactantes amamantados que presenten sangrado rectal sin afectación del crecimiento o del estado general. : Introduction: Eosinophilic colitis is induced by antigens present in cow’s milk proteins in formula or human milk. In the last few years, an increasing number of cases have been diagnosed in exclusively breast-fed infants. Patients and methods: We performed a retrospective study of 13 infants diagnosed with allergic colitis in our unit between January 1997 and January 2004. All the infants had been exclusively breast-fed. Results: In all patients, initial symptoms were digestive (12 with mucus and bloody stools). Onset of symptoms occurred at 0-3 months in 77 %. Laboratory data of the allergic compound were negative. The main locations were the descending and sigmoid colon (75 %). Biopsy demonstrated acute inflammation, with neutrophil infiltration and an increase in eosinophils. In all patients, initial treatment consisted of exclusion of cow’s milk proteins from the mother’s diet. Ten of the 13 patients showed no improvement, requiring exclusive administration of protein-free hydrolyzate. In 3 infants, breastfeeding was maintained (breastfeeding without cow’s milk proteins plus hydrolyzate). Conclusions: Diagnosis of eosinophilic colitis is based on exclusion of other causes of specific colitis and typical endoscopic and ultrastructural findings. Moreover, a satisfactory response to dietary treatment must be demonstrated. This diagnosis should be considered in breast-fed infants with rectal bleeding without involvement of general health status.

Allergic colitis (AC) typically develops in the first weeks or months of life and is characterized by the presence of red blood in the stools of healthy breastfed or formula fed infants. In this paper, we describe a case of rectal bleeding in monozygotic preterm twins that was resolved with the introduction of a cow's milk protein-free diet (CMPFD). The occurrence of this disorder in monozygotic twins raises the question as to whether the underlying abnormality in the immune regulation, which leads to poor acquisition of tolerance to cow's milk proteins, might be inherited or environmentally acquired. The case also highlights the use of the probiotic Lactobacillus GG (LGG) in the treatment of allergic colitis.

Si Shen Wan is a traditional Chinese herbal medicine formula for the treatment of diseases with diarrhea, such as ulcerative colitis, allergic colitis and chronic colitis. To investigate the protective and healing effects of Si Shen Wan in the experimental colitis induced by trinitrobenzene sulphonic acid, and to furture explore its mechanism of action.Rats with colitis treated with Si Shen Wan for 10 days. Colon wet weight, colon organ coefficient, colonic damage score and pathological change after trinitrobenzene sulphonic acid challenge were determined. The levels of MPO, MDA, GSH-PX, SOD and the expression of IL-4 and IL-10 mRNA in the colon were also measured.After treatment, colon wet weight, colon organ coefficient and colonic damage score were lower than that in the control group (p0.05). MDA and MPO concentrations in the inflamed colonic tissues were decreased remarkably in the treated groups compared with that in the control group (p0.05). But SOD level, IL-4 and IL-10 mRNA expression in the inflamed colonic tissues were obviously increased.It is a potential path that protective effect of Si Shen Wan on impaired colonic mucosa rats with experimental colitis was accomplished by down-regulating the level of MDA and MPO, and up-regulating the level of SOD and the IL-4 and IL-10 mRNA expression in the colon mucosa.

Pneumatosis intestinalis in newly born infants constitutes a clinical manifestation greatly associated with the presence of necrotizing enterocolitis, a highly severe medical condition. This study provides a cli-nical case series presenting with bloody stools and benign pneumatosis intestinalis. A short colonoscopy proven diagnosis of allergic colitis was made, which was confirmed in the 87,5% (7/8) of the cases, while a number of biopsies showed eosinophiles exceeding the normal ranges. Diagnosis in 12,5% of patients (1/8) was based on clinical records, lab-tests, imaging and treatment responses. The suppression of cow’s milk protein in the maternal diet or the replacement of human milk by a substitute free from that protein led to a rapid regression of symptomatology. Key words: Pneumatosis, necrotizing enterocolitis. Resumen: La neumatosis intestinal en el recien na-cido es un signo que se asocia mayoritariamente a la presencia de enterocolitis necrotizante, una condicion grave. Se presenta una serie de casos clinicos que debutaron con sangre en la deposicion y neumatosis intestinal de curso benigno, diagnosticandose una colitis alergica, que fue demostrada en el 87,5% (7/8) de los casos mediante colonoscopia corta y biopsias que demostraron un numero de eosinofilos mayor que lo normal; en el 12,5% (1/8) el diagnostico se baso en clinica, laboratorio, imagenes y respuesta a tratamiento. La supresion de la proteina de la leche de vaca en la dieta de lamadre o el reemplazo de la leche materna por un sustituto libre de esta proteina, llevo a una rapida regresion de la sintomatologia.

Twenty-eight exclusively breast-fed healthy infants and 16 infants also exclusively breast-fed with allergic colitis (aged 85 +/- 60 and 98 +/- 58 d, respectively) were screened for differences in fecal flora. Bifidobacteria were detected in 23 healthy infants and only in 4 fecal samples of infants with allergic colitis. All bifidobacteria-free infants possessed Gram-positive regular rods as a major group of their fecal flora. These bacteria were identified as clostridia using genus-specific FISH probe. Infants with allergy colitis possessed significantly lower counts of bifidobacteria and total anaerobes and significantly higher counts of clostridia in their feces. In healthy infants, Bifidobacterium longum was the most frequently found species (54.5% of the samples), followed by B. adolescentis (20.0), B. breve (18.2), B. bifidum (16.4), B. dentium (10.9) and B. pseudocatenulatum (1.80). Bifidobacterial isolates from two babies with allergic colitis were identified as B. longum, one child from patients group contained species B. dentium and one baby B. adolescentis. Our results suggest that there are significantly lower counts of bifidobacteria in infants with allergic colitis than in healthy infants.

re likely to be more susceptible to these problems due to possible disturances of both oesophageal function and respiratory regulation at this stage f life. In our cases almost all GER-related apnoeas were linked with noncid GER (63/64). pH-monitoring alone does not recognize these episodes f GER. This highlights the importance of combined pH-MII monitoring o characterize all GER features. Furthermore 20 apnoeas were related to GER that is possible recognize only by a manual analyse of the impedance egistration. Most apnoeas are preceded by reflux (48/64): this finding suports our hypothesis that GER is the causative factor. Seventeen percent of pnoeas was related to swallow events; further studies are necessary in order o clarify the relationship between these two events.

The authors present a neonatal case of allergic colitis, which manifested the difficulty of spontaneous defecation and irregular narrowing of distal rectum in contrast enema. Rectal suction biopsy showed positive acetylcholinesterase activity. These clinical, radiological and histological findings were indistinguishable from Hirschsprung’s disease. Gastrointestinal symptoms were improved by the cessation of cow’s milk formula. The present findings may impact on the less recognizable gastrointestinal manifestation of allergic colitis.

RACIONAL: Recentes estudos indicam a importância do infiltrado eosinofílico na mucosa retal que, juntamente com os dados clínicos, pode servir para estabelecer o diagnóstico de colite alérgica. OBJETIVOS: Descrever, prospectivamente, as características clínicas e a morfologia da mucosa retal em pacientes com enterorragia e suspeita diagnóstica de alergia às proteínas do leite de vaca. MATERIAL E MÉTODOS: Foram estudados 20 pacientes, menores de 6 meses para descrever suas características clínicas e a histologia da mucosa retal que foi comparada com um grupo controle, com suspeita de megacólon congênito. RESULTADOS: A idade média dos pacientes foi 97 ± 47 dias; enterorragia teve início antes dos 120 dias em 85% deles; em vigência de aleitamento materno (40%) artificial ou misto (60%). O achado histológico, estatisticamente significativo, foi o infiltrado aumentado de eosinófilos, na mucosa retal, em 18 pacientes. CONCLUSÃO: Pode-se afirmar que esses achados constituem, associados aos dados clínicos, os mais importantes elementos no diagnóstico de colite alérgica, em pacientes menores de 6 meses com enterorragia, que estejam recebendo aleitamento materno e/ou aleitamento artificial. BACKGROUND: Recent studies indicate the importance of eosinophilis infiltrated in the rectal mucous which jointly with the clinical features can serve to establish the diagnostic of allergic colitis. AIM: To describe prospectively, the clinical features and morphological abnormalities of the rectal mucosa in patients with rectal bleeding and clinical diagnosis of cow's milk allergy. METHODS: Clinical features of 20 infants under 6 months of age were described. Morphological findings in rectal mucosa were compared with control group, with suspicion of congenital megacolon. RESULTS: The mean age of the patients was 97 ± 47 days, rectal bleeding started before 120 days in 85% of them; 40% were breastfed, 60% cow's milk formula or both. The most striking morphological feature, in 18 patients, was eosinophilic infiltration in the rectal mucosa. There was a significant statistical difference when these values were compared with control group. CONCLUSIONS: The increased number of eosinophils in the rectal mucosa represent the most important characteristic of allergic colitis, in patients under 6 months, with rectal bleeding, when breastfed, cow's milk formula or both.

We appreciate the interest shown in our case report and the comments of Drs Gordon and Clark.1 Gordon and Clark provide very interesting findings from the largest dataset of preterm infants with necrotizing enterocolitis (NEC) and their eosinophil counts at the time of the NEC diagnosis. In their dataset, in addition to the lack of feeding history (pathogenesis of allergic colitis is driven by dietary antigens), it is not clear whether stool examination for leucocytes was done in the subset of NEC patients categorized based on peripheral eosinophil count. The supposition about the allergic enterocolitis as a benign entity compared to NEC in general is based on lack of reported mortality rates in neonatal literature attributed to allergic enterocolitis as a clinical entity in itself and the dramatic improvement and non-progression of systemic symptomatology with removal of offending dietary antigen. Although a mortality rate of 16.8% relative to the higher mortality rate of 22% between low (

Gastrointestinal (GI) bleeding is an alarming problem in children. Although many causes of GI bleeding are common to children and adults, the frequency of specific causes differs greatly, and some lesions, such as necrotizing enterocolitis or allergic colitis, are unique to children. This article reviews the spectrum of GI bleeding in infants and children. The causes, diagnostic evaluation, and management are discussed, and differences with adult medicine are highlighted.

To investigate the characteristics of mucosal lesions and their relation to laboratory data and long-term follow up in breast-fed infants with allergic colitis.In this study 31 breast-fed infants were prospectively evaluated (mean age, 17.4 wk) whose rectal bleeding had not ceased after a maternal elimination diet for cow's milk. Thirty-four age-matched and breast-fed infants (mean age, 16.9 wk) with no rectal bleeding were enrolled for laboratory testing as controls. Laboratory findings, colonoscopic and histological characteristics were prospectively evaluated in infants with rectal bleeding. Long-term follow-up with different nutritional regimes (L-amino-acid based formula or breastfeeding) was also included.Iron deficiency, peripheral eosinophilia and thrombocytosis were significantly higher in patients with allergic colitis in comparison to controls (8.4 ± 3.2 μmol/L vs 13.7 ± 4.7 μmol/L, P0.001; 0.67 ± 0.49 G/L vs 0.33 ± 0.17 G/L, P0.001; 474 ± 123 G/L vs 376 ± 89 G/L, P0.001, respectively). At colonoscopy, lymphonodular hyperplasia or aphthous ulceration were present in 83% of patients. Twenty-two patients were given L-amino acid-based formula and 8 continued the previous feeding. Time to cessation of rectal bleeding was shorter in the special formula feeding group (mean, 1.4 wk; range, 0.5-3 wk) when compared with the breast-feeding group (mean, 5.3 wk; range, 2-9 wk). Nevertheless, none of the patients exhibited rectal bleeding at the 3-mo visit irrespective of the type of feeding. Peripheral eosinophilia and cessation of rectal bleeding after administration of elemental formula correlated with a higher density of mucosal eosinophils.Infant hematochezia, after cow's milk allergy exclusion, is generally a benign and probably self-limiting disorder despite marked mucosal abnormality. Formula feeding results in shorter time to cessation of rectal bleeding; however, breast-feeding should not be discouraged in long-lasting hematochezia.

Two atypical cases of colitis due to cow's milk protein intolerance (CMPI) are reported, affecting preterm infants. One developed a toxic dilatation of the colon and responded well to a casein hydrolysate based feed. The second presented insidiously and failed to tolerate a casein hydrolysate, but responded well to a chicken-based modular feed.

Background: Allergic colitis (AC) is a well recognised cause of rectal bleeding in infancy. Dietary antigens have been clinically implicated, in particular, cow's milk protein (CMP). The underlying immune mechanism remains elusive. The aim of the study is to characterise the systemic and gut mucosal T-helper type1/ type 2 (Th1/Th2) cytokine profile in infants with allergic colitis and, to correlate the clinical CMP sensitivity with in vitro response.

Thirteen infants with eosinophilic colitis caused by food allergy were reviewed after five to 10 years. By the age of 5 years most foods were tolerated. The colon was normal in the one child re-examined. There was an atopic association, but no family history of classical inflammatory bowel disease. Allergic colitis is a temporary disorder of early childhood.