Coeliac disease in patients with short stature: A tertiary care centre experience.

Background. We aimed to determine the prevalence of coeliac disease among children with short stature at a tertiary care centre and to define the predictors for coeliac disease, if any, in them. Methods. In this retrospective study, we reviewed the case records of children and adolescents with growth retardation attending the Paediatric Endocrinology Clinic from January 2008 to June 2011. All patients underwent the multi-tier stratified diagnostic protocol for complete evaluation of short stature. Coeliac disease was screened using IgA-anti-tissue transglutaminase antibody. The diagnosis of coeliac disease was made on the basis of the modified European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) criteria. Results. Of 432 patients (238 boys) who presented with short stature, 72 (16.7%) had physiological, while 360 (83.3%) had pathological causes. Endocrine causes were growth hormone deficiency (86 patients, 19.9%), hypopituitarism (31, 7.2%), hypothyroidism (22, 5.1%) and others (7, 1.6%). The systemic causes were: coeliac disease (47, 10.9%), haematological diseases (14, 3.2%), renal diseases (11, 2.5%) and others (24, 5.6%). Chronic diarrhoea (OR 15.7, 95% CI 7.8–31.5) and anaemia (OR 4.9, 95% CI 1.9–12.7]) were significant predictors for coeliac disease in patients with short stature. There was a definite response to gluten-free diet in them and the mean (SD) growth velocity measured over at least 6 months of gluten-free diet was 8.1 (3.0) cm/year. Conclusion. Nearly 11% of patients presenting with short stature have coeliac disease. In these patients chronic diarrhoea and anaemia were significant predictors of coeliac disease.

Evaluation of lactose and milk intolerance, and bone mineral density in Indian patients with inflammatory bowel disease.

Background. A misconception that milk and lactose intolerance increases disease activity in inflammatory bowel disease leads to the exclusion of dietary dairy products, and patients are at an increased risk of low bone mineral density. Methods. Patients with inflammatory bowel disease (n=45, 19 men and 26 women) and healthy controls were included in this prospective open-label study. As part of exploratory dietary intervention, patients were advised to exclude milk and milk products from diet for the first 7 days and reintroduce at least 250 ml of milk for the next 21 days. Milk and lactose intolerance was assessed in patients and healthy subjects using clinical symptoms and lactose hydrogen breath test, respectively; bone mineral density was assessed in patients using a Hologic QDR 4500A DXA machine. Results. Milk and lactose intolerance was statistically comparable in patients with inflammatory bowel disease (31% and 44%, respectively) and healthy subjects (22% and 27%, respectively). Most of the patients (40%) had excluded dairy products from their diet, and 53% had dietary intake of calcium <200 mg/day. More than 60% of the patients had either osteopenia or osteoporosis. Conclusion. Milk and lactose intolerance in patients with inflammatory bowel disease was not different from that in healthy subjects. The proportion of patients with osteoporosis and osteopenia was high in this population. Hence, patients with inflammatory bowel disease in remission phase may be encouraged to add dairy products in their diet, unless otherwise indicated.

Body composition in Indian patients with Crohn’s disease during active and remission phase.

Background: The alterations in the body composition (BC) in both the active and remission phase of Crohn’s disease (CD) are poorly characterized. Objective: To assess the BC of the patients with CD in active and remission phase, and compare with healthy controls (HC). Methods: BC was assessed by bioelectrical impedance analysis using Tanita TBF-215 leg to leg portable impedance analyzer in 123 patients with CD and 100 matched HC. Diet intake was assessed by 24 hours diet recall method. Results: The mean age of patients was 36.4+12.6 years and 56% were males. Patients in active phase as well as in remission phase had a lower BMI than HC (18.8+3.6 vs. 23.9+4.0; p=0.001 and 18.8+3.6 vs. 21.6+5.0; p=0.002). The fat mass (FM) in active phase was significantly lower than that in remission phase (8.2+5.9 vs. 13.4+10.6 kg; p=0.005) and HC (8.2+5.9 kg vs. 14.1+7.5 kg; p=0.001). FM did not differ between remission phase and HC. The fat free mass (FFM) of HC was significantly higher than that of both remission phase (48.9+7.4 kg vs. 43.3+10.4 kg; p=0.001) and active phase (48.9+7.4 kg vs. 40.7+8.5 kg; p=0.001). There was no difference in the FFM of patients in both phases; p=0.356. The intake of macronutrients was comparable between the two phases; however lower than that of HC. Conclusion: Both FM and FFM were depleted in the active phase, while only FFM was deficient in the remission phase of CD, indicating a poor recovery of lean mass in remission.

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.

Clostridium difficile associated diarrhea: new rules for an old game.

C.difficile associated diarrhea (CDAD) is now considered to be one of the commonest causes of nosocomial diarrhea. CDAD, once considered to be a “nuisance” disease, has lately become a “killer” disease with appearance of a hypervirulent strain, toxinotype III. Although the incidence and severity of CDAD have increased in the western world especially in health care settings; it still is under-recognized in India and Asia. Any episode of diarrhea with fever and leucocytosis in a patient on some antibiotics in a health care setting is strong pointer towards presence of CDAD. Clinical suspicion is usually confirmed by ELISA based C. difficile toxin assays in the stool sample. The aim of therapy is to restore normal colonic microflora, resulting in the elimination of C. difficile. Treatment of C.difficile needs to be individualized depending on the severity of the disease and patient characteristics. Majority of patients will require antibiotic therapy and, whenever possible, discontinuation of the predisposing antibiotics. Metronidazole and vancomycin are the mainstay of the treatment of CDAD, as both these agents are highly active against all strains of pathogenic C.difficile. Neither of these drugs is however effective for the carrier state of C. difficile. Approximately 15%-30% of patients experience a symptomatic recurrence after discontinuation of antibiotics. Control of health care associated CDAD involves a range of primarily preventive measures including proper hand hygiene, use of personal protective equipment, environmental decontamination, isolation or cohort nursing and adequate treatment of CDAD cases.

Evaluation of risk factors for antituberculosis treatment induced hepatotoxicity.

Background & objectives: Antituberculosis (anti-TB) drug induced hepatotoxicity (DIH) is the most common side effect leading to interruption of therapy. Wide variations have been found in the reported incidence of hepatotoxicity during short-course chemotherapy. Several risk factors for hepatotoxicity have been suggested in previous studies. We undertook a prospective case-control study to assess the role of these putative risk factors in the development of DIH in patients receiving anti-TB treatment. Methods: One hundred and seventy five consecutive cases with a diagnosis of anti-TB DIH were compared with 428 consecutive controls who took anti-TB drugs for the full duration of chemotherapy without clinical or biochemical evidence of hepatitis. Cases positive for markers of acute viral hepatitis were carefully excluded. Cases and controls were compared with respect to age, sex, site of tuberculosis, radiological extent of disease on chest radiograph, body mass index (BMI), mid-arm circumference (MAC) and liver function at baseline which included serum bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), serum total protein and serum albumin. Results: Univariate logistic regression revealed that the risk of developing DIH was greater in older patients. Significantly greater percentage of cases had extrapulmonary tuberculosis (TB) (P<0.01). Also, a significantly higher percentage of cases had moderate to far advanced disease severity on chest radiograph (P<0.01). On multivariate logistic regression, the adjusted odds were significant (P<0.01) for age >35 yr, MAC <20 cm and hypoalbuminaemia (albumin <3.5 g/dl). Interpretation & conclusions: Older age, poor nutritional status including baseline hypoalbuminaemia were independent predictors of occurrence of anti-TB DIH. Clinicians should be vigilant for occurrence of hepatotoxicity in this high risk group.

Role of acute viral hepatitis as a confounding factor in antituberculosis treatment induced hepatotoxicity.

BACKGROUND & OBJECTIVE: Drug induced hepatotoxicity (DIH) is an important and commonly encountered adverse effect with antituberculosis (anti-TB) treatment. Acute viral hepatitis (AVH) is an important confounding reason which clinically, biochemically and histologically mimics DIH. METHODS: The contributory role of acute viral hepatitis as a confounding factor in patients with normal baseline liver functions who developed acute hepatitis while receiving short-course anti-TB treatment was prospectively studied. The sera of all patients who developed acute hepatitis were analysed for markers for hepatitis A, B, C and E viruses. RESULTS: Viral hepatitis was present in 15 of the 102 (14.7%) patients who developed acute hepatitis while receiving anti-TB treatment with hepatitis E virus being the most common cause Later onset of acute hepatitis [58 (5-133) vs. 26 (3-221) days; P=0.04], large elevations in aspartate aminotransferase (AST) [371 (30-2643) vs. 212 (63-1990 IU/l); P=0.03] and alanine aminotransferase (ALT) [388 (31-2997) vs. 225 (52- 1670 IU/l); P= 0.002] and a longer time for normalization of deranged liver functions [36.7 +/- 13.3 vs. 24.5 +/- 19.3 days; P=0.02] indicated acute viral hepatitis as the cause of liver function derangement. INTERPRETATION & CONCLUSION: Our findings showed AVH in 14.7 per cent patients who developed hepatotoxicity while an anti-TB treatment. Therefore, in endemic areas, viral hepatitis should be sought after and excluded in all patients suspected to have DIH before attributing the hepatotoxic effect to the anti-TB drugs.

Nutritional status of patients with Crohn's disease.

BACKGROUND AND AIM: Malnutrition is a common feature in patients with Crohn's disease (CD), which leads to frequent infections and poor prognosis. In view of the rising incidence of CD in India we planned this study to assess the nutritional status of patients with CD. METHODS: Nutritional status of 112 patients (mean age 35.9 [SD 11.7] years; 61 men) with CD was assessed by anthropometric, dietary and biochemical parameters. Patients were considered malnourished if 3 or more anthropometric parameters (% ideal body weight [IBW], % tricep skin fold [TSF], %mid upper arm circumference [MUAC], and % mid arm muscle circumference [MAMC], body mass index [BMI]) were abnormal. Dietary intake was assessed by a 24-hour dietary recall along with a semi-quantitative food frequency method. Eighty volunteers were taken as healthy controls (HC). RESULTS: At the time of assessment, 77 patients were in remission and 35 had active disease. The values of BMI, MUAC, TSF and mid arm fat area (MAFA) in patients were significantly lower than those in healthy controls. MAMC and mid arm muscle area (MAMA) of patients and controls were comparable. TSF (Rem vs HC = 10.4 [2.8-71] vs 16 [3-41]) and MAFA (Rem vs HC = 1236 [240-7757] vs 1858 [322-5650]) of the patients in the remission phase were significantly lower than those of healthy controls; the remaining parameters were comparable. There was no difference in the dietary intake of patients in the remission and active phases, and healthy controls. The percentage energy fulfillment of the patients was lower than that of healthy controls. Twenty-nine of 35 (82.8%) patients in the active and 30 of 77 (38.9%) patients in the remission phase were malnourished (OR 7.5, 95% CI 2.8-20.4). The overall prevalence of malnutrition was 52.6% among patients. CONCLUSION: The percentage of malnourished patients in the active and remission phases of the disease was 82.8% and 38.9%, respectively, possibly due to low percentage energy fulfillment.

Evaluation of bone mineral density among patients with inflammatory bowel disease in a tertiary care setting in India.

BACKGROUND: Patients with inflammatory bowel disease (IBD) have low bone mineral density (BMD). Dietary calcium is important for them in the prevention of osteopenia and osteoporosis. There are no reports on the status of BMD in Indian patients with IBD. METHODS: Dietary calcium intake and cumulative steroid and immunosuppressive drug use was noted in 46 randomly selected patients (mean [SD] age 40.5 [14.7] years; 28 men) with IBD (ulcerative colitis 22, Crohn's disease 24). To compare values of BMD for patients, data from 46 age- and sex-matched healthy controls (age 40.5 [14.6] years; 28 men) were selected from an existing database of healthy Indian volunteers whose BMD had been measured in a community-based survey carried out among people residing in Delhi (unpublished data). BMD was measured using DXA (Hologic QDR 4500). Osteopenia and osteoporosis were defined as per the standard WHO criteria. RESULTS: The mean duration of disease was 87.7 (78.3) months. The mean calcium intake by 41 patients (89.1%) was <200 mg/day, by 2 patients (4.3%) 200-400 mg/day and by 3 patients (6.4%)>400 mg/day. Significantly lower values of BMD at the spine and hip regions were seen in patients with both ulcerative colitis and Crohn's disease as compared with Indian healthy controls. In comparison to age- and sex-matched healthy controls, 29 (63%) and 21 (45.6%) patients had either osteopenia or osteoporosis at the spine and hip region, respectively. Of them, 4 and 7 patients had osteoporosis at the spine and hip region, respectively. There was no correlation between values of BMD and the age of patient, duration of disease, and cumulative steroid dose. CONCLUSIONS: Two thirds of Indian patients with IBD have low BMD. Since the intake of dietary calcium is inadequate in a majority of these patients, they should be advised to increase the intake of dairy products.

Dietary survey and total dietary fiber intake in patients with irritable bowel syndrome attending a tertiary referral hospital.

BACKGROUND: Based on their chemical extraction, dietary fibers are classified into crude fibers and total dietary fibers (TDF). TDF gives the best estimate of fiber content in the diet. Whereas data on intake of crude fibers are available, there is a lack of data on intake of TDF in patients with irritable bowel syndrome (IBS). AIM: We assessed the TDF and its source in the diet of patients with IBS and healthy controls (HC). METHODS: Based on their predominant symptoms, 81 patients with IBS (according to Rome II criteria) were categorized into constipation-predominant (IBS-C, n=48), diarrhea-predominant (IBS-D, n=16) and mixed type (IBS-M, n=17). Information was collected on fiber supplementation and preference for high-fiber food. A pretested, open-ended, semi-quantitative food frequency questionnaire was used to collect dietary information on food groups and TDF. Age- and sex-matched healthy individuals (n=89) were recruited as HC. The mean (SD) age of patients and HC was 36.5 (11.4) years (59 men), and 36 (12) years (62 men), respectively. RESULTS: Thirty-nine patients (48%) were taking medicinal fiber supplements, of which 28 patients were taking supplements daily (2.10 [0.84] teaspoon full). The mean daily TDF intake was 51.7 (23.1) g vs. 52.3 (21.6) g for patients and HC, respectively (p=0.8). The intake of TDF was similar in patients having less (n=41) or more (n=40) preference for fiber-rich foods (55 [23] g vs. 47 [22] g, p=0.16). The daily mean cereal intake in patients was significantly lower than that in HC (322 g vs. 404 g, p=0.001). However, consumption of fruits (150 g vs. 80 g, p=0.001) and vegetables (348 g vs. 219 g, p=0.006) was higher in patients in comparison with HC. There was a positive correlation between TDF with cereals (p=0.001), pulses (p=0.001), vegetables and fruits (p=0.033) in patients with IBS but only with cereals (p=0.001) in HC. CONCLUSION: The intake of TDF in patients with IBS and HC is much higher than the dietary recommendation for healthy Indians. Patients with IBS consumed more fruits and vegetables rather than cereals as compared with HC.

Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force.

AIMS: To study the profile of irritable bowel syndrome (IBS), and the frequency of such symptoms among the general population, in India. METHODS: In this prospective, multi-center study, data were obtained from 2785 patients with chronic lower gastrointestinal symptoms (complainants) with no alarm feature and negative investigations for organic causes visiting physicians at 30 centers, and from 4500 community subjects (non-complainants), using separate questionnaires. RESULTS: Most complainants were middle-aged (mean age 39.4 years) and male (1891; 68%). The common symptoms were: abdominal pain or discomfort (1958; 70%), abdominal fullness (1951; 70%); subjective feeling of constipation (1404 of 2656; 53%), or diarrhea (1252 of 2656, 47%), incomplete evacuation (2134; 77%), mucus with stools (1506; 54%), straining at stools (1271; 46%), epigastric pain (1364; 49%) and milk intolerance (906; 32%). Median stool frequency was similar in patients who felt they had constipation or those who felt they had diarrhea. Information to subtype symptoms using standard criteria was available in 1301 patients; of these, 507 (39%) had constipation-predominant IBS ( 3 <or= stools/week), 50 (4%) had diarrhea-predominant IBS (>3 stools/day) and 744 (57%) had indeterminate symptoms. Among non-complainants, most subjects reported daily defecation frequency of one (2520 [56%]) or two (1535 [34%]). Among non-complainants, 567 (12.6%) reported abdominal pain, 503 (11%) irregular bowel, 1030 (23%) incomplete evacuation, 167 (4%) mucus and 846 (18%) straining at stools; a combination of abdominal pain or discomfort relieved by defecation, and incomplete evacuation was present in 189/4500 (4.2%) community subjects. CONCLUSIONS: Most patients with IBS in India are middle-aged men, and have a sense of incomplete evacuation and mucus with stools. Abdominal pain or discomfort is frequent but not universal. Importantly, stool frequency was similar irrespective of whether the patients felt having constipation or diarrhea. Most (90%) non-complainant subjects had 1 or 2 stools per day; symptoms complex suggestive of IBS was present in 4.2% of community subjects.

Primary intestinal lymphangiectasia as a component of autoimmune polyglandular syndrome type I: a report of 2 cases.

Chronic diarrhea and steatorrhea occur frequently in patients with autoimmune polyglandular syndrome (APS) type I. Intestinal lymphangiectasia has been reported earlier as a cause of steatorrhea in a young girl with APS Type I. We describe 2 patients with APS Type I who were found to have intestinal lymphangiectasia, one of whom had symptomatic protein-losing enteropathy.

Spectrum of microscopic colitis in a tertiary care centre in India.

INTRODUCTION: The incidence of microscopic colitis has recently increased. Although collagenous colitis and lymphocytic colitis are the two main subtypes of microscopic colitis, many patients may not fit into either category and are thus included under the header nonspecific colitis. Of late, the spectrum of microscopic colitis has widened to include minimal change colitis, microscopic colitis not otherwise specified and microscopic colitis with giant cells. There is a lack of information concerning the spectrum of microscopic colitis in Asia. METHOD: In a retrospective analysis, case records of 29 patients diagnosed with microscopic colitis between 1999-2005 were analysed. Drug use parasitic infection and common bacterial infections were excluded. Colonoscopic/ sigmoidoscopic examination was done and multiple colonic mucosal biopsies were stained serially with haematoxylin and eosin for detailed histological examination and Masson trichrome for sub-epithelial collagen band. Based on histological criteria, patients were categorised into five subtypes: collagenous colitis (presence of collagenous thickening of surface epithelium basement membrane > 10 microm), lymphocytic colitis (intra-epithelial lymphocytes more than 20 per 100 colonocytes), minimal change colitis (crypt architectural abnormality in the form of cryptitis and crypt dilatation in the absence of increase in intraepithelial lymphocytes and subepithelial collagenous band), microscopic colitis not otherwise specified (increased inflammatory cell infiltrates in the lamina propria in the absence of other abnormalities) and microscopic colitis with giant cells. RESULTS: Mean age of patients was 38.59 years (range 12-62). Of 29 patients with microscopic colitis, 7 (24.1%), 4 (13.8%), 7 (24.1%) and 11 (37.9%) were classified as collagenous colitis, lymphocytic colitis, minimal change colitis and microscopic colitis not otherwise specified, respectively. None of these patients had giant cells. There was no significant correlation between disease type and clinical manifestations. CONCLUSION: Microscopic colitis has a wide histological spectrum. Cases reported as non-specific colitis, may be categorised into definite subtypes of microscopic colitis.

Celiac disease: variations of presentations in adults.

BACKGROUND: Patients with celiac disease, who remain undiagnosed or asymptomatic in childhood, may present in adulthood with either typical or atypical features. METHODS: In a retrospective analysis, we reviewed the case records of 45 consecutive patients with celiac disease diagnosed in adulthood. The diagnosis of celiac disease was made on the basis of the modified European Society of Pediatric Gastroenterology, Hepatology and Nutrition criteria. The modes of presentation, clinical manifestations, endoscopic features and histological features were analyzed. RESULTS: The mean age of these patients at diagnosis was 28.7 (11.2) years. The median duration of symptoms before diagnosis was 2.5 years (range: 6 months to 40 years). Chronic diarrhea was the presenting manifestation in 20 (44%) patients only. Twenty-two (49%) patients were referred to us by hematologists, endocrinologists or gynecologists for evaluation of refractory anemia in 10 (2.2%), short stature in 6 (13.3%), metabolic bone disease in 2 (4.4%) and secondary infertility or delayed menarche in 4 (8.8%). Intestinal mucosal folds were scalloped in 31 (69%), attenuated in 34 (76%) and normal looking in 11 (24%) of them. Mild, moderate and severe villous abnormalities on intestinal mucosal biopsies were present in 10 (22.2%), 15 (33.3%) and 19 (42.2%) patients, respectively. CONCLUSIONS: More than half of adult patients with celiac disease present with atypical manifestations. A high index of suspicion is required for diagnosing variant forms of celiac disease in adults.

Corrosive-like strictures caused by ingestion of aluminium phosphide.

Aluminium phosphide ingestion is a major cause of poisoning-related mortality in tropical countries. Local oesophageal complications due to aluminium phosphide have been reported to occur rarely. We describe 3 patients who survived the intake of aluminium phosphide tablets and developed oesophageal strictures.

Chronic diarrhea and malabsorption caused by Leishmania donovani.

Chronic diarrhea and malabsorption are uncommon in immunocompetent patients with visceral leishmaniasis. We report two immunocompetent patients with visceral leishmaniasis where the predominant presentation was chronic diarrhea. One of them had clinically overt malabsorption and duodenal mucosa was loaded with Leishmania donovani bodies. The other patient had diffuse colonic aphthous and discrete ulcerations and Leishmania donovani bodies were seen in the crush smears of the colonic mucosa. With amphotericin B, there was reversal of malabsorption and healing of colonic ulcers.