Gluten-free diet does not appear to induce endoscopic remission of eosinophilic esophagitis in children with coexistent celiac disease

BACKGROUND:

Celiac disease and eosinophilic esophagitis are usually considered to be separate gastrointestinal diseases; however, it appears that they may coexist more often than would be expected. It is unknown whether eosinophilic esophagitis in patients with celiac disease responds to a gluten-free diet.

OBJEVTIVES:

To examine the clinical, endoscopic and histological features of children with both conditions to evaluate whether eosinophilic esophagitis responds to a gluten-free diet.

METHODS:

From January 1, 2009, to June 30, 2011, the medical records of children <18 years of age diagnosed with eosinophilic esophagitis and/or celiac disease were reviewed. Patients with clinical, endoscopic and histological diagnoses of both diseases were identified and included. These findings were analyzed, as were laboratory results, treatment and follow-up.

RESULTS:

During the study period, there were 206 celiac disease patients, 86 eosinophilic esophagitis patients and nine (4.4% of total celiac) patients with both diagnoses. Gluten-free diet was the primary treatment for both conditions in seven of nine (78%) cases. In six of these seven (86%) patients, no endoscopic or histological improvement of eosinophilic esophagitis was observed, while in one patient, histological remission of esophageal eosinophilia occurred while on a gluten-free diet.

CONCLUSION:

The prevalence of eosinophilic esophagitis in patients with celiac disease was 4.4%, confirming a higher than expected prevalence of eosinophilic esophagitis compared with the general population. In patients with celiac disease, a gluten-free diet did not appear to induce remission of coexistent endoscopic and histological features of eosinophilic esophagitis.     

Cervical esophageal web and celiac disease

Background and Aim:  There is paucity of prospective data on association between cervical esophageal webs and celiac disease. It is not clear whether all patients with cervical esophageal web need screening for celiac disease. Hence, the present study was carried out to determine the association of cervical esophageal web with celiac disease.
Methods:  This prospective study included consecutive patients with symptomatic cervical esophageal web diagnosed over a period of 4.5 years. Tissue transglutaminase antibody was measured in serum of each patient. Patients with elevated tissue transglutaminase antibody titer were subjected to esophagogastroduodenoscopy and biopsies were obtained from the descending duodenum to look for histological changes of celiac disease. Esophageal web was treated with bougie dilatation. Celiac disease was diagnosed on the basis of elevated tissue transglutaminase antibody and suggestive duodenal histology.
Results:  Twenty one patients were diagnosed to have cervical esophageal web. Eighteen (85.7%) had evidence of iron deficiency. Five (23.8%) patients with cervical esophageal web fulfilled criteria for diagnosis of celiac disease. All five had evidence of iron deficiency. None of these patients gave a history of chronic diarrhea. All patients were treated with bougie dilatation. Patients with celiac disease were advised of a gluten-free diet. All five celiac disease patients are free of dysphagia without recurrence after a mean follow up of 10 months (range: 3 to 16 months).
Conclusions:  There is association between cervical esophageal web and celiac disease. All adult patients with cervical esophageal web and iron deficiency need screening for celiac disease even in the absence of chronic diarrhea.     

Metabolic risk factors associated with erosive esophagitis

Background and Aim:  Our aim was to determine associations between metabolic risk factors and erosive esophagitis.
Methods:  In this retrospective case-control study, diagnosis of erosive esophagitis was based on the Los Angeles classification. Endoscopic findings in subjects with erosive esophagitis were reviewed by two experienced endoscopists and those with agreement of diagnosis were enrolled for study. Body mass index (BMI), abdominal girdle, blood pressure, and serum triglyceride, glucose, and β-lipoprotein levels were compared between individuals with and without erosive esophagitis. Multivariate binary logistic regression analysis was used to identify independent metabolic risk factors associated with erosive esophagitis.
Results:  Between October 2004 and April 2006, 518 of 4206 subjects who underwent endoscopic examination were diagnosed as having erosive esophagitis. After expert review, 427 (male : female = 365:62) individuals met the study criteria of having erosive esophagitis (10.5%). Compared with age- and gender-matched controls, patients with erosive esophagitis had significantly higher BMI, abdominal girdle, blood pressure, and triglyceride levels, and lower levels of high density lipoprotein (HDL) cholesterol ( P  < 0.05). More subjects with metabolic syndrome had erosive esophagitis than without metabolic syndrome (OR: 1.76, 95% CI: 1.27–2.44, P  = 0.001). Multivariate logistic regression analysis revealed that central obesity (OR: 1.41, 95% CI: 05-1.89, P  = 0.023) and hypertriglyceridemia (OR: 1.57, 95% CI: 1.19–2.13, P  = 0.004) were significantly associated with erosive esophagitis.
Conclusions:  Obesity and hypertriglyceridemia, which are key components of metabolic syndrome, are moderate independent risk factors for erosive esophagitis.     

Helicobacter pylori eradication may induce de novo, but transient and mild, reflux esophagitis: Prospective endoscopic evaluation

Backgrounds and Aim:  The effect on reflux esophagitis of eradicating Helicobacter pylori is variable and not fully defined. We previously reported that in patients who have reflux esophagitis associated with duodenal ulcer, a significant improvement in the pre-existing reflux esophagitis occurred after H. pylori was eradicated. In the present study, we asked whether H. pylori eradication leads to de novo development of reflux esophagitis in peptic ulcer patients.
Methods:  Prospective post-eradication evaluations were conducted in 1195 H. pylori -positive patients with peptic ulcer diseases who were confirmed not to have reflux esophagitis by endoscopic examination before eradication therapy. After eradication therapy, endoscopy and a urea breath test were performed yearly.
Results:  A total of 1187 patients were followed for up to 10.0 years (a mean of 3.6 years). Reflux esophagitis developed in 279 of 1000 patients cured of infection and in 26 of 187 patients who had persistent infection ( P  < 0.0001, Fisher's exact test). The esophagitis was mild (Los Angeles grade A) in most patients, transient in approximately one-half, and rarely necessitated long-term medication for the condition. Cure of infection, alcohol consumption, younger age, and high body mass index were identified as significant factors for the risk of developing non-transient reflux esophagitis.
Conclusions:  Cure of H. pylori infection may increase the risk of developing reflux esophagitis in patients with peptic ulcer, but the esophagitis is mostly mild and transient, and long-term medication is rarely required. Thus, H. pylori eradication therapy need not be withheld for fear of provoking reflux esophagitis.     

Does magnifying endoscopy improve the diagnosis of erosive esophagitis?

Background and Aims:  Low-grade erosive esophagitis (i.e. Los Angeles grade A) is the most predominant type of esophagitis in Japan. It is unclear whether all the mucosal breaks detected by conventional endoscopy are indicative of esophageal mucosal erosion. Hospital-based, cross-sectional, cross-over, observational study was assigned to investigate the value of magnifying endoscopy for diagnosis of erosive esophagitis.
Methods:  From August to December 2006, 178 consecutive patients with upper gastrointestinal symptoms were enrolled at three university hospitals and one national medical center in western Japan. Before endoscopy, all participants were requested to answer questionnaires concerning their symptoms. Experienced endoscopists performed an endoscopic diagnosis of each patient first with a conventional standard view and then with a magnifying view. Endoscopic diagnostic concordance between conventional and magnifying endoscopic view for erosive esophagitis was calculated. Relationship between a variety of symptoms and erosive esophagitis was also evaluated.
Results:  Erosive esophagitis was identified using conventional and magnifying endoscopy in 14.6% and 17.4% of patients, respectively. Eleven false-negative and six false-positive diagnoses using conventional endoscopy occurred among the 178 enrolled patients. The weighted kappa value of diagnostic concordance for erosive esophagitis between the two endoscopic views was 0.76. The prevalence of erosive esophagitis in patients with reflux-, dysmotility-, and ulcer-like symptoms was 20.7%, 24.1%, and 15.2%, respectively.
Conclusions:  Magnifying endoscopy did not significantly improve the diagnostic sensitivity of erosive esophagitis over non-magnifying, conventional endoscopy. Erosive esophagitis was frequently identified in patients that did not have reflux symptoms.     

Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years

BACKGROUND & AIMS: Primary eosinophilic esophagitis is a chronic, increasingly recognized, interleukin 5-driven inflammatory disorder of the esophagus. The leading symptom in adults is uniform attacks of dysphagia, and the established histologic sign is a dense eosinophilic infiltration of the esophageal epithelium. Before this study, the natural course of eosinophilic esophagitis had not been defined and information regarding potential long-term risks was lacking. METHODS: This prospective case series included 30 adult patients with eosinophilic esophagitis (22 men and 8 women; mean age, 40.6 years) whose diagnosis had been made >1 year before study debut based on typical history, consistent endoscopic abnormalities, and infiltration of the esophageal epithelium with >24 eosinophils/high-power field. After a mean of 7.2 years, patients underwent a comprehensive follow-up examination. RESULTS: All patients survived the study period in good health and stable nutritional state. Dysphagia persisted in 29 patients, exerting a major negative effect on socioprofessional activities on 1 patient and a minor impact on 15. Attacks of dysphagia were more frequent in patients with blood eosinophilia or pronounced endoscopic alterations. The esophageal eosinophilic infiltration persisted in all symptomatic patients, but cell numbers spontaneously decreased significantly (78.7 vs. 40.3 cells/high-power field). The inflammatory process evoked fibrosis of the esophageal lamina propria but did not spread to the stomach or duodenum. No case evolved to a hypereosinophilic syndrome. CONCLUSIONS: Eosinophilic esophagitis, a primary and chronic disease restricted to the esophagus, leads to persistent dysphagia and structural esophageal alterations but does not impact the nutritional state. To date, no malignant potential has been associated with this disease.     

Systematic review: Eosinophilic esophagitis in Asian countries

AIM: To investigate the prevalence and the clinical characteristics of Asian patients with eosinophilic esophagitis.METHODS: We conducted a systematic search of the PubMed and Web of Science databases for original studies, case series, and individual case reports of eosinophilic esophagitis in Asian countries published from January 1980 to January 2015. We found 66 and 80 articles in the PubMed and Web of Science databases, respectively; 24 duplicate articles were removed. After excluding animal studies, articles not written in English, and meeting abstracts, 25 articles containing 217 patients were selected for analysis.RESULTS: Sample size-weighted mean values were determined for all pooled prevalence data and clinical characteristics. The mean age of the adult patients with eosinophilic esophagitis was approximately 50 years, and 73% of these patients were male. They frequently presented with allergic diseases including bronchial asthma, allergic rhinitis, food allergy, and atopic dermatitis. Bronchial asthma was the most frequent comorbid allergic disease, occurring in 24% of patients with eosinophilic esophagitis. Dysphagia was the primary symptom reported; 44% of the patients complained of dysphagia. Although laboratory blood tests are not adequately sensitive for an accurate diagnosis of eosinophilic esophagitis, endoscopic examinations revealed abnormal findings typical of this disease, including longitudinal furrows and concentric rings, in 82% of the cases. One-third of the cases responded to proton pump inhibitor administration.CONCLUSION: The characteristics of eosinophilic esophagitis in Asian patients were similar to those reported in Western patients, indicating that this disease displays a similar pathogenesis between Western and Asian patients.     

Is Barrett's esophagus characterized by more pronounced acid reflux than severe esophagitis?

Objective: Barrett's esophagus is related to gastroesophageal reflux disease (GERD). However, only a small fraction of patients with GERD develop Barrett's esophagus. We evaluated whether gastroesophageal acid reflux is more pronounced in Barrett's patients than in patients with moderate or severe endoscopic esophagitis.
Methods: Retrospective evaluation of results of esophageal manometry and 24 hour ambulatory pH monitoring performed between 1990 and 1996 at the Leiden University Medical Center in those patients who also underwent endoscopy ≤3 months before pH-metry. Included were 51 patients with Barrett's esophagus, 30 patients with severe esophagitis, 45 patients with moderate esophagitis, and 24 healthy control subjects.
Results: Patients with Barrett's esophagus had significantly increased acid reflux time (   p < 0.01  –0.05) compared to patients with moderate, but not compared to patients with severe esophagitis. Distal esophageal body motility and LES pressure were significantly (   p < 0.01  –0.05) reduced in patients with Barrett's esophagus compared to patients with moderate esophagitis but not compared to those with severe esophagitis.
Conclusion: Although acid reflux is increased in patients with Barrett's esophagus and esophageal motility is impaired, other factors apart from acid exposure and motility contribute to the development of Barrett's esophagus.     

Antroduodenojejunal motor activity in untreated and treated celiac disease patients

Background and Aim:  Patients with celiac disease may present with abnormal upper gut motor activity. However, it is not known if these abnormalities persist after the introduction of a gluten-free diet. The present study aimed to compare antroduodenojejunal motor variables recorded in untreated celiac patients with those of celiac patients given a gluten-free diet and healthy volunteers.
Methods:  Eleven untreated celiac disease patients, 12 age- and sex-matched celiac patients on a gluten-free diet (at least 12 months), and 33 controls entered the study. Antroduodenojejunal motility was recorded for 6 h during fasting and for 3 h after a standard meal by means of a perfused, multiple lumen catheter.
Results:  More than 80% of untreated celiac patients had discrete motor abnormalities of the upper gut, in both fasting and fed recordings, compared to the other subjects. Patients on a gluten-free diet also showed motor abnormalities, albeit to a lesser extent. In these patients histological evaluation showed the persistence of mild mucosal abnormalities.
Conclusions:  Upper gut motor abnormalities are frequent in patients with celiac disease, even in those on a gluten-free diet. In the latter group, these abnormalities may suggest an incomplete adherence to the dietary regimen.     

Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features

BACKGROUND: Eosinophilic esophagitis is an inflammatory condition in which there is dense eosinophilic infiltration of the surface lining of the esophagus. Reports of eosinophilic esophagitis pertain almost exclusively to pediatric populations. However, eosinophilic esophagitis is emerging as a clinical affliction of adults. This report describes the clinical and endoscopic findings of eosinophilic esophagitis in the largest cohort of adult patients reported to date. METHODS: Twenty-nine patients (21 men, 8 women; mean age 35 years) with documented eosinophilic esophagitis (>/=15 eosinophils per high-power field in biopsy specimens) and a significant history of chronic dysphagia for solid food (24 patients) were evaluated clinically and endoscopically during a 3-year period (1999-2002). Fourteen patients (48%) had a history of asthma, environmental allergy, or atopy. In a subset of 15 patients, the diagnostic accuracy of endoscopy was compared with that of barium contrast esophagography. RESULTS: Twenty-seven patients (93%) had abnormal endoscopic findings; 25 (86%) had unique esophageal structural changes, associated with a preserved mucosal surface, that were highly atypical for acid reflux injury. Structural alterations seen in adult patients with eosinophilic esophagitis may occur in combination or as a primary characteristic, e.g., uniform small-caliber esophagus, single or multiple corrugations (rings), proximal esophageal stenosis, or 1 to 2 mm whitish vesicles scattered over the mucosal surface. Barium contrast radiography combined with swallow of a barium-coated marshmallow identified 10 (67%) of the primary features observed endoscopically in 15 patients. However, radiography failed to detect other features noted at endoscopy (e.g., only 3/6 patients with proximal stenosis, 5/9 patients with concentric rings and none of 4 patients with small caliber esophagus). Eight of the 29 patients (20%) had a history of chronic heartburn. Twelve patients had been treated with a proton pump inhibitor and only 3 reported some improvement in the severity of dysphagia. CONCLUSIONS: Relatively young age, a history of chronic dysphagia for solid food, and endoscopic detection of unique structural alterations atypical for GERD in an adult patient should prompt a suspicion of EE and subsequent biopsy confirmation. Acid reflux appears to have a secondary role in eosinophilic esophagitis. In an uncontrolled comparison, endoscopy was superior to barium contrast radiography for the diagnosis of eosinophilic esophagitis. The incidence of eosinophilic esophagitis in adults appears to be increasing.     

Gastroscopy in immigrants of Turkish descent

Background and Aim:  Little data is known on morbidity and Helicobacter pylori in the upper part of the gastrointestinal tract in male and female patients of Turkish descent. A study was done in order to assess the presence of H. pylori in Turkish men and women in relation to the diagnostic yield of the endoscopy.
Methods:  All consecutive patients of Turkish descent were included in the present study. Detection of H. pylori was done with hematoxylin–eosin stain, an immunoperoxidase and Gram stain and culture.
Results:  In 16 years, 2427 procedures (10.4%) were done in Turkish patients. After exclusions, 842 endoscopies in Turkish women and 827 procedures in Turkish men remained. Peptic ulcer disease was diagnosed in 101 (6%) patients and reflux esophagitis in 97 patients (5.8%). Seven patients had cancer. In 749 patients (64%), no macroscopic abnormalities were seen. Turkish men suffered more often from reflux esophagitis (81% vs 19%, P  < 0.0001), hiatus hernia (58% vs 42%, P  < 0.0001) and peptic ulcer disease (74% vs 26%, P  < 0.0001). Women more often showed no abnormalities ( P  < 0.0001). There was no change in the yearly prevalence of reflux esophagitis and peptic ulcer disease in women, while the peptic ulcers decreased, and reflux esophagitis increased in men. Men were significantly more often H. pylori -positive ( P  = 0.03). There was a clear trend towards a decrease in H. pylori -positives.
Conclusion:  There are differences in the presence of ulcer disease and reflux esophagitis between Turkish men and women. Men are significantly more often H. pylori -positive. Prevalence of H. pylori infection in Turkish patients slowly decreases in the consecutive years in both men and women.     

A Japanese case of lymphocytic esophagitis

We report the case of a 68‐year‐old Japanese man diagnosed with lymphocytic esophagitis (LE), a rare disease associated with refractory dysphagia. He has had severe dysphagia and heartburn since 2007. Findings of esophagogastroduodenoscopy (EGD) carried out by a local physician in 2010 showed pale mucosa with white exudate and lateral furrows in the esophagus. He was referred to Tohoku University Hospital in 2012, because the symptoms did not improve, despite regular use of a proton pump inhibitor (PPI). At that time, EGD revealed the coexistence of a slight stricture in the upper esophagus, the histopathological findings of which included a predominantly peri‐papillary distribution of abundant, infiltrating CD3⁺/CD4⁺/CD8⁺/CD20^? lymphocytes without any granulocytes (CD4⁺ : CD8⁺ = 3.3:1). These were consistent with a diagnostic criteria of LE. Thereafter, severe dysphagia with food impaction occurred twice a month, despite the long‐term use of a PPI, and EGD showed worsened strictures, where endoscopic ultrasonography findings showed marked circumferential thickness of the mucosal and submucosal layers. Then, one session of endoscopic balloon dilatation dramatically improved the dysphagia. Accordingly, LE should be considered an important differential diagnosis of refractory dysphagia based on the characteristic features of endoscopic and pathological findings.     

Eosinophilic Esophagitis in Patients with Refractory Gastroesophageal Reflux Disease

Background Eosinophilic esophagitis is among the causes of refractory reflux disease. Biopsy of esophagus is the gold standard for diagnosis. In this study we determined the frequency of eosinophilic esophagitis (EE) in refractory reflux cases referred to Motility Department of Shahid Beheshti Research Center of Gastroenterology and Liver Disease, Tehran, Iran. Methods In this cross-sectional study, 68 cases with refractory reflux disease underwent endoscopy and had biopsies taken. Specimens were stained by hematoxylin and eosin and two independent pathologists confirmed the diagnosis of eosinophilic esophagitis. Results Mean (standard deviation, SD) age at diagnosis was 41.8 (10.94) years. All had allergy or atopy, and unknown dysphagia was noted for 66%. Endoscopic findings were as follows: esophagitis (33.3%), rings (33.3%), and whitish plaques (33.3%). Prevalence of eosinophilic esophagitis was 8.8% (N = 6; one man and five women). No statistical difference in demographic variables was found between eosinophilic esophagitis cases and others, except for history of atopy, food impaction, and endoscopic features (P value <0.005). Conclusion Eosinophilic esophagitis should be considered in the differential diagnosis of any cases with refractory reflux who complain of chronic unexplained dysphagia, with history of recurrent food impaction, and atopy or abnormal endoscopic features.     

Clinical and endoscopic features of eosinophilic esophagitis in adults

BACKGROUND: Eosinophilic esophagitis in adults is regarded as unusual, being diagnosed mostly in young men presenting with dysphagia. Mucosal furrows are a sentinel endoscopic feature. This study examined the demographic and clinical profile of adults with eosinophilic esophagitis seen from 1981 to 2002. METHODS: All patients from an Australian provincial city (population 198,000) with otherwise unexplained eosinophilic inflammation of the squamous epithelium (>/=30 eosinophils per high-power field) were included in a retrospective review. RESULTS: A diagnosis of eosinophilic esophagitis was made in 31 patients (24 men, 7 women; mean age 34 years, range 14-77 years). The diagnosis was made in 19 (61%) of the 31 patients during the most recent 2 years (none between 1981 and 1994 vs. 12 between 1995-2000 vs. 19 between 2000-2001). Esophageal mucosal furrows were present in 30 (97%), a finding infrequently recognized before 2001. Dysphagia was documented in 26 (89%). Symptoms had been present for long periods before diagnosis (mean 54 months; range 0-180 months), and diagnosis was delayed in 7 (mean 81 months, range 20-144 months) because sentinel features were overlooked at endoscopy. Strictures, often evident only as a result of mucosal shearing during dilation, were present in 17 (57%). Esophageal dilation preformed in 17 (mean 3.4 dilations per patient, range 1-13) consistently relieved symptoms; tears were recorded in 13 (87%), but no serious complication resulted. CONCLUSIONS: Eosinophilic esophagitis in adults of all ages is more common than recognized. Mucosal furrows are easily overlooked at endoscopy although this finding is an important clue to diagnosis. Strictures, a frequent consequence, can be safely managed by dilation.     

Eosinophilic esophagitis in adults, an emerging cause of dysphagia. Description of 9 cases.

BACKGROUND: Eosinophilic esophagitis is a rare condition mainly affecting children, although the number of cases reported in adults is on the increase. It is characterized by intense infiltration of eosinophilic leukocytes in the esophageal mucosa, without involvement of other sections of the alimentary canal. MATERIAL AND METHODS: Over the past year, following the performance of endoscopies and biopsies, our service identified nine patients who were diagnosed with suffering from this disorder. Each patient sought medical help for episodes of long-term, self-limited dysphagia or food impaction in the alimentary canal. RESULTS: Endoscopy revealed esophageal stenosis in the form of simultaneous contraction rings or regular stenosis. In six cases, the manometric study showed a nonspecific motor disorder of severe intensity affecting the esophageal body, and another patient had a disorder characterized by the presence of simultaneous waves and secondary peristaltic waves in the three thirds of the organ. These disorders are presumably due to eosinophilic infiltration of the muscular layer or ganglionar cells of the esophagus, and account for symptoms in these patients. Although the etiopathogenesis of this illness is uncertain, it is clearly an immunoallergic manifestation. CONCLUSIONS: As the number of diagnosed cases is on the increase, eosinophilic esophagitis is in adults a specific entity within the differential diagnosis of dysphagia in young males with a history of allergies. Eosiniphilic esophagitis responds in a different number of ways to therapies used. We successfully used fluticasone propionate, a synthetic corticoid applied topically, which proved to be efficient in the treatment of this illness by acting on the pathophysiological basis of the process. It does not have any adverse effects, thus offering advantages over other therapies such as systematic corticoids or endoscopic dilations.     

A case of eosinophilic esophagitis with atypical clinical course

Eosinophilic esophagitis is a rare chronic disease that mainly occurs in middle-aged males. Treatment with a glucocorticoid and/or proton pump inhibitor is usually necessary to relieve unpleasant symptoms. An 83-year-old female patient with dysphagia and heartburn was diagnosed with eosinophilic esophagitis based on endoscopic findings, while histological examination identified dense infiltration of intraepithelial eosinophils. The symptoms and eosinophil infiltration spontaneously disappeared without any treatment approximately 2 months later. No obvious lifestyle or dietary changes to explain elimination of possible antigens were identified in this case. We report an atypical case of eosinophilic esophagitis with spontaneous regression.     

Correlation of Clinical and Histopathological with Endoscopic Findings of Celiac Disease in the Turkish Population

Endoscopic findings have been described for the diagnosis of celiac disease but the relationship amond the clinical presentation, endoscopic markers, and the degree of histopathological findings is not clear. Thirty patients who were thought to have celiac disease were included in this study. Biopsies taken from the duodenum were examined histopathologically. The relationship among the endoscopic, clinical, and histopathological findings were investigated. Partial villous atrophy was seen in 14 patients (46.6%), and subtotal and total villous atrophy were seen in 6 (20%) patients each. Eighty six percent of patients with a mosaic appearance, 76% of patients with the finding of loss of folds, and 90% of patients with scalloping on endoscopy had either partial villous atrophy, subtotal villous atrophy, or total villous atrophy on biopsy. We conclude that endoscopic findings in celiac disease can reveal valuable information both for diagnosis and for demonstration of the severity of the disease state.     

Esophageal Impairment in Adult Celiac Disease With Steatorrhea

Objective: A high prevalence of reflux esophagitis in celiac children and gut motor disorders in adult patients have been described. The aim of this study is to investigate the prevalence of esophageal symptoms and the esophageal motility pattern in adult celiac patients before and after gluten-free diet.
Methods: In 22 consecutive adult celiac patients, before and after gluten-free diet, and in controls we calculated an esophageal symptom score regarding heartburn, regurgitation, dysphagia, and chest pain, and performed esophageal manometry using a constantly perfused multilumen catheter.
Results: Patients were divided into two groups: with and without steatorrhea. Before gluten-free diet, the prevalence of esophageal symptoms was 45.5% in all patients, but was significantly higher in patients with steatorrhea than in those without and in 44 control subjects (80% vs 16.7% and 27%,   p < 0.05  ). Lower esophageal sphincter pressure was 17.5 ± 5.3 in all patients, but was significantly lower in patients with steatorrhea than in patients without steatorrhea and 11 controls subjects (13.1 ± 4.1 vs 21.0 ± 2.9 and 20.7 ± 3.7 mm Hg (mean ± SD,   p < 0.05  ). After the diet, the prevalence of esophageal symptoms diminished in all patients (9% vs 45.4%,   p < 0.05  ) and lower esophageal sphincter pressure, measured in 13 patients, increased (19.0 ± 3.7 vs 15.7 ± 5.3 mm Hg,   p < 0.05  ).
Conclusion: Adult celiac patients with steatorrhea present a higher prevalence of esophageal symptoms and a lowered lower esophageal sphincter pressure compared with celiac patients without steatorrhea and control subjects, but these phenomena can be reverted to control levels by gluten-free diet.     

Esophageal intra-abdominal ultrasonographic in children with gastroesophageal reflux: correlation between endoscopic and histopathologic data]

Gastroesophageal reflux disease has been very often in children and one of its most critical complications is the peptic esophagitis disease. The diagnosis of peptic esophagitis is obtained based on the endoscopic changes and the histologic features. The pressure reduction of the lower esophageal sphincter is one of the elements of the esophagitis pathogenesis. The pressure is related with the length of the esophageal abdominal segment, which can be measured by ultrasonography. The research presented in this paper aims to relate ultrasonographic measurements of esophageal abdominal segment length with endoscopic changes and with esophageal biopsy obtained from children with gastroesophagel reflux disease. We submitted 16 children with gastroesophagel reflux disease, between 10 and 156 months old (median 63.5 months old), to endoscopy and to esophageal biopsy. We verified the following results from endoscopy and biopsy: six of the 16 patients had endoscopic peptic esophagitis and, in five of these (six patients), the same diagnosis was confirmed by biopsy. Ten of the 16 patients had normal endoscopy, but the biopsy of four of these 10 patients showed histologic changes compatible with esophagitis. We observed no relationship between endoscopy and biopsy, when all degrees of histologic change were used to diagnose esophagitis. However, we found high relationship when the mild histologic changes were considered as only a consequence of the reflux. We verified the following results from ultrasonography: five of the six patients with endoscopic peptic esophagitis and all patients with esophagitis determined by biopsy (excluding those with mild histologic changes) had reduced esophageal abdominal segment length. In conclusion, we have found relationship between endoscopic changes and histologic features in the diagnosis of esophagitis and correlation between the reduced esophageal abdominal segment length and the presence of esophagitis.     

Aetiologies and outcomes of diffuse alveolar haemorrhage presenting as acute respiratory failure of uncertain cause

Background and objective:   Connective tissue diseases are the most common disorders causing diffuse alveolar haemorrhage (DAH) confirmed by open lung biopsy. However, it is not known whether these diseases are also the most common causes of DAH in patients presenting with the features of ARDS/acute lung injury (ALI). This study evaluated the frequency of concomitant disease in patients with ARDS/ALI and DAH.
Methods:   The sampling frame comprised all patients in a tertiary referral hospital diagnosed with ARDS/ALI and who underwent BAL between January 2000 and July 2006. The medical records of those patients who had BAL fluid findings compatible with DAH were reviewed.
Results:   Of the 97 patients diagnosed with ARDS/ALI and who underwent BAL, 27 had BAL fluid findings compatible with DAH. Sixteen of the 27 patients did not have connective tissue diseases (59%); of these 12 patients had concomitant haematological malignancies or solid tumours. Of the seven patients who presented with DAH and no known underlying disease, only two were subsequently diagnosed with a connective tissue disorder. The in-hospital mortality rate was 55% and 63% for patients with DAH with and without connective tissue diseases, respectively ( P  = 0.710).
Conclusions:   The majority of patients with DAH presenting with the features of ARDS/ALI did not have underlying connective tissue diseases. Concomitant malignancies were found frequently in these patients. The outcome did not differ between patients with DAH with or without connective tissue diseases.