Pancreatic enzyme therapy in childhood celiac disease

The validity of pancreatic enzyme substitution therapy in the two months following diagnosis of celiac disease was investigated. Twenty patients (8 males, 12 females), mean age 14.2 months (group A) received an enzyme substitution preparation. The control group (group B) included 20 patients (9 males, 11 females), mean age 14.5 months, treated with placebo. Before starting treatment, we performed a stratification for age, weight-for-age at diagnosis, and degree of pancreatic insufficiency. The therapies were then administered randomly in double-blind fashion. On diagnosis and 30 and 60 days after commencement of a gluten-free diet with identical calorie intake in both groups, a series of anthropometric variables were determined. After 30 days weight increase in group A patients was significantly higher (in grams) than in group B: 1131±461 vs 732±399 (P<0.006). Weight-for-age increase also was greater in group A than in group B: 9.2±5.1% vs 5.0±4.0% (P<0.002). The increase in height Z score, weight-for-height, arm circumference, and subscapular and tricipital fold measurements were greater in group A patients than those in group B, but the difference was not significant. After 60 days of therapy none of the parameters considered were significantly different in the two groups. We concluded that pancreatic enzyme therapy is certainly useful in the first 30 days after diagnosis of celiac disease.     

增龄与肾功能不全对老年人营养状况的影响

目的评价不同肾功能水平老年患者的营养状态及其影响因素。方法回顾性分析2016年9月至2017年2月在南京医科大学第一附属医院老年肾科住院的患者189例。依据微型营养评估简表(MNA-SF)评分结果分为3组:营养正常组(12~14分)、营养不良危险组(8~11分)和营养不良组(0~7分)。比较各组临床资料。采用SPSS 20.0软件进行数据分析。根据数据类型分别采用t检验或X~2检验比较组间差异。营养不良发生的危险因素采用logistic回归分析。结果 189例患者中,营养不良组10例,占5.3%;营养不良风险组58例,占30.7%;营养正常组121例,占64.0%。与营养正常组相比,营养不良风险组和营养不良组患者的体质量指数(BMI)、白蛋白(ALB)、红细胞计数、血红蛋白(Hb)和淋巴细胞计数百分比均显著降低(P0.05),而营养不良组患者的中性细胞计数百分比显著增加(P0.05)。不同营养状况患者的年龄分布、肾功能及贫血状况差异均有统计学意义(P0.05)。多因素回归分析表明,高龄(OR=1.06,95%CI 1.00~1.12)、低估算肾小球滤过率(OR=0.97,95%CI 0.94~1.00)、低BMI(OR=0.76,95%CI0.65~0.87)、低ALB(OR=0.93,95%CI 0.86~0.99)和贫血(OR=2.46,95%CI 1.60~3.32)是患者发生营养不良及营养不良风险的危险因素。结论增龄与肾功能不全可能增加营养不良风险及营养不良的发生率,且营养不良也与患者的BMI、ALB水平及贫血严重程度相关。     

Assessing nutritional status in children with chronic liver disease

The metabolic changes compounded by anorexia associated with chronic liver disease adversely affect growth in children. In many cases, this requires the administration of artificial nutritional support. It is important in this group of patients that those who are becoming nutritionally depleted are identified quickly and in those receiving artificial nutritional support, the effectiveness is monitored. The current review is an examination of methods available to assess nutritional status. These include anthropometry, methods available in the laboratory and a selection of less commonly used methods undergoing evaluation at research level. A brief discussion accompanies each technique, outlining the limitations of its use in children with chronic liver disease. The review concludes with an outline of how nutritional status should be assessed in this group of children, and suggests further research.     

Value of endoscopic markers in celiac disease

Duodenoscopy in celiac disease has identified several markers of the disease. Our aim was to evaluate, in a prospective study, the usefulness of the different endoscopic features in 100 consecutive cases referred to endoscopy for intestinal biopsy. Histological examination of duodenal samples showed severe villous atrophy (grade III/IV) in 36 patients. Of these patients, 34 had endoscopic markers suggestive of celiac disease. These were reduction in number or loss of Kerkring's folds (in 27), mosaic pattern (14), scalloped folds (12), and visibility of the underlying blood vessels (5). Endoscopic visualization of these markers had a sensitivity of 94%, a specificity of 92%, and a positive predictive value of 84%. Reduction in number, or loss of, Kerkring's folds was the most sensitive (76%) and specific (98%) single endoscopic change indicating celiac disease. Duodenoscopy permitted diagnosis in three of four asymptomatic patients in a group of 24 first-degree relatives of celiac disease patients. We conclude that endoscopy of distal duodenum is a sensitive and specific indicator of celiac disease.     

Nutritional consequences of celiac disease and the gluten-free diet

Celiac disease is a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals and represents a major health issue. The immune mediated response results in villous atrophy of the small intestine with subsequent malabsorption. The classic mode of presentation is that of a malabsorption syndrome resulting in deficiencies of macro and micronutrients. The gluten-free diet is the only treatment currently available for this disorder. The aim of this special report is to elucidate and explain the various nutritional deficiencies seen in newly diagnosed patients with celiac disease and while on the gluten-free diet. Though initiation of the gluten-free diet results in improvement of symptoms and most deficiencies, certain nutritional limitations are associated with the gluten-free diet.     

慢性阻塞性肺疾病肺功能、CAT评分等与营养状况的相关性

目的探讨慢阻肺患者肺功能、血气分析、CAT评分与营养状况的关系。方法将我院2012年6月-2014年6月间收治的500例慢阻肺患者按微型营养评定法进行营养状况评定,分为营养良好组、营养不良危险组、营养不良组,比较不同营养状况下慢阻肺患者的肺功能及CAT评分,探讨慢阻肺肺功能、血气分析、CAT评分与营养状况的相关性。结果营养状况越好的患者,肺功能各项指标越好,FVC%、FEV1%、MVV%、MMF%越高(P0.01);患者营养状况越好,血气分析越好,PaO2、SaO2越高,PaCO2越低(P0.01);CAT评分也越低(P0.01);通过对各指标与MNA值的Pearson相关分析得出,FEV1%、MVV%、MMF%、PaO2与MNA值呈正相关,PaCO2、CAT与MNA值呈负相关。结论慢阻肺患者的肺功能、血气分析、CAT评分与营养状况间存在显著相关性,提高患者的营养状况可有效改善患者的病情与预后。     

慢性阻塞性肺疾病患者血清脂联素与营养状况、炎症因子的相关性

目的探讨慢性阻塞性肺疾病(简称慢阻肺)患者血清脂联素与其营养状况、炎症因子的相关性。方法慢阻肺患者58例为病例组,健康人群30例为健康对照组,检测两组的血清脂联素、肿瘤坏死因子-α水平,及营养指数评分系统,评估受试者的营养状况,对比两组受试者MNI评分结果。结果病例组营养不良的发生率为46.55%,显著高于健康对照组(P0.05);病例组的%IBW为(86.27±9.82)%,上臂肌围为(23.41±3.58)cm,血清脂联素水平为(8.04±3.91)μg/L,均显著低于健康对照组,而肿瘤坏死因子-α水平为(20.89±2.49)ng/L,显著高于健康对照组(均P0.05)。结论慢阻肺患者血清脂联素水平和肿瘤坏死因子水平呈负相关关系,血清脂联素参与患者营养状况和炎症反应的调节。     

Capsule endoscopy in celiac disease

Video capsule endoscopy is an attractive and patient- friendly tool that provides high quality images of the small bowel. Obscure gastrointestinal bleeding is the primary and most evaluated indication to capsule endoscopy; however, indications are expanding and a small number of preliminary reports have been presented concerning the role of video capsule endoscopy in the diagnosis of celiac disease. The purpose of this review is to update the current knowledge and to hypothesize on future perspectives of the use of video capsule endoscopy in patients with celiac disease.     

Adult celiac disease in the elderly

There is an increased awareness that celiac disease may occur in the elderly although presentations with either diarrhea, weight loss or both may be less common causing delays in diagnosis for prolonged periods. Higher detection rates also seem evident owing to active case screening, largely through serodiagnostic measures. In some elderly patients who are genetically predisposed, it has been hypothesized that celiac disease might be precipitated late in life by an antigen, possibly from an infectious agent. As a result, peptide mimicry or other poorly-defined mechanisms may precipitate an autoimmune gluten-dependent clinical state. Although diarrhea and weight loss occur, only isolated iron deficiency anemia may be present at the time of initial diagnosis. In addition, the risk of other autoimmune disorders, particularly autoimmune thyroiditis, and bone disease, are increased. Osteopenia may also be associated with an increased risk of fractures. Finally, elderly celiacs have an increased risk of malignant intestinal disease, especially lymphoma.     

Markers of nutritional status and mortality in older adults: The role of anemia and hypoalbuminemia

Aim

The aim of the present study was to analyze the impact of anemia and hypoalbuminemia on mortality in a 5‐year period.

Methods

This was longitudinal population‐based observational survey part of the Saúde, Bem‐Estar e Envelhecimento study (Health, Well‐being and Aging), carried out with 1256 older adults from the third wave of the cohort, followed for 5 years, when they were contacted for the fourth wave, in Sao Paulo, Brazil. Anemia was defined when hemoglobin was <12 g/dL for women and <13 g/dL for men, and hypoalbuminemia when serum albumin was <3.5 g/dL. Survival functions were estimated according to nutritional status in four groups: (i) without nutritional alteration; (ii) anemia only; (iii) hypoalbuminemia only; and (iv) anemia and hypoalbuminemia. Hazard ratios were calculated, following the Cox proportional hazards model, controlling for baseline covariates. All analyses considered sample weights, and were carried out using the Stata 12.

Results

After the 5‐year period, 12.3% of the participants died, and 8.2% were lost to follow up. Those who died had lower hemoglobin and albumin concentrations (13.4 g/dL and 3.7 g/dL) compared with survivors (14.3d/dL and 3.9 g/dL; P < 0.001). The crude death rate was 27.6/1000 person‐years for participants in group i, 124.3 in group ii, 116.0 in group iii and 222.8 in group iv (P < 0.001). In the final Cox models, group 2 and 3 had a similar effect (hazard ratio 2.23, P = 0.020; 2.53, P = 0.005; respectively) and group 4 had a higher risk (hazard ratio 3.36; P = 0.004).

Conclusions

Anemia and hypoalbuminemia are important markers for death in older adults, and have an additive effect on mortality. Because they are common and cost‐effective biomarkers, their use should be encouraged in geriatric evaluation for all health professionals and in population settings, such as primary care. Geriatr Gerontol Int 2018; 18: 177–182 .     

Eosinophilic esophagitis in children with celiac disease

Background and Aims:  Eosinophilic esophagitis and celiac disease are distinct gastrointestinal disorders. The present study in children highlights the possible coexistence of these two conditions. This study also analyzes the epidemiological and clinical profiles of these patients.
Methods:  The medical records of patients diagnosed with celiac disease from 1 April 1999 to 31 March 2007 were reviewed. Patients with coincident histological diagnosis of eosinophilic esophagitis were retrospectively identified. The presenting symptoms, laboratory evaluations, endoscopic and histopathological findings, and treatment and follow-up outcomes of these patients were analyzed.
Results:  Of the 221 patients with celiac disease, seven (3.2%) were also diagnosed with eosinophilic esophagitis. A majority (6/7) presented with periumbilical pain and diarrhea. None had dysphagia. Each patient had abnormal celiac screening tests. Three patients had peripheral blood eosinophilia and elevated eosinophil cationic protein. Endoscopic changes of eosinophilic esophagitis and celiac disease were apparent in the majority of patients (6/7). A gluten-free diet was instituted in every patient. Topical corticosteroid therapy was started in one patient at diagnosis and in another patient after repeat endoscopic and histopathological evaluations.
Conclusions:  Awareness of the potential coexistence of eosinophilic esophagitis and celiac disease should promote optimal diagnosis of these conditions. Routine esophageal biopsies may be warranted when investigating for celiac disease.     

Pancreatic endocrine and exocrine changes in celiac disease

Although there is a great deal of information on celiac disease and associated involvement of other nonintestinal sites, data on concomitant changes in the structure and function of the pancreas is limited. The present review critically examines pancreatic endocrine changes that have been well documented in the literature, including insulin-dependent diabetes mellitus. Pancreatic exocrine alterations may also occur, and if severe, marked malnutrition with pancreatic failure and ductal calcification have been observed. Finally, other pancreatic disorders have been recorded with celiac disease.     

Liver transplantation in a child with celiac disease

Recently, an atypical form of celiac disease (CD) has been identified, in which gastrointestinal symptoms are less pronounced. Other organs can be more or less severely affected, and the disease might be unrecognized and undiagnosed. In some cases, hypertransaminasemia has been indicated as the first symptom of CD in infancy. A direct relationship between liver damage and glutensensitivity has been proven by the disappearance of biochemical signs and histological lesions of the liver after the initiation of the gluten-free diet. The present case report is of a 14-year-old girl affected by CD and severe hepatic failure who underwent a liver transplant. To our knowledge, this case is the first report of liver involvement related to CD which is so severe as to require a liver transplant in a child. Because most patients with CD remain undiagnosed, and, as observed in the present report, untreated CD with subclinical hepatic involvement can lead to more serious liver disease, a more aggressive diagnostic work-up for CD in the general population is warranted.     

Pancreatic involvement in celiac disease

Celiac disease (CD) is well recognized as a systemic, chronic autoimmune disease mainly characterized by gluten-sensitive enteropathy in genetically predisposed individuals but with various extraintestinal features. One of the affected organs in CD is the pancreas, consisting of both endocrine and exocrine alterations. Over the last decades there has been increasing interest in the pancreatic changes in CD, and this has been reflected by a great number of publications looking at this extraintestinal involvement during the course of CD. While pancreatic endocrine changes in CD, focusing on type 1 diabetes mellitus, are well documented in the literature, the relationship with the exocrine pancreas has been less studied. This review summarizes currently available evidence with regard to pancreatic exocrine alterations in CD, focusing on risk of pancreatitis in CD patients, association with autoimmune pancreatitis, prevalence and outcomes of pancreatic exocrine insufficiency in newly diagnosed and gluten-free diet treated CD patients, and the link with cystic fibrosis. In addition, we discuss mechanisms behind the associated pancreatic exocrine impairment in CD and highlight the recommendations for clinical practice.     

Refractory celiac disease: an unusual disease in a Chinese patient

Celiac disease (CD) is an autoimmune disease characterized by mucosal inflammation and villous atrophy of the small bowel upon exposure to ingested gluten. Although common in developed countries, it is extremely rare in the Chinese population. Refractory celiac disease (RCD) is a rare complication of CD with poor prognosis. Patients may die of severe malabsorption or development of enteropathy-associated T-cell lymphoma. We report a case of RCD in a Chinese woman who required steroid therapy in addition to a gluten-free diet to induce disease remission. The possibility of CD in Chinese patients should not be overlooked.     

老年慢性阻塞性肺疾病患者营养状况调查

目的 应用微型营养评定（MNA）、人体测量学和实验室检查指标调查和分析老年慢性阻塞性肺疾病（COPD）患者非住院期间营养状况.方法 58例老年COPD患者在非住院期间接受MNA的问卷调查、人体测量学检测和临床实验室检查.结果 （1）根据MNA得分,老年COPD患者中营养不良和营养不良高危人群的发生率分别是6.9%和60.3%.（2）根据体质指数（BMI）、三头肌皮褶厚度（TSF）、中臂肌围（AMC）的测量值老年COPD患者营养不良发生率分别为55.2%、31%、24.1%.（3）根据血浆前白蛋白、血浆白蛋白相淋巴细胞计数显示老年COPD患者营养不良发生率分别是13.8%、31%、49.9%.结论 （1）老年COPD患者营养不良和营养不良的高危状态的发生率较高,必须加强营养干预.（2）提倡在老年COPD患者中应用MNA问卷进行营养状态评估,以供临床参考.