Celiac Crisis: an unusual presentation of gluten-sensitive enteropathy

Celiac disease (CD)­also known as gluten-sensitive enteropathy­is a chronic, genetically predisposing and autoimmune entity with a wide range of clinical manifestations triggered by gluten ingestion, which affects 1% of the general population. Currently, up to 60% of the diagnosis of CD is in adults due to the atypical course of the disease. The severe acute onset of CD­also called celiac crisis­is very uncommon and is still not well documented in adults. We report the case of a 58-year-old man who presented a 45-day history of subtle-onset diarrhea followed by malabsorption syndrome with progressive weight loss, anasarca, and electrolyte disturbances. The diagnostic work-up included an upper digestive endoscopy, which showed scalloping of the duodenal mucosa with pathological features confirmed on biopsies. Specific antibodies were positive, and a satisfactory clinical response was obtained once a gluten-free diet was started. Celiac crisis is a rare initial presentation of CD characterized by severe diarrhea, dehydration, weight loss, hypoproteinemia, and metabolic and electrolyte disturbances. Although rare, it should be considered in patients with apparently unexplained chronic diarrhea.

Recomendações da Sociedade Brasileira de Endocrinologia e Metabologia (SBEM) para o diagnóstico e tratamento da hipovitaminose D / Recommendations of the Brazilian Society of Endocrinology and Metabology (SBEM) for the diagnosis and treatment of hypovitaminosis D

Objetivo Apresentar uma atualização sobre o diagnóstico e tratamento da hipovitaminose D baseada nas mais recentes evidências científicas. Materiais e métodos O Departamento de Metabolismo Ósseo e Mineral da Sociedade Brasileira de Endocrinologia e Metabologia (SBEM) foi convidado a conceber um documento seguindo as normas do Programa Diretrizes da Associação Médica Brasileira (AMB). A busca dos dados foi realizada por meio do PubMed, Lilacs e SciELO e foi feita uma classificação das evidências em níveis de recomendação, de acordo com a força científica por tipo de estudo. Conclusão Foi apresentada uma atualização científica a respeito da hipovitaminose D que servirá de base para o diagnóstico e tratamento dessa condição no Brasil. .

Objective The objective is to present an update on the diagnosis and treatment of hypovitaminosis D, based on the most recent scientific evidence. Materials and methods The Department of Bone and Mineral Metabolism of the Brazilian Society of Endocrinology and Metabology (SBEM) was invited to generate a document following the rules of the Brazilian Medical Association (AMB) Guidelines Program. Data search was performed using PubMed, Lilacs and SciELO and the evidence was classified in recommendation levels, according to the scientific strength and study type. Conclusion A scientific update regarding hypovitaminosis D was presented to serve as the basis for the diagnosis and treatment of this condition in Brazil. .

Spectrum of malabsorption syndrome among adults & factors differentiating celiac disease & tropical malabsorption.

Background & objectives: Aetiology of malabsorption syndrome (MAS) differs in tropical and temperate countries over time; clinical and laboratory parameters may differentiate between various causes. This study was undertaken to investigate the spectrum of MAS among Indian adults and to find out the features that may help to differentiate between TM and celiac disease. Methods: Causes of MAS, and factors differentiating tropical malabsorption (TM) from celiac disease (CD) were determined in 275 patients. Results: Using standard criteria, causes in 275 patients [age 37.5+13.2 yr, 170, (61.5%) male] were, TM 101 (37%), CD 53 (19%), small intestinal bacterial overgrowth 28 (10%), AIDS 15 (5.4%), giardiasis 13 (5%), hypogammaglobulinemia 12 (4%), intestinal tuberculosis 7 (2.5%), strongyloidiasis 6 (2%), immunoproliferative small intestinal disease 5 (2%), Crohn's disease 6 (2%), amyloidosis 4 (1.5%), intestinal lymphangiectasia 3 (1%) and unknown 22 (8%). On univariate analysis, patients with CD were younger than TM (30.6+12 vs. 39.3+12.6 yr, P<0.001), had lower body weight (41.3+11.8 vs. 49.9+11.2 kg, P<0.001), longer diarrhoea duration (median 36 inter-quartile range 17.8-120 vs. 24-months, 8-48, P<0.01), lower stool frequency (6/day, 5-8 vs. 8, 5-10, P<0.05), lower haemoglobin (9.4+3.2 vs. 10.4+2.7 g/dl, P<0.05), higher platelet count (2,58,000, range 1,35,500-3,23,500 vs. 1,60,000, 1,26,000-2,58,000/mm3, P<0.05), and more often had hepatomegaly (9/53, 17% vs. 4/101, 4%, P<0.01), and subtotal or partial villous atrophy (36/50, 72% vs. 28/87, 32%, P<0.001). Younger age (<35 yr), longer diarrhoea duration, higher platelet count and villous atrophy were significant on multivariate analysis. Interpretation & conclusions: TM and CD are common causes of MAS among Indian adults. Younger age (<35 yr), longer diarrhoea duration, higher platelet count and villous atrophy were found to be associated with CD.

Doença celíaca e infertilidade / Celiac disease and infertility

Doença celíaca ou enteropatia por sensibilidade ao glúten é uma doença crônica condicionada pelo desenvolvimento de uma hipersensibilidade ao glúten. É associada a uma ampla gama de manifestações clínicas existindo, simultaneamente, má digestão e um déficit na absorção de muitos nutrientes e vitaminas. Diversos estudos têm mostrado, também, uma maior prevalência desta com quadros de infertilidade, aparentemente sem uma causa definida. Este é o motivo da presente revisão.

Celiac disease or gluten-sensitive enteropathy is a chronic illness characterized by the development of hypersensitivity to gluten. It is associated with a vast array of clinical manifestations, such as the occurrence of digestive problems and poor absorption of nutrients and vitamins. Several studies have also linked it to cases of infertility, apparently, without a known cause. This link is the motivation of the following review.

Pancreatitis crónica: nuevas terapias / Chronic pancreatitis: new therapies

Chronic pancreatitis occurs by the prolonged inflammation of pancreatic tissue that induces the irreversible destruction of the organ, leading to a global pancreatic insufficiency. The most common manifestations are abdominal pain, diarrhea, malabsorption, and possibly diabetes mellitus. Chronic pancreatitis treatment includes dietary restrictions, enzymatic supplementation, vitamins, and endoscopic or surgical methods depending on the degree of ductal involvement. In addition to the known therapies, new therapies are under development and research.

La pancreatitis crónica se desarrolla por la inflamación prolongada del tejido pancreático que induce la destrucción irreversible del órgano, llevando a una insuficiencia pancreática global. Las manifestaciones más frecuentes son dolor abdominal, diarrea, malabsorción y eventualmente diabetes mellitus. El tratamiento en pancreatitis crónica incluye restricciones dietarias, suplementación enzimática, vitamínica, y métodos endoscópicos o quirúrgicos, dependiendo del grado de compromiso ductal. Además de lo descrito, están en desarrollo y experimentación nuevas terapias.

Increased levothyroxine requirement in a woman with previously well-controlled hypothyroidism and intestinal giardiasis / Aumento da necessidade de levotiroxina em uma paciente com hipotireoidismo previamente bem-controlado e giardíase intestinal

The most common cause of apparent inefficiency or resistance to oral therapy with levothyroxine for hypothyroidism is nonadhesion. However, in some subjects in whom the control of hypothyroidism is extremely difficult, levothyroxine bioavailability defects should be considered. We report here the case of a 57-year-old woman with hypothyroidism that was well-controlled for the previous 6 years but suddenly presented with poor hormonal control and abdominal symptoms, despite repeatedly reporting good compliance to therapy. Adequate control of thyroid function was only obtained after intestinal giardiasis was diagnosed and treated.

A causa mais comum de aparente ineficácia ou resistência ao tratamento do hipotireoidismo com levotiroxina oral é a má adesão. No entanto, em alguns pacientes nos quais o controle do hipotireoidismo é extremamente difícil, defeitos na biodisponibilidade da levotiroxina devem ser considerados. Relatamos aqui o caso de uma mulher de 57 anos de idade com hipotireoidismo que vinha previamente bem controlado durante 6 anos, mas que, abruptamente, começou a apresentar mau controle hormonal, apesar de insistentemente relatar boa adesão ao tratamento. O controle adequado da função tireoidiana só foi possível depois que uma giardíase intestinal foi diagnosticada e tratada.

[Celiac disease as a potential cause of liver enzyme dysfunction]

Celiac disease is one of the most common cause of malabsorption syndrome. The symptom of this disease associated secondary to malabsorbtive problems. Celiac can be accompanied with liver enzyme dysfunction with various extra intestinal findings. This case was a 27-year old man presented with abnormal liver function test over period of 1 year. He did not have another symptom such as diarrhea, weight loss or skin lesion. In medical examination, there was no ascites, peripheral edema or jaundice. Diagnostic re-examination of the patient include serology tests and Viral hepatitis, Wilson disease and auto imuune responses showed to be normal. Abdominal and biliary sonography had normal results. Liver biopsy revealed no sign of any pathology, but duodenal biopsy and serologic findings were compatible by Celiac disease. The symptom improved on a gluten-free diet and his liver enzyme function tests became normal subsequently

Gastrointestinal problems at high altitude.

Gastrointestinal (GI) problems at high altitude are commonplace. The manifestations differ considerably in short-term visitors, long-term residents and native highlanders. Ethnic food habits and social norms also play a role in causing GI dysfuntion. Symptoms like nausea and vomiting are common manifestations of acute mountain sickness and are seen in 81.4% short-term visitors like mountaineers. Anorexia is almost universal and has a mutifactorial causation including effect of hormones like leptin and cholecystokinin and also due to hypoxia itself. Dyspepsia and flatulence are other common symptoms. Diarrhoea, often related to poor hygiene and sanitation is also frequently seen especially among the short-term visitors. Peptic ulceration and upper gastro-intestinal haemorrhage are reported to be common in native highlanders in the' Peruvian Andes (9.6/10000 population per year) and also from Ladakh in India. A hig h incidence o f gastriccarcinoma is also reported, especially from Bolivia (138.2 cases per 10000 population per year). Megacolon and sigmoid volvulus are common lower GI disorders at high altitude. The latter accounted for 79% of all intestinal obstructions at a Bolivian hospital. Thrombosis of the portosystemic vascultature and splenic hematomas has been reported from India. Malnutrition is multifactorial and mainly due to hypoxia. Fat malabsorption is probably significant only at altitudes > 5000m. Neonatal hyperbilirubinemia was found to be four times more common in babies born at high altitude in Colorado than at sea level. Gall stones disease is common in Peruvian highlands. A high seroprevalence of antibodies to H pylori (95%) has been found in Ladakh but its correlation to the prevalence of upper gastro-intestinal disease has not been proven.

Malabsorption syndrome due to various causes is associated with antroduodenal hypomotility.

BACKGROUND: Patients with celiac disease who present with symptoms of gastrointestinal hypomotility have abnormal antroduodenal manometry. There are no data on antroduodenal manometry in malabsorption syndrome (MAS) due to causes other than celiac disease. METHODS: Fasting, post-prandial and post-octreotide antroduodenal motility parameters were compared in 18 untreated patients with MAS presenting with chronic diarrhea (tropical sprue 10, small bowel bacterial overgrowth 3, celiac disease 2, common variable immunodeficiency 1, AIDS with isosporidiasis and bacterial overgrowth 1, giardiasis 1) and 8 healthy subjects. RESULTS: Number of patients with MAS and controls having spontaneous migratory motor complexes (MMC) during fasting was comparable (11/18 vs 7/8; p=ns). Fasting contraction amplitude was weaker in MAS than in controls in the gastric antrum (median 42 [range 17-90] vs 80 [31-120] mmHg; p=0.001), proximal duodenum (50 [18-125] vs 72 [48-107]; p=0.013) and distal duodenum (45 [20-81] vs 76 [51-98]; p=0.001). In the fed state too, contraction amplitudes were weaker in patients with MAS in the antrum (32 [15-110] vs 76 [61-103] mmHg, p=0.002), proximal duodenum (57 [20-177] vs 73 [56-113]; p=0.07) and distal duodenum (45 [24-87] vs 75 [66-97]; p<0.0001). Patients with MAS had lower fasting and post-prandial antral and duodenal motility indices than healthy subjects. Intravenous octreotide induced MMC in all patients and controls. CONCLUSIONS: MAS due to various causes is associated with antroduodenal hypomotility typical of myopathic disorders.

Intestinal amyloidosis presenting as malabsorption syndrome.

Intestinal amyloidosis presenting with small bowel diarrhoea with malabsorption is an infrequent clinical entity. The present case report includes such a case and discusses the diagnostic approach in such a case.

Gastrointestinal tract infestation with strongyloides

Stercoralis is common in the tropical and subtropical areas of the world. In an immunocompetent person, disease is generally asymptomatic. However, it has the potential to cause serious life threatening disease in an immunocompromised patient. We report a 55 years old immunocompetent person who presented with malabsorption secondary to strongyloides stercoralis infestation. Unusual infestations like strongyloides should also be considered while investigating malabsorption

Manifestaciones cutáneas de deficiencias nutricionales / Skin manifestations of nutritional deficiencies

Las enfermedades malabsortivas son las más importantes en ilustrar deficiencias nutricionales y se caracterizan por alteración en la absorción de uno o varios nutrientes en el intestino delgado. Se manifiestan clínicamente con diarrea, anemia, baja de peso, hipoalbuminemia o deficiencias nutricionales específicas. El compromiso cutáneo en las enfermedades malabsortivas es frecuente y podría corresponder al primer signo clínicamente reconocible de deficiencias nutricionales que amenazan la vida. Los principales signos asociados a malabsorción de nutrientes son ictiosis, hiperpigmentación cutánea, keratosis folicular, púrpura, dermatitis eccematosas, alopecia, patología ungueal y compromiso de mucosas. Merecen especial mención las lesiones cutáneas asociadas a enfermedad celíaca, dermatitis herpetiforme, acrodermatitis enteropática y enfermedad de Whipple. En este artículo se revisarán las manifestaciones cutáneas de la malabsorción intestinal generalizada y de las deficiencias de nutrientes específicos.

Intestino Corto / Short bowel syndrome

El intestino corto está asociado a pérdida o disfunción del intestino delgado por resección del mismo, que causa diarreas, tránsito intestinal acelerado, malabsorción intestinal, y eventualmente la pérdida de peso y el desgaste muscular. El objetivo de este trabajo fue actualizar el conocimiento acerca de este síndrome. Se realiza una revisión del tema de intestino corto donde se refiere a su definición, causas fundamentales frecuentes e infrecuentes en el niño y en el adulto, cómo se adapta el intestino a la resección de diferentes extensiones, las funciones del íleon terminal. Se hacen una valoración clínica inicial, con el interrogatorio médico, revisión minuciosa de la historia clínica para cuantificar la capacidad de absorción. Se habla de los síntomas y signos de deficiencia nutricional. Se explican las estrategias del tratamiento, que tienen 3 etapas de evolución clínica. Se concluye que se indica la dietoterapia adecuada según el estado nutricional del paciente y la resección intestinal realizada, evitando las complicaciones para lograr una calidad máxima de vida(AU)

Short bowel is associated with loss or dysfunction of the small bowel due to its resection, which causes diarrheas, accelerated intestinal transit, intestinal malabsorption and, eventually, weight loss ansd muscular waste. The objective of this paper was to update knowledge about this syndrome. A review of the short intestine topic is made, making reference to its definition, common and uncommon main cuases in the child and adult, how the bowel adapts itslef to resection of different extensions, and the functions of the terminal ileum. An initial clinical assessment is made with the medical questionnaire and a detailed review of the medical history to quantify the absorption capacity. The symptoms and signs of nutritional deficiency are dealt with. The strategies of the treatment consisting of 3 stages of clinical evolution are explained. It is concluded that the adequate diet therapy is indicated according to the nutritional state of the patient and the performed intestinal resections, preventing complications to achieve a maximum quality of life(AU)

Ozonoterapia en el síndrome de malabsorción intestinal secundario a parasitismo por Giardia lamblia: estudio preliminar / Ozone therapy in the syndrome of malabsorption secondary to parasitism caused by Giardia lamblia: a preliminary study

Se estudió el efecto de la ozonoterapia combinada (OLEOZON® oral y ozonoterapia rectal) en el síndrome de malabsorción intestinal, secundario a parasitismo intestinal por Giardia lamblia. Se tomaron 186 pacientes y se formaron 3 grupos de 62 pacientes cada uno. El primer grupo se trató con metronidazol y vitaminoterapia, el segundo con OLEOZON® oral y vitaminoterapia y el tercero con ozonoterapia combinada y vitaminoterapia. Los pacientes fueron evaluados clínicamente por drenaje biliar y biopsia de yeyuno al inicio y final del tratamiento. Se alcanzó una mejoría importante en el tercer grupo (66,1 por ciento), de los cuales, los diagnosticados tempranamente, 40,3 por ciento obtuvo su curación. Se concluyó que la ozonoterapia combinada puede ser eficaz en esta patología

Absorção intestinal de D-xilose em crianças infectadas pelo vírus da imunodeficiência humana / Intestinal absorption of D-xylose in children infected with the human immunodeficiency virus

AIM: To evaluate the intestinal absorption in HIV-infected children children 14 months to 14 years and to investigate its relationship to diarrhea, nutritional status, immune dysfunction, classical enteric parasites and Cryptosporidium. METHODS: Intestinal absorption was investigated by measuring serum D-xylose. Fecal samples were investigated for classical pathogens and Cryptosporidium. The sample size was calculated considering a 30% prevalence of altered D-xylose absorption in HIV-infected children with a 5% accuracy. Statistical procedures used were: descriptive measurements, multiple correspondence analysis and logistic regression. RESULTS: D-xylose absorption was altered in only 8 out of 104 (7.7%) and Cryptosporidium was positive in 33 out of 104 (31.73%) HIV-infected children. The multiple correspondence analysis suggested an association between an altered D-xylose test and Cryptosporidium. D-xylose malabsorption was not associated with diarrhea, nutritional status, immune disfunction and classic enteric parasites. CONCLUSIONS: Intestinal malabsorption evaluated through the D-xylose test was an uncommon finding in HIV-infected children. Intestinal dysfunction when present seems to be related to Cryptosporidium, but not to diarrhea, nutritional status, immune disfunction and classic enteric parasites

Tricocefalosis masiva en un adulto diagnosticada por colonoscopía / Massive trichuriasis in an adult diagnosed by colonoscopy

A case of massive trichuriasis in a 37 year old female from a rural locality of the Metropolitan Region of Chile, with antecedentes of alcoholism, chronic hepatic damage and portal cavernomatosis, is presented. Since 12 year ago she has had geophagia. In the las six months she has frequently presented liquid diarrhea, colic abdominal pains, tenesmus and sensation of abdminal distention. Clinical and laboratory test confirmed her hepatic affection associated with a celiac disease with anemia and hypereosinophilia. Within a week diarrhea became worse and dysentery appeared. A colonoscopy revealed and impressive and massive trichuriasis. The patient was succesfully treated with two cures of 200 mg tablets of mebendazole twice daily for three days with a week interval. After the first cure she evacuated a big amount of tricuris trichiura, fecal evacuations became normal, geophagia disappeared and recovered 4 kg of body weight