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Diarrheal syndrome in the practice of a general practitioner: medical algorithm
Abstract
According to the frequency of seeking medical care, diarrhea is one of the most common complaints, being an important health problem. Acute diarrhea, as a rule, is infectious in nature, thus, the scope of diagnostics is aimed at assessing the patient's condition and clarifying the pathogen etiology. Chronic diarrhea has a diverse etiology, which poses a difficult task for the clinician to conduct differential diagnosis. Therefore, most guidelines on the relevant problem suggest the use of medical algorithms aimed at step-by-step exclusion of diseases accompanied by diarrhea: from the most common causes to the more rare ones. First of all, it is necessary to detail complaints, identify the presence of red flags, collect an epidemiological, drug and hereditary history, assess the nutrition habits, dietary preferences of the patient and their possible association with the manifestation of diarrhea. The general examination reveals signs of dehydration and malabsorption, as well as the presence of stigma of the underlying disease. Also, at the first stage, it is advisable to conduct the minimum necessary laboratory and instrumental studies. Subsequently, if there are difficulties in establishing the diagnosis, it is advised to re-assess the clinical picture and prescribe additional examination methods. Alongside this, symptomatic and pathogenetic therapy, dehydration, timely detection and correction of electrolyte disorders should be indicated for all patients with acute and chronic diarrhea at the stage of further examination and diagnosis confirmation. KEYWORDS: acute diarrhea, chronic diarrhea, diagnostic algorithm, celiac disease, intestinal tuberculosis, ischemic colitis, radiation colitis, eosinophilic colitis, microscopic colitis, Whipple disease. FOR CITATION: Livzan M.A., Gaus O.V., Gavrilenko D.A. Diarrheal syndrome in the practice of a general practitioner: medical algorithm. Russian Medical Inquiry. 2023;7(5):300–309 (in Russ.). DOI: 10.32364/2587-6821-2023-7-5-8.
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Dermatitis herpetiformis (DH), Duhring disease, is caused by gluten sensitivity and affects 11.2 to 75.3 per 100,000 people in the United States and Europe with an incidence of 0.4 to 3.5 per 100,000 people per year. DH is characterized by a symmetrical blistering rash on the extensor surfaces with severe pruritus. The diagnosis continues to be made primarily by pathognomonic findings on histopathology, especially direct immunofluorescence (DIF). Recently, anti-epidermal transglutaminase (TG3) antibodies have shown to be a primary diagnostic serology, while anti-tissue transglutaminase (TG2) and other autoantibodies may be used to support the diagnosis and for disease monitoring. Newly diagnosed patients with DH should be screened and assessed for associated diseases and complications. A gluten-free diet (GFD) and dapsone are still mainstays of treatment, but other medications may be necessary for recalcitrant cases. Well-controlled DH patients, managed by a dermatologist, a gastroenterologist, and a dietician, have an excellent prognosis. Our review comprehensively details the current diagnostic methods, as well as methods used to monitor its disease course. We also describe both the traditional and novel management options reported in the literature.
Raynaud's phenomenon (RP) is a common vasospastic condition which affects ~5% of the general population. The majority of individuals have primary RP; however, Raynaud's can also occur secondary to a broad range of underlying medical conditions and drug therapies. RP is a cardinal feature in patients with systemic sclerosis and is often the earliest symptom of the disease. Unlike primary RP, patients with secondary RP can develop persistent digital ischaemia, including ulcers and gangrene. Patients require a comprehensive clinical assessment and investigation, in particular, the detection of autoantibodies and nailfold capillaroscopic abnormalities. Non-pharmacological management is indicated in all patients. There are a wide range of available drug therapies to treat RP, including when complicated by digital ulceration, and surgical intervention is sometimes required. Future research is needed to understand the complex pathogenesis of RP and to measure the impact and severity of RP to develop optimised approaches to management.
Introduction
Microscopic colitis is a chronic inflammatory bowel disease characterised by normal or almost normal endoscopic appearance of the colon, chronic watery, non-bloody diarrhoea and distinct histological abnormalities, which identify three histological subtypes, the collagenous colitis, the lymphocytic colitis and the incomplete microscopic colitis. With ongoing uncertainties and new developments in the clinical management of microscopic colitis, there is a need for evidence-based guidelines to improve the medical care of patients suffering from this disorder.
Methods
Guidelines were developed by members from the European Microscopic Colitis Group and United European Gastroenterology in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists, pathologists and basic scientists, and voted upon using the Delphi method.
Results
These guidelines provide information on epidemiology and risk factors of microscopic colitis, as well as evidence-based statements and recommendations on diagnostic criteria and treatment options, including oral budesonide, bile acid binders, immunomodulators and biologics. Recommendations on the clinical management of microscopic colitis are provided based on evidence, expert opinion and best clinical practice.
Conclusion
These guidelines may support clinicians worldwide to improve the clinical management of patients with microscopic colitis.
Background:
Gastrointestinal tuberculosis (TB) is diagnostically challenging; therefore, many cases are treated presumptively. We aimed to describe features and outcomes of gastrointestinal TB, determine whether a clinical algorithm could distinguish TB from non-TB diagnoses, and calculate accuracy of diagnostic tests.
Methods:
We conducted a prospective cohort study of hospitalized patients in Kota Kinabalu, Malaysia, with suspected gastrointestinal TB. We recorded clinical and laboratory characteristics and outcomes. Tissue samples were submitted for histology, microscopy, culture and GeneXpert MTB/RIF®. Patients were followed for up to 2 years.
Results:
Among 88 patients with suspected gastrointestinal TB, 69 were included in analyses; 52 (75%) had a final diagnosis of gastrointestinal TB; 17 had a non-TB diagnosis. People with TB were younger (42.7 versus 61.5 years, p = 0.01) and more likely to have weight loss (91% versus 64%, p = 0.03). An algorithm using age < 44, weight loss, cough, fever, no vomiting, albumin > 26 g/L, platelets > 340 × 109/L and immunocompromise had good specificity (96.2%) in predicting TB, but very poor sensitivity (16.0%). GeneXpert® performed very well on gastrointestinal biopsies (sensitivity 95.7% versus 35.0% for culture against a gold standard composite case definition of confirmed TB). Most patients (79%) successfully completed treatment and no treatment failure occurred, however adverse events (21%) and mortality (13%) among TB cases were high. We found no evidence that 6 months of treatment was inferior to longer courses.
Conclusions:
The prospective design provides important insights for clinicians managing gastrointestinal TB. We recommend wider implementation of high-performing diagnostic tests such as GeneXpert® on extra-pulmonary samples.
One of the most important differential diagnoses that not to be missed in patients with hyperpigmentation changes in the skin is Addison's. The diagnosis of the disease is relatively difficult, and its misdiagnosis leads to dangerous morbidity and even mortality. It confirms by cosyntropin test. One of the most important differential diagnoses that not to be missed in patients with hyperpigmentation changes in the skin is Addison's. The diagnosis of the disease is relatively difficult, and its misdiagnosis leads to dangerous morbidity and even mortality. It confirms by cosyntropin test.
Introduction: Data on the use of Xpert Mtb/Rif for the diagnosis of intestinal tuberculosis is
sparse. We report on the utility of Xpert Mtb/Rif testing for diagnosis of intestinal tuberculosis
(ITB) in patients with ileocecal ulcers
Methodology: We performed a retrospective analysis of patients with ileocecal ulcers
and suspected to have ITB and in whom testing of intestinal tissue for Xpert Mtb/Rif was
performed. The patients were divided into two groups: those with a final diagnosis of intestinal
tuberculosis and those with other diagnosis. These patients were compared for clinical
features and presentation. The sensitivity, specificity, positive predictive value, and negative
predictive value of Xpert Mtb/Rif for the diagnosis of ITB were calculated.
Results: Of the 40 patients studied, 23 were women and the mean age was
32.92 ± 12.78years. Abdominal pain was present in 33 (88.5%) patients and diarrhea in 12
(30%). A total of 25 patients had underlying ITB whereas 15 patients had other diagnoses
(Crohn’s disease, amebiasis, nonspecific ileitis, etc.). The sensitivity, specificity, negative
predictive value, positive predictive value, and accuracy of GeneXpert-Mtb/Rif was 32%
(CI: 14.95–53.50%), 100% (78.2–100), 46.88% (40.27–53.59%), 100 & 57.50 (40.89–72.89%)
respectively.
Conclusion: A positive GeneXpert-Mtb/Rif helps in the diagnosis of ITB, but the sensitivity is
low.
Abstract Diagnosing abdominal tuberculosis remains a great challenge even for experienced clinicians. It is a great mimicker that has unusual presentations. A high index of suspicion is essential for reaching its diagnosis. Clinical and radiological findings of abdominal tuberculosis are non-specific. Herein, we report the lessons we have learned over the last 30 years stemming from our own mistakes in diagnosing abdominal tuberculosis supported by illustrative challenging clinical cases. Furthermore, we report our diagnostic algorithm for abdominal tuberculosis. This diagnostic algorithm will help in reaching the proper diagnosis by histopathology or microbiology. Our diagnostic workup depends on categorizing the clinical and radiological findings of abdominal tuberculosis into five different categories including (1) gastrointestinal, (2) solid organ lesions, (3) lymphadenopathy, (4) wet peritonitis, and (5) dry/fixed peritonitis. The diagnosis in gastrointestinal tuberculosis and dry peritonitis can be reached by endoscopy. The diagnosis in solid organ lesions can be reached by ultrasound-guided aspiration. The diagnosis in wet peritonitis and lymphadenopathy can be reached by ultrasound-guided aspiration followed by laparoscopy if needed. Diagnostic laparotomy should be kept as the last option for achieving a histological diagnosis. Capsule endoscopy and enteroscopy were not included in the diagnostic algorithm because of the limited data of using these modalities in abdominal tuberculosis. They need special expertise, and rarely used in low- and middle-income countries. Furthermore, capsule endoscopy may cause complete intestinal obstruction in small bowel strictures. A definite diagnosis can be reached in only 80% of the patients. Therapeutic diagnosis should be tried in the remaining 20%.
Background
Epidemiological studies of microscopic colitis have shown varying but increasing incidence rates.
Aim
To assess the incidence of microscopic colitis in Sweden.
Methods
Nationwide cohort study performed in 1995‐2015 based on biopsy reports. Age‐specific and age‐standardised incidence rates were calculated.
Results
We identified 13 844 patients with an incident diagnosis of microscopic colitis. Lymphocytic colitis (n = 9238) constituted 67% and collagenous colitis (n = 4606) 33% of microscopic colitis. The mean age at time of diagnosis of microscopic colitis was 60.2 years (58.6 for lymphocytic colitis, 63.3 for collagenous colitis). The lifetime risk of developing microscopic colitis was 0.87% in women (95% confidence interval, CI: 0.85‐0.88) and 0.35% in men (95% CI: 0.34‐0.36). From 2006, the overall incidence of microscopic colitis was approximately 10.5 cases per 100 000 person‐years (95% CI: 9.8‐11.3) with higher rates in women (72% of cases, incidence rate ratio = 2.4 (95% CI: 2.3‐2.5) and the elderly with increasing rates up to 75‐79 years. From 2006‐2015, there was a significant increase of 1% per year (P = 0.02) in the overall microscopic colitis incidence rate in women; the estimated annual percent change was similar, although not statistically significant, in men (P = 0.15).
Conclusions
In Sweden, the incidence of microscopic colitis is still increasing in women, although the rate appears to be stabilising. The incidence is particularly high in women and the elderly up to age 75‐79 years. Finally, across a lifetime, 1 in 115 females and 1 in 286 males are expected to be diagnosed with microscopic colitis and thus posing a considerable disease burden.
Eosinophilic gastrointestinal disorders (EGID) are a group of disorders characterized by pathologic eosinophilic infiltration of the esophagus, stomach, small intestine, or colon leading to organ dysfunction and clinical symptoms (J Pediatr Gastroenterol Nutr; Spergel et al., 52: 300–306, 2011). These disorders include eosinophilic esophagitis (EoE), eosinophilic gastritis (EG), eosinophilic gastroenteritis (EGE), eosinophilic enteritis (EE), and eosinophilic colitis (EC). Symptoms are dependent not only on the location (organ) as well as extent (layer invasion of the bowel wall). Common symptoms of EoE include dysphagia and food impaction in adults and heartburn, abdominal pain, and vomiting in children. Common symptoms of the other EGIDs include abdominal pain, nausea, vomiting, early satiety, diarrhea, and weight loss. These disorders are considered immune-mediated chronic inflammatory disorders with strong links to food allergen triggers. Treatment strategies focus on either medical or dietary therapy. These options include not only controlling symptoms and bowel inflammation but also on identifying potential food triggers. This chapter will focus on the clinical presentation, pathophysiology, and treatment of these increasingly recognized disorders.
Ischemic colitis (IC) results from reduced colonic vascular perfusion, accounting for 50-60% of all gastrointestinal ischemic episodes. IC leads to mucosal damage with clinical symptom severity developing based on the duration and extent of colonic injury. In rare cases IC may form a mass-like lesion mimicking malignancy. Here we present the case of a 55-year-old female with hematochezia and diarrhea, who on workup was found to have a mass-like lesion at the ileocecal valve. Multiple biopsies demonstrated ischemic change and mucosal injury without evidence of dysplasia or carcinoma. Two months later on follow-up imaging, after supportive treatment the lesion was completely resolved. It is critical for gastroenterologists and pathologists to be aware of this variant of IC to avoid unnecessary surgical procedures and treatment of patients.
Eosinophilic gastrointestinal diseases (EGIDs) comprise a group of chronic, inflammatory diseases of the gastrointestinal (GI) tract, that are characterized, clinically, by symptoms related to the dysfunction of the involved segment(s) of the GI tract, and histologically, by dense eosinophilic inflammation, in the absence of an identifiable secondary cause. The group of EGIDs comprises eosinophilic esophagitis (EoE), eosinophilic gastritis (EG), eosinophilic gastroenteritis (EGE), and eosinophilic colitis (EC). EoE is the most common and the best described EGID compared to EG, EGE, and EC. The clinical presentation of the EGIDs differs depending on the location and the extent of the eosinophilic infiltration in the GI tract, as well as its depth through the bowel wall. In the absence of biological markers, the diagnosis is based on the combination of clinical symptoms with the histological features of EGIDs, after the exclusion of secondary causes of eosinophilic inflammation of the GI tract. Treatment is individualized and includes elimination diets (mainly empiric or elemental) and/or drugs, according to the involved GI segment: proton pump inhibitors or local steroids in EoE; local or oral systemic steroids in EG/EGE limited to the duodenum; oral systemic steroids in EGE with lower small intestine and/or colon involvement. In patients with EoE, maintenance treatment with lower doses may be considered following histological remission with the means of drugs. In patients treated with elimination diets, disease food triggers identified during food reintroduction need to be further eliminated. Esophageal stenosis despite medical treatment requires endoscopic dilation, while the use of thiopurines or anti-TNF drugs may be considered in refractory or steroid-dependent EGID (other than EoE). The aim of this review is to provide the available evidence on each of the above disorders, to aid clinicians to interpret the clinical manifestations and the laboratory findings and choose the best available treatment option.
We present a case of 45-year-old male presented with stools mixed with blood and intermittent pain abdomen for one week. Abdominal x-ray supine revealed ‘thumb printing’ sign and dilated transverse colon suggestive of ischemic colitis. Ischemic colitis is predominantly seen in older patients in the sixth to the seventh decade. Abdominal X-rays although not specific but has an important role in picking up complicated cases and narrowing down differential diagnosis.
Introduction
Eosinophilic gastroenteritis (EGE) is a rare idiopathic disease that can affect one or more organs of the digestive tract. It has an estimated incidence of 1–20 cases per 100,000 patients. Klein et al. classified EGE into 3 subtypes: predominant mucosal, muscular, or subserosal.
Clinical Case
We report a case of a 32-year-old woman, who presented with diffuse abdominal pain, nausea, postprandial infarction, diarrhea, and moderate ascites of three-week evolution. The rest of physical examination did not show alterations. The past medical history was unremarkable. Laboratory test results revealed peripheral blood eosinophilia. Abdominal CT scan revealed diffuse and concentric parietal thickening of the distal 2/3 of esophagus, moderate volume ascites, and small bowel wall thickening and distension on the left quadrants. The paracentesis revealed 93.3% of eosinophils. The colon biopsies evidenced an increase in the number of eosinophils. Secondary causes of eosinophilia were excluded. The patient was treated with oral prednisolone 40 mg/day with immediate clinical and analytical improvement.
Conclusion
Eosinophilic gastroenteritis is a rare condition with a nonspecific and highly variable clinical presentation, which requires a high level of clinical suspicion. It is a diagnosis of exclusion. Secondary causes of eosinophilia such as intestinal tuberculosis, parasitosis, and malignant neoplasms should be excluded.
Background/aims
As increasing numbers of Crohn’s disease (CD) cases are being recognized in India, so the differential diagnosis of CD and gastrointestinal tuberculosis (GITB) is becoming increasingly important. If patients are misdiagnosed with GITB, toxicity may result from unnecessary anti-TB therapy and treatment of the primary disease (ie, CD) gets delayed. We therefore aimed to assess the accuracy of various parameters that can be used to predict GITB diagnosis at index evaluation.
Materials and methods
This was a prospective, unicentric, observational study carried out in the gastroenterology department of a tertiary care hospital between August 2011 and January 2013. Patients who presented to our hospital and were suspected of having GITB were included in our study. Patients were then followed up over a 6-month period.
Statistical analysis
Chi-square test was used to analyze the data.
Results
Of the 69 patients with GITB, 49 (71.01%) had thickening of the involved part of the colon and 33 (47.83%) had abdominal lymphadenopathy. The ileocecal valve was involved in 58 patients (84.05%) Histological detection of granulomas had 78.95% specificity, 36.23% sensitivity, and 51.40% accuracy. Tuberculosis polymerase chain reaction was found to have 78.95% specificity, 71.01% sensitivity, and 73.83% accuracy. BACTEC-MGIT culture was found to have 100% specificity, 20.29% sensitivity, and 48.60% accuracy.
Conclusion
Although histology is helpful in ruling out other conditions, TB-specific findings such as caseating granuloma and acid-fast bacilli are rarely seen. Instead, tuberculosis polymerase chain reaction has the highest diagnostic accuracy followed by BACTEC culture.
Background: Tuberculosis (TB) remains a worldwide problem. Intestinal TB (ITB) constitutes a major public health problem in developing countries and has been associated with significant morbidity and mortality. The aim of this study was to characterize the clinical, radiological, endoscopic, and pathological features of ITB and to define the strategy for establishing the diagnosis.
Methods: A retrospective study (from January 2000 to June 2015) was carried out in Peking Union Medical College Hospital and all hospitalized cases were diagnosed as ITB during the study period were included. The relevant clinical information, laboratory results, microbiological, and radiological investigations were recorded.
Results: Of the 85 cases, 61 cases (71.8%) were ranged from 20 to 50 years. The ileocecal region was involved in about 83.5% (71/85) of patients. About 41.2% (35/85) of patients had co-existing extra ITB, especially active pulmonary TB. Abdominal pain (82.4%) was the most common presenting symptom followed by weight loss (72.9%) and fever (64.7%). Both T-cell spot of TB test (T-SPOT.TB) and purified protein derivatives (PPD) tests were performed in 26 patients: 20 (76.9%) positive T-SPOT.TB and 13 (50.0%) positive PPD were detected, with a statistical significant difference (P = 0.046). Twenty cases (23.5%) were histopathology and/or pathogen confirmed TB; 27 cases (31.8%) were diagnosed by clinical manifestation consistent with ITB and evidence of active extra ITB; 38 cases (44.7%) were diagnosed by good response to diagnostic anti-TB therapy.
Conclusions: ITB is difficult to diagnose even with modern medical techniques due to its nonspecific clinical and laboratory features. At present, combination of clinical, endoscopic, radiological, and pathological features continues to be the key to the diagnosis of ITB.
Background:
Eosinophilic esophagitis (EoE) is related to allergic diseases such as bronchial asthma (BA), atopic dermatitis, and allergic rhinitis. The aim of this study was to examine the eosinophil infiltration in the upper gastrointestinal (GI) tract in patients with BA using esophagogastroduodenoscopy.
Methods:
Patients with BA who had upper GI tract symptoms were enrolled. Patients who received systemically administered steroids were excluded. Eosinophil infiltrations in the esophagus, stomach, and duodenum were examined with regard to the endoscopic findings and pathological findings of biopsy specimens (UMIN000010132).
Results:
Ninety patients were enrolled from October in 2012 to September in 2014. Thirty-six were male, 54 were female, and the mean age was 57.5 years. Eighty-one (90%) used inhaled corticosteroids. Fourteen patients (15.6%) had reflux esophagitis, 8 of whom had grade A and 6 had grade B. No patient with EoE was observed. One female patient who had marked eosinophil infiltration in the esophagus, stomach, and duodenum was diagnosed as having eosinophilic gastroenteritis, but endoscopy showed only mucosal edema in the antrum. Another female patient who had marked eosinophil infiltration in the esophagus, stomach, and duodenum was diagnosed as having eosinophilic granulomatosis with polyangiitis, and endoscopy showed erosions in the antrum and the duodenum. Three patients had eosinophil infiltration in the stomach, but none of them had severe symptoms.
Conclusions:
Patients with asthma who had upper gastrointestinal symptoms rarely had eosinophilic gastrointestinal disorders. Biopsy specimens are of high importance in the diagnosis of eosinophilic gastrointestinal disorders even if there is no remarkable endoscopic finding.
Background:
The clinical manifestations of eosinophilic gastroenteritis are nonspecific and vary depending on which layer of the gastrointestinal tract is involved. Computed tomography (CT) is valuable for detecting and characterizing gastrointestinal wall abnormalities.
Case report:
We report a case of eosinophilic gastroenteritis that formed a chamber in the rigid duodenal wall of a 67-year-old woman. Abdominal CT showed symmetrical wall thickening of the gastric antrum and duodenal bulb, and the bowel walls consisted of 2 continuous, symmetrically stratified layers. There was a chamber mimicking a giant ulcer at the orifice of the descending duodenum. Eosinophilic inflammation was present through this rigid wall of the descending duodenum, accompanied by perienteric inflammation, which infiltrated the anterior pararenal space, gall bladder, and right colic flexure. Gastrointestinal endoscopy showed spotty erosions and reddish mucosa, with the edematous gastric antrum and duodenal bulb narrowed at their lumens. Just beyond the supraduodenal angle at the orifice of the descending duodenum, there was a chamber with only minor mucosal changes, and it was not a duodenal ulcer. Endoscopic biopsy of the duodenum showed intramucosal eosinophilic infiltration. Treatment with prednisolone resulted in normalization of radiologic and endoscopic abnormalities.
Conclusions:
We present a case of eosinophilic gastroenteritis with both mucosal and muscular involvement. CT imaging and endoscopic examination confirmed the diagnosis.
There is a lack of prospective studies evaluating the natural history of colonic ischaemia (CI). We performed such a study to evaluate the clinical presentation, outcome, and mortality as well as clinical variables associated with poor prognosis.
An open, prospective, and multicentre study was conducted in 24 Spanish hospitals serving a population of 3.5 million people. The study included only patients who met criteria for definitive or probable CI. A website (www.colitisisquemica.org) provided logistical support.
A total of 364 patients met criteria for inclusion. CI was suspected clinically in only 24.2% of cases. The distribution of clinical patterns was as follows: reversible colopathy (26.1%), transient colitis (43.7%), gangrenous colitis (9.9%), fulminant pancolitis (2.5%), and chronic segmental colitis (17.9%). A total of 47 patients (12.9%) had an unfavorable outcome as defined by mortality and/or the need for surgery. Multivariate analysis identified the following signs as independent risk factors for an unfavorable outcome: abdominal pain without rectal bleeding [odds ratio (OR) 3.9; 95% confidence interval (CI) = 1.6-9.3], non-bloody diarrhoea (OR 10; 95% CI = 3.7-27.4), and peritoneal signs (OR 7.3; 95% CI = 2.7-19.6). Unfavorable outcomes also were more frequent in isolated right colon ischaemia (IRCI) compared with non-IRCI (40.9 vs. 10.3%, respectively; p < 0.0001). The overall mortality rate was 7.7%.
The clinical presentation of CI is very heterogeneous, perhaps explaining why clinical suspicion of this disease is so low. The presence of IRCI, and occurrence of peritoneal signs or onset of CI as severe abdominal pain without bleeding, should alert the physician to a potentially unfavorable course.
An International Expert Committee (IEC) and the American Diabetes Association (ADA) proposed diagnostic criteria for diabetes and pre-diabetes based on A1C levels. We hypothesized that screening for diabetes and pre-diabetes with A1C measurements would differ from using oral glucose tolerance tests (OGTT).
We compared pre-diabetes, dysglycemia (diabetes or pre-diabetes), and diabetes identified by the proposed criteria (A1C ≥ 6.5% for diabetes and 6.0-6.4% [IEC] or 5.7-6.4% [ADA] for high risk/pre-diabetes) with standard OGTT diagnoses in three datasets. Non-Hispanic white or black adults without known diabetes who had A1C and 75-g OGTT measurements were included from the prospective Screening for Impaired Glucose Tolerance study (n = 1,581), and from the National Health and Nutrition Examination Survey (NHANES) III (n = 2014), and NHANES 2005-2006 (n = 1,111).
OGTTs revealed pre-diabetes in 35.8% and diabetes in 5.2% of combined study subjects. A1C provided receiver operating characteristic (ROC) curve areas for diabetes of 0.79-0.83, but ROC curve areas were ≤ 0.70 for dysglycemia or pre-diabetes. The proposed criteria missed 70% of individuals with diabetes, 71-84% with dysglycemia, and 82-94% with pre-diabetes. Compared with the IEC criteria, the ADA criteria for pre-diabetes resulted in fewer false-negative and more false-positive result. There were also racial differences, with false-positive results being more common in black subjects and false-negative results being more common in white subjects. With use of NHANES 2005-2006 data, ∼5.9 million non-Hispanic U.S. adults with unrecognized diabetes and 43-52 million with pre-diabetes would be missed by screening with A1C. CONCLUSIONS The proposed A1C diagnostic criteria are insensitive and racially discrepant for screening, missing most Americans with undiagnosed diabetes and pre-diabetes.
Previous reports on the anatomic portions of colon involved in cases of supposed ischemic colitis (IC) have been limited by the absence of confirmation of the true nature of the disease. This is the first anatomic study to define the patterns of colon involvement in which only cases with biopsy-proven or -compatible IC and in which the entire colon had been visualized at surgery or at colonoscopy were included. The aims of this study were to re-examine patterns of colonic involvement in IC using only cases in which the diagnosis was biopsy proven or compatible, and to examine the clinical features and outcomes with regard to the segments of colon involved.
A retrospective study was undertaken of patients with IC who were hospitalized at Montefiore Medical Center from 1998 to 2009. Patients were identified using computerized searches of ICD-9 (International Classification of Diseases, ninth revision) codes for colon ischemia, and patterns of colon involvement were then tabulated and categorized into five major groups: right colon, transverse colon, left colon, distal colon, and pancolon involvement. Patterns were classified based on the most proximal location of injury. Major anatomic patterns were then subcategorized into more specific segments of involvement. Only biopsy-proven or -compatible cases of IC in which the entire colon had been visualized at surgery or at colonoscopy were used in this study.
A total of 313 cases of biopsy-proven or -compatible IC were identified. Patterns and frequencies of involvement were: right colon, 25.2%; transverse colon, 10.2%; left colon, 32.6%; distal colon, 24.6%; and pancolon, 7.3%. Compared with all other patterns of IC, the right colon pattern was more likely to be associated with coronary artery disease (39.2 vs. 21.4%) or end-stage kidney disease requiring dialysis (20.3 vs. 7.7%), a longer hospitalization (median stay, 10 vs. 6 days), a greater need for surgery (44.3 vs. 11.5%), and the highest mortality rate (20.3 vs. 9%). Patients with a left colon pattern were less likely to be operated upon, and had a shorter length of stay than any other pattern of IC. Hyperthyroidism, stroke, and chronic obstructive pulmonary disease (COPD) were statistically significant independent predictors of mortality.
IC is typically a segmental disease, flanked by normal colon on either side of the affected area. Comorbid disease associations and severity of disease as reflected by length of hospitalization, need for surgery, and mortality vary with the segment involved. IC isolated to the right side of the colon is a more severe disease than IC affecting any other segment of colon.
Radiation therapy is commonly utilized as a major component in the treatment of pelvic malignancy. Unfortunately, secondary toxicity to the lower gastrointestinal tract can occur. This most commonly affects the rectum, although injuries to the colon and small intestine are not uncommon. The presentation can be acute or chronic, and different mechanisms are responsible for each. Symptomatology is quite variable but can result in significant compromise for the patient. Numerous preventive and treatment strategies have been applied to this disease process. This article presents a summary of the current knowledge regarding radiation injury to the lower gastrointestinal tract with special emphasis on treatment options for radiation proctitis.
We investigated the distribution of the collagen band in 33 patients with collagenous colitis to estimate the likelihood of the disease being diagnosed in biopsy specimens from the left side of the colon, such as those obtained using flexible sigmoidoscopy. To be included in this study patients had a subepithelial collagen band greater than or equal to 10 microns, an increase in chronic inflammatory cells in the same specimen, and diarrhoea for which there was no other apparent cause. In 17 patients undergoing full colonoscopy with a thickened collagen band, collagenous colitis was frequently patchy, even though overall the thickened collagen band was almost equally distributed throughout the colon. Rectal biopsy specimens showed a normal collagen band in 73% of patients, while a thickened collagen band was found in 82% of patients in at least one specimen from the left side of the colon. Three patients had a thickened collagen band only in the caecum. In three of eight rectal biopsy specimens with a normal collagen band there was no mucosal inflammation to raise the possibility of proximal disease, although all but one specimen with a normal collagen band from the sigmoid and descending colon were inflamed. Rectal biopsy alone is therefore a relatively poor method of making the diagnosis. Flexible sigmoidoscopy with multiple biopsy specimens from several sites is a reasonable initial investigation but not sufficient to exclude collagenous colitis when based on the presence of a thickened collagen band alone. Should left sided biopsy specimens show a normal collagen band but an inflamed mucosa, total colonoscopy with multiple specimens including the caecum may be required to establish the diagnosis.
Inflammatory bowel diseases (IBD) are systemic disease that manifest not only in the gut/GI tract but also in many patients in extraintestinal organs. The quality of life of IBD patients may be significantly affected by those extraintestinal manifestations (EIMs). It is important to have knowledge of the prevalence, pathophysiology and clinical presentation of EIMs in order to adapt therapeutic options to cover all aspects of IBD. EIMs may occur in up to 24% of IBD patients before the onset of intestinal symptoms and need to be recognized to initiate appropriate diagnostic procedures. EIMs most frequently affect joints, skin, or eyes, but may also affect other organs such as the liver, lung and pancreas. It is a frequent misconception that a successful therapy of the intestinal inflammation will be sufficient to treat EIMs satisfactorily in the majority of IBD patients. In general, peripheral arthritis, oral aphthous ulcers, episcleritis, or erythema nodosum may be associated with active intestinal inflammation and may improve upon standard treatment of the intestinal inflammation. On the other hand, anterior uveitis, ankylosing spondylitis (AS) and primary sclerosing cholangitis (PSC) usually occur independent of disease flares. This review provides a comprehensive overview of epidemiology, pathophysiology, clinical presentation and treatment of EIMs in IBD.
Chronic diarrhea is defined as a predominantly loose stool lasting longer than four weeks. A patient history and physical examination with a complete blood count, C-reactive protein, anti-tissue transglutaminase immunoglobulin A (IgA), total IgA, and a basic metabolic panel are useful to evaluate for pathologies such as celiac disease or inflammatory bowel disease. More targeted testing should be based on the differential diagnosis. When the differential diagnosis is broad, stool studies should be used to categorize diarrhea as watery, fatty, or inflammatory. Some disorders can cause more than one type of diarrhea. Watery diarrhea includes secretory, osmotic, and functional types. Functional disorders such as irritable bowel syndrome and functional diarrhea are common causes of chronic diarrhea. Secretory diarrhea can be caused by bile acid malabsorption, microscopic colitis, endocrine disorders, and some postsurgical states. Osmotic diarrhea can present with carbohydrate malabsorption syndromes and laxative abuse. Fatty diarrhea can be caused by malabsorption or maldigestion and includes disorders such as celiac disease, giardiasis, and pancreatic exocrine insufficiency. Inflammatory diarrhea warrants further evaluation and can be caused by disorders such as inflammatory bowel disease, Clostridioides difficile, colitis, and colorectal cancer.
This guideline presents recommendations for the management of coeliac disease (CD) and other gluten-related disorders both in adults and children. There has been a substantial increase in the prevalence of CD over the last 50 years and many patients remain undiagnosed. Diagnostic testing, including serology and biopsy, should be performed on a gluten-containing diet. The diagnosis of CD is based on a combination of clinical, serological and histopathological data. In a group of children the diagnosis may be made without biopsy if strict criteria are available. The treatment for CD is primarily a gluten-free diet (GFD), which requires significant patient education, motivation and follow-up. Slow-responsiveness occurs frequently, particularly in those diagnosed in adulthood. Persistent or recurring symptoms necessitate a review of the original diagnosis, exclude alternative diagnoses, confirm dietary adherence (dietary review and serology) and follow-up biopsy. In addition, evaluation to exclude complications of CD, such as refractory CD or lymphoma, should be performed. The guideline also deals with other gluten-related disorders, such as dermatitis herpetiformis, which is a cutaneous manifestation of CD characterized by granular IgA deposits in the dermal papillae. The skin lesions clear with gluten withdrawal. Also, less well-defined conditions such as non-coeliac gluten sensitivity (NCGS) and gluten-sensitive neurological manifestations, such as ataxia, have been addressed. Newer therapeutic modalities for CD are being studied in clinical trials but are not yet approved for use in practice.
Background:
The diagnosis of intestinal tuberculosis (TB) and its differentiation from Crohn's disease (CD) remain a challenge. We review here in detail the various methods for the diagnosis of intestinal TB.
Summary:
Colonoscopy findings in intestinal TB are useful and suggestive; histopathology of colonoscopic biopsies is contributory but rarely confirmatory. Increasing the number of colonoscopic biopsies increases the histological yield. Recent culture methods that have improved the yield for TB offer hope. Mycobacteria Growth Indicator Tube (MGIT) culture is now the standard of care as its yield is superior to that of the traditional Lowenstein-Jensen medium. Increasing the number of colonoscopic biopsy samples for MGIT culture can increase the yield. The culture and histology are complimentary. Even then a significant proportion of patients do not have a positive diagnosis of intestinal TB. Scoring systems have been developed with a sensitivity and specificity of 90 and 60%, respectively, but their utility in routine practice is yet to be established. Similarly, the ratio of visceral fat to total fat is helpful in differentiating CD from intestinal TB. Polymerase chain reaction has been used but its value seems uncertain. Gene Xpert® in an emerging technique that has been found to be useful in the diagnosis of pulmonary TB, and its utility in intestinal TB needs to be looked at. Newer technologies like TB-LAMP (loop-mediated isothermal amplification) need to be assessed in clinical studies.
Key message:
Optimization of the present diagnostic tools (taking an adequate number of biopsies for histology and culture) and study of newer techniques to learn their actual utility seems to be the way forward.
This study was conducted to investigate body mass index (BMI), levels of cholesterol and triglycerides in prison inmates at the Institution for Reform and Rehabilitation in Southern Libya to be considered as an indication about their health and the provided foods. The results of this study showed that 26.5% of BMI of the prison inmates were found to be higher than the normal levels. Generally, the average level of cholesterol and triglycerides concentrations were found to be within normal range 142.6 mg/dl and 135.4 mg/dl, respectively. The findings also established that there were a significant relationship and direct correlation between BMI levels and age and concentration of cholesterol and triglycerides levels. The results of this showed that the served foods for these prison inmates are well balanced as indicated by their cholesterol and triglycerides levels.
Aim
To determine the pathologic features of colon ischemia (CI) and their relationship to symptom duration, disease distribution, and clinical outcome in a real‐world, clinical setting.
Method
A retrospective, multi‐center chart review was performed in patients diagnosed with CI at Montefiore Medical Center (01/2005‐07/2015), and Yale‐New Haven Hospital (01/2005‐06/2010). Patients were included if clinical presentation, colonoscopic findings, and colonic pathology were all consistent with CI.
Results
616 patients with pathologically‐proven CI were included. Common pathologic findings included inflammation (51.1%), ulceration (38.2%), fibrosis (26.0%), and necrosis (20.4%). Infarction and ghost cells were seen in 1.6% and 0.2% of cases, respectively. There was a significant relationship between symptom duration and hyalinization of the lamina propria (P = 0.05) and cryptitis/crypt abscesses (P = 0.01). Patients with isolated‐right CI (IRCI) were more likely than patients with isolated‐left CI (ILCI) to exhibit necrosis (P <0.01), cryptitis/crypt abscess (P <0.01), and inflammation (P = 0.03). Patients with poor outcomes were more likely to exhibit necrosis (P <0.01) and capillary fibrin thrombi (P <0.01) and less likely to exhibit fibrosis (P <0.01) and epithelial changes (P <0.01).
Conclusion
CI is accompanied by a broad spectrum of pathologic findings. Traditional pathognomonic findings of CI are rare and cannot be relied upon to exclude the diagnosis. Patients with IRCI and/or poor outcomes were more likely to have pathologic findings of necrosis, than patients who had ILCI and/or non‐poor outcomes.
Microscopic colitis (MC) is a relatively common cause of chronic watery diarrhea, especially in older persons. Associated symptoms, including abdominal pain and arthralgias, are common. The diagnosis is based upon characteristic histological findings in the presence of diarrhea. The two types of MC, collagenous and lymphocytic colitis, share similar clinical features, with the main difference being the presence or absence of a thickened subepithelial collagen band. There are several treatment options for patients with MC, although only budesonide has been well studied in multiple controlled clinical trials. This review will describe the clinical features, epidemiology, pathophysiology, diagnostic criteria, and treatment of patients with MC.
Colon ischemia (CI) is a common disease diagnosed in 16–24% of patients presenting to the hospital with acute lower gastrointestinal bleeding (1) and accounting for ~16–18 per 100,000 hospital admissions (2, 3). Indeed, it is the most common ischemic disorder of the GI tract, and it and infectious colitis are the most common colitides seen in patients older than 65 years of age.
Radiotherapy not only plays a pivotal role in the cancer care pathways of many patients with pelvic malignancies, but can also lead to significant injury of normal tissue in the radiation field (pelvic radiation disease) that is sometimes as challenging to treat as the neoplasms themselves. Acute symptoms are usually self-limited and respond to medical therapy. Chronic symptoms often require operative intervention that is made hazardous by hostile surgical planes and unforgiving tissues. Management of these challenging patients is best guided by the utmost caution and humility.
Ischemic colitis is the result of colonic hypoperfusion and is regarded as a relatively rare condition. It can be roughly classified as occlusive and non-occlusive. Pathogenesis includes a usually transient compromise in the colonic vasculature, with a parallel activation of an inflammatory cascade caused primarily by reperfusion. Diagnosis of ischemic colitis remains often difficult and requires a combination of diagnostic techniques, whereas clinical signs are occasionally only seen late as complications. Gold standard is considered to be colonoscopy. Clinical presentation and treatment of ischemic colitis vary widely depending on the degree of ischemia. Patients of intensive care unit (ICU) with ischemic colitis are often under-diagnosed, since the parallel co-morbidities and the nonspecific nature of symptoms that mimic almost any abdominal pathology, can mislead the doctor. Moreover, sedated or ventilated patients can mask many of the characteristic features of ischemic colitis and make the diagnosis challenging. Bedside colonoscopy and diagnostic laparoscopy in ICUs are two options, which seem lately to be reliable and promising in diagnosing ischemic colitis in critically ill patients.
Goals:
The aim of this study was to retrospectively analyze the clinical, endoscopic, and pathologic features of intestinal tuberculosis (TB).
Background:
The prevalence of intestinal TB has been increasing in China.
Study:
The clinical, imaging and laboratory examination, endoscopic, and pathologic data of 81 cases of intestinal TB patients were retrospectively analyzed.
Results:
There were 48 male and 33 female cases whose age ranged from 17 to 76 years (mean, 32.4±1.6 y). Fifty-five cases were diagnosed by endoscopic biopsy, and 26 cases by postoperative pathologic examination. The common symptoms were chronic right lower abdominal and periumbilical pain (87.7%), weight loss (80.2%), anemia (64.2%), diarrhea (46.9%), fever (43.2%), diarrhea alternating with constipation (38.3%), and night sweats (30.9%). Purified protein derivative test (51.9%), TB antibody (34.6%), and TB protein chip (40.7%) had lower sensitivity. T-spot test sensitivity was 86.4%. Endoscopic types included ulcerative (52.7%), ulcero-proliferative (27.3%), and proliferative (20.0%) with mucosal hyperemia and edema (87.2%), mucosal erosion (76.4%), patulous ileocecal valve (65.5%), polypoid hyperplasia (58.2%), annular ulcer (52.7%), nodular hyperplasia (45.5%), and luminal stenosis (29.1%). Histopathologic findings were chronic mucosal inflammation (87.3%), ulceration (74.5%), lymphocytic aggregation (69.1%), and granulomatous fusion (58.2%). The presence of caseating granulomas (74.5%) and necrosis (25.5%) was helpful, but not common.
Conclusions:
The clinical symptoms of intestinal TB are nonspecific. The most common anatomic locations for intestinal TB are the ileocecal valve and cecum. The T-spot test has high sensitivity, and it can be used to support the diagnosis of intestinal TB. The typical endoscopic features are circumscribed intestinal ulcers, and histopathologic findings of biopsy specimens can be also useful in making the diagnosis.
We systematically evaluated the clinicopathologic features and outcome of a rare, unusual variant of ischemic colitis that presents as a mass lesion mimicking malignancy on imaging or colonoscopy. A retrospective search was performed for cases with a histologic diagnosis of ischemic colitis and a clinical impression of malignancy. Of the 23 patients initially identified, 4 were excluded because clinical and histologic review showed mucosal prolapse (n=1), discrete colon polyp (n=2), and a diverticular mass (n=1) without concern for malignancy. The mass-forming variant of ischemic colitis (n=19) was seen predominantly in elderly (mean age 71.8 y) women (63.2%) with a striking predilection for the right colon (13/19), particularly the cecum (n=6). Abdominal pain (52.6%) and hematochezia (26.3%) were the most common presenting symptoms. A computed tomography scan showed segmental thickening suspicious for malignancy in 6/8 patients. Colonoscopy revealed an exophytic (n=16) or stricturing (n=3) mass with a mean size of 4.67 cm. Mucosal biopsies showed features typical for ischemic colitis in all cases. A colectomy was performed in 4 cases. In 2, the mass-like appearance was due to marked submucosal and mural edema, whereas in the other 2 cases, with a malignant stricture-like lesion, marked submucosal fibrosis and cholesterol emboli were present. No malignancy was identified on follow-up in any patient (mean 39.9 mo). Follow-up colonoscopy was performed in 7 patients 1 to 32 weeks after initial presentation and showed resolution of the mass in all cases. Awareness of this rare variant of ischemic colitis will prevent unnecessary resections in these patients.
Objective:
Microscopic colitis (MC) includes two main types: collagenous colitis (CC) and lymphocytic colitis (LC). Previous studies have indicated an increasing incidence, but these have mainly been based on regional databases. We found it important to study the epidemiology based on a comprehensive nationwide cohort.
Material and methods:
We studied the epidemiological data of MC in Denmark from 2002 to 2011. The cohort consisted of all patients with a recorded diagnosis of either CC or LC in the Danish Pathology Register during the study period. Data on all patients with a registered colon biopsy were also included.
Results:
A total of 7777 patients, 4749 (61%) with CC and 3028 (39%) with LC, were identified. Over the study period, the annual incidence of diagnosed cases of CC increased from 2.9/10(5) to 14.9/10(5) and of LC from 1.7/10(5) to 9.8/10(5). In 2011, the incidence of MC was 24.7/10(5) inhabitants. The age-specific incidence showed that the risk of both CC and LC increased with age. The female/male ratio, distribution of the type of colitis and mean age at diagnosis were relatively stable during the study period. The annual number of registered colon biopsies in the pathology register increased from 21.583 in 2002 to 39.733 in 2011, indicating an increased diagnostic activity.
Conclusion:
In a nationwide cohort study, the incidence of CC and LC continued to increase from 2002 to 2011. An increased diagnostic activity could in part explain the increase in the number of diagnosed cases.
The American Journal of Gastroenterology is published by Nature Publishing Group (NPG) on behalf of the American College of Gastroenterology (ACG). Ranked the #1 clinical journal covering gastroenterology and hepatology*, The American Journal of Gastroenterology (AJG) provides practical and professional support for clinicians dealing with the gastroenterological disorders seen most often in patients. Published with practicing clinicians in mind, the journal aims to be easily accessible, organizing its content by topic, both online and in print. www.amjgastro.com, *2007 Journal Citation Report (Thomson Reuters, 2008)
Incidence rates of microscopic colitis are mainly based on regional data from a limited number of countries. To evaluate geographical differences and changes over time, more nationwide incidence rates are needed.
The aim of this retrospective study was to assess the incidence rate of microscopic colitis in the Netherlands in a nationwide cohort.
A search was performed in the Dutch pathology registry, covering records of all approximately 16.5 million inhabitants. Incident cases were defined as a first diagnosis of microscopic colitis (collagenous or lymphocytic colitis) between 2000 and 2012.
In total, 7228 incident cases were identified with a mean annual incidence rate of 3.4 per 100,000 person years. Collagenous colitis was present in 3741 cases and lymphocytic colitis in 2718 cases, with a mean annual incidence rate of 1.8 and 1.3 per 100,000 person years, respectively. Remaining 769 cases were described as undefined microscopic colitis. Collagenous and lymphocytic colitis incidence rates increased significantly over time (p<0.001) with a male:female ratio of 1:3 and 1:2, respectively.
The Dutch mean annual incidence rates of collagenous and lymphocytic colitis were considerably lower than previously reported by other countries. However, incidence rates increased gradually over time, with a clear female predominance.
Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Microscopic colitis has emerged as a major cause of chronic watery non-bloody diarrhoea, particularly in elderly females. The term is used as an umbrella term to categorize a subgroup of colitides with distinct clinicopathologic phenotypes and no significant endoscopic abnormalities: Lymphocytic colitis is defined by an increased number of surface intraepithelial lymphocytes, collagenous colitis by a thickened collagen band underneath the surface epithelium. There is increased inflammation in the lamina propria, but only little or no crypt architectural distortion. Incomplete and variant forms showing less characteristic features have been reported under different names. Differential diagnosis mainly includes resolving infectious colitis and changes related to the intake of drugs such as non-steroidal anti-inflammatory drugs. Substantial clinical and histological overlap between lymphocytic and collagenous colitis has been described, raising the suspicion that the conditions are two histological manifestations of the same entity, possibly representing different manifestations during the disease course or different stages of disease development. In this review we provide a practical approach for pathologists with focus on diagnostic criteria and differential diagnosis, discuss recent insights into the pathogenesis of disease and the relation to classical chronic inflammatory bowel disease, i.e. Crohn's disease and ulcerative colitis.This article is protected by copyright. All rights reserved.
Eosinophilic gastroenteritis (EGE) is an uncommon disease characterised by eosinophilic infiltration in the gastrointestinal tract. EGE may involve more than one layer of the gastrointestinal tract. Clinical features depend on the layer and location which is involved. We report an unusual case of eosinophilic ascites associated with antinuclear antibody positivity, which is an unusual variety of serosal form of EGE.
Eosinophilic esophagitis (EoE) shows characteristic microscopic pathologic features in endoscopically obtained esophageal biopsies, including an eosinophil-rich inflammatory infiltrate in esophageal epithelium, but other inflammatory cells are also increased. Additional alterations are found in epithelium and lamina propria. Esophageal biopsy pathology is a sensitive but not specific marker for EoE related to antigen exposure. Several of the pathologic features of EoE correlate with dysregulated genes in the EoE transcriptome. Eosinophilic gastrointestinal diseases affecting the remainder of the gastrointestinal tract are less well characterized; this article discusses pathologic features in mucosal biopsies that could form the basis for diagnosis and future study.
To review and highlight the unappreciated roles of eosinophils suggested by recent studies.
The literature, unpublished observations, and insights by the authors.
Basic studies of mouse models and patient-based clinical studies of disease.
Eosinophils are often thought of as destructive end-stage effector cells primarily linked to parasite host defense and dysregulated immune responses associated with allergic diseases, such as asthma. However, recent studies (ie, research focused on mechanisms of action and translational studies examining disease/inflammatory pathways) are suggesting far more complex roles for eosinophils. The goal of this review is 3-fold. (1) The authors examine the dynamic history of eosinophils and how physicians over time used this information to formulate defining hypotheses. Particular emphasis is placed on recent studies challenging the parochial view of host defense in favor of roles maintaining homeostasis through immune modulation and tissue remodeling/repair. (2) They discuss diagnostic approaches to assess eosinophils in clinical settings as a means of disease identification and subsequently as a measurement of disease severity. (3) They examine how contemporary views of eosinophils and their perceived roles in diseases have led to specific therapeutic strategies. The emphasis is to review the successes and failures of these strategies as the basis of formulating future clinical studies targeting eosinophils as potential therapies of disease.
Despite the complexities of eosinophil-mediated activities and the less than overwhelming success of initial attempts targeting these cells, eosinophils remain a potentially important focal target of disease diagnosis and subsequent treatment strategies.
Microscopic colitis is a chronic inflammatory bowel disease characterized by chronic, non-bloody diarrhea and specific histopathology features. Active disease, defined as ≥ 3 stools or ≥1 watery stool per day, significantly reduces quality of life. Epidemiology studies have found the incidence and prevalence of microscopic colitis to be comparable to those of Crohn`s disease and ulcerative colitis. Nevertheless, microscopic colitis is still under-recognized in clinical practice-most health care workers know little about its etiology and pathophysiology. Furthermore, there are many challenges to diagnosis and treatment of patients. We review the epidemiologic and clinical features of this disorder and discuss its pathogenesis. We also outline the criteria for histopathology evaluation of microscopic colitis, recently published by the European Consensus on Inflammatory Bowel Disease, and discuss a treatment algorithm created by the European Microscopic Colitis Group. Treatment options for patients with budesonide-refractory disease are discussed.
Approximately one-third of patients with chronic radiation enteritis (CRE) require surgery, which is associated with a high morbidity rate and a high risk of reoperation. The aim of this study was to report outcome after surgery for CRE.
Patients with CRE who underwent operation with extensive small bowel resection between 1980 and 2009 were included in the study. Postoperative morbidity and mortality, reoperation for recurrent enteritis and risk factors for reoperation were analysed.
Of 107 patients (94 women; 87·8 per cent) with CRE included in the study, the main indication for surgery was symptomatic stricture (82 patients; 76·6 per cent). Forty-nine ileocaecal resections (45·8 per cent) were performed. Overall and surgical morbidity rates were 74·8 per cent (80 patients) and 28·0 per cent (30) respectively. Fourteen patients (13·1 per cent) underwent reoperation for complications. Reoperation rates for CRE at 1 and 3 years of follow-up were 37 and 54 per cent respectively. Risk factors for reoperation for recurrent enteritis were: emergency surgery (odds ratio (OR) 2·72, 95 per cent confidence interval 1·57 to 4·86), anastomotic leakage (OR 2·53, 1·54 to 4·42) and male sex (OR 3·57, 1·82 to 7·29). The only protective factor for reoperation was ileocaecal resection during the first surgical procedure (OR 4·48, 2·52 to 8·31).
Ileocaecal resection was the only factor that protected against reoperation for recurrent CRE, demonstrating the importance of resecting all damaged tissue in these patients. These results suggest that there is little place for intestinal bypass surgery or adhesiolysis.
Culture of Tropheryma whipplei, the agent of Whipple disease (WD), was achieved in our laboratory in 2000, allowing new perspectives for the diagnosis of this disease and for the description of other potential clinical manifestations caused by this microorganism. Since 2000, we have developed new tools in our center in Marseille, France, to optimize the diagnosis of T whipplei infections. Classic WD was characterized by positive periodic acid-Schiff performed on duodenal biopsy. In the absence of duodenal histologic involvement, localized infections were defined by specific positive T whipplei polymerase chain reaction (PCR) results obtained using samples of other tissues and body fluids. The physicians in charge of patients were asked to complete a questionnaire. A total of 215 diagnoses were performed or confirmed and, among these, 142 patients with sufficient clinical data were included.Herein, we report epidemiologic data, clinical manifestations, and diagnostic tools of T whipplei infections. In the 113 patients with classic WD, the main symptom was arthralgia (88/113, 78%), which explains the many cases misdiagnosed as inflammatory rheumatoid disease (56/113, 50%). Frequently immunosuppressive treatments, more recently including tumor necrosis factor inhibitor, had been previously prescribed (50%) and were often responsible for more rapid clinical progression (43%). Sometimes a short course of antibiotics improved the clinical status.Endocarditis was the second most frequent manifestation of T whipplei, with 16 cases. The clinical picture of this entity corresponds to cardiovascular involvement with acute heart failure (50%) occurring without fever (75%) or previous valvular disease (69%). Neurologic symptoms were the third major manifestation. Other localized infections such as adenopathy, uveitis, pulmonary involvement, or joint involvement were sporadic. Infection with T whipplei resulted in multifaceted conditions. Some localized infections due to this agent have recently been reported and may correspond to emerging entities. Patients with inflammatory rheumatoid disease must be systematically interviewed to determine the efficacy of previous immunosuppressive and antibiotic therapies.
Whipple's disease is a systemic, chronic, relapsing disorder caused by a combination of environmental (Tropheryma whipplei) and unknown host factors. Because it is a rare disease, the association between HLA type and Whipple's disease has been studied in only small numbers of patients; these studies have led to conflicting results. We aimed to investigate whether disease phenotype and outcome are associated with HLA type in 122 patients with Whipple's disease.
Genomic DNA was collected from 103 German, 11 Italian, and 8 Austrian patients with Whipple's disease, along with 62 healthy Austrian workers exposed to T whipplei (14 stool samples contained the bacterium). HLA class I and II alleles were identified by polymerase chain reaction analysis. Patient genotypes were compared with those of healthy German and Austrian populations; data for Italian controls were obtained from the Pavia HLA bone marrow donors' bank.
HLA-DRB1*13 and DQB1*06 alleles occurred significantly more frequently in patients with Whipple's disease but not in healthy individuals who had been exposed to T Whipplei. The cumulative odds ratios for disease were 2.23 for the DRB1*13 allele (P < .0001) and 2.25 for the DQB1*06 allele (P < .0001).
DRB1*13 and DQB1*06 alleles were found to be risk factors in the largest HLA study ever performed in patients with Whipple's disease.
Ischemic colitis accounts for more than half of all cases of gastrointestinal ischemia and constitutes between 1 per 2000 and 3 per 1000 acute hospital admission. It typically affects elderly patients, being a frequent cause of rectal bleeding, abdominal pain, and diarrhea. This article describes the epidemiology, physiology, and pathology of this underdiagnosed condition; reviews the clinical patterns of this disease, which constitute a key diagnostic point in patients who have a thickening of the colonic wall; and describes the ultrasound (US) and CT findings, pitfalls, and differential diagnoses of ischemic colitis. The value and limitations of US and CT at the different diagnostic stages is discussed.
Ischemic colitis is the most common type of intestinal ischemia and has a clinical spectrum of injury that ranges from mild and transient ischemia to acute fulminant colitis. The aim of this study was to explore endoscopic findings and clinicopathologic characteristics of ischemic colitis and be accurate enough to avoid missed diagnosis or misdiagnosis. A retrospective analysis was undertaken of endoscopy findings and clinicopathologic characteristics of 85 cases of ischemic colitis from March 2005 to April 2008 in the endoscopy center of our hospital. All cases underwent colonoscopy with biopsy within 2 weeks of the onset of symptoms, and all specimens with forceps were stained with hematoxylin-eosin and observed under light microscopy. Of the 85 cases of ischemic colitis (24 men and 61 women, average age 61.36 +/- 14.49 years old, range 29-84), 71 were over 50 years of age. These cases were associated with the basal diseases such as hypertension, cardiovascular disorders, diabetes, and hematological diseases as well as a history of abdominal operation. The clinical features usually presented with sudden onset of abdominal pain, diarrhea, and hematochezia. Ischemic lesions were located mainly in the left colon with segmental form (only descending colon affected 16%, only splenic flexure 14%, and only sigmoid colon 23%). The 85 patients consisted of the non-gangrenous type (82), which were composed of reversible IC (76) and chronic IC (6), and the gangrenous type (3). Endoscopic appearance of the transient ischemic colitis consisted of petechial hemorrhages, edematous and fragile mucosa, segmental erythema, scattered erosion, longitudinal ulcerations, and sharply defined segment of involvement. Ischemic colitis of stricture was characterized by full-thickness mucosa, lumens stricture, and diseased haustrations. The mucosa of gangrenous colitis with cyanotic and pseudopolyps was endoscopically observed as well. Clinicopathologic characteristics showed mucosal inflammation accompanied by erosion, granulation tissue hyperplasia and gland atrophy, lamina propria hemorrhage, and macrophages with hemosiderin pigmentation in submucosa in particular. Although endoscopy findings and clinicopathologic characteristics of ischemic colitis are nonspecific, colonoscopy with biopsy plays a vital role in the early diagnosis of ischemic colitis.
The goal to create a standardized diagnostic classification scheme of food-related gastrointestinal hypersensitivity disease syndromes included the diagnosis of eosinophilic gastroenteritis. This article reviews the history of this diagnosis and the current concepts of this complex disorder. The common symptoms from the literature are discussed. Because no standards for this diagnosis exist, the wide variety of diagnostic criteria from the literature are presented. No consistent immunologic abnormalities have been associated with the diagnosis of eosinophilic gastroenteritis in the literature. A review of the current immunologic concepts associated with the diagnosis of eosinophilic gastroenteritis is presented. The history of this disorder, which spans more than 6 decades is also discussed. The contributions made by the original authors during this period are presented. Attention was directed to the variety of clinical features associated with this disorder, but particular attention was paid to the evolution of the pathophysiologic mechanisms proposed. Some of the difficulties associated with the prospective study of patients with eosinophilic gastroenteritis are also discussed. The establishment of appropriate control populations, as well as the fundamental difficulties encountered with the establishment of the certainty of the link between abnormal immunohistochemical findings, and initial clinical symptoms are presented and discussed. A new classification system is proposed for food-related gastrointestinal hypersensitivity disease syndromes. Age, symptoms, and the region of the gastrointestinal tract involved were the variables that were considered most important by consensus opinion. Finally, recommendations to refocus our collective investigative efforts are presented.