Subtotal Villous Atrophy Research Articles

Prevalence of celiac-related antibodies and its impact on metabolic control in Egyptian children with type 1 diabetes mellitus.

The simultaneous presence of celiac disease and type 1 diabetes (T1DM) is coupled with more hazards of comorbidities and complications. This current study aimed to screen for celiac disease in Egyptian children with type 1 diabetes and evaluate its impact on glycemic control. A cross-sectional study was verified with 200 Egyptian children diagnosed with T1DM and having a diabetic duration of less than five years. Testing for anti-tissue transglutaminase IgA (tTG-IgA), anti-tissue transglutaminase IgG (tTG-IgG), anti-Endomysial IgA (EMA), and Hb A1c levels were done. The serological screening revealed that 11 cases (5.5%) tested positive; 8 children with T1DM (4.0%) showed tTG-IgA antibodies ≥ 10 times the upper limit of normal (ULN) with at least one symptom; and 3 cases (1.5%) had levels between 20 and 50 IU/ml (considering a cut-off point of 10 U/ML for positive results). Intestinal biopsy was performed for these three cases, with one case detected to have subtotal villous atrophy, resulting in an overall prevalence of celiac disease in T1DM as 4.5%. Children with positive screening exhibited a higher insulin dose, a higher HbA1c, an increased frequency of hypoglycemic attacks, and recurrent DKA compared to negative cases. A negative correlation was detected between tTG-IgA antibodies with height Z score and hemoglobin level, while a positive correlation was found between tTG-IgA antibodies and HbA1c level. Undiagnosed celiac disease in children with T1DM negatively impacted metabolic control and affected their general health.

Case Report: Tropical sprue, diagnostic challenges of an old but unrecognized disease

Tropical sprue (TS) is a post-infective disease of the small bowel characterized by a malabsorption syndrome affecting tropics inhabitants and visitors. Diagnosis of TS remain challenging since it can be confused with common diarrheal diseases, especially in non-endemic areas. We report a Tunisian case of latent TS. A 58-year-old male with a history of chronic watery diarrhea, was admitted to the intensive care unit for confusion which was related to dehydration[J1] . Despite the neurological improvement after hydro-electrolytic resuscitation and acid-base disorders correction, the patient continued to have three to five loose stools daily. A nutritional assessment showed a malabsorption syndrome: iron, Vitamin B12 and folate deficiencies; normochromic normocytic anemia and hypoalbuminemia. Gastrointestinal endoscopy showed duodenal villous atrophy and biopsy confirmed subtotal villous atrophy with increased intraepithelial lymphocytosis and a thickened hyalinized [J2] sub-epithelial basal lamina. Celiac disease was evoked, however the patient did not improve on a gluten-free diet and the celiac serology was negative. On re-interviewing, we discovered that the patient had spent two months in India three years prior. Given the travel history, clinico-biological and histological data TS was highly considered and a good response to a five-month antibiotic course combined to nutritional supplementation supported this diagnosis. Clinico-biological, endoscopic and histological findings were overlapping between TS and other malabsorption diseases, explaining diagnosis difficulties. TS should be systematically discussed in tropics visitors presenting with chronic diarrhea. Improvement after micronutrient and vitamin deficiencies replacement combined to a prolonged antibiotic course supports the diagnosis of TS. [J

Maternal and child FUT2 and FUT3 status demonstrate relationship with gut health, body composition and growth of children in Bangladesh

Fucosyltransferase 2 (FUT2) and 3 (FUT3) may influence host biological functions. We aim to assess the relationship between maternal and child FUT2 (Secretor) and FUT3 (Lewis) status with growth, body composition, gut health and histologic features in Bangladeshi children. We conducted a case–control study where secretor and Lewis status were ascertained from saliva samples of 408 mother–child dyads. Upper-arm fat area estimate (UFE) and total upper arm area (TUA) were found higher among children of Lewis negative mothers (p = 0.01 and p = 0.07, respectively). Changes in UFE after nutrition intervention were significantly greater among Lewis positive children than those of negative for Lewis (p = 0.05). Significant differences were observed for child UFE based on secretor and Lewis status of the mothers (p = 0.04). Lewis positive children had greater changes in WAZ (p = 0.07) and WLZ (p = 0.02) than Lewis negative children at the end of nutrition intervention. Fecal Reg1B was elevated in secretor positive children compared to their counterparts (p = 0.03). Lewis negative children had higher concentrations of MPO compared to Lewis positive children (p = 0.08). We also observed a higher frequency of subtotal villous atrophy among secretor negative and Lewis positive children (p = 0.09 and p = 0.01, respectively) than those of their counterparts. The findings provide insights for further studies to elucidate causal influences.

S3482 Small Bowel Enteropathy Induced by Immune Checkpoint Inhibitors: A Case Series

Introduction: While there is a growing understanding of the identification and management of colonic complications of immune checkpoint inhibitors (ICI), less is known about proximal intestinal complications. In this case series, we present 3 patients who developed small bowel enteropathies (SBE) after initiation of ICI. Case Description/Methods: Case 1: A 68-year-old female with stage IV non-small cell lung adenocarcinoma on pembrolizumab developed diarrhea with 7 watery bowel movements daily. EGD was normal and colonoscopy showed minimal sigmoid erythema endoscopically with histologic duodenitis and colitis. Despite treatment with vedolizumab, she remained steroid-dependent. Repeat EGD and sigmoidoscopy showed variable villous abnormality in the duodenum with associated epithelial lymphocytosis, focal active duodenitis, and resolution of colitis. Serologic evaluation revealed hypogammagobulinemia. Nine months after last dose of pembrolizumab, and ultimately therapy with intravenous immunoglobulin therapy and open-capsule budesonide, her symptoms resolved. Case 2: A 42-year-old male with metastatic melanoma treated with ipilimumab and nivolumab developed grade 2 diarrhea with steatorrhea, nausea, vomiting, and unintentional weight loss. EGD was endoscopically normal with biopsies showing active duodenitis with normal colonoscopy. He was initially treated with steroids, but due to persistent symptoms transitioned to infliximab. After receiving 3 doses of infliximab, he had complete resolution of symptoms. Case 3: A 59-year-old female with celiac disease (CD) and metastatic melanoma was started on nivolumab. She developed abdominal pain, early satiety, softer stools, and unintentional weight loss. EGD revealed non-bleeding duodenal erosions and duodenal mucosal changes consistent with celiac disease. Biopsies showed subtotal villous atrophy with increased intraepithelial lymphocytes. CD typing did not suggest refractory sprue. Her presentation was suggestive of a nivolumab-induced exacerbation of CD. After a year of intermittent steroid therapy and adherence to a gluten-free diet, symptoms resolved. Repeat EGD with biopsies showed normal villi and reduced intraepithelial lymphocytes. Discussion: In this case series, we present three patients who developed SBE, highlighting the challenge of its diagnosis and management. SBE should be suspected in individuals with altered stools and no evidence of classic colitis.

Hardly Ants-ipated Capsule Endoscopy Finding

Question: A 74-year-old man was referred for evaluation of weight loss and diarrhea. His past medical history included depression, hypertension, and atrial fibrillation. Additionally, he underwent an aortic valve replacement and mitral valve repair. Six years ago, the patient had an anterior resection owing to rectal carcinoma. Current medications were warfarin (Coumadin), ramipril, and dutasteride (Avodart). Blood and stool tests were nonrevealing. A computed tomography scan f the abdomen did not disclose any significant findings. Colonoscopy was normal except for a 3-mm tubular adenoma, which was resected. No random biopsies were taken. Gastroscopy showed a hyperemic mucosa in the antrum and nodular mucosa in the duodenal bulb. Random biopsies were taken from the antrum and the duodenum. Pathology revealed subtotal villous atrophy, represent Marsch 3A consistent with celiac disease. Tissue transglutaminase immunoglobulin A was twice the upper limit of normal. The patient was started on a gluten-free diet without any improvement. Considering his lack of improvement despite of a strict diet for 12 months with continuous positive serology, a video capsule endoscopy was performed after 12 hours of fasting. The findings are shown in Figure A and B. What are the findings on video capsule and how are they connected to the patient’s complaints? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The capsule endoscopy revealed several intact dead ants in the jejunum. The patient denied deliberate or inadvertent ingestion of ants. There are only a few cases of insects findings on endoscopy described in the literature, and most of them are bees or wasps.1Lynch J.P. Rothstein R.D. A gastric “bee-zoar”.N Engl J Med. 1997; 336: 1763-1764Crossref PubMed Scopus (7) Google Scholar,2Shah D. Tsang T.-K. Bee sting dysphagia.An Intern Med. 1998; 129: 253Crossref PubMed Scopus (5) Google Scholar A recent case report described an 80-year-old male whose upper endoscopy revealed a large peptic ulcer and, in its base, a dead intact ant.3Shaoul R. Rainis T. The new meaning of “ant-acid”.Gastrointest Endosc. 2008; 67: 748Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar We believe this is likely an incidental finding that does not relate to the patient complaints. Nevertheless, this finding on capsule has not been described previously in the literature and needs to be recognized as yet another possible rare finding on capsule endoscopy.

Gene Expression of NLRP3 Inflammasome in Celiac Disease of Iraqi Children

Celiac disease (CD) is an autoimmune disorder characterized by chronic inflammation that essentially affects the small intestine and is caused by eating gluten-containing foods. This study sought to determine gene expression of NLRP3 Inflammasome in peripheral blood of Iraqi CD children using quantitative real-time PCR (qRT-PCR) assay. Thirty children with CD (12 males and 18 females) were enrolled in the study and their age range was 3-15 years. The diagnosis of the disease was confirmed by serological examinations and intestinal endoscopy. A control sample of 20 age-matched healthy children was also included. The children were stratified for age, gender, body max index (BMI), histological findings, and marsh classification. Further, the sera were examined for IgA anti-tissue transglutaminase (tTG) antibody, IgA anti-gliadin antibody, and interleukin-1 beta (IL-1β). Based on Marsh classification, the results revealed that the majority of patients (70%) had partial villous atrophy (Marsh Ш 3A), while children with subtotal and total villous atrophy (Marsh III: 3B/3C) were presented with a lower frequency (30.0%). Neither Marsh I nor Marsh II has been observed among the patients studied. Serum levels of anti-tTG and anti-gliadin IgA antibodies were significantly higher in CD children than in control children (73.8 and 31.8 vs. 0.8 U//ml, respectively; p < 0.001). Conversely, IL-1β serum level was decreased in CD children but the difference was not significant (35.5vs. 53.4 pg/ml; p = 0.285). In the case of NLRP3 inflammasome, the Relative Fold Change method (2-∆∆Ct) was used to assess the gene expression. The results revealed that the expression of NLRP3 inflammasome was decreased by 0.594 fold in CD children. In conclusion, the NLRP3 inflammasome was down-regulated in the present sample of CD children, and it was accompanied by a decreased serum level of IL-1β.

Alterations in the histological features of the intestinal mucosa in malnourished adults of Bangladesh

There is paucity of knowledge on the histological features of the intestinal mucosa in malnourished adults of Bangladesh. The purpose of the study was to explore the histological features of the intestinal mucosa in malnourished adults of Bangladesh and to compare the findings with their well-nourished counterparts. 64 adults (37 malnourished with body mass index, BMI < 18.5 kg/m2 and 27 controls with BMI > 18.5 kg/m2) from the Bangladesh Environmental Enteric Dysfunction (BEED) study, who underwent upper-gastrointestinal endoscopy, were selected for this study. With a view to address the association of environmental enteric dysfunction (EED) with malnutrition, upper-gastrointestinal endoscopy was performed and mucosal biopsies from the distal duodenum were studied for histopathology. Villous height, crypt depth, and presence of inflammatory infiltrates in lamina propria were investigated. Bivariate analysis was performed to quantify the relation between malnutrition and the histological features. About 95% adults, irrespective of nutritional status, were diagnosed to have chronic non-specific duodenitis on histopathology. Malnourished adults suffered significantly more from chronic active duodenitis compared to their well-nourished counterparts (p = 0.003). Malnourished adults also had significantly higher frequency of subtotal villous atrophy, crypt hyperplasia and marked cellular infiltration in the lamina propria than the healthy controls (p < 0.05).

Celiac Disease Presenting as Cardiomyopathy - A Rare Extra Intestinal Manifestation

Cardiac manifestations of celiac disease has been poorly described in literature though some studies have emphasized on correlation of ischemic heart disease, atrial fibrillation and dilated cardiomyopathy with celiac disease. We describe a patient with celiac disease associated cardiomyopathy whose cardiac function improved substantially after treatment with a gluten-free diet. A young lady of 35 years age was admitted with complaints of chronic diarrhea, vomiting, significant weight loss, dizziness and chronic iron deficiency anemia since last 3 months. Physical examination revealed tachycardia, tachypnoea and hypotension requiring multiple high dose inotropic support. She had pallor, skin changes and pedal edema suggestive of malabsorption. Investigations revealed iron deficiency anemia, high bilirubin and transaminases, prothrombin time, low albumin and elevated tissue trasglutaminase antibody. Echocardiography showed global hypokinesia with a left ventricular ejection fraction of 20%. Diagnosis of celiac disease made on clinic features, serology and biopsy finding of subtotal villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes. She was kept on gluten free diet and on intravenous steroids for acute celiac crises and celiac related cardiomyopathy as patient had severe diarrhea, hypocalcaemia, weight loss, hypoproteinemia and hypotension. Patient improved within 48 hours of steroid with discontinuation of inotropes. She was discharged with gluten free diet and follow up after 6 months showed near normalization of all biochemical abnormalities and ejection fraction of 55%. Cardiomyopathy associated with celiac disease and celiac crisis is a serious and potentially lethal condition. However, with early diagnosis and treatment with a gluten free diet, and steroids cardiomyopathy in patients with celiac disease may be completely reversible.

Immunosuppression-induced clonal T-cell lymphoproliferative disease causing severe diarrhoea mimicking coeliac disease following renal transplantation: a case report

BackgroundPost-transplant lymphoproliferative disease is a recognized complication following solid organ transplantation. This is usually a B cell disease and frequently associated with Epstein Barr virus infection, although T cell PTLD can occur. T cell PTLD is usually a monomorphic, lymphomatous disease associated with an adverse prognosis.Case reportWe report a 52 year old male pre-emptive renal transplant recipient who developed severe diarrhea with weight loss following intensification of his immunosuppression due to antibody mediated rejection 3 years after transplantation. Duodenal biopsy demonstrated monoclonal CD8+ T cell duodenitis leading to increased intraepithlieal lymphocytes and sub-total villous atrophy mimicking coeliac disease. Coeliac disease was excluded by negative anti-tissue transglutaminase antibody, HLA-DQ2 and HLA-DQ8 testing. There was no evidence of lymphoma either on biopsy or CT enterography and no FDG avid disease on PET. Symptoms did not improve with reduction of immunosuppression, but resolved fully on complete withdrawal of treatment. The transplant failed and he was established on dialysis. The diagnosis was early PTLD.ConclusionsOesophagogastroduodenoscopy with small bowel biopsies is a useful investigation for determining the cause of diarrhoea in renal transplant patients when more common causes have been excluded. This is the first report that we are aware of clonal T cell PTLD mimicking coeliac disease which only resolved after complete withdrawal of immunosuppression. As treatments for lymphoma are aggressive they are only initiated in the malignant phase and management of early stage PTLD is to minimise risk of progression by reducing immunosuppression. Any plans to retransplant will have to take into consideration the possibility that PTLD will recur.

Is celiac disease misdiagnosed in children with functional constipation?

Functional constipation is one of the common problems in childhood, and it comprises approximately 5% of the pediatric outpatient clinical applications. On the other hand, celiac disease (CD) is an immune enteropathy with the prevalence between 1/150 and 1/200. In addition to the classical symptoms of the disease such as diarrhea and weight loss, the incidence of atypical symptoms is increasing. This study aims to determine the prevalence of CD in patients with chronic constipation. The study was conducted between 2010 and 2012 and included 1046 children (range, 2-18 y; median, 11.4 y) diagnosed with chronic constipation according to the Rome III criteria. Serum immunoglobulin A, tissue transglutaminase, and/or anti-endomysial antibodies were examined. The patients with serological positive results were subjected to upper gastrointestinal system endoscopy and duodenal biopsy to confirm the diagnosis of CD. Blood tests were positive in 36 patients (3.25%). One of the patients had Hashimoto's thyroiditis, and 4 patients had short stature. Endoscopic findings included nodularity in bulbus and duodenal mucosa (n=16), scalloping fold (n=13), and normal mucosa (n=5). Histopathologic findings revealed that 10 patients had total villous atrophy, 24 patients had subtotal and partial villous atrophy, and 34 patients had intraepithelial lymphocyte infiltration. All patients followed a gluten-free diet, resulting in a resolution of symptoms. In the present study, a CD ratio of 1:28 was diagnosed in chronically constipated children. The use of screening tests for CD should be considered in children with conventional treatment-resistant constipation.

Histologic recovery among children with celiac disease on a gluten-free diet. A long-term follow-up single-center experience.

IntroductionCeliac disease (CD) is defined by gluten-induced immune-mediated enteropathy, affecting approximately 1% of the genetically predisposed population. The immunologic response to gluten causes characteristic intestinal alterations with gradual development. Histologic recovery of intestinal architecture was reported to occur within 6–12 months after starting a gluten-free diet, simultaneously with clinical remission. The aim of this study was to assess the rate and timing of histologic recovery among children with CD on a gluten-free diet, diagnosed and followed in an academic referral pediatric center during a 10-year period.Material and methods105 biopsy-confirmed CD children underwent follow-up small intestinal biopsies within at least 1 year after dietary gluten withdrawal. Further biopsies were performed if villous alterations were persistent. The Marsh classification modified by Oberhuber was used to score the histologic injuries. ResultsIn all 19 cases with Marsh type II at diagnosis, villous alterations normalized to Marsh type 0 within the first year. From 86 children enrolled with Marsh type III lesions, histologic remission was observed in 81.4% after 1 year, 91.8% within 2–3 years and 97.6% in long-term follow up (≥ 3 years). Two (2.3%) patients with concomitant selective IgA deficiency had symptoms of malabsorption and persisting villous atrophy lasting more than 3 years despite a gluten-free diet. There was a significant statistic difference between the proportion of children with Marsh type IIIA, type IIIB and Marsh type IIIC respectively that achieved histologic recovery within 1 to 2 years after gluten withdrawal. There were more children with partial 25 (92.6%) and subtotal villous atrophy 30 (88.2%) showing histologic improvement, compared to only 15 (60%) patients with total villous atrophy that recovered within the first 2 years of diet (p = 0.01 and p = 0.02 respectively).ConclusionsHistologic recovery in CD after starting a gluten-free diet in children takes at least 1 year and might be incomplete only in a small proportion of children, mainly associated with IgA immunodeficiency. Systematic follow-up of children with CD and persistent malabsorption syndrome is needed in order to avoid secondary complications.

English

This is a study to answer the question: Is there a relationship between occult celiac disease and functional dyspepsia? The study was carried out on 400 dyspeptic patients. Upper gastrointestinal tract (GIT) endoscopy was done for all patients and those with non-functional dyspepsia were excluded from the study. Duodenal biopsies with histopathological examination according to the Marsh-Oberhuber criteria were done. Serum tissue transglutaminase IgA antibody (anti-tTG-IgA) was done for patients with histopathological findings suggestive to have celiac disease (subtotal and total villous atrophy). 172 patients with endoscopic findings explaining their dyspeptic symptoms were excluded. Only patients with functional dyspepsia were enrolled in this study (228 patients). Bloating was the most common symptom (46.5%). Normal villous pattern was found in 199 cases (87.2%). Villous atrophy was found in 29 patients, subtotal atrophy in 20 cases (8.7%) and total atrophy in 9 cases (3.9%). Age group of 14-20 years (20/29, 90.9% patients) with villous atrophy was reported to have statistically significant difference (P value =0.000). Serum anti-tTG-IgA level was measured in all cases of abnormal villous pattern. Nine patients (3.9%) were proved to have a celiac disease (total villous atrophy and high serum anti-tTG-IgA) and fourteen dyspeptic patients (6.1%) had subtotal villous atrophy with high anti-tTG-IgA level could be diagnosed as occult celiac disease. Occult celiac disease should be suspected among patients with functional dyspepsia complaining of bloating, especially in age 14 to 20. Subtotal villous atrophy and high anti-tTG-IgA could be considered as occult celiac disease. Key words: Celiac disease, endoscopy, duodenal biopsy, functional dyspepsia.

Screening for coeliac disease in type 1 diabetes

In this issue of Acta Paediatrica, Laitinen et al. 1 explore symptoms and mucosal damage in 22 patients with type 1 diabetes who were screened for coeliac disease and compared them to 498 individuals diagnosed with coeliac disease on a clinical basis. The authors concluded that screening for coeliac disease should be considered among children with type 1 diabetes, which is in line with current recommendations 2-4. A meta-analysis found that coeliac disease occurred in more than one in 20 patients with type 1 diabetes 5, and long-term coeliac disease may influence the risk of both retinopathy and chronic renal disease in type 1 diabetes 6, 7, potentially due to an increased prevalence of microvascular complications in patients with both type 1 diabetes and coeliac disease 8. The paper by Laitinen et al. 1 is interesting for several reasons. First of all, the authors found that patients with type 1 diabetes and coeliac disease did differ from patients diagnosed with coeliac disease due to clinical symptoms. For instance, patients with type 1 diabetes and coeliac disease did not experience such poor growth as those with clinically diagnosed coeliac disease. That is reassuring, as poor growth in childhood can have long-term consequences. Although catch-up growth is commonly seen in children with coeliac disease just after diagnosis, restricting food intake to make a diet suitable for both type 1 diabetes and coeliac disease could theoretically make catch-up growth more difficult to achieve. The authors also found that while children with type 1 diabetes and coeliac disease often had unrecognised gluten-dependent symptoms, these were less severe than in children who were clinically diagnosed with coeliac disease. That was to be expected, because otherwise the children with type 1 diabetes and coeliac disease should have been diagnosed before, due to gastrointestinal symptoms, rather than just after their diagnosis of type 1 diabetes. We believe that the lower prevalence of symptoms reflects the fact that patients with type 1 diabetes and coeliac disease may have less severe small-bowel mucosal atrophy than patients who just have coeliac disease. We disagree with Laitinen et al. on their interpretation in this regard, as we believe that the lack of difference with regard to mucosal atrophy in their study was due to lack of power. Laitinen et al. based their findings on only 22 patients with type 1 diabetes and coeliac disease and the statistical lack of difference was probably due to the equal proportions of patients with subtotal villous atrophy. Estimating total villous atrophy from their Figure 1B seems to indicate that it was more common in patients with clinical suspicion of coeliac disease (roughly 23% versus 9%), while partial villous atrophy was more common in patients with type 1 diabetes (52% versus roughly 32%). The same objection could be raised about the conclusion that dietary adherence was similar in patients with both type 1 diabetes and coeliac disease and those with just coeliac disease. The power for dietary adherence was limited in type 1 diabetes and coeliac disease patients as there was only dietary data for 16 of the 22 patients, and the p value of 0.086 may have reached statistical significance if the type 1 diabetes and coeliac disease group had been larger. This said, it should be emphasised that a very high proportion of patients with type 1 diabetes and coeliac disease did comply with the diet. Nevertheless, the long-term implications of prescribing a life-long diet for a child based on screening are unknown, as adherence to a gluten-free diet may decline in adolescence among children with screen-detected coeliac disease. While the strongest evidence for the value of screening for coeliac disease would be derived from a randomised trial, in which a nonscreened group would be compared to a screened group with regard to morbidity, the length and expense of such a trial would probably be prohibitive. As such, we rely on observational studies, such as those by Laitinen et al., to inform us of the potential outcomes of screening. In conclusion, this article makes a valuable contribution to the literature and once again underlines the potential value of examining children with type 1 diabetes for other autoimmunity problems, including coeliac disease. None. None.

Pseudoxanthoma elasticum and coeliac disease: a fortuitous association?

A 10-year-old male presented with complaints of yellowish papules on his neck. At the age of five years, he had abdominal pain and haemorrhagic diarrhoea with high levels of anti-transglutaminase and anti-endomysium antibodies, and negative hypercoagulable workup. The endoscopic examination of an intestinal biopsy showed subtotal villous atrophy, crypt hyperplasia, and lymphocyte infiltration of crypts, which confirmed the diagnosis of coeliac disease. The patient's mother noticed the appearance [...]

Anemia and Iron Deficiency in Children With Potential Celiac Disease.

Active screening for celiac disease frequently detects seropositive children with normal villous morphology (potential celiac disease). It remains unclear whether these subjects should be treated. We here investigated the prevalence of anemia and iron deficiency in children with potential and mucosal atrophy celiac disease. The prospective study involved 19 children with potential disease, 67 with partial or subtotal villous atrophy (P/SVA), and 16 with total villous atrophy (TVA). Twenty-three healthy children comprised the control group. The groups were compared for various clinical, histological, and laboratory parameters and hepcidin. The prevalence of abnormal parameters was as follows (controls, potential celiac disease, P/SVA, and TVA, respectively): anemia 0%, 15%, 22%, and 63%; low iron 5%, 0%, 14%, and 50%; increased transferrin receptor 1 5%, 16%, 20%, and 47%; low ferritin 0%, 21%, 35%, and 87%; and low transferrin saturation 10%, 11%, 41%, and 71%. One subject had low folate and none had low vitamin B12. The median values for hemoglobin, total iron, ferritin, and transferrin saturation were significantly lower and transferrin receptor 1 values higher in TVA group compared with other groups. After a median of 7 months on a gluten-free diet hemoglobin, total iron, ferritin, and albumin in children with P/SVA exceeded the baseline values in the potential celiac disease group. The development of anemia and iron deficiency in celiac disease is a continuum and may already be present in children with normal villous morphology, advocating an early diagnosis and possible dietary treatment of these patients.

Telmisartan-induced sprue-like enteropathy: a case report and a review of patients using non-olmesartan angiotensin receptor blockers.

Recent studies have identified sprue-like illness associated with the use of the antihypertensive agent olmesartan medoxomil. However, whether this condition is specific to the use of olmesartan or is associated with the use of drugs belonging to the class of “sartans” remains to be clarified. A 45-year-old woman with chronic kidney disease along with hypothyroidism and hypertension presented with chronic diarrhea and significant weight loss. Endoscopy of the upper gastrointestinal tract showed scalloping and grooving of the duodenum, and histopathological examination showed subtotal villous atrophy. She was on telmisartan for hypertension, which was discontinued. Subsequently, diarrhea ameliorated dramatically, and she regained weight. To our knowledge, this is the first study to report telmisartan-associated sprue-like enteropathy. Further, we have reviewed the cases of patients with sprue-like enteropathy caused by valsartan, irbesartan, and eprosartan.

The Prevalence Of Celiac Disease in Saudi Patients with Type 1 Diabetes Mellitus: Cross Sectional Study

Objectives: The relationship between type I diabetes mellitus (T1DM) and celiac disease (CD) has been known. The prevalence of CD in the Kingdom of Saudi Arabia (KSA) has not been determined. We examined the prevalence of celiac CD in patients in the Kingdom of Saudi Arabia with T1DM. Methods: A cross-sectional study for 218 patients with T1DM at the diabetic clinic of King Fahd Armed Force Hospital in Jeddah, KSA between January 2008 and June 2009. Anti-tissue transglutaminase antibodies (AntiTTG) was done in all patients. Duodenal biopsy were performed for patients with positive serology for Anti-TTG antibodies. Results: There were 69 males and 54 females who ranged in age from 12-50 years (mean ± SD 21.3 ± 7.2). The age at onset of type I diabetes mellitus was 13.8 ± 7.1 and the duration of type I diabetes mellitus was between 1 and 28 years (7.6 ± 5.7). Elevated Anti-TTG levels were found in the sera of 16 (7.3%) of 218 diabetic patients in our clinic. The gender ratio of the Anti-TTG positive is 1 male: 3 female. All None had any gastrointestinal symptoms. 12 of the 16 subjects had duodonal biopsies and 8 ( 3.7% ) biopsies showed total villous atrophy, 2 ( 0.8% ) subtotal villous atrophy and 2 ( 0.8 % ) chronic duodonitis , biopsy was not carried out in the other 4 subjects. Conclusion: The maximum prevalence of celiac disease in our population was 7.3% based on immunological marker and the minimum was 4.6% based on antibodies and biopsy results.

The Association of Crohn’s Disease, Celiac Disease and Selective Ig A Deficiency

Concomitant occurrence of celiac disease (CeD) and Crohn’s disease (CD) is rare and has been reported in several case reports and series. We report a case of a 63-year-old man with proximal CD, CeD and selective immunoglobulin (Ig) A deficiency (SIgAD). The patient was admitted in our Clinic for evaluation of epigastric pain, nausea, vomiting and weight loss (up to 7 kg) appeared in the last 3 months. The imaging findings from abdominal ultrasound and CT enterography raised suspicion of a lymphoproliferative disease of the jejunum. To exclude the development of lymphoma based on long standing untreated atypical CeD, upper endoscopy with biopsies and serological tests were conducted, showing and subtotal villous atrophy and elevated levels of IgG tissue transglutaminase tTG. Histopathology documented CD (A3,L4,B2 according to Montreal’s classification).

Celiac Disease Associated with Facioscapulohumeral Muscular Dystrophy

Introduction. The association of celiac disease and facioscapulohumeral muscular dystrophy was not reported earlier in the literature. Case presentation. A 35-year-old woman diagnosed clinically with facioscapulohumeral muscular dystrophy 23 years ago. In the family history patients’ mother was diagnosed with facioscapulohumeral muscular dystrophy, too. Physical examination revealed bilateral facial weakness, she had narrow smile and murmuring speech. She had low-degree atrophy of shoulder girdle muscles with left-dominated scapular winging. facioscapulohumeral muscular dystrophy DNA testing showed allele 1 deletion. From 2001 on, patient presented epigastrial pain, diarrhoea, weight loss. She had permanent fatigue and she was unable to do regular physical exercises, which led to the progression of muscular dystrophy. Since serological examination detected elevated tissue transglutaminase and deaminated gliadin peptide antibodies levels, and duodenal biopsy revealed subtotal villous atrophy. Celiac disease was diagnosed. She started strict gluten free diet. After 3 months of gluten free diet, patient reported the elimination of gastrointestinal symptoms, better general condition, weight gain and increased muscle strength. Conclusion. Appropriate nutrition is essential for facioscapulohumeral muscular dystrophy patients, therefore detection and treatment of any disorders leading to malabsorption, most commonly celiac disease, are of utmost importance.

Entéropathie due à l’olmésartan

The olmesartan is a selective antagonist of angiotensin II indicated for the treatment of essential hypertension. We report the case of a gastrointestinal involvement with duodenal villous atrophy and lymphocytic infiltrate duodenal epithelial and colonic secondary to the olmesartan taking with test of positive reintroduction. The patient had chronic diarrhea with weight loss of 10kg occurring one month after the passage of 20 to 40mg/day olmesartan took three years. A rectosigmoidoscopy highlighted some puncture slightly erythematous areas. The responsibility of olmesartan was suspected and the drug was stopped. The evolution was rapidly favorable with disappearance of diarrhea 48hours later. Two days after the patient took the drug on its own initiative. Sigmoid biopsies showed an inflammatory infiltrate rich in lymphocytes. Gastroscopy showed erosive esophagitis and duodenal biopsies showed chronic duodenitis with epithelial lymphocytosis and subtotal villous atrophy. The reintroduction has led to the immediate resumption of diarrhea. Olmesartan was finalized. Diarrhea has not returned since. A colonoscopy performed six weeks after discharge was normal. Knowledge of the bowel olmesartan is recent and based almost solely on the description of 22 cases observed at the Mayo Clinic with patients, as in our case, have similar symptoms and lesions. We stress, about a publication of an isolated case, the possibility of less severe cases with histological abnormalities without clinical translation.