Cross-sectional imaging of intestinal barrier dysfunction by confocal laser endomicroscopy can identify patients with food allergy in vivo with high sensitivity.

Food allergy (FA) affects approximately 3 to 4% of the adult population in westernized countries. Suspected FA is even more prevalent and requires extensive diagnostic work-up. Within this study, we evaluated whether assessment of the integrity of the epithelial barrier by confocal laser endomicroscopy (CLE) during colonoscopy can be used as a screening tool to identify patients with FA. 60 patients with suspected FA were prospectively included. Serology with total and food-specific IgE, anti-tissue transglutaminase, skin prick testing, food intolerance tests, food intake registration and assessment of clinical complaints were performed. During colonocopy, standardized CLE was performed in the terminal ileum and at two colorectal sites. Analysis of CLE images included functional (i.e. presence of epithelial barrier dysfunction) and quantitative parameters of intestinal architecture. 27 of 60 patients (45%) were diagnosed with FA. Barrier dysfunction was analyzed on 65.837 ileal and on 93.251 colonic images. 96% of patients with FA exhibited functional and structural barrier defects while barrier dysfunction was found in only 33% of patients without FA (p < 0.0001). Visualizing barrier dysfunction with CLE for in vivo diagnosis of FA had a sensitivity and specificity of 96% and 67%, respectively, with a positive and negative prediction of 70% and 96%, respectively. Parameters intrinsic to the crypt architecture including crypt diameter, intercrypt distance, crypt lumen diameter and colonic vasculature were not different between patients with and without FA. CLE-based imaging of the intestinal barrier during colonoscopy might help in stratifying patients with suspected FA for further diagnostic work-up.

Anetodermia secundaria a moluscos contagiosos / Anetoderma secondary to molluscum contagiosum

No disponible

Epinephrine auto-injector needle lengths: Can both subcutaneous and periosteal/intraosseous injection be avoided?

BACKGROUND: Epinephrine should be administered intramuscularly in the anterolateral aspect of the thigh. The length of the epinephrine auto-injector (EAI) needle should ensure intramuscular injection. OBJECTIVE: To discuss suitable EAI needle lengths based on ultrasound measurements related to weight. METHODS: The skin-to-muscle distance (STMD) and skin-to-bone distance (STBD) were measured by ultrasound in the mid-third of the anterolateral area of the right thigh when applying high pressure (8 lb; high-pressure EAI [HPEAI]) or low pressure (low-pressure EAI [LPEAI]) on the ultrasound probe. The study included 302 children and adolescents and 99 adults. The maximum and minimum STMD and the maximum and minimum STBD were estimated. RESULTS: Using HPEAIs, the risk of periosteal or intraosseous penetration was 32% in children weighing less than 15 kg. The risk of subcutaneous injection was 12% in adolescents and 33% in adults. With LPEAIs, there was no risk of periosteal or intraosseous injection and the risk of subcutaneous injections in adolescents and adults was lower at 2% and 10%, respectively. A new EAI for injection in small children would have no risk of periosteal or intraosseous injection but would have 71% chance of subcutaneous deposit of epinephrine. CONCLUSION: Common HPEAIs have a high risk of periosteal or intraosseous penetration in children and subcutaneous injections in overweight and obese adults. LPEAIs have some risk of subcutaneous injection in adults. HPEAIs with 0.1 mg of epinephrine and shorter needles have no risk of periosteal or intraosseous injection but have a high risk of subcutaneous deposit. For adult or overweight or obese patients, HPEAIs and LPEAIs should have longer needles. Future studies should focus on triggering pressures and variations in needle length.

Propofol Use in Pediatric Patients With Food Allergy and Eosinophilic Esophagitis.

Propofol is a safe, well-tolerated anesthetic that is labeled as contraindicated in patients with egg or soy allergy. This contraindication has become increasingly problematic given the rising incidence of food allergy and eosinophilic esophagitis (EoE). To address this issue, we studied practice patterns of propofol use for esophagogastroduodenoscopies in children with EoE and food allergies at our institution. A retrospective observational study of 1365 esophagogastroduodenoscopies from January 2013 to June 2014 was performed. Data were analyzed using Student t tests, chi square tests, Fisher exact tests, and multivariable logistic regression. We found that propofol was used significantly less in patients with egg or soy allergy, and in patients with EoE, even after adjusting for the presence of food allergy. There was no difference in complication rates relative to propofol use. Propofol was used safely in pediatric patients with EoE and food allergy in this limited single-center review.

A retrospective study of enteroclysis in patients with manifest food allergy.

PURPOSE: The aim of this study was to investigate whether there are typical findings in enteroclysis of patients suffering from food allergy (FA). MATERIALS AND METHODS: Findings of enteroclysis of 26 FA patients were correlated with results of endoscopic and histologic examinations. In two patients allergen provocation was performed during enteroclysis. RESULTS: No specific mucosal pathologies were found without provocation. After provocation, low mucosal contrast adhesion was observed. CONCLUSION: Without provocation no specific alterations were found. However, enteroclysis may be used for monitoring of allergen challenge.

Two-dimensional grayscale ultrasound and spectral Doppler waveform evaluation of dogs with chronic enteropathies.

Sonography is an important diagnostic tool to examine the gastrointestinal tract of dogs with chronic diarrhea. Two-dimensional grayscale ultrasound parameters to assess for various enteropathies primarily focus on wall thickness and layering. Mild, generalized thickening of the intestinal wall with maintenance of the wall layering is common in inflammatory bowel disease. Quantitative and semi-quantitative spectral Doppler arterial waveform analysis can be utilized for various enteropathies, including inflammatory bowel disease and food allergies. Dogs with inflammatory bowel disease have inadequate hemodynamic responses during digestion of food. Dogs with food allergies have prolonged vasodilation and lower resistive and pulsatility indices after eating allergen-inducing foods.

Advanced imaging and visualization in gastrointestinal disorders.

Advanced medical imaging and visualization has a strong impact on research and clinical decision making in gastroenterology. The aim of this paper is to show how imaging and visualization can disclose structural and functional abnormalities of the gastrointestinal (GI) tract. Imaging methods such as ultrasonography, magnetic resonance imaging (MRI), endoscopy, endosonography, and elastography will be outlined and visualization with Virtual Reality and haptic methods. Ultrasonography is a versatile method that can be used to evaluate antral contractility, gastric emptying, transpyloric flow, gastric configuration, intragastric distribution of meals, gastric accommodation and strain measurement of the gastric wall. Advanced methods for endoscopic ultrasound, three-dimensional (3D) ultrasound, and tissue Doppler (Strain Rate Imaging) provide detailed information of the GI tract. Food hypersensitivity reactions including gastrointestinal reactions due to food allergy can be visualized by ultrasonography and MRI. Development of multi-parametric and multi-modal imaging may increase diagnostic benefits and facilitate fusion of diagnostic and therapeutic imaging in the future.

Food hypersensitivity reactions visualised by ultrasonography and magnetic resonance imaging in a patient lacking systemic food-specific IgE.

BACKGROUND: Abdominal complaints related to food intake might be due to hypersensitivity. A firm diagnosis of food allergy is often difficult to establish, particularly in the absence of systemic food-specific IgE. Using ultrasonography and magnetic resonance imaging (MRI) we were able to visualise the intestinal response in one such case. METHODS: A 24-year-old female presented with self-reported food hypersensitivity, particularly related to the intake of egg. Nausea and diarrhoea were predominant symptoms. Double-blind placebo-controlled food challenge with raw egg was positive, but all other conventional tests of food hypersensitivity, including skin prick test, total and food-specific IgE in serum, were negative. A thorough investigation programme could not reveal any organic disease of the gastrointestinal tract. We extended the evaluation to include two new provocation tests, where intestinal wall thickening and the amount of luminal liquid were monitored by external abdominal ultrasound and MRI. RESULTS: Both ultrasound and MRI investigations indicated intestinal wall thickening and influx of large amounts of fluid into the proximal small intestines within 10 min of duodenal challenge with egg. The response was associated with abdominal pain and bloating. CONCLUSIONS: The response to provocation was typical of an immediate allergic reaction. Our results indicate that local food-induced hypersensitivity reactions can occur in the gut in the absence of systemic indications of IgE-mediated allergy. Abdominal ultrasonography and MRI might become valuable tools for documenting such responses.

Response to intestinal provocation monitored by transabdominal ultrasound in patients with food hypersensitivity.

OBJECTIVE: Owing to lack of objective measures, the diagnosis of food hypersensitivity may be difficult. The aim of this study was to investigate whether the intestinal response to direct provocation in patients with food hypersensitivity could be recognized by ultrasound. MATERIAL AND METHODS: Thirty-two patients with chronic abdominal complaints, self-attributed to food hypersensitivity/allergy were included in the study. Via a nasoduodenal tube, the duodenal mucosa was challenged with the suspected food item dissolved in 10 ml water or saline. Using external ultrasound, the sonographic features (wall thickness and diameter of the duodenal bulb and jejunum, peristalsis activity and luminal fluid) were recorded before and during one hour after challenge. RESULTS: Sonographic changes were observed after challenge in 14 (44%) of the 32 patients. A positive sonographic response (increased wall thickness, diameter, peristalsis and/or luminal fluid) was significantly related to a positive skin prick test (p = 0.008) and a positive double-blind placebo-controlled food challenge (p = 0.03). A significant correlation was found between provocation-induced symptoms and wall thickness of the duodenal bulb (r = 0.50, p = 0.004) or the jejunum (r = 0.42, p = 0.02). Intra- and interobserver variation of the tracing procedure showed low values. CONCLUSIONS: Responses of the proximal small intestines to direct provocation (swelling of the wall and exudation of fluid into the lumen) could be visualized by transabdominal ultrasound. This new provocation test could be helpful in the evaluation of patients with food hypersensitivity.

Food allergy and intolerance: response to intestinal provocation monitored by endosonography.

OBJECTIVE: Objective assessment of adverse reactions to food is a long-felt want. We report our preliminary experience with a new endosonographic allergen provocation test. METHODS: Twenty patients were examined, seven patients having food allergy and 13 having food intolerance. The duodenal mucosa was challenged with allergen extracts via a nasoduodenal tube. The responses were recorded using a miniprobe for endosonography through the tube. Thereafter, intestinal lavage was performed by giving 2 l PEG solution containing micro Ci (51)CrEDTA. The gut lavage fluid and urine for 5 h were collected. RESULTS: Increased mucosal thickness in response to provocation was recorded in 11 patients, but not more often or pronounced in the allergic than in the intolerance group. Interestingly, increased mucosal thickness associated with a new echogenic layer was seen in two patients and a sustained duodenal contraction, lasting 15-20 min associated with pain, in another two. Intestinal permeability and inflammatory mediators were not significantly different in the two groups. CONCLUSION: In patients with self-reported adverse reactions to food abnormal responses to duodenal provocation may be recognised by endosonography. However, neither endosonography nor intestinal permeability or faecal calprotectin responses were able to distinguish between food allergy and intolerance. Sustained duodenal contractions in response to food might be a cause of abdominal pain.

Bowel wall thickening in infants with food allergy.

BACKGROUND: Food allergy may be partly due to impairment of the intestinal barrier and is frequently associated with atopic dermatitis (AD) in early life. OBJECTIVE: To determine whether bowel wall thickening, as demonstrated by US, is useful for the identification of food allergy. MATERIALS AND METHODS: We used US to study eight infants with food allergy and ten non-allergic controls to clarify whether specific intestinal findings in the jejunum, ileum and colon are present in infants with AD who have food allergy. RESULTS: Wall thickening was observed in all eight patients with food allergy, but only in the jejunum; it disappeared after elimination of suspected dietary allergens. Bowel wall thickening returned in the two allergic patients who received a food challenge test. CONCLUSIONS: Wall thickening of more than 2 mm on US in the jejunum in infants with AD may be a useful marker to evaluate the presence of food allergy and therapeutic effects.

Vitamin D deficiency rickets due to inappropriate feeding: report of one case.

Vitamin D deficiency rickets is rare among infants and children in the industrialized countries. In this paper, we report a 2-year-5-month-old girl with aching and bowed legs. A food allergy with atopic dermatitis was diagnosed since her early infancy. Strict dietary restrictions were done and she was mostly fed soybean juice and rice foods. Fortified soybean formula (Isomil) was introduced one month before admission. Vitamin D deficiency rickets was diagnosed by a history of inappropriate feeding, roentgenographic and laboratory findings. The therapeutic regimen included 1, 25-dihydroxycholecalciferol 0.5 ug/day and calcium carbonate 100 mg/kg/day. Extensive nutritional counseling was also given for correction of aberrant dietary practices. After a one-year follow-up, there was radiological evidence of bone healing, and marked improvement of leg deformities.

Cow's milk protein/soy protein allergy: gastrointestinal imaging.

Positive radiologic findings were identified in the small and large bowels in three infants with various gastrointestinal manifestations of cow's milk protein/soy protein allergy, which was diagnosed on the basis of clinical features and histologic findings. Small bowel findings were thickened valvulae conniventes (plicae circulares), a ribbon-like ileum, and a thickened bowel wall. Narrowing, thumbprinting, and spasm were seen in the large bowel. These cases were seen at intervals far enough apart to exclude an endemic infection. The diagnosis of food protein allergy should be considered when diffuse small bowel disease or colitis is identified in an infant.

Barium enema findings (? segmental colitis) in four neonates with bloody diarrhea--possible cow's milk allergy.

Four neonates with sudden onset of bloody diarrhea and barium enema findings suggestive of segmental colitis are reported. The infants were not very ill and in all four, the condition was self-limiting. An exact etiology for the condition was not determined but in all of the infants a possible association with cow's milk intolerance was suggested.

Proximal small bowel transit pattern in patients with malabsorption induced by bovine milk protein ingestion.

Seven allergic patients with bovine milk or milk protein-inducible transient intestinal malabsorption exhibited radiologic signs of rapid transit of ingested barium through the proximal small intestine hours following oral challenge with bovine milk or milk protein solution. Control studies in the same patients without prior milk challenge revealed significantly more leisurely progress of contrast medium in the proximal small bowel. The possible pathogenetic role of such hasty transit through the functionally most effective portion of the digestive tract in patients with malabsorption points up the physiologic importance of roentgen examination of motility patterns in this particular segment of small bowel.