Clinicopathological Correlation of Endoscopic Duodenal Biopsies in a Tertiary Care Hospital in Haryana

The study included endoscopic duodenal biopsies received in the department of pathology, MMIMSR,Mullana, Haryana. 44 biopsies were included in the study. The most common presenting complaintwas pain abdomen followed by diarrhea. The neoplastic lesions commonly presented as carcinomawhereas the non-neoplastic lesions presented as inflammatory lesions on endoscopy. Non-neoplasticlesions were found to be common with villous atrophy predominating the list. Majority of the lesionswere non-neoplastic, presenting with pain abdomen & inflammatory findings on endoscopy. Theneoplastic lesions comprised of adenocarcinoma. A single case of ampullary carcinoma was alsonoted. Percentage of concordance between endoscopic & histologic diagnoses was calculated whereinduodenitis, scalloping, polypoidal & carcinomatous lesions showed 100%, 60.7%, 0% & 100%concordance between the two diagnostic modalities respectively. The conclusion of the study wasthat endoscopic examination alone might miss out in diagnosing majority of the lesions. So, histologicalexamination in adjunct with endoscopy should be considered as much more valuable diagnostic toolrather than endoscopy alone.

Narrow-band imaging with magnification and the water immersion technique: a case-finding, cost-effective approach to diagnose villous atrophy

INTRODUCTION@#Narrow-band imaging with magnification endoscopy (NBI-ME) allows real-time visual assessment of the mucosal surface and vasculature of the gastrointestinal tract. This study aimed to determine the performance of NBI-ME combined with the water immersion technique (NBI-ME-WIT) in detecting villous atrophy.@*METHODS@#All patients who underwent gastroscopy were included. The duodenum was further examined with NBI-ME-WIT only after examination with white light endoscopy did not reveal a cause of anaemia or dyspepsia. Targeted biopsies were taken of visualised areas. NBI-ME-WIT findings were compared with the final histopathological analysis. We calculated the sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of NBI-ME-WIT in detecting villous atrophy and the hypothetical cost saved by using a biopsy-avoiding approach.@*RESULTS@#124 patients (83 female) with a mean age of 46 (range 18-82) years were included. The most common indication for gastroscopy was abdominal pain (39%), followed by anaemia (35%), chronic diarrhoea/altered bowel habits (19%) and dyspepsia (6%). NBI-ME-WIT was able to detect all nine patients with villous atrophy - eight patchy and one total villous atrophy. The Sn, Sp, PPV and NPV of NBI-ME-WIT in detecting villous atrophy were 100.0%, 99.1%, 90.0% and 100.0%, respectively. Taking into account the cost of biopsy forceps (AUD 17) and pathology (AUD 140), this biopsy-avoidance strategy could have saved AUD 18,055 in these patients.@*CONCLUSION@#NBI-ME-WIT is a specific and sensitive tool to recognise and accurately diagnose villous atrophy. Biopsies can be avoided in patients with normal-sized villi, which may decrease the overall cost of the procedure.

Uso de nuevas técnicas y procedimientos endoscópicos en el diagnóstico y seguimiento de la enfermedad celíaca / Use of new techniques and endoscopic procedures in the diagnosis and monitoring of celiac disease / Uso de novas técnicas e procedimentos endoscópicos no diagnóstico e monitoramento da doença celíaca

Resumen: Desde que inició la toma de biopsias a través de métodos endoscópicos para el diagnóstico de enfermedad celíaca (EC), se ha intentado describir distintos marcadores macroscópicamente visibles que sugirieran o confirmaran la presencia de atrofia vellositaria en la zona estudiada. Algunos de estos signos son altamente específicos pero su sensibilidad es baja por lo que, por si solos, tienen escaso valor en el algoritmo diagnóstico. El objetivo de esta revisión es analizar la evidencia científica existente sobre la utilidad de las nuevas tecnologías y técnicas endoscópicas en la identificación de marcadores de atrofia vellositaria en el diagnóstico y seguimiento de la enfermedad celíaca Método. Se llevó a cabo una revisión descriptiva de bibliografía donde se buscaron artículos originales en las bases de datos Pubmed y LILACS en el periodo 2006-2016. Resultados. El valor de la cromoendoscopía digital para la búsqueda de marcadores endoscópicos de atrofia vellositaria ha sido escasamente estudiado La sensibilidad de NBI con magnificación se estima entre 83 y 95%. Los únicos trabajos con OBI e I-Scan evidenciaron especificidad y sensibilidad perfectas, pero únicamente en pacientes con alta probabilidad de ser celiacos o portadores de atrofia severa. Con respecto a la microscopía endoscópica, la endocitoscopía no parece mejorar el desempeño de la endoscopía de manera significativa, sin embargo, con solo dos trabajos con bajo número de pacientes, la endomicroscopía laser confocal ha mostrado mayor sensibilidad en la detección de marcadores de atrofia. La VCE tiene alta especificidad (95-100%) pero menor sensibilidad (89%) y su mayor utilidad se encuentra en objetivar alteraciones que están más allá del alcance de la endoscopía tradicional y valorar su extensión. No existen trabajos que evalúen específicamente su presencia con enteroscopía doble balón, balón único o espiral. Conclusiones. Algunas de las nuevas técnicas y tecnologías parecen ser altamente específicas pero poco sensibles en la detección de marcadores endoscópicos de atrofia vellositaria. Son necesarios más estudios para determinar el valor de técnicas de microscopía endoscópica como herramienta diagnóstica a futuro.

Abstract: Since endoscopic methods are used for biopsying the duodenum at diagnosis or follow-up in celiac disease, attempts have been made to find macroscopically visible markers that suggest or confirm the presence of villous atrophy in the studied area. Some of these signs are highly specific but their sensitivity is low so that, if alone, they have little value in the diagnostic algorithm. The objective of this review is to analyze the existing scientific evidence on the usefulness of new technologies and endoscopic techniques in the identification of markers of villous atrophy in the diagnosis and follow-up of celiac disease. Method. A descriptive review of literature was conducted, where original articles were sought in Pubmed and LILACS databases in the period 2006-2016. Results. The value of digital chromoendoscopy for the search of endoscopic markers of villous atrophy has barely been studied. Sensitivity of NBI with magnification is estimated between 83 and 95%. The only studies with OBI and I-Scan showed perfect specificity and sensitivity, but only in patients with high probability of being celiac or with severe atrophy. Regarding endoscopic microscopy, endocytoscopy does not seem to improve performance in a significant way, however, with only two studies with a small number of patients, confocal laser endomicroscopy has shown greater sensitivity in the detection of atrophy markers. The VCE has high specificity (100%) but low sensitivity and its greatest utility is finding alterations that are beyond the scope of traditional endoscopy and assess its extent. There are no studies that specifically evaluate the presence of the same signs with double balloon enteroscopy, single balloon or spiral. Conclusions. Some of the new techniques and technologies appear to be highly specific but less sensitive in the detection of endoscopic markers of villous atrophy. More studies are needed to determine the value of endoscopic microscopy techniques as a diagnostic tool in the future.

Resumo: Desde o início das biópsias através de métodos endoscópicos para o diagnóstico de CD, uma tentativa foi feita para descrever diferentes marcadores macroscopicamente visíveis que sugerem ou confirmam a presença de atrofia vilosa na área estudada. Alguns desses sinais são altamente específicos, mas sua sensibilidade é baixa, por si só, eles têm pouco valor no algoritmo de diagnóstico. O objetivo desta revisão é analisar a evidência científica existente sobre a utilidade de novas tecnologias e técnicas endoscópicas na identificação de marcadores de atrofia vilosa no diagnóstico e monitoramento da doença celíaca. Método. Foi realizada uma revisão descritiva da literatura onde os artigos originais foram pesquisados ​​nas bases de dados Pubmed e LILACS no período 2006-2016. Resultados. O valor da cromoendoscopia digital para a busca de marcadores endoscópicos de atrofia vilosa foi mal estudado. A sensibilidade do NBI com ampliação é estimada entre 83 e 95%. O único trabalho com OBI e I-Scan mostrou especificidade e sensibilidade perfeita, mas apenas em pacientes com alta probabilidade de serem celíacos ou portadores de atrofia grave. Em relação à microscopia endoscópica, a endocitoscopia não parece melhorar o desempenho da endoscopia de forma significativa, no entanto, com apenas dois estudos com um número reduzido de pacientes, a endomicroscopia confocal laser mostrou maior sensibilidade na detecção de marcadores de atrofia. O VCE tem alta especificidade (95-100%), mas menor sensibilidade (89%) e sua maior utilidade é objetivar alterações que estão além do alcance da endoscopia tradicional e avaliam sua extensão. Não há estudos que avaliem especificamente sua presença com balão duplo, bola única ou enteroscopia espiral. Conclusões. Algumas das novas técnicas e tecnologias parecem ser altamente específicas, mas não muito sensíveis na detecção de marcadores endoscópicos de atrofia vilosa. Mais estudos são necessários para determinar o valor das técnicas de microscopia endoscópica como ferramenta de diagnóstico no futuro.

Consumo crónico de olmesartán como causa de enteropatía "sprue-like" / Chronic consumption of olmesartan as a cause of "sprue-like" enteropathy

La diarrea es un efecto secundario habitual a la toma de fármacos, y en algunas ocasiones la enteropatía perdedora de proteínas tipo "sprue like" puede estar detrás de esta patología. El estudio de esta enfermedad puede suponer un desafío importante para el clínico, sobre todo en los casos que cursan con serología negativa para enfermedad celiaca. La atrofia vellositaria duodenal secundaria a la ingesta de micofenolato-mofetil y metotrexate es bien conocida y descrita desde hace tiempo, pero desde la inclusión en la posológica habitual de olmesartán como antihipertensivo de primera elección hemos objetivado un repunte importante de esta entidad. Debido al amplio uso de esta medicación, queremos poner de manifiesto esta enteropatía iatrogénica a través de dos casos clínicos ocurridos en nuestro hospital en 2014.(AU()

Diarrhea is a common side effect of medical treatment. "Sprue like" enteropathy may be behind this pathology. The study of this disease can be an important clinical challenge, especially in those cases with negative serology for celiac disease. Duodenal villous atrophy secondary to the intake of mycophenolate mofetil and methotrexate have been well known and described but since the inclusion of olmesartán as a first-line antihypertensive, we have seen an important rebound of this entity. Due to the wide use of this medication we want to report this iatrogenic effect through two clinical cases that occurred in our hospital in 2014.(AU)

Enteropatia associada à Olmesartana / Olmesartan associated enteropathy

A enteropatia induzida por olmesartana é uma entidade reconhecida recentemente como diagnóstico diferencial de atrofia vilosa. A apresentação clínica é semelhante à doença celíaca, porém a não resposta à retirada do glúten e sorologia antitransglutaminase negativa são chaves para o diagnóstico diferencial. A fisiopatologia é incerta, havendo especulações quanto à predisposição genética e mecanismo de ação da própria droga. A melhora clínica e histológica após a suspensão da medicação é a principal característica. Aqui reportamos um caso de enteropatia induzida por olmesartana de apresentação clínica aguda.(AU)

The olmesartan induced enteropathy is a recently recognized entity in the differential diagnosis of villous atrophy. The clinical presentation is similar to celiac disease, but transglutaminase negative sorology and noimprovement after gluten removal are key to the differential diagnosis. The pathophysiology is uncertain, withspeculations about genetic predisposition and the medication's mechanism of action itself. The clinical and histological improvement after drug discontinuation is the main feature. Here we report a case of Olmesartaninduced enteropathy with acute clinical presentation.(AU)

Histopathological features of coeliac disease in a sample of Sudanese patients

Introduction: Coeliac disease can occur at any age but is more common in children. Its diagnosis requires correlation between clinical presentations, serological results, endoscopic findings and histopathological classification using the modified Marsh grading system. This study of coeliac disease with biopsies received in the department of histopathology at Soba University Hospital, and Fedail Hospital aimed to gain insight into the demographic profile, clinical presentations and histopathological classification of patients with coeliac disease. Methods: This was a descriptive study carried out at Soba University Hospital and Fedail Hospital during the period from January 2010-December 2013. Haematoxylin & Eosin and CD3-stained slides of small intestinal biopsies of coeliac disease patients were reviewed for various histological features (1) intraepithelial lymphocytes (IEL) count per 100 enterocytes, (2) crypt hyperplasia and (3) degree of villous atrophy. Based on the histopathological findings, the cases were categorized according to the modified Marsh classification. Demographic and clinical data were obtained from the patient request forms. The data were analyzed using Statistical Package for Social Sciences Software (SPSS). Results: The study included 60 patients. Their age ranged from 2 to 70 years with a mean of 19.5 years (±15.7 SD). The most common age group was below 10 years old (41.6%). Male and female are equally affected. The most common clinical presentation was chronic diarrhoea (55.0%), followed by iron deficiency anemia (41.7%). The degree of villous atrophy ranged from complete atrophy (45.0%), marked atrophy (38.3%) to mild atrophy (16.6%). Marsh grade IIIC was the most common grade. The younger age-groups had a higher prevalence of iron deficiency anaemia and higher Marsh grade.

Spectrum of chronic small bowel diarrhea with malabsorption in Indian subcontinent: is the trend really changing?

BACKGROUND/AIMS: This study aimed to document the recent etiological spectrum of chronic diarrhea with malabsorption and also to compare features that differentiate tropical sprue from parasitic infections, the two most common etiologies of malabsorption in the tropics. METHODS: We analyzed 203 consecutive patients with malabsorption. The etiological spectrum and factors that differentiated tropical sprue from parasitic infections were analyzed. RESULTS: The most common etiology was tropical sprue (n=98, 48.3%) followed by parasitic infections (n=25, 12.3%) and tuberculosis (n=22, 10.8%). Other causes were immunodeficiency (n=15, 7.3%; 12 with human immunodeficiency virus and 3 with hypogammaglobulinemia), celiac disease (n=11, 5.4%), Crohn's disease (n=11, 5.4%), small intestinal bacterial overgrowth (n=11, 5.4%), hyperthyroidism (n=4, 1.9%), diabetic diarrhea (n=4, 1.9%), systemic lupus erythematosus (n=3, 1.4%), metastatic carcinoid (n=1, 0.5%) and Burkitt's lymphoma (n=1, 0.5%). On multivariate analysis, features that best differentiated tropical sprue from parasitic infections were larger stool volume (P=0.009), severe weight loss (P=0.02), knuckle hyperpigmentation (P=0.008), low serum B12 levels (P=0.05), high mean corpuscular volume (P=0.003), reduced height or scalloping of the duodenal folds on endoscopy (P=0.003) and villous atrophy on histology (P=0.04). Presence of upper gastrointestinal (GI) symptoms like bloating, nausea and vomiting predicted parasitic infections (P=0.01). CONCLUSIONS: Tropical sprue and parasitic infections still dominate the spectrum of malabsorption in India. Severe symptoms and florid malabsorption indicate tropical sprue while the presence of upper GI symptoms indicates parasitic infections.

Enfermedad celíaca: revisión / Celiac disease: a review

La Enfermedad Celiaca (EC) tiene una prevalencia cercana al 1% de la población general y se considera que hay un número importante de pacientes asintomáticos no diagnosticados. Su presentación clínica es variable comprendiendo el clásico síndrome de malabsorción, formas menores y la EC silente. El diagnóstico serológico tiene una elevada sensibilidad y especificidad y siempre debe confirmarse con biopsia. El diagnóstico en pacientes en dieta libre de gluten incluye test de tipificación de HLA y prueba de dieta con gluten con estudio serológico e histológico posterior. El pilar del tratamiento es la dieta libre de gluten, que debe ser supervisada por un nutriólogo con experiencia. La monitorización de la terapia debe realizarse con serología. La EC mal controlada puede determinar complicaciones como linfoma y adenocarcinoma de intestino delgado. En el futuro es probable que nuevas terapias farmacológicas sean de utilidad en el manejo de la EC.

Celiac disease has a prevalence near to 1% of general population and there is an important amount of asymptomatic people not yet diagnosed. Clinical presentation includes the classical malabsorption syndrome, minor and silent celiac disease. Serologic diagnosis has an elevated sensitivity and specificity, and must be confirmed by biopsy. Diagnosis in those on gluten free diet includes HLA type and gluten challenge with posterior serologic and histologic evaluation. The core of the treatment is the gluten free diet that must be supervised by an expert nutritionist. Monitoring is with serology. Poor disease control can determine complications such as lymphoma and small bowel adenocarcinoma. In the future, it is likely that new pharmacologic therapies will be available for the management of celiac disease.

Patrón clínico y sensibilidad de la serología frente a la histología en niños celiacos HLA DQ2/DQ8 / PATTERNS IN CLINICAL PRESENTATIONS, SEROLOGY SENSITIVITY IN FRONT OF HISTOLOGY IN THE CHILDREN CELIACS HLA DQ2/DQ8

Introducción: En áreas tropicales donde el diagnóstico diferencial para enfermedad celíaca está presente, la determinación de HLA DQ2/DQ8 es útil para confirmar la existencia de la enfermedad en pacientes sintomáticos o no con serología negativa y lesión mucosal o anticuerpo positivo y mucosa nor- mal, con la limitante del costo elevado. Objetivo: conocer el patrón clínico en niños celiacos con determinación HLA DQ2/DQ8 e investigar la sensibilidad de la serología frente a la histología en el despistaje diagnóstico de la enfermedad. Pacientes y método: estudio prospectivo y transversal, que incluyo 18 niños celíacos con determinación de DQ2/DQ8. Se registró: edad, sexo, clínica, serología, biopsia y genética. Resultados: edad promedio 3,39 años (8meses-13 años),55,55% hembras. Patrón clínico clásico en 12/18 (66,67%), atípico 3/18 (16,67%), latente 2/18 (11,11%), potencial 1/18 (5,55%). En total 12/18 pacientes (66,67%) con serolo- gía positiva. A la histología: 2/18 mucosa normal (11,11%) y 16/18 alterada (88,89%), de ellos, 4 Marsh I, 5 Marsh II, 7 Marsh III. En todos los niños con serología positiva se observo lesión intestinal, 25% con atrofia de vellosidades. Con serología negativa, 4 con atrofia vellositaria (2/4 con déficit de Ig A) y 2 mucosa normal. Se encontró una sensibilidad de la serología para el diagnóstico en 75%, specificidad 100%. Exactitud diagnóstica en 77,77% de la serología frente a la histología. Conclusiones: la serología resulto con una sensibilidad aceptable para el despistaje diagnóstico de celíaca y la determinación de HLA DQ2/DQ8 fue de utilidad en la caracterización del patrón clínico y la detección de la enfer- medad un grupo de pacientes.

Introduction: In tropical areas where the differential diag- nosis for celiac disease is present, the determination of HLA DQ2/DQ8 is useful to confirm the existence of the disease in symptomatic patients or HIV negative and positive mucosal injury and mucosal antibody or normal with limiting the high cost. Objective: To determine the clinical pattern in celiac children with HLA determination DQ2/DQ8 and investigate the sensitivity of the serology screening histology in the diagnosis of disease. Patients and methods: Prospective, cross-sectional, which included 18 children with celiac DQ2/ DQ8 determination. Was recorded: age, sex, clinical, sero- logy, biopsy and genetics. Results: mean age 3.39 years (8m-13), 55.55% females. Classic clinical pattern in 12/18 (66.67%), atypical 3/18 (16.67%), latent 2/18 (11.11%), potential 1/18 (5.55%). In total 12/18 patients (66.67%) with positive serology. A histology: 2/18 normal mucosa (11.11%) and 16/18 altered (88.89%), of whom 4 Marsh I, 5 Marsh II, 7 Marsh III. In all children with positive serology bowel injury was observed, 25% villus atrophy. With negative serology, 4 with villous atrophy (2/4 with IgA deficiency) and 2 normal mucosa. We found a sensitivity of serology for diagnosis in 75%, specificity 100%. 77.77% diagnostic accuracy of serology against histology. Conclusions: resulted serology with acceptable sensitivity for the screening and diagnosis of celiac HLA determining DQ2/DQ8 was useful in characterizing the clinical pattern and disease detection a group of patients in characterizing the clinical pattern and detection of the disease a group of patients.

A series on intestinal strongyloidiasis in immunocompetent and immunocompromised hosts.

Background: Strongyloidiasis, endemic in tropical areas, may be asymptomatic in immunocompetent subjects or may cause potentially fatal hyper-infection in immunocompromised patients. Methods: Of the 13,885 patients referred to the parasitology laboratory at our tertiary care referral center for stool microscopy, 15 were diagnosed as strongyloidiasis over a 6 year period. We assessed these patients retrospectively. Results: Most patients were young (median age 32 years, range 3-66) males (12, 80%). Seven patients (46.6%) were immunocompromised. All patients were symptomatic, and symptoms included chronic diarrhea (4, 26.7%), acute diarrhea (1, 6.7%), abdominal pain (6, 40%), weight loss (3, 20%), cough (2, 13.33%), vomiting (1, 6.7%), anemia (10, 66.7%) and eosinophilia (3, 20%). Thirteen patients (86.6%) were diagnosed on first stool microscopy. Duodenal biopsy showed normal histology in twelve (80%) and partial villous atrophy in one (6.7%) patient. Stool microscopy also revealed giardiasis and cryptosporidiosis in one patient each. Nine patients responded well to ivermectin and albendazole, one died and five were lost to followup. Conclusions: In endemic areas, even immunocompetent subjects may suffer from symptomatic strongyloidiasis and associated eosinophilia is uncommon.

Current spectrum of malabsorption syndrome in adults in India.

Aim Tropical sprue was considered to be the most important cause of malabsorption in adults in India. However, several reports indicate that celiac disease is now recognized more frequently. Methods We analyzed the clinical presentation, endoscopic and histological features of 94 consecutive patients (age >12 years) with chronic diarrhea and malabsorption syndrome. The spectrum of disease in these patients and features differentiating celiac disease and tropical sprue are reported here. Results Celiac disease (n=61, 65%) was the most common cause of malabsorption followed by tropical sprue (21, 22%). Other conditions including cyclosporiasis (3), Crohn’s disease (2), common variable immunodeficiency (2), lymphangiectasia (1), William’s syndrome (1), and idiopathic malabsorption (3) accounted for the remainder. A greater number (21, 34%) of patients with celiac disease than those with tropical sprue (4, 19%) presented with atypical manifestations. Patients with celiac disease were younger (p=0.001), more often had anemia, (p=0.001), scalloping of folds (p=0.001), moderate (p=0.02) or severe (p=0.001) villous atrophy, higher grade of intraepithelial lymphocytic infiltration (p=0.001), crypt hyperplasia (p=0.001), cuboidal (p=0.001) and pseudostratified (p=0.009) surface epithelial cells, and diffuse (p=0.001) epithelial damage. In comparison, patients with tropical sprue were older and more often had normal duodenal folds, normal villi, tall columnar epithelial cells and focal epithelial damage. Conclusions Celiac disease was the most frequent cause of malabsorption syndrome in this series of patients. There are significant clinical and histological differences between celiac disease and tropical sprue.

A Case of Protein-losing Enteropathy Associated with Small Bowel Villous Atrophy / 대한소화기학회지

Protein losing enteropathy is described as a diverse group of disorders associated with excessive loss of serum proteins into the gastrointestinal (GI) tract. The etiology of protein losing enteropathy is various. Increased mucosal permeability to protein as a result of cell damage, mucosal erosion, or lymphatic obstruction may develop protein losing enteropathy. Celiac disease is a common cause of protein losing enteropathy associated with small bowel villous atrophy in Europe. We experienced a case of protein losing enteropathy associated with small bowel villous atrophy of unknown origin. A 36-year-old woman was admitted due to chronic watery diarrhea and weight loss. Laboratory findings showed total protein 4.7 g/dL, albumin 2.7 g/dL, cholesterol 100 mg/dL, WBC 6,000/mm(3) (lymphocyte 13.6%) with the absence of proteinuria. On esophagogastroduodenoscopic examination, duodenal ulcer scar was noted on the bulb and colonoscopic finding was nonspecific. On small bowel enteroscopy, jejunal and ileal villi was scantly noticed. Small bowel biopsy showed marked villous atrophy. Her symptoms did not improve after supportive care. Gluten free diet was tried because celiac disease could not be ruled out completely. Diarrhea ceased and body weight regained after gluten free diet.