chronic diarrhea in young lady
TRANSCRIPT
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An intresting case of gastroentrology
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Patient details:
Patient Ms. S Age 40 years Resident of Central India
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Presenting complaints
Pain & discomfort in abdomen- 30 years Frequent loose motions – 30 years Feeling of weakness and malaise- 25
years Low grade fever- 20 years Body ache and Joints pain- 20 years Dark Patches over face- 5 years
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H/O Present illness
Patient is not comfortable about her abdomen since her remembrance . she feels bloating of abdomen, gurgling and pain on and off . Pain is generalized, with no diurnal
variation and not associated with vomiting.
Pain is aggravated after food consumption and is not relieved after motion
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She is also having loose motions on and off . It is generally semisolid
Associated with mucus Never had blood in stool Some time mal odorous Frequency 6 to 8 per day some time quantity is large
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Symptoms aggravated by
Milk Spicy food High calorie food Fried and junk food
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Patient and her relative noticed a yellowness in her complexion
She feels exhausted most of the time Her weight is always on lower side Since last 10 years she also
complaining of generalized body ache and joint pains. Which involves small joints of fingers wrist elbow and shoulders. Which is associated with morning stiffness, More in winters .
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History of past illness
No h/o diabetes, hypertension, hyperuricemia, blood transfusions
Family history Mother – Severe Rheumatoid arthritis
Personal history Nothing significant
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General examination
G.C- Good Pallor + Pulse- 72/min Resp-
18/min BP- 106/74 mm of Hg N.V.-Not
engorged N.G. –Not palpable JVP – Not
raised No edema, Jaundice, cyanosis or clubbing Pigmentation over forehead and face.
Systemic examinationGIT- NAD R/s –NADGIT- NAD R/s –NAD
CVS- NAD CNS - NADCVS- NAD CNS - NAD
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Investigations -blood picture Hb- 8.4 gm % TRBC - 3.9 million cu.mm TWBC – 10500 DWBC – P-47, L-51, m-2% E- nil Platelets – adequate Anemia typing- Normocytic
hyprochomic No immature cells seen No MP seen
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Stool- Fat +ve Mucus & Blood -ve USG –NAD Urine –NAD X-Ray chest- Normal Serum Uric Acid- 4.1 mg/dl R.A Factor –ve HIV- Nonreactive Thyroid function tests – WNL Serum Calcium- 7.8 (Normal 8.5 to 10.5 mg/dl) High sensitivity C-reactive protein- 0.47
mg/dl ( Normal less than 0.3 mg/dl)
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Anti CCP
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Anti nuclear antibody
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Hemoglobin elecrophoresis
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Tissue Transglutaminase antibody
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Vit. B-12 level
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Upper & Lower GI endoscopies
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Biopsy from IInd part of duodenum
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What can be the diagnosis
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Coeliac disease with early sero negative rheumatoid arthritis
Final Diagnosis
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Coeliac disease- Introduction CD is a common chronic inflammatory bowel condition
characterized by mal absorption abnormal small bowel histology and intolerance to gluten and prolamines found in wheat, barley and rye.
Gliadin is a protein found in wheat and barley is water insoluble
The disease multifaceted in nature with variable clinical presentation ranging from GI manifestation to asymptomatic silent and extra intestinal forms
It may present from first year of life till 8th decade CD in children and non tropical sprue in adults are
probably the same entity Dermatitis Herpetiformis a bullous skin disease is also
known to be induce by Gluten. Untreated CD is associated with high morbidity and
increase mortality
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Coeliac disease
Coeliac disease is not an allergy or simple food intolerance.
In fact it's an autoimmune disease, where the body's immune system attacks its own tissues.
In people with coeliac disease this immune reaction is triggered by gluten, a collective name for a type of protein found in the cereals wheat, barley and prolamines in rye. A few people are also sensitive to oats.
In coeliac disease, eating gluten causes the lining of the gut (small bowel) to become damaged and may affect other parts of the body.
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Possible symptoms include:
bloating, abdominal pain, nausea, diarrhoea, excessive wind, heartburn, indigestion, constipation
any combination of iron, vitamin B12 or folic acid deficiency
tiredness, headaches weight loss (but not in all cases) recurrent mouth ulcers hair loss (alopecia) skin rash (dermatitis herpetiformis- 'DH') defective tooth enamel osteoporosis depression infertility recurrent miscarriages joint or bone pain neurological (nerve) problems such as ataxia
(poor muscle co-ordination) and neuropathy (numbness and tingling in the hands and feet).
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Median age for diagnosis of CD In adults- 4th and 5th decade Median delay in diagnosis ranges
from – 5-11 years in developed
countries In India 30-40 years
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Etiology
Unknown Environmental Immunologic and Genetic factors
contributes to the disease.
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Types
Classic Type- Silent or Atypical form present with
non specific abdominal pain, esophageal reflux, osteoporosis, Cryptogenic hypertrans aminasimia, insulin dependent DM or Neurological symptoms
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Diagnosis of CD
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Prevalence 0.5 to 1 % 1 in 113 people in Europe Most Common in Whites of North European
ancestry PGI Chandigarh data is around 1% in India Ratio of undiagnosed to diagnosed in children is
7:1 and in adult is 68:1 The prevalence of CD was 1:22 for first degree
relative and 1:39 for second degree relatives. All Patients with CD express HLA-DQ2 ALLELE
though only a minority of patients express DQ2 have CD
Absence of DQ2 excludes the diagnosis of CD
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Serological Markers
IgA and IgG anti Glidnin anti bodies (Predictive values +ve and –ve more than 96%)
IgA antiendomysial antibody( 92 to 95 % )
IgA tissue transglutaminasse antibody Antibody negative CD also exist if
patients are IgA deficient (6.4% of all cases)
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Histopathological findings Gold standard for diagnosis is villous
atrophy on duodenal biopsy Marsh’s histological grade Grade 0- Normal duodenal mucosa Grade-I – Increased intraepithelial lymphocyte count Grade-II- Grade I + Crypt
Hyperplasia Grade III- Grade I+ grade II+ villous
atrophy
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Course of the disease
Started with anaprashan Spontaneous remission Reappears in second decade of life. Remission and exacerbation known
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Treatment
Gluten free diet Supportive and symptomatic
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Gluten Containing foods
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complications
GI and Non Gi neoplasams Intestinal lymphomas intestinal ulcers collegenous sprue
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Many faces of CD
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Symptoms of Malabsorptive disorders
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Tests useful in diagnosis of Malabsorption
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My experience
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