New strategies for diagnosis and management of celiac disease

Celiac disease is a gastrointestinal disorder characterized by inflammation, leading to injury to the mucosal lining of the small intestine. The inflammation occurs when gliadin, a protein found in such gluten-containing foods as wheat, rye, and barley, is ingested by genetically susceptible individuals. The mucosal damage and subsequent malabsorption of nutrients leads to various complications. Researchers estimate that more than 2 million people in the United States have celiac disease-a prevalence that is greater than was previously believed. Approximately 60,000 Americans are diagnosed annually with celiac disease. Until recently, diagnosis has been complicated by the fact that the indicators of celiac disease are nonspecific. However, because of the development of new, easy-to-administer serology tests, diagnosis has become much less complicated. After conducting a review of the literature, the authors recommend a serologic testing sequence for diagnosis of celiac disease and urge that adults and children with an assortment of symptoms be tested for this disease. Common signs and symptoms of celiac disease include anemia, arthralgia, fatigue, infertility, neuropathy, and weight loss, in addition to such gastrointestinal symptomatology as abdominal pain, anorexia, bloating, constipation, and diarrhea. The only treatment for patients with celiac disease remains a gluten-free diet.     

Development of clinical celiac disease after pancreatoduodenectomy: a potential complication of major upper abdominal surgery

Background Celiac disease is a gluten-induced disease of global malabsorption. There is a subset of patients with celiac disease who are free of major symptoms but who have typical damage to the intestinal mucosa (silent disease). We present the case of a 50-year-old white woman with no clinical symptoms of celiac disease who developed diarrhea and weight loss 12 weeks after a pancreatoduodenectomy for ampullary cancer.Methods Microbiological and biochemical examination of the feces did not provide clues useful to diagnosis, and diarrhea was not affected by pancreatic enzyme replacement or administration of antiperistaltic drugs.Results Review of the pathologic specimen and blood tests were compatible with celiac disease.Conclusion This clinical scenario illustrates that subclinical celiac disease may be an underdiagnosed cause of malabsorption after major upper gastrointestinal surgery and should be considered in the differential diagnosis of diarrhea after pancreatoduodenectomy.     

Practical Approach to the Flattened Duodenal Biopsy

Celiac disease features duodenal intraepithelial lymphocytosis with or without villous atrophy. Lymphocytosis without villous atrophy will be proven to represent celiac disease in 10% to 20% of cases. The differential diagnosis is broad: Helicobacter pylori gastritis, NSAID injury and bacterial overgrowth are considerations. Lymphocytosis with villous atrophy is very likely to be celiac disease, but there are mimics to consider, including collagenous sprue, tropical sprue, drug injury, and common variable immunodeficiency. Histologic clues to a diagnosis other than celiac disease include paucity of plasma cells, excess of neutrophils, granulomas, and relative paucity of intraepithelial lymphocytes.     

Laparoscopic treatment of mucinous adenocarcinoma of jejunum associated with celiac disease. Case report

Mucinous adenocarcinoma of the small bowel is very rare, and only few cases have been described in the literature. Association of this tumor with celiac disease has never been published. The authors report a unique case of jejunal mucinous adenocarcinoma in which a concomitant celiac disease has been histologically recognized. The difficult diagnosis, the role of laparoscopic surgery and the relationship between small bowel tumors and celiac disease are discussed. A 49-year-old man presented with recurrent melena, nausea, vomiting and anemia. A stenosis of the jejunum was documented by means of CT scan and video capsule enteroscopy. A laparoscopy was scheduled. A tumor, found in the first jejunal loop, was removed by laparoscopic surgery. Histopathology revealed a rare mucinous adenocarcinoma associated with epithelial changes secondary to celiac disease. Although small bowel tumors are rare entity, in patients with celiac disease complaining of symptoms related to altered intestinal transit or occult bleeding, an appropriate work-up should be planned for diagnosis. Mucinous type intestinal adenocarcinoma, even if never published before, could be observed. Laparoscopic surgery is often essential for the diagnosis and treatment.     

Manifestations articulaires des affections intestinales

Inflammatory enterocolonopathies or intestine chronic inflammatory diseases refer to both Crohn's disease and haemorrhagic rectocolitis. They are part of the spondylarthropathies group. Osteoarticular lesions occur in 1/3 of affected patients; they are the most frequent extra-digestive manifestations of these diseases and may reveal the intestinal affection. The frequency of osteopenia and osteoporosis imposes early detection and adapted management. Arthralgias or non destructive asymmetric pauciarticular arthritis often occur together with enterocolonopathy-induced digestive crises. Frequently, they are associated with other extra-intestinal manifestations. Sacro-iliitis may occur as an isolated event. About 6% of patients with an intestine chronic inflammatory disease have also a real spondylarthropathy as defined by Amor's criteria or the European criteria. The clinical manifestations occur independently from the digestive crises. When managing a spondylarthropathy, systematic screening for inflammatory enterocolonopathy should be undertaken. Whipple's disease is a curable chronic bacterial infection with a multisystemic pattern, due to Tropheryma whipplei. It generally begins with a recurrent joint lesion in a middle-aged man, followed some years later by emaciation and diarrhoea diversely associated with other clinical manifestations. Arthralgia, and even real polyarthritis and tenosynovitis may be encountered when managing intestinal bypass, celiac disease, and microscopic colitis.     

Type 1 diabetes and celiac disease: The effects of gluten free diet on metabolic control

Type 1 diabetes mellitus is associated with celiac disease, with a prevalence that varies between 0.6% and 16.4%, according to different studies. After a diagnosis of celiac disease is confirmed by small bowel biopsy, patients are advised to commence a gluten-free diet (GFD). This dietary restriction may be particularly difficult for the child with diabetes, but in Europe (and in Italy) many food stores have targeted this section of the market with better labeling of products and more availability of specific GFD products. Treatment with a GFD in symptomatic patients has been shown to improve the symptoms, signs and complications of celiac disease. However, the effects of a GFD on diabetic control are less well established. Initial reports of improved hypoglycemic control were based on children who were diagnosed with celiac disease associated with malabsorption, but there have subsequently been reports of improvement in patients with type 1 diabetes with subclinical celiac disease. There are other studies reporting no effect, improved control and an improvement of hypoglycemic episodes. Moreover, in this review we wish to focus on low glycemic index foods, often suggested in people with type 1 diabetes, since they might reduce postprandial glycemic excursion and enhance long-term glycemic control. In contrast, GFD may be rich in high glycemic index foods that can increase the risk of obesity, insulin resistance and cardiovascular disease, worsening the metabolic control of the child with diabetes. Hence, it is important to evaluate the impact of a GFD on metabolic control, growth and nutritional status in children with type 1 diabetes.     

Small bowel intussusception in celiac disease

Intussusception is not a widely recognized complication of celiac disease and yet it is not rare. The authors report on 3 children with spontaneously resolving small bowel intussusception in association with celiac disease. Small bowel intussusception in a child with suspected celiac disease initially should be managed expectantly rather than by early surgical reduction. The finding of transient small bowel intussusception, either by contrast radiology or sonography, should prompt investigation for celiac disease.     

Mesenteric Buerger's Disease

A young male patient with a history of heavy smoking and low-extremity Buerger's disease was operated on because of small bowel infarction. The postoperative histopathological diagnosis was mesenteric involvement of Buerger's disease. Mesenteric Buerger's disease is extremely rare, the early diagnosis is difficult, and the prognosis is poor. Considering the difficulty in diagnosis and the poor prognosis, patients with Buerger's disease presenting with gastrointestinal manifestations should be carefully evaluated, and early surgical intervention is recommended.     

Celiac artery aneurysmectomy with pancreatectomy

A case of symptomatic celiac artery aneurysm with pancreatic involvement treated by excision, 85% pancreatectomy, and direct reanastomosis of the common hepatic artery with restoration of arterial continuity is reported. This is the first reported case, of which we are aware, in which celiac artery aneurysm resection also required partial pancreatectomy. Pancreatic involvement by celiac artery aneurysm is discussed. The rationale for early diagnosis and recommended treatment is presented.     

Celiac Disease and Metabolic Bone Disease

Celiac disease is a common autoimmune gastrointestinal disorder affecting multiple organs, precipitated in genetically vulnerable persons by the ingestion of gluten. Gluten is poorly digested and is presented to the intestinal mucosa as a large polypeptide. Binding to human leukocyte antigen-DQ2 and human leukocyte antigen-DQ8 molecules on antigen-presenting cells stimulates cellular and humeral immune reactions. Although common serological tests are available to diagnose celiac disease, the diagnosis of celiac disease is often delayed or missed because of lack of recognition as the disease presentation in adults is highly variable and may be asymptomatic. Celiac disease is a common secondary cause of metabolic bone disease and delayed treatment with gluten-free diet affects bone mineral density and fracture risk, so it is crucial to diagnose and treat celiac disease promptly. In this article, we will review recent studies of celiac disease in adults and provide practical, easily accessible information for busy clinicians.     

Truncus-coeliacus-Kompressionssyndrom

The celiac axis compression syndrome is a rare disease in adults. In childhood it is extremely uncommon. Vascular reasons or chronic irritation of the celiac ganglion are discussed as causes for this syndrome, leading to chronic abdominal pain. Lateral aortography is acknowledged to be the best method for diagnosis of the celiac axis compression syndrome. New duplex scanning methods are gaining more and more importance. The indication for surgery is the subject of controversy in the current literature. We present the case of a 15-year-old girl who recovered completely after transsection of the ligamentum arcuatum medianum and resection of the celiac ganglion.     

人工智能在骨质疏松症中应用的研究进展

骨质疏松症(osteoporosis, OP)是一种与增龄相关的骨骼疾患,其起病隐匿,呈渐进性发展,患者初期无明显的临床表现,但随着病情的进展,骨量不断流失及骨组织微结构破坏,进而出现骨痛、脊柱变形,甚至出现骨质疏松性骨折(osteoporotic fracture, OPF)等严重并发症。双能X线吸收法是目前临床诊断OP的金标准,但由于其诊断的准确度受到体重、腰椎退行性改变及主动脉壁钙化等因素的影响,存在假阴性诊断的可能。近年来,人工智能(artificial intelligence, AI)在医学领域快速发展,目前AI已广泛应用于OP的研究中,其在OP筛查、诊断及预测领域的研究已成为一个新的热点。该文从AI应用于OP的早期筛查、医学影像学表现、临床诊疗资料及OPF风险预测等4个方面,阐述AI在OP诊疗过程中的应用现状及优势,为OP的精准诊疗提供新方向。     

特发性青少年骨质疏松症研究进展

特发性青少年骨质疏松症（idiopathic juvenile osteoporosis,IJO）是一种罕见的、具有自限性的,以青春期早期全身骨痛、骨折、行走困难为主要表现的全身性骨病,大部分患者的症状可随青春期发育而自发缓解。目前病因尚不清楚,影像学表现为全身骨骼骨密度下降,容易出现腰椎椎体及长骨尤其干骺端骨折,“新生骨骨质疏松症”是其独特的影像学表现,其诊断需先排除其他常见的青少年降低骨密度原因。目前其药物治疗规范尚未达成共识,以补充钙剂、维生素D及双膦酸盐为主要治疗措施。大部分患者预后较好,极少部分遗留严重残疾。笔者就近年来特发性青少年骨质疏松症的发病机制、临床表现、影像学特点、诊治等方面的最新进展作一综述。     

Association of adult celiac disease with surgical abdominal pain: a case-control study in patients referred to secondary care

BACKGROUND: Acute abdominal pain is the most common indication for surgical admission. Nonspecific abdominal pain (NSAP) may account for up to 40% of cases. There has been no published prospective study in which adult patients presenting with acute abdominal pain are investigated for celiac disease. AIMS: We aimed to assess the association of celiac disease with surgical abdominal pain. PATIENTS AND METHODS: A case-control study was undertaken involving 300 consecutive new unselected patients presenting with acute abdominal pain (in a university hospital) and healthy controls (age and sex matched) without abdominal pain (n = 300). Initial investigations for celiac disease were immunoglobulins, IgA/IgG anti-gliadin (AGA), and endomysial antibodies (EMA). Any patient with a positive IgA AGA, EMA, or only IgG AGA in the presence of IgA deficiency was offered a small bowel biopsy to confirm the diagnosis. RESULTS:: There were 33 patients with abdominal pain who had positive antibodies, of whom 9 had histologically confirmed celiac disease (6 EMA positive; 3 EMA negative). One antibody positive patient (EMA in isolation) declined duodenal biopsy and the remaining 23 had normal duodenal mucosa. Within the control group, there were 2 cases of celiac disease. Compared with matched controls the association of acute abdominal pain with celiac disease gave an odds ratio 4.6. (P = 0.068, 95% confidence interval, 1.11-19.05). When only considering NSAP the prevalence of celiac disease was highly significant at 10.5% (9 of 86, P = 0.006). Patients' symptoms improved on a gluten-free diet at 12- to 18-month follow-up. CONCLUSION: Celiac disease was diagnosed in 3% of patients who presented with unselected acute abdominal pain to secondary care. Targeting patients who have NSAP or celiac associated symptoms/diseases may improve the diagnostic yield.     

Compression stenosis of the celiac trunk in children and adolescents

Operations for compression stenosis of the celiac trunk (CSCT) were made on 97 patients aged 5.5-18 years (56 women and 41 men). Three basic clinical syndromes were observed: pain abdominal, dyspeptic and neurovegetative. The appearance or intensification of abdominal pains observed in 71.3% of the patients were connected with meal, in 59.69% of them it was simultaneous with physical exercise. The diagnosis of OSCT was based mainly on findings of ultrasonic duplex scanning. The indications to decompression of the celiac trunk were: clinical manifestations of CSCT, the stenosis degree at the maximal expiration more than 50%, peak systolic velocity of the blood flow more than 2 m/s and a gradient of arterial pressure more than 15 mm Hg. The decompression of the celiac trunk consisted in the dissection of a median arcuate ligament of the diaphragm, its interior crura and celiac ganglion fibers. Convalescence and recovery was stated in 87 of 97 patients in the nearest and long-term follow-up.     

Poststreptococcal glomerulonephritis in the elderly. Report of a case and review of the literature

Acute poststreptococcal glomerulonephritis (PSGN) is uncommonly seen in the elderly population and its diagnosis is not without some difficulty because clinical manifestations may mimic other diseases. Renal biopsy for diagnosis and early intervention, if indicated, is very valuable in such a situation. We present here a case of an elderly patient with PSGN and a review of the literature. In addition to the typical clinical manifestations of the disease, dyspnea and pulmonary congestion are commonly present in elderly patients, probably a result of excessive salt and water retention in the face of compromised cardiovascular function. Elderly patients with PSGN appear to have a remarkably poor prognosis, with significant incidences of acute mortality and chronic renal disease. Our patient had the unusual finding of a large number of glomerular crescents with near complete clinical recovery after short-term follow-up.     

Sclerosing peritonitis. Possible early diagnosis by computerized tomography of the abdomen

Sclerosing peritonitis (SP) has come to be recognized as a serious complication of peritoneal dialysis (PD). However, diagnosis is often established at a late stage of the disease and at laparotomy. The use of computerized tomography (CT) of the abdomen in 2 patients, clinically suspected of suffering from SP, revealed loculated ascites, adherent bowel loops, bowel lumenal narrowing, and thickening of the peritoneal membrane. Such radiological changes in patients on PD seem highly consistent with a diagnosis of SP. We feel that CT of the abdomen may help in attaining an early, correct, and noninvasive diagnosis of SP. We recommend that CT of the abdomen be performed in any patient on chronic PD who has clinical manifestations suggestive of SP. Early diagnosis of SP can lead to early cessation of PD and hopeful recovery of the peritoneal membranes and space.     

Bone and celiac disease

Celiac disease is an intestinal disease due to an abnormal immuno-mediated response to gluten and other peptides from different cereals in genetically susceptible subjects. Several systemic alterations, including bone alterations, may be present in affected subjects. Once considered rare, it is now known to be quite frequent in both Europe and North America, as the recent availability of specific serological markers has drastically changed our perspective on its prevalence. The diagnosis of celiac disease may be very difficult because the clinical picture is highly variable and the characteristic intestinal signs and symptoms may be completely absent. Among the extra-intestinal alterations, bone mass decrease and bone metabolism derangement are frequently present and can be the only signs of an otherwise silent celiac disease. Clinical and epidemiological data are now plentiful but no conclusive data on the pathogenesis of bone involvement in celiac disease are available yet. Bone alterations were once thought to derive from calcium and vitamin D deficiency secondary to simple intestinal malabsorption, but now a more complex interaction between cytokines and local/systemic factors influencing bone formation and reabsorption is envisaged, Also, there is now substantial evidence supporting a lifelong gluten-free diet as the first-choice therapy for celiac disease, and as far as we know, this is the only effective measure to restore bone metabolism to an apparent normality. In the young, an early-started gluten-free diet can even lead to a satisfactory recovery of bone mass. In adults, however, there is no spontaneous recovery, and there are no conclusive data on the efficacy of standard therapies for osteoporosis in reducing the fracture risk. For these reasons, we feel that a review of the clinical findings on bone problems in celiac disease may be useful for both gastroenterologists and osteoporosis specialists.     

影像学技术在颅缝早闭诊疗中的应用进展

颅缝早闭是一种较为常见的先天性颅面畸形,表现为一条或多条颅缝的过早闭合。尽管患儿的临床表现及病史可为该病的诊断提供一定的依据,但其确诊很大程度上还有赖于影像学的检查结果。影像学技术的发展,对颅缝早闭的诊断及评估有重要临床价值。本文就原发性颅缝早闭的影像学研究现状及进展进行综述。