Download - Celiac Disease 07.09.2012
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Morning Report
7/9/12
Molly Montes PGY2
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Patient
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History
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Exam
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Differential Infectious
Viral gastroenteritis
Rota, entero, adeno
Bacterial
Salmonella, yersinia, E.coli
Campylobacter,aeromonas, Plesiomonas
Protozoal
Giardia, Cryptosporidium
Chronic Nonspecific Diarrhea
of Childhood
Disaccharide Intolerance
Primary, secondary
Bacterial Overgrowth
IBS
Gastritis
H. pylori, postinfectious
Allergic Enteropathy
Celiac Disease
Inflammatory Bowel Disease
Congenital SecretoryDiarrhea
Neuroendocrine Tumors
Hirschprungs Disease
Cystic Fibrosis
Metabolic Disorder
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LabsCBCd: WBC 9.5 (12B 33S 45L 4M 5E 1+ atypical lymphs) Hgb 15.7 Hct45.1 Plt 220
CMP: Na 136 K 4.4 Cl 103 CO2 20 BUN 9 Cr 0.37 Gluc 85 Ca 8.9 Prot5.9 Alb 3.3 Bili 0.3 Alk Phos 11 ALT 22 AST 25CRP 1.5Lipase 13
Adenovirus 40/41 negative
H. Pylori negativeC diff negativeStool culture negative for salmonella, shigella, campylobacterRotavirus negativeCryptosporidium negativeEHEC negativeGiardia negativeStool guaiac negative
Celiac panel - IgA normal TTG 68 (nl 0-19) Deamidated gliadin peptideantibody IgA normalIgE 928Food Profile 13 - minimal reaction to egg whites (negative to all others)Duodenal Disaccharidases - normal
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Celiac Panel
IgA
If normal, then may interpret TTG correctly
If low, TTG not necessarily reliable
Tissue Transglutaminase (IgA Ab) Enzyme that binds gliadin (gluten protein)
Sensitivity >90%, Specificity >95%
PPV 90%
Deamidated Gliadin Peptide (IgG or IgA Ab)
end product of TTG and gliadin (increased binding toimmune cells)
Sensitivity 91%, Specificity 26%-80%
PPV 48%
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Imaging/Pathology
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Celiac Disease
Auto-immune chronic inflammatory disorder
Pathology
Partial->total villous atrophy
Elongated crypts
Increased intraepithelial lymphocytes Plasma cells, lymphocytes, mast cells, eosinophils, basophils in lamina propria
Extra-intestinal manifestations
Short stature
Iron deficiency anemia
Arthritis/arthralgias
Enamel hypoplasia
Dermatitis herpetiformis
Therapy
Gluten free diet
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IgE and Eosinophils?
Not clear
Inflammation
Post infectious?
Reflux
Allergic enteropathy
Eosinophilic esophagitis/gastritis
Peripheral eosinophilia, GI bleeding, poor
growth
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References
Wyllie, Robert, et al. Pediatric Gastrointestinal and Liver Disease3rd ed. Saunders Elsevier, 2006.
Wallach, Jacques. Interpretation of Diagnostic Tests, 8th ed.Lippincott Williams and Wilkins, 2007.
Zella, Garrett, et al. Chronic Diarrhea in Children. Pediatricsin Review. May 2012;33(5):207-16.
Vermeersch, P et al. Diagnostic Performance of IgG anti-deamidated gliadin peptide antibody assays is comparable toIgA anti-tTG in celiac disease. Clinica Chimica Acta July2010;411(13-14):931-5.
Olen, O. et al. Antibodies Against Deamidated GliadinPeptides and Tissue Transglutaminase for Diagnosis of CeliacDiseaseDiagnostic Performance and Cost in ClinicalPractice. Jouranl of Pediatric Gastroenterology Nutrition 2012Epublished ahead of print.