¿La detección de toxinas de Clostridioides difficile es necesaria cuando se detecta la enzima glutamato deshidrogenasa? / Is Clostridioides difficile toxins detection necessary when the glutamate dehydrogenase enzyme is detected?

Resumen Introducción: Clostridioides difficile causa diarrea y colitis pseudomembranosa. Su diagnóstico se realiza con la detección de glutamato-deshidrogenasa (GDH) o las toxinas A y B y se confirma con pruebas de amplificación de ácidos nucleicos. Objetivo: Definir si la determinación de GDH es redundante a la de las toxinas. Métodos: Estudio observacional retrospectivo de muestras fecales de pacientes con sospecha de infección por Clostridioides difficile. Las toxinas y GDH se determinaron mediante inmunocromatografía. Se realizó una simulación bayesiana con los cocientes de probabilidad; se consideró significativo un valor de p < 0.05. Resultados: Se analizaron 329 resultados de GDH y toxinas A y B. Se encontró una prevalencia de infección de Clostridioides difficile de 18.2 %. La sensibilidad y especificidad de la prueba de GDH fue de 0.90 y 0.89, respectivamente. El cociente de probabilidad positivo fue de 8.9 y el negativo, de 0.11. Conclusiones: Un resultado negativo de GDH disminuye considerablemente la probabilidad de infección, pero no la descarta. La detección de toxinas de Clostridioides difficile puede ser necesaria en instituciones donde la amplificación de ácidos nucleicos no es económica o accesible.

Abstract Introduction: Clostridioides difficile causes diarrhea and pseudomembranous colitis. Its diagnosis is made with glutamate dehydrogenase (GDH) or toxins A and B detection and is confirmed with nucleic acid amplification tests. Objective: To define if GDH determination is redundant to that of toxins. Methods: Retrospective, observational study in diarrheal stools of patients with suspected Clostridioides difficile infection. Toxins and GDH were determined by immunochromatography. Bayesian simulation was performed with likelihood ratios; a p-value < 0.05 was regarded as significant. Results: 329 GDH and toxin A and B results were analyzed. Clostridioides difficile infection prevalence was 18.2 %. Sensitivity and specificity of the GDH test were 0.90 and 0.89, respectively. Positive likelihood ratio was 8.9, and negative was 0.11. Conclusions: A negative GDH result considerably reduces the probability of infection but does not rule it out. Clostridioides difficile toxins detection may be necessary in institutions where nucleic acid amplification is not affordable or accessible.

Clinical Significance of Fecal Lactoferrin and Multiplex Polymerase Chain Reaction in Patients with Acute Diarrhea

BACKGROUND/AIMS: The diagnostic yield of fecal leukocyte and stool cultures is unsatisfactory in patients with acute diarrhea. This study was performed to evaluate the clinical significance of the fecal lactoferrin test and fecal multiplex polymerase chain reaction (PCR) in patients with acute diarrhea. METHODS: Clinical parameters and laboratory findings, including fecal leukocytes, fecal lactoferrin, stool cultures and stool multiplex PCR for bacteria and viruses, were evaluated prospectively for patients who were hospitalized due to acute diarrhea. RESULTS: A total of 54 patients were included (male, 23; median age, 42.5 years). Fecal leukocytes and fecal lactoferrin were positive in 33 (61.1%) and 14 (25.4%) patients, respectively. Among the 31 patients who were available for fecal pathogen evaluation, fecal multiplex PCR detected bacterial pathogens in 21 patients, whereas conventional stool cultures were positive in only one patient (67.7% vs 3.2%, p=0.000). Positive fecal lactoferrin was associated with presence of moderate to severe dehydration and detection of bacterial pathogens by multiplex PCR (21.4% vs 2.5%, p=0.049; 100% vs 56.5%, p=0.032, respectively). CONCLUSIONS: Fecal lactoferrin is a useful marker for more severe dehydration and bacterial etiology in patients with acute diarrhea. Fecal multiplex PCR can detect more causative organisms than conventional stool cultures in patients with acute diarrhea.

The Usefulness of a Novel Screening Kit for Colorectal Cancer Using the Immunochromatographic Fecal Tumor M2 Pyruvate Kinase Test

BACKGROUND/AIMS: M2 pyruvate kinase (M2-PK) is an enzyme that is produced in undifferentiated and proliferating tissues. This study aims to evaluate the usefulness of the immunochromatographic M2 pyruvate kinase (iM2-PK) for the screening of colorectal cancer (CRC) and premalignant lesions. METHODS: Healthy volunteers and patients with colorectal neoplasia were enrolled in six academic hospitals in the capital province of Korea. The iM2-PK value was compared with the immunochromatographic fecal occult blood test (iFOBT) and fecal tumor M2-PK enzyme-linked immunosorbent assay (ELISA). RESULTS: A total of 323 subjects were enrolled. The sensitivity of iM2-PK for CRC was 92.8%, which was superior to iFOBT (47.5%, p<0.0001). For adenomatous lesions, the sensitivity of iM2-PK was 69.4%, which was also superior to iFOBT (12.1%, p<0.001). Compared with M2-PK ELISA, iM2-PK exhibited significantly enhanced sensitivity for CRC (97.5% vs 80.0%, p=0.0289). The sensitivity of iM2-PK was higher in advanced stages of CRC compared with cancers confined to the mucosa and submucosa (p<0.05). However, lymph node metastasis had no influence on the sensitivity of iM2-PK. CONCLUSIONS: The iM2-PK exhibited increased sensitivity for identifying CRC and adenomatous lesions compared with iFOBT. Given its rapid results and convenience, CRC screening using iM2-PK is promising.

Utilidade da concentração da elastase-1 fecal monoclonal na avaliação da função pancreática nos pacientes com fibrose cística / Use of monoclonal faecal elastase-1 concentration for pancreatic status assessment in cystic fibrosis patients

OBJETIVO: Avaliar a concentração da elastase-1 (EL-1) fecal em pacientes pediátricos com fibrose cística, portadores da mutação ∆F508. MÉTODOS: Estudo transversal com amostras colhidas consecutivamente de 51 pacientes com idade entre 4 meses e 17 anos (média 9,11±4,74), sendo 32 (62,8 por cento) pacientes do sexo masculino. Houve coleta de dados clínico-demográficos e do tipo de mutação. A insuficiência pancreática exócrina foi definida pela atividade da EL-1 fecal < 200 µg/g. A quantificação da EL-1 foi realizada pelo método ELISA monoclonal (ScheBo Biotech AG, Germany). A suplementação pancreática foi utilizada em 46 (90,2 por cento) pacientes. RESULTADOS: Quarenta e um (80,4 por cento) pacientes apresentaram insuficiência pancreática (EL-1 fecal < 100 µg/g), sendo 17 (41,5 por cento) homozigotos, 14 heterozigotos (34,1 por cento) e 10 sem ∆F508 (24,4 por cento). Ao considerar a mutação, houve associação estatisticamente significativa entre os homozigotos e a concentração da EL-1 fecal < 100 µg/g (p = 0,010). Todos os pacientes considerados insuficientes pancreáticos (n = 41) pelo teste utilizavam suplemento pancreático. Dez (19,6 por cento) apresentaram EL-1 fecal > 200 µg/g, e 5/10 (50 por cento) utilizavam enzimas. CONCLUSÕES: A atividade de EL-1 fecal < 100 µg/g, indicativa de insuficiência pancreática, apresentou-se em 17/17 (100 por cento) dos homozigotos, conforme o esperado, sendo menos frequente nos heterozigotos para ∆F508 e nos pacientes com ausência dessa mutação. Não houve relação entre a concentração da EL-1 fecal com idade e sexo dos pacientes. O teste foi padronizado, é de fácil execução e poderá ser utilizado para avaliação da função pancreática dos pacientes com fibrose cística.

OBJECTIVE: To assess the concentration of faecal elastase-1 (EL-1) in pediatric patients with cystic fibrosis with mutation ∆F508. METHODS: Cross-sectional study with samples collected consecutively from 51 patients aged 4 months to 17 years old (mean 9.11±4.74); 32 (62.8 percent) patients were male. Clinical-demographic data were collected, as well as data on the type of mutation. Exocrine pancreatic insufficiency was established by the activity of faecal EL-1 < 200 µg/g. EL-1 was quantified through the monoclonal ELISA method (ScheBo Biotech AG, Germany). Pancreatic supplements were used in 46 (90.2 percent) patients. RESULTS: Forty-one (80.4 percent) patients presented with pancreatic insufficiency (EL-1 fecal < 100 µg/g): 17 (41.5 percent) were homozygous, 14 were heterozygous (34.1 percent) and 10 were non-∆F508 (24.4 percent). Regarding the mutation, there was a statistically significant association of homozygosity with faecal EL-1 concentration < 100 µg/g (p = 0.010). All patients considered to be pancreatic insufficient (n = 41) by the test were using pancreatic supplements. Ten (19.6 percent) presented faecal EL-1 > 200 µg/g, and 5/10 (50 percent) used enzymes. CONCLUSIONS: The activity of faecal EL-1 < 100 µg/g, indicating pancreatic insufficiency, was observed in 17/17 (100 percent) of homozygous patients, as expected, and was less frequent in patients who were heterozygous for ∆F508 and in patients without the mutation. There was no association of faecal EL-1 concentration with age and sex of patients. The test was standardized, is easy to execute, and can be used to assess the pancreatic status of patients with cystic fibrosis.

Diagnosis of Irritable Bowel Syndrome: a Systematic Review / 대한소화기학회지

Irritable bowel syndrome (IBS) is a very common functional gastrointestinal disorder characterized by abdominal discomfort, bloating, and disturbed defecation. Patients with IBS have a tendency to visit physicians more frequently than those without IBS, thus annual economic consequences of IBS in the Western countries are substantial. Therefore, guidelines for the diagnosis and treatment of IBS patients have been designed to give a favored effect on the Department of Gastroenterology's overall performance. A variety of criteria have been developed to identify a combination of symptoms to diagnose IBS, including Manning and Rome I, II, and III criteria. Overall, Manning's criteria had a pooled sensitivity and specificity, 78% and 72%, respectively. In addition, the Rome I criteria had a sensitivity and specificity, 71% and 85%, respectively. However, none described the accuracy of Rome II and III yet. Alarm features such as rectal bleeding and nocturnal pain offer little discriminative value in separating patients with IBS from those with organic diseases. Even though anemia and weight loss have poor sensitivity for organic diseases, they offer very good specificity. Since specific biomarker of IBS is not yet available, diagnostic tests are frequently performed to exclude organic diseases. However, the accuracy of diagnostic tests is disappointing. CBC, chemistry, thyroid function test, stool exam, ultrasonography, hydrogen breath test, erythrocyte sedimentation rate, and C-reactive protein have all very limited accuracy in discriminating IBS from organic diseases. This systemic review is targeted to establish the strategy of IBS treatment, which is very necessary for the current clinical practice.

Diagnosis of Irritable Bowel Syndrome: a Systematic Review / 대한소화기학회지

Irritable bowel syndrome (IBS) is a very common functional gastrointestinal disorder characterized by abdominal discomfort, bloating, and disturbed defecation. Patients with IBS have a tendency to visit physicians more frequently than those without IBS, thus annual economic consequences of IBS in the Western countries are substantial. Therefore, guidelines for the diagnosis and treatment of IBS patients have been designed to give a favored effect on the Department of Gastroenterology's overall performance. A variety of criteria have been developed to identify a combination of symptoms to diagnose IBS, including Manning and Rome I, II, and III criteria. Overall, Manning's criteria had a pooled sensitivity and specificity, 78% and 72%, respectively. In addition, the Rome I criteria had a sensitivity and specificity, 71% and 85%, respectively. However, none described the accuracy of Rome II and III yet. Alarm features such as rectal bleeding and nocturnal pain offer little discriminative value in separating patients with IBS from those with organic diseases. Even though anemia and weight loss have poor sensitivity for organic diseases, they offer very good specificity. Since specific biomarker of IBS is not yet available, diagnostic tests are frequently performed to exclude organic diseases. However, the accuracy of diagnostic tests is disappointing. CBC, chemistry, thyroid function test, stool exam, ultrasonography, hydrogen breath test, erythrocyte sedimentation rate, and C-reactive protein have all very limited accuracy in discriminating IBS from organic diseases. This systemic review is targeted to establish the strategy of IBS treatment, which is very necessary for the current clinical practice.

Diferenciação entre Entamoeba histolytica e Entamoeba dispar por meio de ensaio imunoenzimático para pesquisa de antígenos em amostras fecais / Differentiation between Entamoeba histolytica and Entamoeba dispar by means of immunoenzymatic assay for antigens detection in children fecal samples

A diferenciação do agente patogênico causador de amebíase obteve grande importância desde que Entamoeba histolytica (patogênica) foi considerada como espécie distinta de Entamoeba dispar (não patogênica). No presente estudo, foi realizada a pesquisa de antígenos de E. histolytica em amostras fecais de crianças residentes na cidade de São Leopoldo, Rio Grande do Sul, Brasil, utilizando-se ensaio imunoenzimático, ELISA (E. histolytica Test, TechLab Inc., Blacksburg, EUA) disponível no comércio. Foram analisadas 262 amostras de fezes pela técnica de Hoffman, Pons e Janer (HPJ), em que três amostras apresentaram positividade para o complexo E. histolytica/E. dispar. Do total de amostras, 91 (incluindo aquelas positivas pela técnica de HPJ) foram analisadas por meio de ELISA. Houve discordância entre os resultados obtidos no exame coproparasitológico e no ELISA, pois todas amostras foram não reagentes no ELISA. Estes dados indicam a presença de E. dispar e ausência de E. histolytica nas três amostras positivas pela técnica de HPJ. Os dados do presente estudo mostram a importância de utilização de técnica mais específica para efetuar identificação e diferenciação da amebíase intestinal.

Función pancreática exocrina en diabetes mellitus: Determinación de elastasa fecal / Pancreatic exocrine function in diabetes mellitus: Determination of fecal elastase

Background: One of the complications of diabetes mellitus is the development of pancreatic exocrine insufficiency. Aim: To study pancreatic exocrine function in diabetics patients. Material and methods: Seventy two diabetic patients were included in the protocol, but two were withdrawn because an abdominal CAT scan showed a chronic calcified pancreatitis, previously undiagnosed. Fecal elastase was measured by ELISA and the presence of fat in feces was assessed using the steatocrit. Results: Mean age was 60±12 years and 67 (96%) patients had a type 2 diabetes. Fecal elastase was normal (elastase >200 µg/g) in 47 (67%) patients, mildly decreased (100-200 µg/g) in 10 (14%) and severely decreased in 13 (19%). There was a significant association between elastase levels and time of evolution of diabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit (p=0.042). No significant association was found between elastase levels and other chronic complications of diabetes such as retinopathy, nephropathy, neuropathy, microangiopathy or with insulin requirement. Conclusions: One third of this group of diabetic patients had decreased levels of fecal elastase, that was associated with the time of evolution of diabetes. Patients with lower levels of elastase have significantly more steatorrhea. Among diabetics it is possible to find a group of patients with non diagnosed chronic pancreatitis.

Diaper dermatitis--an overview.

Diaper dermatitis, also know as nappy rash, is an inflammation of the skin covered by nappy. It probably results due to an interaction of multiple factors like increased wetness, elevated pH due to urine, fecal enzymes and microorganisms under the nappy. It manifests as an erythematous rash occurring on the convex surfaces of skin under the nappy. Rashes resembling nappy dermatitis can also be caused by some diseases which may have serious systemic manifestations. Therefore it is essential to differentiate and treat them. The principle of treatment of diaper dermatitis is to keep the skin in the nappy area as dry as possible with frequent nappy change. The superabsorbent disposable diapers are known to reduce the incidence of diaper dermatitis. Barrier creams to protect the infant's skin and mild topical corticosteroids to reduce the inflammation are mainstays of therapy. The incidence and severity can be reduced by keeping the skin dry under the nappy and protected from irritants and infections.

Cuantificación de neutrófilos fecales mediante la determinacián de MPO (Mieloperoxidasa) en pacientes con diarrea invasiva / Quantify of fecal neutrophils by MPO (myeloperoxidase) determination in patients with invasive diarrhea

La mieloperoxidasa (MPO) es una enzima especifíca de los polimorfonucleares neutrófilos, la cual ha sido previamente usada para cuantificar elmnúmero de neutrófilos en tejidos, desde que su actividad se correlaciona linealmente con el número de neutrófilos. Con el objetivo de demostrar la presencia y realizar la cuantificación de leucocitos en materia fecal la MPO se disolvió en Bromuro de hexadeciltrimetilamonio y la actividad fue medida usando un ensayo de H2O2O-dianosid-ina. Se midió la actividad de MPO en 39 pacientes con diarrea producida por bacterias enteropatógenas y en 10 sujetos control. La presencia de leucocitos fue también determinada mediante la observación microscópica usando azul de metileno. La actividad de MPO fue positiva en 36 (92 por ciento) de los pacientes y la observació microscópica resultó positiva en 30 (77 por ciento). En los sujetos control la actividad de MPO fue indetectable y no se encontraron leucocitos en material fecal. En los pacientes la actividad de MPO en materia fecal tuvo un recuento de 1.6 a 2830 x 10(3) UMPO por gramo de heces (mediana: 46.0). El número de neutrófilos obtenido a través de la actividad de MPO tuvo un recuento de 6 a 13216.0 x mm(3) (mediana: 1261.0), la actividad fecal de MPO es una determinación bioquímica simple para la detección y cuantificación de leucocitos en materia fecal.

Recién nacido con íleo meconial / Newborns with meconium ileus

Introducción: El íleo meconial es una forma grave de obstrucción intestinal del recién nacido, caracterizado por la presencia de meconio anormalmente espeso que ocluye el íleon terminal. Puede ser una forma de presentación de la fibrosis quística pancreática en el período neonatal. En este trabajo se analizaron las características clínicas, el tratamiento y la evolución de los RN con íleo meconial. Resultados: Durante un período de 6 años se diagnostico íleo meconial en 17 recién nacidos. El 41 por ciento (n:7) presentó íleo meconial complicado. En 15 pacientes (88 por ciento) el tratamiento fue quirúrgico. El 82 por ciento de los niños recibió nutrición parenteral total y la alimentación enteral se inició en promedio al 9º día posquirúrgico. En 6 pacientes se confirmó el diagnóstico de enfermedad fibroquística y en 6 se descartó dicha entidad mediante la búsqueda de mutaciones genéticas y/o prueba del sudor. La sobrevida al alta fue del 88 por ciento y permanecieron en seguimiento 12 pacientes (un paciente con fibrosis quística falleció a los 6 meses de vida por complicaciones respiratorias y nutricionales). Los pacientes con íleo meconial que no padecen enfermedad fibroquística presentaron una evolución favorable a diferencia de aquellos en los que se asocia dicha enfermedad. En estos últimos las complicaciones respiratorias y nutricionales fueron precoces y severas

Clearance fecal de Ó1 antitripsina: valores normales en niños de la ciudad de Córdoba / Faecal clearence of the Ó1-antitrypsin: values normal in children of the Cordoba city

En las enteropatías perdedoras de proteínas (EPP) el incremento de la permeabilidad de las paredes del TGI causa exudación proteica superior a la normal que se manifiesta por elevada excreción proteica fecal. El estudio del turnover metabólico, mediante la inyección intravenosa de proteínas marcadas con radioisótopos del yodo, provee información sobre el metabolismo proteico, pero no es útil para medir pérdida proteica gastrointestinal pues el yodo libre atraviesa con facilidad la mucosa gástrica en ambos sentidos, lo que conduce a una valoración errónea de la excreción proteíca en la materia fecal (MF). La albúmina marcada con 51Cr permite valorar la pérdida proteíca gastrointestinal caracterizada por un patron de pérdida al bulto. Los mencionados son metodos de referencia, invasores, costosos y su empleo está reglamentado por la legislación especial pues es material radioactivo. El clearance fecal de Ó1 antitripsina es inocuo y accesible a laboratorios clínicos y posee eficacia clínica probada para valorar la excreción proteica gastrointestinal. Se ha implementado la metodología y establecido valores normales de referencia para la población infantil de la ciudad de Córdoba. La muestra estuvo conformoda por 30 niños clínicamente sanos de ambos sexos, cuyas edades estuvieron comprendidas entre los 14 y 120 meses; en el protocolo de estudio de identificación se registró la edad, sexo y análisis de laboratorio. La determinación de Ó1AT sérica y fecal se realizó por inmunodifusión radial simple (IDRS). En las enteropatías puede ocurrir malabsorción proteíca, causante de hipoalbuminemia, o pérdida proteica gastrointestinal (en enteropatías exudativas), la cual afecta las fracciones albúmina y globulinas. El clearance fecal de Ó1AT indica los mililitros de plasma depurados en 24 horas por el tracto gastrointestinal y provee orientación diagnóstica útil para el uso clínico de rutina. Los valores de referencia hallados en la población infantil de Córdoba son: -clearance fecal de Ó1AT= desde no determinable hasta 10.8ml/24h; -concentración de Ó1AT sérica = 118 a 396mg por ciento

Faecal chymotrypsin assay in tropical and alcoholic chronic pancreatitis.

Faecal chymotrypsin (FCT) levels were estimated in a group of patients with tropical chronic pancreatitis (TCP) and compared with patients with alcoholic chronic pancreatitis (ACP), 'gastrointestinal' controls and 'healthy' subjects. Exocrine pancreatic insufficiency as assessed by low faecal chymotrypsin levels (less than 5.8 mu/g) were present in 85.7 per cent of TPC and 84.6 per cent of ACP patients. Mean FCT levels as well as the distribution of FCT values were similar in TCP and ACP patients and significantly lower than the two control groups (P less than 0.001). There was also no difference with respect to mean FCT levels between subgroups of TCP patients with and without diabetes and those with and without calcification. Faecal chymotrypsin assay is a simple test for diagnosis of chronic pancreatitis in gastroenterological centres in tropical countries.