History Of Gastrointestinal Symptoms Research Articles

Clozapine induced oesophagitis: A case report

IntroductionThere are several case reports describing clozapine side effects such as agranulocytosis, constipation,tachycardia but rarely cases describing oesophagitis caused by clozapine were reported.ObjectivesTo report the first case in our country about clozapine induced oesophagitis.MethodsWe describe a case in which a patient who has no gastrointestinal past history,has developed an oesophagitis stage 2 of Savary and Miller Classification without any gastroesophageal reflux disease, few weeks after introducing clozapine at therapeutic dose.ResultsA 25 years old male patient with resistant schizophrenia managed with clozapine,was admitted to reinitiate his treatment after weeks of stopping his medication.During hospitalization, our patient developed a sudden haematemesis in 10 days after commencement of clozapine. The patient had no history of gastrointestinal symptoms or disease. The clinical examination and blood tests did not find any signs of bleeding severity.A gastroscopy was performed, revealing esophagitis stage 2 of Savary and Miller classification and a cardiac polyp removed with biopsy forceps that showed no malignant lesions .The patient was treated with acid suppressant therapy.There was no further episode of haematemesis and our patient healed uneventfully within a week.As for clozapine, it wasn’t interrupted and we continued increasing doses very carefully with no further incident.ConclusionsAlthough it is a rare side effect, oesophagitis may appear at therapeutic doses of clozapine, and this possibility should be taken into account when treating patients with resistant psychiatric disorders.DisclosureNo significant relationships.

The diagnosis of avoidant restrictive food intake disorder in the presence of gastrointestinal disorders: Opportunities to define shared mechanisms of symptom expression.

Individuals with a gastrointestinal (GI) disorder often alter their diet to manage GI symptoms, adding complexity to understanding the diverse motivations contributing to food avoidance/restriction. When a GI disorder is present, the DSM-5 states that Avoidant/Restrictive Food Intake Disorder (ARFID) can be diagnosed only when eating disturbance exceeds that expected. There is limited guidance to make this determination. This study attempts to address this gap by characterizing the presentation of ARFID in adults with and without a self-reported GI disorder. Participants were 2,610 adults ages 18-44 who self-identified as "picky eaters." Participants reported on motivations for food avoidance, affective experiences towards food, and perceived impairment. Responses were compared across four groups: GI issues and likely ARFID (L-ARFID/GI), L-ARFID-only, GI-only, and No-ARFID/No-GI. Groups with a GI disorder (L-ARFID/GI, GI-only) reported more fear of aversive consequences of eating than those without a GI disorder, while groups with L-ARFID (L-ARFID, L-ARFID/GI) evidenced significantly greater sensory aversion to food and indifference to food or eating, negative emotional reactions to food and overall disgust sensitivity, and eating related impairment. Consideration of the interplay of a GI disorder with ARFID can add precision to case conceptualization. Food avoidance may be attempts to manage fears of aversive consequences that are augmented by a history of GI symptoms, while sensory aversions and negative emotional reactions towards foods may be more elevated in ARFID. These findings emphasize the need to consider an ARFID diagnosis in patients with GI disorders to optimize care.

Severe pneumonia in adults caused by Tropheryma whipplei and Candida sp. infection: a 2019 case series

BackgroundWhipple’s disease is a chronic infectious disease caused by the Gram-positive bacterium Tropheryma whipplei (TW), which not only affects the gastrointestinal tract and causes malabsorption of nutrients, but several other systems, such as the cardiovascular system, central nervous system, the joints, and the vascular system, can also be simultaneously involved. The aim of this report was to be able to alert the clinician to severe pneumonia caused by TW combined with Candida sp.Case presentationThe case study was conducted on patients in September and November 2019. After routine examination and treatment, the results were not satisfactory. A bronchoalveolar lavage (BAL) using metagenomics next-generation sequencing was conducted on two adults who presented with fever, cough, and progressive dyspnea and who had no history of gastrointestinal symptoms, immunodeficiency diseases, or use of immunosuppressive agents. TW and Candida sp. were detected in in BAL.ConclusionsThis is a report of life-threatening pneumonia caused by TW combined with Candida sp. in a Chinese population.

Gastrointestinal symptoms as antecedent signs of severe acute respiratory syndrome coronavirus 2 infection

Introduction. The coronavirus disease 2019 (COVID‑19) is an acute infectious disease of the respiratory system caused by severe acute respiratory syndrome coronavirus (SARS‑CoV‑2). Most patients present with typical, respiratory symptoms. Common signs include cough, fever, dyspnea and shortness of breath. In this case we provide atypical indications of COVID-19, which may occur earlier than respiratory symptoms. Aim. This case is an example of an unusual course of SARS-CoV-2 infection. Description of the case. This article describes a case of a 63-year-old man and his wife, a 60-year old woman who were admitted to the emergency department with a few days’ history of gastrointestinal symptoms. Both patients presented with the digestive symptoms of nausea, diarrhea and loss of appetite. They denied abdominal pain and the loss of smell or taste. Due to suspicion of SARS-CoV-2 infection a nasopharyngeal swabs of both patients was taken. The results of real- time reverse transcriptase-polymerase chain reaction were positive. When the final diagnosis of COVID-19 was established they were transported to another hospital. Conclusion. COVID-19 may manifest with atypical indications such a nausea and diarrhea. An atypical indications of COVID-19 may occur earlier than respiratory symptoms. It is important for clinicians to remain alert.

IT LOOKED BLOODY BUT WASN'T: A CASE OF SALMONELLA EMPYEMA

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Non-typhi Salmonella was isolated from sample of pleural empyema of an immunocompromised patient. The patient was treated with prolonged antibiotic course, thoracotomy with decortication, and chest tube placement; endured complications including chest tube induced pleural cutaneous fistula, subcutaneous emphysema, pneumomediastinum, and persistent hydropneumothorax with trapped lung. Pulmonary salmonellosis is a rare infection that generally occurs with history of gastrointestinal symptoms or enterocolitis and should be considered in patients with immunodeficiency, sickle cell anemia, and lung cancer. CASE PRESENTATION: 57-year-old man with PMH of RA and recurrent right sided pleural effusion (PE) presented with right sided pleuritic chest pain. The patient was septic with a leukocytosis of 15.8 10E3/uL. CT chest showed moderate sized, loculated PE with adjacent passive atelectasis [Figure 2]. A thoracentesis was performed with 650 cc bloody fluid drained. Pleural fluid was exudative with glucose less than 10, pH 6.83, and LDH 1175. A chest tube was placed and pleurolysis initiated. He subsequently underwent right thoracotomy decortication with findings of extensive adhesions, trapped middle and lower lobe lung, and thick chronic rind with no dissection plane. Fluid culture speciated to Salmonella group D and ABX were narrowed to ceftriaxone. He was successfully treated with a 65-day course. DISCUSSION: Salmonella is a gram-negative non-spore forming anaerobic motile bacilli of the Enterobacteriaceae family. Clinical presentation of a Salmonella infection depends on the serotype and ranges from sepsis to gastroenteritis. Non-typhi salmonella organisms often produce a localized reaction, most commonly intestinal infections.1 There have been rare cases of pleuropulmonary infections, which are abrupt in onset without gastrointestinal symptoms in two-thirds of cases and incidence is highest in immunosuppressed patients.2 Pathogenesis is unclear, however it is suggested that Salmonella may rest dormant in the reticuloendothelial system. Blood spread may be a consequence of reactivation however due to low bacterial load, blood cultures are often negative.3 Due to Salmonella organisms’ propensity for prolonged infection a 4 to 12-week course of ABX should be anticipated and include a third-generation cephalosporin or fluoroquinolone. CONCLUSIONS: In patient with relapsing infections, drainage of empyema is likely necessary, with the possibility of decortication. Patients without known preexisting conditions should also undergo further testing for associated immunodeficiency including HIV and malignancy as well as investigation for focal gastrointestinal tract infections and fistulas.Lastly, in the setting of an immunocompromised patient with exudative pleural effusions or empyema, non-typhi Salmonella should be considered as a causative agent and investigated as early as possible. Reference #1: Abuhasna S, Al Jundi A, et al. Non-typhoidal Salmonella group D bacteremia and urosepsis in a patient diagnosed with HIV Infection. Journal of Global Infectious Diseases. 2012;4(4):218. Reference #2: Pathmanathan, S., Welagedara, S., Dorrington, P. et al. Salmonella empyema: a case report. Pneumonia 6, 120–124 (2015). Reference #3: Saeed N. Salmonella pneumonia complicated with encysted empyema in an immunocompromised youth: Case report and literature Review. The Journal of Infection in Developing Countries. 2016;10(04):437-444. DISCLOSURES: No relevant relationships by Sarah Luber, source=Web Response no disclosure on file for David Sharpe; No relevant relationships by Abigayle Sullivan, source=Web Response

Hypoadrenocorticism in dogs – the Mad Hatter of veterinary internal medicine

Hypoadrenocorticism arises from insufficient adrenal gland function and is also known as Addison’s disease, a rarely occurring disease (0.1%) in dogs. Due to its oscillatory course and overall nonspecific symptoms, it is a diagnostic challenge for clinicians, and is often misdiagnosed or unattended among other differentials. There are two forms of hypoadrenocorticism: primary and secondary. The aim of this study was to analyse the data of dogs suffering from Addison’s disease, treated at the Clinic for Internal Medicine, Faculty of Veterinary Medicine, University of Zagreb, Croatia and to compare them with data from similar institutions worldwide. The archive of Clinic for Internal Medicine, Faculty of Veterinary Medicine, Zagreb, Croatia was searched to investigate and statistically analyse signalment, clinical and laboratory data, and the duration of symptoms, treatment protocols and outcome of canine hypoadrenocorticism. The study group included 14 dogs (36% male and 64% female) diagnosed with hypoadrenocorticism. All dogs had a history of gastrointestinal symptoms, i.e. vomiting in 100%, diarrhoea in 64% and melena in 7%. Hypovolemic shock was noted in 57%, hypothermia in 64% and bradycardia in 29% of cases. The most frequently observed laboratory abnormalities were an increase in BUN (86%), creatinine (57%) and potassium concentration (79%), and a decrease in sodium (71%), Na/K ratio (86%), cholesterol (21%) and glucose concentration (21%). Duration of symptoms (till ACTH stimulation test performance) was broad, from 2 – 2190 days (median 90±1195.5 days). The outcome was favourable in 100% cases after initiation of adequate treatment.

Gastric emptying: methodology and normal ranges for two commonly used meals in the UK.

A recent audit has highlighted that there is a large variation in the way gastric emptying scintigraphy is performed, analysed and reported in the UK. In this study, we have established a comprehensive protocol on how to perform gastric emptying including normal ranges for two of the most widely used meals. A standardized scrambled egg sandwich was used as the main meal. Normal ranges were also established for oat porridge as an alternative gluten-free meal. We have calculated normal ranges for several functional parameters which may be used to assess gastric emptying. We hope that establishing a reliable normal range for these two simple and commonly used meals will encourage adoption of a universally accepted protocol for measurement of solid gastric emptying in the UK. A total of 42 volunteers (20 male, 22 female, age range 22-68) with no history of gastrointestinal symptoms or diabetes were studied. Each volunteer fasted overnight and consumed two meals with similar nutritional composition on two separate days: scrambled eggs with two slices of bread were consumed on one day and gluten-free porridge (40 g in 200 mL whole milk) was consumed on a different day. Each meal was radiolabelled with 10 MBq of Tc-DTPA. Simultaneous anterior-posterior 2-min static images were acquired with the patient standing between the gamma camera detectors. Images were acquired every 5 min over a 2 hour period, followed by a single image at 3 hour. The data were modelled using a power-exponential function that allowed measurements of gastric emptying functional parameters including lag time, half-emptying time (HET), peak emptying rate, time-to-peak emptying (TPE) and exponential half-life (EHL). Three-hour retention was also calculated. Paired t-tests were used to compare the two meals and two-sample t-tests were used to assess gender-related differences. Regression analysis was used to assess correlation of the functional parameters with age and body habitus (body surface area, BSA). All gastric emptying functional parameters were significantly different between the two meals (P < 0.001). The normal range for lag time was 0-13 min for porridge and 1-34 min for scrambled egg. The normal range for HET was 18-73 min for porridge and 44-116 min for scrambled egg. The normal range for EHL was 21-57 min for porridge and 20-82 min for scrambled egg. The normal range for 3 hour retention was <7% for porridge and <17% for scrambled egg. Only weak significance was found for gender-related differences in gastric function for the two meals (0.05 < P < 0.10). Weak correlation was also observed for some functional parameters when plotted against age and BSA (0.05 < P < 0.10). We have established gastric emptying normal ranges for the two most commonly used meals in the UK. The normal ranges are meal specific and not interchangeable, with porridge showing significantly faster transit than scrambled egg for all measured parameters. Scrambled egg sandwich is the recommended meal for solid gastric emptying studies as it is more reproducible and more comparable to a normally consumed solid meal for our population. Porridge would be a suitable alternative for patients who are unable to eat egg sandwiches, for example, patients with egg allergy or gluten intolerance.

P455 Adherence to enteral nutrition therapy by adults with active Crohn’s disease is associated with conscientiousness personality trait

Abstract Background Conscientiousness is a personality trait characterised by the ability to control impulses, delay gratification, set and reach goals, and plan in advance. Conscientious people are more likely to be non-smokers, do physical activity and practice healthy eating behaviours. They are also more likely to be adherent to medication. The aim of this study was to assess whether people with Crohn’s disease who score high on conscientiousness are more likely to be adherent to enteral nutrition (EN) therapy than low scorers. Methods Adults aged 16 to 40 years with newly diagnosed Crohn’s disease or having a flare of disease were invited by their gastroenterologist to use nutrition therapy to induce disease remission. Nutrition therapy was either eight weeks of exclusive enteral nutrition (EN) or two weeks of exclusive EN followed by six weeks of partial EN and one meal per day. A convenience control group of healthy participants with no history of gastrointestinal symptoms was also recruited to use exclusive EN for two weeks. Adherence to EN was self-reported fortnightly using a standardised questionnaire. Non-adherence was defined as patients who repeatedly ate foods while using EN or ate more than one meal per day on partial EN. Patients who could not initiate or did not tolerate the EN formula were included in the non-adherent group. Prior to starting nutrition therapy, conscientiousness was measured using the well-validated conscientiousness subset of the Big Five Inventory. Results Twenty-three (59%) of the 39 patients recruited with Crohn’s disease completed and adhered to the eight-week treatment. Reasons for non-adherence by the 14 patients who did not complete treatment included: could not initiate EN (n = 4), non-response at week 4 (n = 2), intolerance of EN (n = 7) or repeated eating of food or started eating food again prior to the end of treatment (n = 2). Seventeen (81%) of the 21 healthy controls completed and adhered to 2 weeks of exclusive EN. Reasons for non-adherence were could not initiate EN (n = 3) or intolerance of the formula (n = 1). Adherence and completion of EN therapy were associated with a greater mean conscientiousness score 35.57 (95% CI: 32.88, 38.25) compared with the non-adherence group mean 30.13 (95% CI: 26.53, 33.73), p = 0.014. Mean conscientiousness score of the healthy controls who completed exclusive EN was similar to the Crohn’s disease group (36.65 (95% CI: 33.53, 39.77), p &amp;gt; 0.05). Conclusion Conscientiousness was associated with adherence to EN therapy. EN therapy can be a cognitively and emotionally demanding treatment and this personality trait should ideally be considered when determining suitable candidates for EN therapy.

Gastrointestinal Symptoms in Autism Spectrum Disorders

The purpose of this study was to characterize individuals with autism spectrum disorders (ASD), who are part of a larger ASD study, in order to determine clinically useful ways to evaluate gastrointestinal (GI) symptomology. Thirty-three children (ages 3-16) were recruited from a variety of community agencies. Potential participants were screened using the Autism Diagnostic Observation Schedule (ADOS). Parental informed consent was obtained from all participants and child assent when appropriate. Parents completed the Gastrointestinal Symptom Rating Scale, Bristol Stool Chart (BSC), and sociodemographic form. Of the 33 participants, 14 were currently experiencing gastrointestinal symptoms and had abnormal bowel movements. Seven had a history of gastrointestinal symptoms and abnormal bowel movements; two parents were unsure of their gastrointestinal health. According to the BSC rescore, 13 participants reported hard stools, 14 had normal stools, and six had loose stools. Moderate correlations were found among many GI symptoms (r33= .396 - .751) indicating that these could be clustered to create a profile. These findings are clinically significant because GI symptoms in ASD are difficult to diagnose due to communication and social impairments and may go undiagnosed and untreated. Further characterizing GI symptomology in this population is a logical role for nurse researchers since nurses are often on the front line intervening within the ASD population.

SNPnotes: high-throughput tissue-specific functional annotation of single nucleotide variants

A key challenge in the application of whole-genome sequencing (WGS) for clinical diagnostic and research is the high-throughput prioritization of functional variants in the non-coding genome. This challenge is compounded by context-specific genetic modulation of gene expression, and variant-gene mapping depends on the tissues and organ systems affected in a given disease; for instance, a disease affecting the gastrointestinal system would use maps specific to genome regulation in gut-related tissues. While there are large-scale atlases of genome regulation, such as GTEx and NIH Roadmap Epigenomics, the clinical genetics community lacks publicly-available stand-alone software for high-throughput annotation of custom variant data with user-defined tissue-specific epigenetic maps and clinical genetic databases, to prioritize variants for a specific biomedical application. In this work, we provide a simple software pipeline, called SNPnotes, which takes as input variant calls for a patient and prioritizes those using information on clinical relevance from ClinVar, tissue-specific gene regulation from GTEx and disease associations from the NHGRI-EBI GWAS catalogue. This pipeline was developed as part of SVAI Research's "Undiagnosed-1" event for collaborative patient diagnosis. We applied this pipeline to WGS-based variant calls for an individual with a history of gastrointestinal symptoms, using 12 gut-specific eQTL maps and GWAS associations for metabolic diseases, for variant-gene mapping. Out of 6,248,584 SNPs, the pipeline identified 151 high-priority variants, overlapping 129 genes. These top SNPs all have known clinical pathogenicity, modulate gene expression in gut tissues and have genetic associations with metabolic disorders, and serve as starting points for hypotheses about mechanisms driving clinical symptoms. Simple software changes can be made to customize the pipeline for other tissue-specific applications. Future extensions could integrate maps of tissue-specific regulatory elements, higher-order chromatin loops, and mutations affecting splice variants.

2559 Adenosquamous Carcinoma of the Ileum: A Rare Entity Found Incidentally

INTRODUCTION: Primary small bowel malignancy accounts for 0.6% of all new cancer cases in the U.S. and 1-3% of gastrointestinal tract neoplasms. The common subtypes of malignant small bowel tumors include carcinoid (44%), adenocarcinoma (33%), lymphoma, (15%) and sarcoma (8%). Adenosquamous carcinoma (ASC) is even more rare with only a few cases reported in the literature. The infrequency with which this malignancy is diagnosed and it's late and nonspecific clinical presentation contribute to delayed diagnosis and consequently worse prognosis. CASE DESCRIPTION/METHODS: A 58-year-old African American male presented for a surveillance colonoscopy. His initial screening colonoscopy at 53 years of age showed six polyps, of which, one was a 1 cm sized tubular adenoma. He had no history of gastrointestinal symptoms. During the colonoscopy and routine terminal ileum (TI) intubation, a 4 cm sized mass with central ulceration was visualized. The rest of the colonoscopy was significant only for two small hyperplastic polyps in the rectum. Endoscopic biopsies of the mass showed atypical epithelium. Further, abdominal computed tomography (CT) scan showed no lymphadenopathy or evidence of metastatic disease. He underwent exploratory laparotomy with ileocecectomy and pathology of the mass revealed poorly differentiated, high grade adenocarcinoma with areas of squamous differentiation, arising from a villous adenoma and extending into the muscularis propria (pT2). DISCUSSION: ASC can involve any organ including lungs, pancreas, liver, gallbladder and the gastrointestinal (GI) tract. ASC of ileum is an extremely rare diagnosis. Published case reports show that metastases of small intestinal ASC is common at the time of diagnosis. Our patient was fortuitous enough to have been diagnosed with ileal ASC in an early stage without evidence of metastasis, due to TI intubation during a routine colonoscopy. Surgical resection was likely curative for this patient. To our knowledge, no study has been published to evaluate the prevalence of TI malignant tumors during routine colonoscopy. In addition, intubation of the TI is currently not required during routine colonoscopy. This raises the question if there is utility in measuring TI intubation rates as a potential quality indicator for colonoscopists in the future.

RESOLUTION OF VESTIBULAR MIGRAINE COMPLICATED BY AUTOIMMUNE HYPOTHYROID WITH A PROGRAM OF MULTIMODAL NEUROREHABILITATION AND CLINICAL NUTRITION

Event Abstract Back to Event RESOLUTION OF VESTIBULAR MIGRAINE COMPLICATED BY AUTOIMMUNE HYPOTHYROID WITH A PROGRAM OF MULTIMODAL NEUROREHABILITATION AND CLINICAL NUTRITION David Schiller1* 1 Independent researcher, United States Background: A 51 year old female presented to a private clinic with a history of chronic dizziness that had been getting progressively worse over the last several months. She had been given a diagnosis of vestibular migraine by an Ear, Nose and Throat specialist. She had numerous episodes of Benign Paroxysmal Positional Vertigo (BPPV) previously in her history which were resolved with Epley's maneuver. She has a history of gastrointestinal symptoms that were diagnosed as Irritable Bowel Syndrome (IBS) and hypothyroid that was diagnosed as Hashimoto's. The patient describes the dizziness symptoms as her head is "a balloon floating above my body." Her autoimmune hypothyroid was being managed with medications by her endocrinologist. Methods: Neurological examination revealed paradoxical findings on multi position blood pressure with a rise in blood pressure when the patient changed from seated to supine. Convergence insufficiency was observed on the right during eye movement analysis. Optokinetic eye movements were insufficient leftward and upward. Alternating hand movements revealed dysdiadochokinesia (DDK) on the left. Saccodometry of 100 saccades revealed hypometria with leftward and rightward saccades. Computerized Dynamic Posturography (CDP) revealed an anterior center of pressure (aCOP) on perturbed surface testing. CDP testing with head in right rotation revealed an abnormal loss in stability. CDP testing with head in extension on a perturbed surface revealed a near fall. Palpation revealed several areas of aberrant spinal segmental movement in the cervical and thoracic spine. A program of multimodal neurorehabilitation included vestibular rehabilitation (VR), spinal manipulative therapy (SMT) and Low Level Laser Therapy (LLLT). VR included gaze stability exercises, passive and active vestibular canal stimulation, laser guided visual feedback and eye movement exercises. Results: Saccodometry revealed resolution of the hypometria. CDP revealed an improvement in stability with head to the right and in extension. There was a resolution of aCOP on perturbed surfaces. Convergence test normalized. OPK testing normalized. Patient reported a resolution of dizziness symptoms that now only rarely occur with extreme fatigue. Conclusion: this author recommends further investigation into multimodal neurorehabilitation protocols that include VR, LLLT and SMT for the treatment of chronic dizziness and vestibular migraine Keywords: Dizziness, dizziness and vertigo, vestibular migraine, Vertigo, Hashimoto's, autoimmune disease, Hypothyroid, IBS – Irritable bowel syndrome, Neck Pain, Shoulder Pain, Spinal manipulative therapy, Low level laser therapy ( LLLT), Vestibular Rehabilitation, Clinical Nutrition, Center of Pressure (COP), saccodometry, convergence insufficiency, Benign paroxysmal positional vertigo (BPPV), Migraine, dysautonomia, orthostatic blood pressure Conference: International Symposium on Clinical Neuroscience, Orlando, United States, 24 May - 26 May, 2019. Presentation Type: Poster Presentation Topic: Clinical Neuroscience Citation: Schiller D (2019). RESOLUTION OF VESTIBULAR MIGRAINE COMPLICATED BY AUTOIMMUNE HYPOTHYROID WITH A PROGRAM OF MULTIMODAL NEUROREHABILITATION AND CLINICAL NUTRITION. Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience. doi: 10.3389/conf.fneur.2019.62.00015 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 02 Apr 2019; Published Online: 27 Sep 2019. * Correspondence: Dr. David Schiller, Independent researcher, Avon, United States, drschiller@comcast.net Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers David Schiller Google David Schiller Google Scholar David Schiller PubMed David Schiller Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

SERUM ANTIGLIADIN ANTIBODIES IN EGYPTIAN CHILDREN WITH AUTISM SPECTRUM DISORDER: RELATIONSHIP TO GASTROINTESTINAL SYMPTOMS, BEHAVIORAL AND SOCIAL COMMUNICATIONS

Objectives: Gastrointestinal symptoms are major characteristic in children with autism spectrum disorder (ASD), drawing attention to a potent association with gluten sensitivity. The goal of this study was to evaluate anti-gliadin antibodies serum levels in a group of Egyptian children with ASDs and to address the potential link to gastrointestinal (GI) symptoms, behavioral, and social communications.Patients and Methods: This descriptive case–control study included 45 children diagnosed as ASD according to Diagnostic and Statistical Manual of Mental Disorders 5th Edition and a history of GI symptoms, compared with 45 apparently healthy children of matched age and sex. Serum anti-gliadin antibodies were measured using enzyme-linked immunosorbent assay kits.Results: Serum levels of IgM, IgA, and IgG class antibodies to gliadin showed a significant increase compared to healthy controls (p&lt;0.000). Multiple logistic regression analysis showed a significant association between the high serum levels of IgA and IgM class antibodies to gliadin in the studied patients and GI symptoms (p&lt;0.05). A significant association was detected between the high serum levels of IgG antibodies to gliadin and the behavior symptoms (p&lt;0.05).Conclusions: The anti-gliadin antibody response and its association with GI symptoms indicated the involvement of abnormal immunologic intestinal permeability in affected children. Immune system of some autistic patients could be abnormally triggered by gluten assumption.

Ruptured congenital jejunal diverticulum resulting in a mechanical gastrointestinal tract obstruction in a dog

An 18-month-old female neutered English Springer Spaniel was referred due to persistent vomiting for 48 hours, following a five-week history of gastrointestinal symptoms that failed to respond to symptomatic medical management. Clinical examination revealed a firm tubular structure in the mid-abdomen, which was painful on palpation. Biochemistry showed hypoproteinaemia, hypoalbuminaemia and low serum alkaline phosphatase. A right lateral abdominal radiograph was consistent with a mechanical obstruction of the gastrointestinal tract. An exploratory coeliotomy was performed and an annular jejunal stricture was identified and excised. Histopathology confirmed the presence of a stricture secondary to a ruptured congenital or developmental jejunal diverticulum arising from the antimesenteric border of the gastrointestinal tract. This has not previously been reported in dogs. The dog made an uncomplicated recovery from surgery and has been asymptomatic for the past 18 months.

Abstract # 1787 Unique immune profiles in children with autism who experience gastrointestinal co-morbidity

Children with an autism spectrum disorder (ASD) are 6–8 times more likely to have persistent gastrointestinal (GI) symptoms. In addition, intestinal and peripheral inflammation, altered microbiome profiles, and impaired intestinal permeability have also been observed in children with ASD who exhibit GI issues. To further assess immune dysfunction and relationship to behavior in children with ASD and GI co-morbidities, we analyzed samples from children placed into the following study groups based on responses from standardized GI questionnaires: children with ASD who experience GI symptoms (ASDGI), children with ASD without a history of GI symptoms (ASDNoGI), or typically developing (TD) children. Cytokine analysis of supernatants collected from stimulated peripheral blood mononuclear cells, revealed elevated innate immune responses from ASDNoGI including increased levels of IL-1alpha, IL-1beta and TNFalpha after stimulation with Toll-Like receptor (TLR)-4 ligands compared to TD. The ASDGI group produced increased levels of mucosa-relevant cytokines IL-5, IL-15 and IL-17 compared to ASDNoGI following TLR-4 stimulation. Interestingly, the production of regulatory cytokine, TGFbeta1, was decreased across all stimulatory conditions in ASDGI compared to either ASDNoGI or TD groups. Furthermore, ASDGI scored worse on the Aberrant Behaviors Checklist than ASDNoGI. Overall, data from this study found evidence of reduced regulatory cytokines and increased mucosa-related cytokines in ASDGI which suggest that children with ASD and GI symptoms have an imbalance between regulatory and inflammatory pathways.

Familial gluten ataxia

Gluten ataxia (GA) is an autoimmune gluteninduced disease that appears in predisposed subjects. It is characterized by sporadic, progressive cerebellar ataxia, alone or in combination with postural tremor and/or peripheral neuropathy. Among the most characteristic findings is the higher serological prevalence of antigliadin antibodies (AGAs) compared to healthy controls. Deposition of immunoglobulin A (IgA) antibodies against isotype 6 of tissue-transglutaminase (tTG6) has been found around the brain vessels in the cerebellum, pons, and medulla of GA patients. Damage to the cerebellum is mainly related to antibody cross-reactivity between antigenic epitopes on Purkinje cells and T-lymphocyte immune response, activated after exposure to gluten proteins. Cerebellar atrophy on magnetic resonance imaging (MRI) is seen in up to 60% of GA patients. Normally the insidious onset of ataxia occurs in the 6th or 7th decade of life. Patients may have a long history of gastrointestinal symptoms but only one third show evidence of mild enteropathy in duodenal biopsies. The response to treatment with a gluten-free diet (GFD) is favorable, not only with respect to digestive complaints but also to the neurological disease. When the cerebellar neuron degeneration is significant as a consequence of a delayed diagnosis, the neurological manifestations may be considered irreversible. 1–4 We present a family composed of 9 siblings, six of whom were suffering from gait ataxia accompanied by varying degrees of postural hand and cephalic tremor. There was no cognitive impairment in any of the patients, but most were suffering from mild to moderate emotional disturbances. Dysarthria, nystagmus and numbness in the legs and feet were present in three of them. Neurological symptoms, which appeared in all six in adulthood, had slowly progressed over the last 3 to 6 years. The six had a long history of digestive symptoms, the most severe of which was gastroesophageal reflux disease (GERD). Their mother, already deceased, had suffered from both neurological and digestive problems. The clinical characteristics of ataxic patients at the time of diagnosis are listed in Table T1 1. The study was approved by the Hospital Ethics Board. The patients included in this study provided written informed consent for video-filming and duodenal biopsy. All 6 patients were screened for inherited ataxias such as Friedreich ataxia and SCA1, SCA2, SCA3, SCA6, SCA7, SCA12, SCA17, and DRPLA with negative results. Tests for the study of progressive ataxia, including CSF analysis, and paraneoplastic antibodies, were also negative. Immunoglobulin quantification was carried out and IgA deficiency was ruled out in all 6 cases. IgA AGAs were positive in 4 cases and IgA antibodies against isotype 2 of tissue-transglutaminase (tTG2) were negative in all six. MRI revealed mild cerebellar atrophy in only 2 cases, both of whom also showed neurophysiological evidence of mild sensorymotor axonal neuropathy. Duodenal biopsies showed increased intraepithelial lymphocytic infiltration in all 6 patients, with over 25 intraepithelial lymphocytes per 100 epithelial cells and normal villous architecture. Lymphocytic enteritis (LE) may be due to many different etiologies affecting the gut. In all our patients the presence of Helicobacter pylori was excluded by using the urea-C13 breath test. Intestinal parasites (Giardia and others) were absent in duodenal biopsies, as were ova and parasites in stools. There were no data of Crohn disease in any of the patients, and none were taking nonsteroidal antiinflammatory drugs on a long term basis. If all these causes have been ruled out, LE may also be part of gluten-sensitive enteropathy (GSE). It is then classified as Marsh 1 type lesion, the most common finding of duodenal biopsies of celiac disease (CD) in adults with negative serology. The 6 patients with ataxia started on a GFD, and after an average period of 3 months, digestive and neurological benefits were noticeable in all of them. -----------------------------------------------------------Funding agencies: None.

Celiac crisis presenting with status epilepticus and encephalopathy

Celiac crisis is a life-threatening presentation of celiac disease which is described in the context of classic gastrointestinal (GI) symptoms of diarrhea, leading to dehydration and electrolyte imbalance. Neurologic manifestations are atypical symptoms of celiac crisis. To the best of our knowledge, there is no published report on seizure or encephalopathy as the presenting manifestation of celiac crisis. We describe a 2-year-old boy presenting with acute status epilepticus and lethargy. Prior to presentation, he had mild abdominal distention and intermittent diarrhea. Laboratory analysis revealed hyponatremia, anemia, hypocalcemia, transaminitis, and hyperglycemia. Electroencephalography revealed severe diffuse encephalopathy, and complete infectious work-up was negative. Initial brain magnetic resonance imaging was normal; however, repeat imaging showed osmotic demyelination syndrome. Given the history of GI symptoms and hyperglycemia, celiac serology was obtained revealing elevated tissue transglutaminase, and a diagnosis was confirmed by Marsh 3c lesions in the duodenum. He significantly improved with steroid therapy in addition to adequate nutrition, fluids, and initiation of a gluten-free diet. We report herein on the first case of celiac crisis presenting with status epilepticus and encephalopathy in the absence of profound GI symptoms. Our case suggests that celiac crisis should be considered in the differential of seizures and encephalopathy in children.

A cross-sectional study of Tritrichomonas foetus infection among healthy cats at shows in Norway

BackgroundIn recent years, the protozoan Tritrichomonas foetus has been recognised as an important cause of chronic large-bowel diarrhoea in purebred cats in many countries, including Norway. The aim of this cross-sectional study was to determine the proportion of animals with T. foetus infection among clinically healthy cats in Norway and to assess different risk factors for T. foetus infection, such as age, sex, former history of gastrointestinal symptoms and concurrent infections with Giardia duodenalis and Cryptosporidium sp.MethodsThe sample population consisted of 52 cats participating in three cat shows in Norway in 2009. Samples were examined for motile T. foetus by microscopy, after culturing and for T. foetus-DNA by species-specific nested PCR, as well as for Giardia cysts and Cryptosporidium oocysts by immunofluorescent antibody test (IFAT).ResultsBy PCR, T. foetus-DNA was demonstrated in the faeces of 11 (21%) of the 52 cats tested. DNA-sequencing of five positive samples yielded 100% identity with previous isolates of T. foetus from cats. Only one sample was positive for T. foetus by microscopy. By IFAT, four samples were positive for Giardia cysts and one for Cryptosporidium oocysts, none of which was co-infected with T. foetus. No significant associations were found between the presence of T. foetus and the various risk factors examined.ConclusionsT. foetus was found to be a common parasite in clinically healthy cats in Norway.

Identification of NSAID Users at Risk for Gastrointestinal Complications

NSAIDs are among the most often used drugs worldwide. Numerous NSAID users are at risk for developing gastrointestinal complications. The purpose of this review was to identify and stratify risk factors for gastrointestinal complications in NSAID users documented in guidelines and consensus agreements, and to collect recommendations regarding over-the-counter (OTC) NSAID use. To facilitate this, a PubMed search from 1 January 1999 until 1 March 2009 was performed, resulting in the inclusion of nine English-language guidelines in our analysis. Risk factors were defined as 'definite' if mentioned in all guidelines; otherwise they were defined as 'controversial' risk factors. 'Definite' risk factors were a history of (complicated) peptic ulcer disease, older age (cut-off range 60-75 years), concomitant anticoagulant or corticosteroid use and multiple NSAID use, including low-dose aspirin (acetylsalicylic acid). 'Controversial' risk factors were high-dose NSAID use, concomitant clopidogrel or selective serotonin reuptake inhibitor use, a history of gastrointestinal symptoms, rheumatoid arthritis disability and cardiovascular disease. Infection with Helicobacter pylori was identified as an additive risk factor. Risk factors in OTC NSAID users were difficult to identify in the current literature. Risk factors were not all uniformly present in analysed guidelines and consensus agreements. We identified a history of (complicated) peptic ulcer disease, older age, concomitant anticoagulant or corticosteroid use and multiple NSAID use, including low-dose aspirin, as definite gastrointestinal risk factors in NSAID users.

What’s Your Diagnosis?

A 6-year-old boy was referred for an &amp;ldquo;abnormal right pupil&amp;rdquo; recognized by his pediatrician at an annual examination, which was associated with reduced vision in the right eye. The child was in good health with no history of gastrointestinal symptoms. On examination, the uncorrected visual acuity was 20/100 in the right eye, which improved to 20/25 with &amp;minus;3.00 diopters, and 20/20 in the left eye. Eyelids and extraocular movements were normal with no evidence of ptosis. Slit-lamp examination revealed clear corneas in both eyes and slight enlargement of the right cornea. No Haab&amp;rsquo;s striae were present. Inspection of the irides showed enlargement of pupillary frill with its extension superiorly onto the anterior iris surface in the right eye (&lt;a href="EditorPage.aspx?da=core&amp;amp;id=%7b6D46A8A5-7376-4C8B-AE2E-566F064F88AE%7d&amp;amp;ed=FIELD2771452684&amp;amp;vs&amp;amp;la=en&amp;amp;fld=%7b3F6A9F60-49AD-4656-AEC8-BF7FC2999528%7d&amp;amp;so=%2fsitecore%2fsystem%2fsettings%2fhtml+editor+profiles%2frich+text+healio&amp;amp;di=0&amp;amp;hdl=H2771452798&amp;amp;us=sitecore%5cEAnderer&amp;amp;mo&amp;amp;pe=0#x01913913-20080501-08-fig1"&gt;Figure&lt;/a&gt;). The iris stroma in the right eye was smooth without normal crypts and circumferential folds and the iris in the left eye was normal. Intraocular pressures were 40 mm Hg in the right eye and 12 mm Hg in the left eye. Corneal thickness measured 528 &amp;mu;m in the right eye and 550 &amp;mu;m in the left eye. Gonioscopy demonstrated circumferential anterior iris insertion with minimally exposed trabecular meshwork in the right eye and normal trabecular mesh-work, scleral spur, and ciliary body band in the left eye. Axial length measured 20.5 mm in the right eye and 19.8 mm in the left eye. The right optic disc had a large cup with a cup-to-disc ratio of 0.9 and minimal neuroretinal rim, whereas the left optic disc was normal. The patient was given topical glaucoma medications with satisfactory initial intraocular pressure control.