Treatment of celiac disease: expected outcomes and how to address the refractory patient Joseph A Murray The Mayo Clinic Rochester, MN 55906
|
|
- Blaise Boyd
- 6 years ago
- Views:
Transcription
1 Treatment of celiac disease: expected outcomes and how to address the refractory patient Joseph A Murray The Mayo Clinic Rochester, MN OBJECTIVES 1. To outline the expected results of treatment with a gluten free diet. 2. To outline the approach to patients with a diagnosis of celiac disease who have persistent or recurrent symptoms despite a gluten-free diet. 3. Define the role for associated diseases in the cause of symptoms. 4. To recognize complications of celiac disease 5. To define the new and evolving classification of refractory celiac disease(sprue) and its relationship to enteropathy-associated lymphoma 6. To describe management strategies for ill patients with refractory sprue INTRODUCTION Celiac disease is a common disorder effecting almost 1% of the population, though only a fraction of these are diagnosed. Most (95%) patients with initially symptomatic celiac disease will have a durable response to a gluten-free diet. This response will include correction of malabsorption, relief of symptoms, and normalization of serological abnormalities. [1] Histological recovery may take a year or more in adults and frequently is incomplete even when other parameters recover. [2] Approximately 5% of patients will have persistent or recurrent symptoms of malabsorption, with villous atrophy, despite apparent adherence to a gluten-free diet. Intermittent symptoms due to the of difficulty with adherence to a gluten-free diet is likely much more common problem.[3] Several case histories will be used to illustrate the common and uncommon but serious scenarios that can occur in patients who have a diagnosis of celiac disease. I will first address the common scenario of non responsive celiac disease and then the less common but serious issue of refractory sprue. NON-RESPONSIVE CELIAC DISEASE The non-response celiac disease patients can be defined as a patient with a diagnosis of celiac disease who has been started on a gluten free diet but has persistent or recurrent symptoms despite self-declared adherence to a gluten free diet (GFD). It is first important to define if the patient ever had a response to the GFD. A failure to have a response should raise the possibility of an alternative diagnosis. 1. Revisit the Original Diagnosis When first faced with a patient, it is important to review the original diagnosis. It is important to re-review the original biopsy slides to verify that there was not a problem with inadequate sampling, malorientation, and missed alternative diagnosis or over interpretation of minor changes such as lymphocytic duodenosis. It is not unreasonable to request a pathological consultation for the biopsies though reviewing the biopsies directly with the pathologist may be very helpful.
2 Identify if any serology was done at the time of diagnosis before withdrawal of gluten from the diet. Negative serology, especially if done with a sensitive and specific test such as tissue transglutaminase antibody, taken before gluten was restricted by the patient, makes the diagnosis suspect. However, a negative test that occurred after the patient had reduced or restricted gluten intake is less useful in this regard. A positive test taken at any time is useful as adjunctive evidence. This illustrates the importance of obtaining serology even in biopsy-detected individuals before starting the GFD. Other information that may be helpful includes a family history of conformed celiac disease of dermatitis herpetiformis, or prediagnosis foreign travel a location where tropical sprue is a risk. Celiac disease can be considered highly probable based on, biopsies showing at least some villous atrophy, with crypt hyperplasia and intraepithelial lymphocytosis and at least one of the following: a partial response to a gluten-free diet; positive tissue transglutaminase or endomysial antibodies; and/or a positive family history of biopsy-confirmed celiac disease or dermatitis herpetiformis. 2. Determine Dietary Compliance The next step would be to identify if these patients have truly excluded gluten from their diet. Firstly usually the gastroenterologist can detect of the patient is deliberately ingesting by direct but tactful inquiry. Direct confrontation may illicit a denial, however after expressing some empathy with how difficult the diet most be many patients will admit to ingestion of gluten as often as several times a week. A little more difficult to detect is the inadvertent ingestion of gluten. Specifically inquiring about the intake of common commercial cereals such as Rice Krispies or Corn Flakes (other than the specifically manufactured and labeled gluten free kind) suggests that the patient is not aware of the hidden sources of gluten in the diet. A systematic review by a dietitian experienced in celiac disease can be invaluable to detect most cases of inadvertent gluten ingestion as well to aid with improving compliance.[4] Follow-up serologic testing using tissue transglutaminase or endomysial antibody is helpful and should show at least a substantial drop in the level of positivity or a negative result by 6-12 months. However different test kits used and normal ranges can make this difficult to gauge whether moderate drops in titers are significant. Persistently positive tests suggest substantial gluten ingestion, though a negative test des not rule out quantities of 1 gram or less, which is still enough to cause persistent villous damage and symptoms. 3. HLA Class 2 typing Patients can be tested to see if they carry the HLA class II genes that virtually required for celiac disease to occur. This should be done by a genotyping as the older serological methods are not accurate enough. The utility of typing the class 2 typing is to identify individuals who do not carry the HLA types associated with celiac disease. If these genes that encode DQ2 or DQ8 are lacking, especially in patients who were negative for tissue transglutaminase or endomysial antibodies or in whom these serologic tests were not done at the time of diagnosis, then again a search for other causes of the sprue-like condition should be sought. There are rare exceptions to this however. Those who not only carry the at risk type DQ2 but are homozygotes are at a higher likelihood of celiac disease but also in one study of developing refractory celiac disease or EATL. [5]
3 4. Alternative Diagnoses Sometimes the review of the initial diagnosis will raise the possibility of alternative diagnoses. (Table 1) Table 1: Differential diagnosis of villous atrophy Tropical Sprue Peptic duodenitis with inadequate sampling Combined variable immunoglobulin deficiency Severe giardiasis ( especially with IgA deficiency) HIV enteropathy Graft versus host disease Chronic ischemia Autoimmune enteropathy NSAID injury Crohn s disease Radiation enteritis Whipple s disease IPSID Self limited enteritis Other food protein intolerances ( children) IPEX ( children) These possibilities are wide but could include combined variable immunoglobulin deficiency which itself can cause sprue. Clues to this diagnosis may be completely negative serology at initial diagnosis and measurement of quantitative immunoglobulin levels especially deficiencies of more than one immunoglobulin isotype. Other possible entities that could occur in this circumstance would be autoimmune enteropathy, non-steroidal anti-inflammatory drug-induced enteritis, so-called self-limited enteritis, or rarely ischemia, Whipple s disease or other disorders that usually have a fairly classic histopathologic appearance. 5. Additional /Associated Diagnoses Assuming that the patient is still likely to have celiac disease and no alternative diagnosis has been made in the foregoing steps, searching for an associated disorder is directed by what predominant symptom the patient has. If it is diarrhea then colon biopsies may find microscopic colitis. Recurrent anemia may be a manifestation of unhealed celiac disease, poor intake, achlorhydria, colon neoplasia, aspirin or NSAID use or rarely small intestinal malignancy including adenocarcinoma. Persistent steatorrhea may suggest pancreatic insufficiency, though I would not assume that until I had re-biopsied the small intestine. Abdominal pain can be due any of the usual causes but remember that celiac disease can be associated with gallstones, duodenal strictures and ulcers, recurrent pancreatitis and motility disturbances.[6, 7] 6. Push/ Extended Endoscopy Unless the evaluation of patients has not revealed some other ready explanation for the symptoms and the patient has been on the gluten free diet for at least 6 months and celiac disease continues to be the presumptive diagnosis, the next step is to undertake a repeat endoscopy preferably with an extended or push enteroscope.[8] This will allow the endoscopist
4 to examine not only the duodenum but the proximal jejunum visually and to obtain multiple samples sufficient for histologic examination, for which samples are fixed in formalin, mounted in paraffin and stained by standard H&E staining and compared with the original pre-treatment biopsies. It may be helpful to save additional biopsies at the time of this endoscopy that are frozen and kept for detailed immunological studies including possible T gene rearrangement. If the biopsies show no significant improvement over the original pre-treatment biopsies with continued inflammation and infiltration of the surface layer with intraepithelial lymphocytes associated with villous atrophy, then immunohistochemical stains to identify aberrant immunophenotype of these IELs maybe undertaken. [9] During the same extended upper endoscopy, an aspirate can be obtained for bacterial overgrowth and whilst the prevalence of bacterial overgrowth in the circumstance varies from 10 to 50%, the demonstration of bacterial overgrowth by quantitative culture, does not exclude the possibility of other explanations for the patient s symptoms such as lymphocytic colitis. In most cases of non responsive celiac disease, the systematic evaluation, as described above, reveals either gluten contamination, an alternative or additional diagnosis. Even in referral populations, only a minority of patients have true refractory celiac disease. When it does not and there is continued villous atrophy then refractory celiac disease is the major concern. Figure 1: Approach to non-responsive celiac disease
5 REFRACTORY SPRUE Refractory sprue can defined as clinical malabsorption associated with continued enteropathy consistent with a sprue-like picture despite the patient adhering to a strict gluten-free diet. Each of these 3 conditions need to be met before embarking on the detailed evaluation called for and indeed justified by a substantial morbidity and mortality of refractory sprue. Typically it is an older patient over the age of 50 years who has lost substantial weight has steatorrhea and diarrhea, negative serology currently and is clinically failing despite strict adherence to a gluten free diet and if applicable treatment of additional diagnosis. Refractory celiac disease has been divided into 2 types. Type 1 refractory celiac disease is defined by the above criteria. Type 2 refractory celiac disease is a similar to type one except there is evidence that identifies an abnormal phenotype of intraepithelial lymphocyte that is clonally expanded. IDENTIFICATION OF ABERRANT IEL PHENOTYPE It has been shown now for over seven years that the intraepithelial lymphocytes in refractory sprue may undergo a switching of their immunophenotype from T cell markers to NK cell markers. Specifically, these cells lose the surface expression of CD3 though they maintain cytoplasmic expression. They lose the surface expression of CD8 and the T cell receptor βf1. Immunohistological stains if they show a substantial proportion (greater than 50%) of intraepithelial lymphocytes have intracellular CD3 staining but lack surface CD8 or βf1 staining; this suggests that there has been a clonal transformation of these cells. [9] It is thought that many, though not all of the lymphomas that occur to complicate celiac disease, arise from this immunophenotype. These aberrant lymphocytes can also spread to the stomach, colon peripheral blood and rarely to the skin. While these cells do not have cytological features of neoplastic cells they can develop chromosomal abnormalities specifically trisomy 1q. These cells that typify refractory celiac disease type 2 are considered by some to be a cryptic lymphoma based on their development of aberrant phenotype, clonality of the t-cell receptors and the chromosomal abnormalities. Clonal T cell receptor gene rearrangement may be identifiable on the biopsies by PCR. This may be done on formalin fixed tissues if adequate DNA can be extracted from the blocks. If frozen samples are available the PCR findings can be confirmed by southern blotting. The demonstration of clonality itself is not sufficient for a designation Type 2 refractory sprue though a careful search for other evidence for an abnormal phenotype t cell population is needed and close follow up needed. Some centers now routinely use flow cytometry on lymphocytes derived from fresh biopsies to identity aberrant lymphocytes. The methods are not yet standardized or in common use as yet. The method that has been used by the Dutch group isolates cels from fresh intestinal biopsies. The cells are gated for CD45 and the homing receptor CD103 that identifies intraepithelial origin on the cells. Then 4 color flow cytometry for surface CD3, CD4 CD8, CD7, CD16/56, CD19 and the gd TCR along with cytoplasmic CD3 is undertaken. A threshold of 10% of the CD103
6 + that have the aberrant phenotype (surface CD3-, CD8-, and cytoplasmic CD3+) signifies a significant expansion. SMALL BOWEL IMAGING The primary role of imaging is to identify complications in the intestine either malignant or non malignant or detect extra intestinal manifestations of malignancy. These can be divided into advanced endoscopic imaging methods such as capsule endoscopy or double balloon enteroscopy and radiographic methods such as CT enterography, small bowel contrast studies or more recently MR enterography or PET scanning. If the endoscopy is in parallel with the endoscopic examination, some other imaging of the small intestine should be considered. CT enterography, small bowel contrast studies, or more recently capsule endoscopic or double balloon enteroscopy have been applied in the setting of refractory sprue and may identify enteropathy associated lymphoma, malignant or benign strictures or obstructions, intussusception, ulcerative jejunoileitis or some other malignant state within the intestine. Standard CT or MR scanning may detect enlarged lymph nodes or masses that suggest neoplastic transformation. However, mesenteric lymphadenopathy alone can occur due to uncomplicated celiac disease alone though it usually shrinks after institution of a gluten free diet. Ct scanning may detect a small spleen that may be associated with a greater risk of lymphoma and indicates a need for vigilance for infection risk and vaccination.[10] PET Scanning may be helpful in detecting EATL in patients with refractory sprue. MANAGEMENT OF REFRACTORY CELIAC DISEASE The work up for these problems has been largely limited to centers that have both the clinical expertise and laboratory to undertake a complete evaluation and early referral is encouraged. Figure 2: approach to refractory sprue
7 TYPE 1 REFRACTORY CELIAC DISEASE Type 1 refractory sprue is defined as refractory sprue but without evidence of an aberrant T cell clone. It is still possible but unlikely that these patients may develop a lymphoma. The evaluation is similar except without the need for the search of a systemic spread of these abnormal lymphocytes. There may be overlap between this type of refractory celiac disease, especially if the patients never responded to a gluten-free diet, with autoimmune enteropathy. Autoimmune enteropathy may be distinguished from celiac disease by: 1) lack of the HLA type s ( DQ2 or DQ8) that define risk for celiac disease; 2) a paucity of goblet cells on biopsies; 3) a relative lack of intraepithelial lymphocytosis by comparison to celiac disease; 4) circulating autoantibodies directed against surface mucosa. Nevertheless, both conditions are treated similarly with steroids and immunosuppressives.( Akram et al, submitted) Type 1 refractory celiac disease usually responds to immunosuppression with steroids and Azothioprine for steroid-sparing effect. Recent reports suggest that patients may also respond to budesonide though the dosing would need to be altered to increase the likelihood of approximal mucosal distribution of the medication. [11] TYPE 2 REFRACTORY SPRUE This particular form is thought by some to be a cryptic lymphoma or at least a pre-lymphomas. [12] It occurs likely as a consequence of both the initial proliferative effect of gluten on the t cells but also an accumulation of genetic defects that favor continued proliferation despite the removal of gluten. The cells of origin are the intraepithelial lymphocytes that under go progressive changes that result in loss of there surface t cell markers CD3, CD8 and TCR, but preservation of cytoplasmic CD3. If these cells exceed a certain percentage (20%) of the IELS that express CD7, CD103 then that indicates a substantial population of phenotypically aberrant cells. It has been suggested that patients with these particular findings have a particularly high mortality and a high likelihood of progression or transformation to enteropathy-associated T cell lymphoma no matter what the treatment used to suppress the symptoms. If the aberrant phenotype is identified on the small bowel biopsies, then a search for systemic spread to the blood and bone marrow is probably justified. Also, careful body imaging and/or endoscopic examination of the small intestine may be justified looking for synchronous tumors in the intestine. Type 2 refractory sprue has a much more guarded prognosis with an uncertain outcome. In patients, either systemic steroids or topically active steroids might be helpful in suppressing symptoms. It is more controversial as to what the role of azathioprine or other immunosuppressives or cytotoxic agents are in this circumstance. Whilst these patients might be respond to immunosuppression, there may be at least theoretically an increased risk of malignancy in the context of immunosuppression. [13] In very ill patients who are refractory to immunosuppression, it may be justified to consider treating these patients as though they have an evolved lymphoma. Chemotherapy directed against T cells has also been tried but may only serve as a temporary suppression of symptoms. [14] There is some recent evidence to justify the use of myeloablative chemotherapy with stem cell transplantation and possibly bone marrow transplant. [15]
8 NUTRITIONAL SUPPORT Patients with refractory sprue are often very ill, have multiple deficiency states both of protein calorie malnutrition as well as micronutrient deficiencies. Careful evaluation for deficiencies including, but not limited to iron, B12, folic acid, zinc, copper as well as electrolyte deficiencies, particularly magnesium, need to be sought and managed aggressively. Vitamin D deficiency and osteomalacia also maybe especially common in these patients and again may need to be managed with malabsorption doses of vitamin D. Patients who cannot achieve their nutritional needs by oral means may require enteral feeding or even if this is unsuccessful, parenteral nutrition.[16] However, even successful maintenance of patients on parenteral nutrition should not be a cause for complacency as mortality may still be quite high in these patients and definitive or continued search for a therapy directed at the small intestine should be continued. ENTEROPATHY ASSOCIATED T-CELL LYMPHOMA (EATL) Enteropathy associated enteropathy ( EATL) may be the end result of a process that starts with a gluten driven t cell proliferation that defines celiac disease. In the face of persistent activation and possibly wit the collusion of the effects of interleukin 15 produced in response to the innate response to gluten, the IELS may acquire sequential genetic changes and eventually chromosomal changes that lead to the development of an aberrant phenotype described above. These cells lose their dependence on gluten and may become neoplastic. Patients with a delay in diagnosis of celiac disease despite persisting severe symptoms and those who have been non compliant with the GFD are substantially increased risk of celiac disease. [17] While EATL may arise in the setting of villous atrophy however it can also appear in healed celiac disease. The presentation of EATL can be either be as an acute event such as perforation, obstruction or bleeding often occurring in the absence of a preceding diagnosis of celiac disease or may cause a gradual and indeed inexorable progressive malabsorption in someone with a prior diagnosis of celiac disease. The outcome may be a little better for those that present in the acute type with occasional prolonged remissions. [18] Once EATL occurs the outlook is grim with five year survival is 10-20%. Patients often succumb to infections may be in a very poor shape to tolerate aggressive chemotherapy. MISCELLANEOUS ISSUES Hyposplenism may be particularly common in patients with refractory celiac disease and vigilance for infective complications is necessary. Most would recommend pneumococcal vaccination. If chemotherapy is being entertained, it would probably be prudent to consider antibiotic prophylaxis as well as a high vigilance for encapsulated organism infections. PROGNOSIS The prognosis of most cases of non responsive celiac disease is good so long as treatable causes can be found. Once refractory sprue has been diagnosed the prognosis varies depending on whether there are aberrant t cells or not. Those with type one RCD usually have a good response to steroids and immunosuppressives, whilst those with type 2 RCD have a much more guarded outlook. Nutritional support may be crucial in supporting the ill patients to withstand therapies
9 that otherwise would be difficult to sustain in the face of severe malabsorption. The prognosis for EATL is dismal though occasional long remissions occur.
10 REFERENCES 1. Murray, J.A., et al., Effect of a gluten-free diet on gastrointestinal symptoms in celiac disease. American Journal of Clinical Nutrition, (4): p Lee, S.K., et al., Duodenal histology in patients with celiac disease after treatment with a gluten-free diet. Gastrointest Endosc, (2): p Fine, K.D., R.L. Meyer, and E.L. Lee, The prevalence and causes of chronic diarrhea in patients with celiac sprue treated with a gluten-free diet [see comments] [published erratum appears in Gastroenterology 1998 Feb;114(2):424-5]. Gastroenterology, (6): p Abdulkarim, A.S., et al., Etiology of nonresponsive celiac disease: results of a systematic approach. American Journal of Gastroenterology, (8): p Al-Toma, A., et al., Human Leukocyte Antigen-DQ2 Homozygosity and the Development of Refractory Celiac Disease and Enteropathy-Associated T-Cell Lymphoma. Clinical Gastroenterology and Hepatology, (3): p Patel, R.S., F.C. Johlin, Jr., and J.A. Murray, Celiac disease and recurrent pancreatitis. Gastrointestinal Endoscopy, (6): p Schweiger, G.D. and J.A. Murray, Postbulbar duodenal ulceration and stenosis associated with celiac disease. Abdominal Imaging, (4): p Cellier, C., et al., Push enteroscopy in celiac sprue and refractory sprue. Gastrointestinal Endoscopy, (5): p Patey-Mariaud De Serre, N., et al., Distinction between coeliac disease and refractory sprue: a simple immunohistochemical method. Histopathology, (1): p Di Sabatino, A., et al., Splenic hypofunction and the spectrum of autoimmune and malignant complications in celiac disease. Clinical Gastroenterology & Hepatology, (2): p Daum, S., et al., Therapy with budesonide in patients with refractory sprue. Digestion, (1): p Mulder, C.J., et al., Refractory coeliac disease: a window between coeliac disease and enteropathy associated T cell lymphoma. Scandinavian Journal of Gastroenterology - Supplement, 2000(232): p Maurino, E., et al., Azathioprine in refractory sprue: results from a prospective, open-label study. Am J Gastroenterol, (10): p Al-toma, A., et al., Cladribine Therapy in Refractory Celiac Disease With Aberrant T Cells. Clinical Gastroenterology and Hepatology, (11): p Al-toma, A., et al., Autologous hematopoietic stem cell transplantation in refractory celiac disease with aberrant T cells. Blood, (5): p Scolapio, J.S., et al., Survival of home parenteral nutrition-treated patients: 20 years of experience at the Mayo Clinic. Mayo Clinic Proceedings, (3): p Holmes, G.K., et al., Malignancy in coeliac disease--effect of a gluten free diet. Gut, (3): p Egan, L.J., et al., Celiac-associated lymphoma. A single institution experience of 30 cases in the combination chemotherapy era. Journal of Clinical Gastroenterology, (2): p
Refractory celiac disease (RCD) KASSEM BARADA LEBANESE SOCIETY OF GASTROENTEROLOGY NOVEMBER, 2014
Refractory celiac disease (RCD) KASSEM BARADA LEBANESE SOCIETY OF GASTROENTEROLOGY NOVEMBER, 2014 Case scenario (1) A 49 year woman presents with intermittent watery diarrhea and bloating of two years
More informationSheila E. Crowe, MD, FRCPC, FACP, FACG, AGAF Department of Medicine University of California, San Diego
Severe and Emergency Presentations of Celiac Disease Sheila E. Crowe, MD, FRCPC, FACP, FACG, AGAF Department of Medicine University of California, San Diego Case Presentation (1) 63 year old male transferred
More informationCoeliac Disease Bible Class Questions and Answers
Coeliac Disease Bible Class Questions and Answers Jan Hendrik Niess What is the definition of coeliac disease? Coeliac disease is an immune reaction to gluten (wheat, barely, rye) in an genetic predisposed
More informationLevel 2. Non Responsive Celiac Disease KEY POINTS:
Level 2 Non Responsive Celiac Disease KEY POINTS: Celiac Disease (CD) is an autoimmune condition triggered by ingestion of gluten leading to intestinal damage and a variety of clinical manifestations.
More informationCoeliac Disease: Diagnosis and clinical features
Coeliac Disease: Diagnosis and clinical features Australasian Gastrointestinal Pathology Society AGM 28 Oct 2016 Dr. Hooi Ee Gastroenterologist, Sir Charles Gairdner Hospital Coeliac disease Greek: koiliakos
More informationTips for Managing Celiac Disease. Robert Berger MD FRCPC Gastroenterology New Brunswick Internal Medicine Update April 22, 2016
Tips for Managing Celiac Disease Robert Berger MD FRCPC Gastroenterology New Brunswick Internal Medicine Update April 22, 2016 Disclosures None relevant to this presentation Objectives Briefly review the
More informationNATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE SCOPE. Coeliac disease: recognition, assessment and management of coeliac disease
Appendix B: NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE 1 Guideline title SCOPE Coeliac disease: recognition, assessment and management of coeliac disease 1.1 Short title Coeliac disease 2 The remit
More informationACG Clinical Guideline: Diagnosis and Management of Celiac Disease
ACG Clinical Guideline: Diagnosis and Management of Celiac Disease Alberto Rubio-Tapia, MD 1, Ivor D. Hill, MD 2, Ciarán P. Kelly, MD 3, Audrey H. Calderwood, MD 4 and Joseph A. Murray, MD 1 1 Division
More informationEDUCATION PRACTICE. Celiac Disease and Persistent Symptoms. Clinical Scenario. The Problem
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:13 17 EDUCATION PRACTICE Celiac Disease and Persistent Symptoms ALBERTO RUBIO TAPIA, SUSAN H. BARTON, and JOSEPH A. MURRAY Division of Gastroenterology and
More informationCeliac disease (CD) is characterized by intestinal damage. Clinical Staging and Survival in Refractory Celiac Disease: A Single Center Experience
GASTROENTEROLOGY 2009;136:99 107 Clinical Staging and Survival in Refractory Celiac Disease: A Single Center Experience ALBERTO RUBIO TAPIA,* DARLENE G. KELLY,* BRIAN D. LAHR, AHMET DOGAN, TSUNG TEH WU,
More informationA Practical Approach to Small Bowel Biopsies: All that flattens is not sprue
A Practical Approach to Small Bowel Biopsies: All that flattens is not sprue UCSF Liver and Gastrointestinal Pathology Update Sept. 4, 2009 How to Go Wrong When Evaluating Small Bowel Biopsies, Based on
More informationKristin Kenrick, FRNZCGP Department of General Practice and Rural Health Dunedin School of Medicine (Supported by Coeliac New Zealand)
Kristin Kenrick, FRNZCGP Department of General Practice and Rural Health Dunedin School of Medicine (Supported by Coeliac New Zealand) That you will go away thinking about your practice population, and
More informationNon responsive coeliac disease: next steps for investigation. Dr Peter Mooney Clinical Research Fellow Royal Hallamshire Hospital, Sheffield, UK
Non responsive coeliac disease: next steps for investigation Dr Peter Mooney Clinical Research Fellow Royal Hallamshire Hospital, Sheffield, UK Outline Cases Non Responsive Coeliac Disease Causes Investigation
More informationGLUTEN RELATED DISORDERS
Celiac disease Overcoming clinical challenges Disclosures Scientific Advisory Board Cellimune, Immunsant, Innovate Pharmaceuticals Peter HR Green MD Phyllis and Ivan Seidenberg Professor of Medicine Director,
More informationCoeliac Disease: Symptoms, Diagnosis, Treatment and Management
Coeliac Disease: Symptoms, Diagnosis, Treatment and Management Dr Matthew Kurien Senior Clinical Lecturer and Honorary Consultant Gastroenterologist, University of Sheffield Benign Diseases Talk Outline
More informationCeliac Disease. M. Nedim Ince, MD University of Iowa Hospital
Celiac Disease M. Nedim Ince, MD University of Iowa Hospital Contents Cases Definition Etiopathogenesis Pathology Diagnosis Management of the disease Management of complications Case I Five year old boy
More informationVideo Capsule Endoscopy in the Evaluation of Celiac Patients with Persistent or Recurrent Symptoms. Who and When?
International Journal of Celiac Disease, 2016, Vol. 4, No. 2, xx Available online at http://pubs.sciepub.com/ijcd/4/2/5 Science and Education Publishing DOI:10.12691/ijcd-4-2-5 Video Capsule Endoscopy
More informationGPMP and TCA Coeliac disease
MP and TCA Coeliac disease ITEM: prepares MP (721) REVIEWS MP (732) prepared TCA (723) REVIEW TCA (732) PATIENT DETAILS: DETAILS: DATE PREPARED: Does a current management plan or Team care arrangement
More informationHistologic Follow-up of People With Celiac Disease on a Gluten-Free Diet Slow and Incomplete Recovery
Anatomic Pathology / HISTOLOGIC FOLLOW-UP OF PEOPLE WITH CELIAC DISEASE ON A GLUTEN-FREE DIET Histologic Follow-up of People With Celiac Disease on a Gluten-Free Diet Slow and Incomplete Recovery Peter
More informationDr Kristin Kenrick. Senior Lecturer Dunedin School of Medicine
Dr Kristin Kenrick Senior Lecturer Dunedin School of Medicine Kristin Kenrick, FRNZCGP Department of General Practice and Rural Health Dunedin School of Medicine (Supported by Coeliac New Zealand) Because
More informationSmall bowel diseases. Györgyi Műzes 2015/16-I. Semmelweis University, 2nd Dept. of Medicine
Small bowel diseases Györgyi Műzes 2015/16-I. Semmelweis University, 2nd Dept. of Medicine Celiac disease (revised definition!) a systemic autoimmune disorder Occurs in genetically susceptible individuals
More informationFollow-up of Celiac Disease
Follow-up of Celiac Disease Benjamin Lebwohl MD, MS Director of Clinical Research Celiac Disease Center Columbia University celiacdiseasecenter.org BL114@columbia.edu @BenjaminLebwohl Disclosures None
More informationRefractory Celiac Disease New Diagnostic Approaches and Current Treatment
International Journal of Celiac Disease, 2014, Vol. 2, No. 1, 33-37 Available online at http://pubs.sciepub.com/ijcd/2/1/10 Science and Education Publishing DOI:10.12691/ijcd-2-1-10 Refractory Celiac Disease
More informationNICE guideline Published: 2 September 2015 nice.org.uk/guidance/ng20
Coeliac disease: recognition, assessment and management NICE guideline Published: 2 September 2015 nice.org.uk/guidance/ng20 NICE 2017. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).
More informationNIH Public Access Author Manuscript Am J Gastroenterol. Author manuscript; available in PMC 2014 May 01.
NIH Public Access Author Manuscript Published in final edited form as: Am J Gastroenterol. 2013 May ; 108(5): 656 677. doi:10.1038/ajg.2013.79. AMERICAN COLLEGE OF GASTROENTEROLOGY CLINICAL GUIDELINE:
More informationSouthern Derbyshire Shared Care Pathology Guidelines. Coeliac Disease
Southern Derbyshire Shared Care Pathology Guidelines Coeliac Disease Purpose of Guideline When and how to investigate patients for Coeliac Disease What the results mean When and how to refer patients Monitoring
More informationCOSA NON È CELIACHIA ( uno sguardo obliquo )
COSA NON È CELIACHIA ( uno sguardo obliquo ) Gino Roberto Corazza I Clinica Medica Fondazione IRCCS Policlinico San Matteo Università di Pavia HOLY PAPERS OF COELIAC DISEASE Gut 2012 Gut 2014 JPGN 2012
More informationSUMMARY Coeliac disease is a common food intolerance in Western populations, in which it has a prevalence of about 1%. In early infancy, when the transition is made to a gluten-containing diet (particularly
More informationPATHOLOGY OF NON NEOPLASTIC LESIONS OF THE UPPER GASTROINTESTINAL TRACT.
PATHOLOGY OF NON NEOPLASTIC LESIONS OF THE UPPER GASTROINTESTINAL TRACT. OESOPHAGEAL LESIONS OESOPHAGITIS AND OTHER NON NEOPLASTIC DISORDERS Corrosive Gastroesophageal reflux (GERD), Pills, Acid intake,
More informationSupplemental Table 1: Moderate and severe definitions of Celiac Disease Symptom Diary
Supplemental Table 1: Moderate and severe definitions of Celiac Disease Symptom Diary symptoms CDSD Symptom Diarrhea Constipation Abdominal Pain Bloating Nausea Tiredness Moderate Once or twice between
More informationFM CFS leaky gut April pag 1
FM CFS leaky gut April 21 2018 pag 1 FIBROMYALGIA / CHRONIC FATIGUE SYNDROME AND LEAKY GUT. SUMMARY OF CLINICAL TRIAL DESIGN. Double-blind randomized placebo-controlled challenge with gluten and milk protein
More informationPERSONALIZED MANAGEMENT OF CELIAC DISEASE: RISK STRATIFICATION AND NOVEL STRATEGIES FOR COMPLICATED PATIENTS
UNIVERSITA DEGLI STUDI DI MILANO FACULTY OF MEDICINE AND SURGERY RESEARCH DOCTORATE IN GASTROENTEROLOGY CICLE XXVII PERSONALIZED MANAGEMENT OF CELIAC DISEASE: RISK STRATIFICATION AND NOVEL STRATEGIES FOR
More informationThey are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see:
bring together everything NICE says on a topic in an interactive flowchart. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest
More informationMalabsorption is characterized by defective absorption of: Fats fat- and water-soluble vitamins Proteins Carbohydrates Electrolytes Minerals water
Malabsorption Malabsorption is characterized by defective absorption of: Fats fat- and water-soluble vitamins Proteins Carbohydrates Electrolytes Minerals water presents most commonly as chronic diarrhea
More informationCoeliac Disease in 2016: A shared care between GPs and gastroenterologists. Dr Roslyn Vongsuvanh
Coeliac Disease in 2016: A shared care between GPs and gastroenterologists Dr Roslyn Vongsuvanh Ms JM 23 year old female Born in Australia. Parents from Lebanon. Engineering student Presents with lethargy
More informationFecal incontinence causes 196 epidemiology 8 treatment 196
Subject Index Achalasia course 93 differential diagnosis 93 esophageal dysphagia 92 95 etiology 92, 93 treatment 93 95 work-up 93 Aminosalicylates, pharmacokinetics and aging effects 36 Antibiotics diarrhea
More informationDefinition. Celiac disease is an immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals.
Definition 1 Definition Celiac disease is an immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals. It occurs in symptomatic subjects with gastrointestinal
More informationCoeliac Disease (CD) Pathological mimics and complications. Dr. Shaun Walsh Dept of Pathology Ninewells Hospital, Dundee
Coeliac Disease (CD) Pathological mimics and complications Dr. Shaun Walsh Dept of Pathology Ninewells Hospital, Dundee Pathological mimics and complications 25 minutes Recent challenging case Place of
More informationGastroenterology. Certification Examination Blueprint. Purpose of the exam
Gastroenterology Certification Examination Blueprint Purpose of the exam The exam is designed to evaluate the knowledge, diagnostic reasoning, and clinical judgment skills expected of the certified gastroenterologist
More informationMassachusetts ACP Meeting Update in Gastroenterology and Hepatology
Massachusetts ACP Meeting Update in Gastroenterology and Hepatology November 19 th, 2016 Norton J. Greenberger, MD Senior Attending Physician Brigham and Women s Hospital 1 Agenda Stomach and Small Bowel
More informationOHTAC Recommendation
OHTAC Recommendation Clinical Utility of Serologic Testing for Celiac Disease in Asymptomatic Patients Presented to the Ontario Health Technology Advisory Committee in May and June 2011 July 2011 Background
More informationCHRONIC DIARRHEA DR. PHILIP K. BLUSTEIN M.D. F.R.C.P.(C) DEFINITION: *LOOSE, WATERY STOOLS *MORE THAN 3 TIMES A DAY *FOR MORE THAN 4 WEEKS
DR. PHILIP K. BLUSTEIN M.D. F.R.C.P.(C) 415 14 TH ST. NW. CALGARY AB T2N2A1 PHONE (403) 270-9555 FAX (403) 270-7479 CHRONIC DIARRHEA DEFINITION: *LOOSE, WATERY STOOLS *MORE THAN 3 TIMES A DAY *FOR MORE
More informationPreface and outline of the thesis
Preface Celiac disease (CD) is characterized by a chronic immune reaction in the small intestine to the gluten proteins that are present in a (Western) daily diet, derived from wheat, barley and rye. It
More informationCeliac Disease. Marian Rewers, MD, PhD. Professor & Clinical Director Barbara Davis Center for Diabetes University of Colorado School of Medicine
Celiac Disease Marian Rewers, MD, PhD Professor & Clinical Director Barbara Davis Center for Diabetes University of Colorado School of Medicine No relevant financial relationships with any commercial interests
More informationHDF Case Whipple s disease
HDF Case 952556 Whipple s disease 63 yo female complaining of a diarrhea for 2 months, weigth loss (12 Kg in 3 months), and joint pains. Duodenal biopsy performed. Scanning view, enlarged intestinal villi,
More informationOutcome of Referrals for Non-Responsive Celiac Disease in a Tertiary Center: Low Incidence of Refractory Celiac Disease in the Netherlands
Citation: (2017) 8, e218; doi:10.1038/ctg.2016.70 & 2017 the American College of Gastroenterology 2155-384X/17 www.nature.com/ctg Outcome of Referrals for Non-Responsive Celiac Disease in a Tertiary Center:
More informationCELIAC DISEASE WHAT S THE LATEST? Peter HR Green MD
CELIAC DISEASE WHAT S THE LATEST? Peter HR Green MD pg11@columbia.edu CELIAC DISEASE Common Underdiagnosed Biopsy is the gold standard for diagnosis CLINICAL FEATURES Dig Dis Sci. 2014 EJGH, Sontig 2013
More informationIs a raised intraepithelial lymphocyte count with normal duodenal villous architecture clinically relevant?
424 ORIGINAL ARTICLE Is a raised intraepithelial lymphocyte count with normal duodenal villous architecture clinically relevant? S Mahadeva, J I Wyatt, P D Howdle... See end of article for authors affiliations...
More informationLymphocytic Gastritis, Isolated Type Occurring in Family Members. A Case Report.
Lymphocytic Gastritis, Isolated Type Occurring in Family Members. A Case Report. Alan Shienbaum, DO; AndriyPavlenko, MD; Jun Liu, MD, PhD; Janusz J Godyn, MD. Pathology Department, Kennedy University Hospitals,
More informationDuodenal Perforation as an Unusual Celiac Disease Presentation in Two Patients
Elmer Press Case Report Duodenal Perforation as an Unusual Celiac Disease Presentation in Two Patients Imad Absah a, e, Rayna M. Grothe a, D. Dean Potter b, Tsung-Teh Wu c, Joseph A. Murray d Abstract
More informationLower Gastrointestinal Tract KNH 406
Lower Gastrointestinal Tract KNH 406 Lower GI Tract A&P Small Intestine Anatomy Duodenum, jejunum, ileum Maximum surface area for digestion and absorption Specialized enterocytes from stem cells of crypts
More informationKids Like to Break the Rules: Gastrointestinal Pathology in Children
Kids Like to Break the Rules: Gastrointestinal Pathology in Children Jeffrey Goldsmith MD Director of Surgical Pathology, Beth Israel Deaconess Medical Center; Consultant in Gastrointestinal Pathology,
More informationGastrointestinal Disorders. Disorders of the Esophagus 3/7/2013. Congenital Abnormalities. Achalasia. Not an easy repair. Types
Gastrointestinal Disorders Congenital Abnormalities Disorders of the Esophagus Types Stenosis Atresia Fistula Newborn aspirates while feeding. Pneumonia Not an easy repair Achalasia Lack of relaxation
More informationCapsule Endoscopy: Is it Really Helpful in the Diagnosis of Small Bowel Diseases? Kashif Malik, Muhammad Joher Amin, Syed Waqar Hassan Shah
Original Article Capsule Endoscopy: Is it Really Helpful in the Diagnosis of Small Bowel Diseases? Kashif Malik, Muhammad Joher Amin, Syed Waqar Hassan Shah ABSTRACT Objective: To determine the diagnostic
More informationESIM: Winter School in Riga Case report
ESIM: Winter School in Riga 2015 Case report Imanta Ozola Zālīte Pauls Stradins Clinical University Hospital Latvia 29.01.2015. January, 2006 32 y., man 2-3 weeks fatigue fluidal stool 2 times per day
More informationMashhad University of Medical Sciences. Azita Ganji MD, MPH
Mashhad University of Medical Sciences Azita Ganji MD, MPH 30.2.95 CD Food sensitivity (NCGS, ) Food intolerance IBS Gluten translocate through the epithelial mucosa via increased tight junction (TJ)
More informationLaboratory Methods for Diagnosing Celiac Disease. Vijay Kumar, PhD, FACB IMMCO Diagnostics, Inc. Buffalo, NY
Laboratory Methods for Diagnosing Celiac Disease Vijay Kumar, PhD, FACB IMMCO Diagnostics, Inc. Buffalo, NY Prevalence of Celiac Disease Group With Symptoms Adults Children Associated Symptoms Chronic
More informationFood Choices and Alternative Techniques in Management of IBS: Fad Versus Evidence
Food Choices and Alternative Techniques in Management of IBS: Fad Versus Evidence Maria Vazquez Roque, MD, MSc Assistant Professor Gastroenterology and Hepatology 2010 MFMER slide-1 Objectives Gluten-free
More informationIBD 101. Ronen Stein, MD Assistant Professor of Clinical Pediatrics Division of Gastroenterology, Hepatology, and Nutrition
IBD 101 Ronen Stein, MD Assistant Professor of Clinical Pediatrics Division of Gastroenterology, Hepatology, and Nutrition Objectives Identify factors involved in the development of inflammatory bowel
More informationCeliac Disease: An Assessment of Subjective Variation and Diagnostic Reproducibility of the Various Classification Systems
: C Microbiology and Pathology Volume 15 Issue 1 Version 1.0 Year 2015 Type: Double Blind Peer Reviewed International Research Journal Publisher: Global Journals Inc. (USA) Online ISSN: 2249-4618 & Print
More informationDone By : shady soghayr
Done By : shady soghayr Malabsorption Malabsorption is characterized by defective absorption of: Fats fat- and water-soluble vitamins Proteins Carbohydrates Electrolytes Minerals Water presents most commonly
More informationMP Madhu 1, Prachis Ashdhir 1, Garima Sharma 2, Gyan Prakash Rai 1, Rupesh Kumar Pokharna 1, Dilip Ramrakhiani 2 ABSTRACT
Tropical Gastroenterology 2017;38(2):102-107 Original Article Correlation of serum levels of IgA antitissue transglutaminase (IgA ttg) with the histological severity in celiac disease MP Madhu 1, Prachis
More informationEosinophilic Esophagitis (EoE)
Eosinophilic Esophagitis (EoE) 01.06.2016 EoE: immune-mediated disorder food or environmental antigens => Th2 inflammatory response. Key cytokines: IL-4, IL-5, and IL-13 stimulate the production of eotaxin-3
More informationEnteropathy-Type T-Cell Lymphoma
AJCP / SHP/EAHP WORKSHOP Enteropathy-Type T-Cell Lymphoma Andreas Zettl, MD, 1 Ron deleeuw, 2 Eugenia Haralambieva, MD, 1 and Hans-Konrad Mueller-Hermelink, MD 1 Key Words: Enteropathy; Celiac disease;
More informationORIGINAL ARTICLE Histopathological features of coeliac disease in a sample of Sudanese patients
Malaysian J Pathol 2016; 38(3) : 267 272 ORIGINAL ARTICLE Histopathological features of coeliac disease in a sample of Sudanese patients MA Noha MOKHTAR, SO MEKKI, HMY MUDAWI*, SH SULAIMAN**, MA TAHIR,
More informationWhat is your diagnosis? a. Lymphocytic colitis. b. Collagenous colitis. c. Common variable immunodeficiency (CVID) associated colitis
Case History A 24 year old male presented with fatigue, fever, watery diarrhea, and a cough with sputum production for the past three weeks. His past medical history was significant for recurrent bouts
More informationCeliac Disease. Disclosures 5/6/2015. Goals/Objectives. Jeff Hunt, DO, FACOI. Speaker for Abbvie. Consultant for Janssen Pharmaceuticals
Celiac Disease Jeff Hunt, DO, FACOI Gastroenterology United of Tulsa OSU Medical Center 5-3-2015 Disclosures Speaker for Abbvie Consultant for Janssen Pharmaceuticals Research projects with Abbvie Goals/Objectives
More informationGASTROENTEROLOGY Maintenance of Certification (MOC) Examination Blueprint
GASTROENTEROLOGY Maintenance of Certification (MOC) Examination Blueprint ABIM invites diplomates to help develop the Gastroenterology MOC exam blueprint Based on feedback from physicians that MOC assessments
More informationClinical Management of Obscure- Overt Gastrointestinal Bleeding. Presented by Dr. 張瀚文
Clinical Management of Obscure- Overt Gastrointestinal Bleeding Presented by Dr. 張瀚文 Definition Obscure: : hard to understand; not clear. Overt: : public; not secret. Occult: : hidden from the knowledge
More informationCase Report Seronegative Intestinal Villous Atrophy: A Diagnostic Challenge
Case Reports in Gastrointestinal Medicine Volume 2016, Article ID 6392028, 4 pages http://dx.doi.org/10.1155/2016/6392028 Case Report Seronegative Intestinal Villous Atrophy: A Diagnostic Challenge Cláudio
More informationINVESTIGATIONS OF GASTROINTESTINAL DISEAS
INVESTIGATIONS OF GASTROINTESTINAL DISEAS Lecture 1 and 2 دز اسماعيل داود فرع الطب كلية طب الموصل Radiological tests of structure (imaging) Plain X-ray: May shows soft tissue outlines like liver, spleen,
More informationChronic Diarrhea in Dogs
Chronic Diarrhea in Dogs Basics OVERVIEW A change in the frequency, consistency, and volume of bowel movement (feces) for more than 3 weeks Can be either small bowel (small intestine) diarrhea, large bowel
More informationLymphoplasmacytic-Plasmacytic Gastroenteritis
Lymphoplasmacytic-Plasmacytic Gastroenteritis (Inflammation of the Stomach and Intestines, Characterized by the Presence of Lymphocytes and Plasmacytes [Types of White Blood Cell]) Basics OVERVIEW An inflammatory
More informationMast Cell Tumors in Dogs
Mast Cell Tumors in Dogs 803-808-7387 www.gracepets.com These notes are provided to help you understand the diagnosis or possible diagnosis of cancer in your pet. For general information on cancer in pets
More informationTumors of the Spleen
Tumors of the Spleen 803-808-7387 www.gracepets.com These notes are provided to help you understand the diagnosis or possible diagnosis of cancer in your pet. For general information on cancer in pets
More informationPrimary Sclerosing Cholangitis and Cholestatic liver diseases. Ahsan M Bhatti MD, FACP Bhatti Gastroenterology Consultants
Primary Sclerosing Cholangitis and Cholestatic liver diseases Ahsan M Bhatti MD, FACP Bhatti Gastroenterology Consultants I have nothing to disclose Educational Objectives What is PSC? Understand the cholestatic
More informationMalabsorption: etiology, pathogenesis and evaluation
Malabsorption: etiology, pathogenesis and evaluation Peter HR Green NORMAL ABSORPTION Coordination of gastric, small intestinal, pancreatic and biliary function Multiple mechanisms Fat protein carbohydrate
More informationDone By : WESSEN ADNAN BUTHAINAH AL-MASAEED
Done By : WESSEN ADNAN BUTHAINAH AL-MASAEED Acute Myeloid Leukemia Firstly we ll start with this introduction then enter the title of the lecture, so be ready and let s begin by the name of Allah : We
More informationABDOMINAL PAIN AND DIARRHEA - IT S NOT (ALWAYS) WHAT YOU THINK. Yakov Wainer, MD Gastroenterology and Hepatology Meir Medical Center
ABDOMINAL PAIN AND DIARRHEA - IT S NOT (ALWAYS) WHAT YOU THINK Yakov Wainer, MD Gastroenterology and Hepatology Meir Medical Center 1 ST ADMISSION - 2015 38 y/o female Abdominal pain, diarrhea - intermittent
More informationTop 10 Things you need to know about IBD. Suresh Pola, MD Kaiser San Diego
Top 10 Things you need to know about IBD Suresh Pola, MD Kaiser San Diego Top 10 Things to Know: IBD What you can eat How to treat the pain Not all diarrhea is a flare Ways to reduce your risk of getting
More informationOriginal Article. Evaluation of Small Intestinal Biopsies in Malabsorption Syndromes
Original Article Evaluation of Small Intestinal Biopsies in Malabsorption Syndromes Ashmeet Kaur 1 *, Poojaba Jadeja 2, Neha Garg 2, SML Rai 2 and N. Mogra 2 1 Department Of Pathology, Santokba Durlabhji
More informationRADIATION INDUCED SMALL BOWEL DISEASE. Dr Mnguni Supervisor: Dr Lohlun Radiation Oncology
RADIATION INDUCED SMALL BOWEL DISEASE Dr Mnguni Supervisor: Dr Lohlun Radiation Oncology INTRODUCTION Radiation therapy is not regularly indicated in the treatment of small bowel disease. Reasons are complex
More informationIBD 101. Ronen Stein, MD Assistant Professor of Clinical Pediatrics Division of Gastroenterology, Hepatology, and Nutrition
IBD 101 Ronen Stein, MD Assistant Professor of Clinical Pediatrics Division of Gastroenterology, Hepatology, and Nutrition Objectives Identify factors involved in the development of inflammatory bowel
More informationGastroenterology Tutorial
Gastroenterology Tutorial Gastritis Poorly defined term that refers to inflammation of the stomach. Infection with H. pylori is the most common cause of gastritis. Most patients remain asymptomatic Some
More informationAsubgroup of patients with celiac disease develops
GASTROENTEROLOGY 2009;136:81 90 CLINICAL Presentation and Long-Term Follow-up of Refractory Celiac Disease: Comparison of Type I With Type II GEORGIA MALAMUT,*,, PAULINE AFCHAIN, VIRGINIE VERKARRE,*, THIERRY
More informationLahey Clinic Internal Medicine Residency Program: Curriculum for Gastroenterology
Lahey Clinic Internal Medicine Residency Program: Curriculum for Gastroenterology Faculty representative: David L. Burns, MD, CNSP Resident representative: Tom Castiglione, MD Revision date: March 6, 2006
More informationGuidelines NICE, not NICE and the Daily Mail. Dr Andy Poullis Consultant Gastroenterologist
Guidelines NICE, not NICE and the Daily Mail 2018 Dr Andy Poullis Consultant Gastroenterologist Coeliac IBS Gall bladder polyps PEI PPI Who to test for Coeliac persistent unexplained abdominal or gastrointestinal
More informationTreatment of Inflammatory Bowel Disease. Michael Weiss MD, FACG
Treatment of Inflammatory Bowel Disease Michael Weiss MD, FACG What is IBD? IBD is an immune-mediated chronic intestinal disorder, characterized by chronic or relapsing inflammation within the GI tract.
More informationMucosal Recovery and Mortality in Adults with Celiac Disease After Treatment With a Gluten-free Diet
From The American Journal of Gastroenterology Mucosal Recovery and Mortality in Adults with Celiac Disease After Treatment With a Gluten-free Diet Alberto Rubio-Tapia MD; Mussarat W Rahim MBBS; Jacalyn
More informationDigestion: Small and Large Intestines Pathology
Digestion: Small and Large Intestines Pathology Dr. Ritamarie Loscalzo Medical Disclaimer: The information in this presentation is not intended to replace a one onone relationship with a qualified health
More informationGastrointestinal, Hepatic, and Nutritional Challenges in FA
Gastrointestinal, Hepatic, and Nutritional Challenges in FA Sarah Jane Schwarzenberg, MD Pediatric Gastroenterology, Hepatology and Nutrition June 29, 2014 GI problems in FA 5% have gastrointestinal tract
More informationBiomarkers of GI tract diseases. By Dr. Gouse Mohiddin Shaik
By Dr. Gouse Mohiddin Shaik Introduction The gastrointestinal (GI) tract is a complex system performing multiple biological functions which are anatomically distributed Site for food processing and absorption
More informationTuesday 10 th April 2018 Dr Rukhsana Hussain. Disclaimers apply:
Tuesday 10 th April 2018 Dr Rukhsana Hussain What is Non-Coeliac Gluten Sensitivity (NCGS)? Symptoms Pathophysiology Diagnosis Treatment Summary NCGS is a condition in which consumption of gluten leads
More informationEtiologies and Predictors of Diagnosis in Nonresponsive Celiac Disease
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2007;5:445 450 Etiologies and Predictors of Diagnosis in Nonresponsive Celiac Disease DANIEL A. LEFFLER, MELINDA DENNIS, BRIAN HYETT, EOIN KELLY, DETLEF SCHUPPAN,
More informationOccult GI Bleed. July 2015
Occult GI Bleed July 2015 Occult GI Bleed Occult vs Obscure Occult positive FOB and/or IDA, but no evidence of visible blood loss to pt or physician Obscure GI bleed that persist/ recurs without obvious
More informationCeliac Disease (CD) Diagnosis and Whom to Screen
Celiac Disease (CD) Diagnosis and Whom to Screen Maureen Leonard MD Fellow, MassGeneral Hospital for Children Twitter-Follow me @CeliacDoc Follow the MGH Celiac Center @CeliacResearch Conflicts of Interest
More informationTHE EFFECT OF CD48 INHIBITION IN MOUSE MEMORY T CELLS AND CELIAC DISEASE. Suzannah Bergstein
THE EFFECT OF CD48 INHIBITION IN MOUSE MEMORY T CELLS AND CELIAC DISEASE Suzannah Bergstein Why Study Celiac Disease? 2-3 million people in the United States diagnosed with Celiac Disease (CD) About 20
More information7 Omar Abu Reesh. Dr. Ahmad Mansour Dr. Ahmad Mansour
7 Omar Abu Reesh Dr. Ahmad Mansour Dr. Ahmad Mansour -Leukemia: neoplastic leukocytes circulating in the peripheral bloodstream. -Lymphoma: a neoplastic process in the lymph nodes, spleen or other lymphatic
More informationDifferentiate IgE-mediated food allergy from non-ige mediated food allergy. List the foods and formulas most commonly associated with food allergy.
Gastroenterology Description: The resident will be exposed to various clinical symptoms and diseases of the gastrointestinal tract which are commonly seen by the gastroenterologist. The resident will be
More informationNEW CONCEPTS IN CROHN S DISEASE GLENDON BURRESS, MD PEDIATRIC GASTROENTEROLOGY ROCKFORD, IL
NEW CONCEPTS IN CROHN S DISEASE GLENDON BURRESS, MD PEDIATRIC GASTROENTEROLOGY ROCKFORD, IL CROHN S DISEASE Chronic disease of uncertain etiology Etiology- genetic, environmental, and infectious Transmural
More information