Alberto Magni

Incidence of Post-Infectious Irritable Bowel Syndrome and Functional Intestinal Disorders Following a Water-Borne Viral Gastroenteritis Outbreak

OBJECTIVES:Post-infectious irritable bowel syndrome (PI-IBS) may develop in 4–31% of affected patients following bacterial gastroenteritis (GE), but limited information is available on long-term outcome of viral GE. During summer 2009, a massive outbreak of viral GE associated with contamination of municipal drinking water (Norovirus) occurred in San Felice del Benaco (Lake Garda, Italy). To investigate the natural history of a community outbreak of viral GE, and to assess the incidence of PI-IBS and functional gastrointestinal disorders, we carried out a prospective population-based cohort study with a control group.METHODS:Baseline questionnaires were administered to the resident community within 1 month of the outbreak. Follow-up questionnaires of the Italian version of Gastrointestinal Symptom Rating Scale (GSRS, a 15-item survey scored according to a 7-point Likert scale) were mailed to all patients responding to baseline questionnaire at 3 and 6 months, and to a cohort of unaffected controls, living in the same geographical area, at 6 months after the outbreak. The GSRS item were grouped in five dimensions: abdominal pain, reflux, indigestion, diarrhea, and constipation. At month 12, all patients and controls were interviewed by a health assistant to verify Rome III criteria of IBS. Students t-test and χ2- or Fishers exact test were used as appropriate.RESULTS:Baseline questionnaires were returned by 348 patients: mean age±s.d. 45±22 years, 53% female. At outbreak, nausea (scored ≥4), vomiting, and diarrhea lasting 2–3 days or more were reported by 66, 60, and 77% of patients, respectively. A total of 50% reported fever and 19% reported weight loss (mean 3 kg). Follow-up surveys were returned at month 6 by 186 patients and 198 controls: mean GSRS score was significantly higher in patients than in controls for abdominal pain, diarrhea, and constipation. At month 12, we identified 40 patients with a new diagnosis of IBS (Rome III criteria), in comparison with 3 subjects in the control cohort (P<0.0001; odds ratio 11.40; 95% confidence intervals 3.44–37.82). The 40 cases of PI-IBS were subtyped according to the predominant stool pattern as follows: 4 IBS with constipation, 7 IBS with diarrhea, 16 with mixed IBS, and 13 with unsubtyped IBS.CONCLUSIONS:Our study provides evidence that Norovirus GE leads to the development of PI-IBS in a substantial proportion of patients (13%), similar to that reported after bacterial GE.

Celiac Disease With Mild Enteropathy Is Not Mild Disease

BACKGROUND & AIMS Patients with celiac disease have varying degrees of damage to the small intestinal mucosa, ranging from lymphocytic duodenosis with normal villous structure to severe villous atrophy. We assessed whether the severity of mucosal lesions was associated with clinical and laboratory features of celiac disease. METHODS We compared demographic, clinical, and laboratory characteristics among patients with celiac disease who were classified based on the severity of duodenal lesions. We analyzed data from 1408 adult patients seen consecutively at a tertiary referral center since 1990. Patients were classified as having villous atrophy (n = 1249) or as having mild enteropathy (n = 159) in the presence or absence of villous atrophy. RESULTS Similar percentages of patients with villous atrophy, vs mild enteropathy, experienced weight loss (17% vs 17%), gastrointestinal manifestations (70% vs 70%), extraintestinal manifestations (66% vs 57%), and other associated conditions (19% vs 23%). More patients with villous atrophy than patients with mild enteropathy developed osteopenia or osteoporosis (22% vs 5%; P = .0005). Greater percentages of patients with villous atrophy than those with mild enteropathy also had anemia (42% vs 29%; P = .002), folate deficiency (75% vs 64%; P = .02), hypocholesterolemia (7% vs 2%; P = .02), hypocalcemia (26% vs 13%; P = .004), or hyperparathyroidism (45% vs 29%; P = .004). CONCLUSIONS Although osteopenia, osteoporosis, and alterations in laboratory parameters are prevalent among patients with celiac disease with mild enteropathy, they are more prevalent and severe in those with villous atrophy. The prevalence of associated conditions is similar between these groups. These results indicate that celiac disease with mild enteropathy is not mild disease, but requires treatment with a gluten-free diet.

High tissue-transglutaminase antibody level predicts small intestinal villous atrophy in adult patients at high risk of celiac disease

BACKGROUND Duodenal biopsy may be unnecessary to confirm celiac disease in patients with high tissue-transglutaminase antibody level. AIMS To define a cut-off value of tissue-transglutaminase antibody with high positive likelihood ratio for duodenal atrophy in patients with suspected celiac disease. METHODS We retrospectively identified 945 patients with suspected celiac disease and classified according to the method used for tissue-transglutaminase antibody assay: Group A (n=393, Eu-tTG® Eurospital), Group B (n=263; Eu-tTG® Eurospital) and Group C (n=289; Celikey® Phadia). Duodenal histology was graded according to Marsh. Sensitivity, specificity, and positive likelihood ratio were used to evaluate cut-off points of tissue-transglutaminase antibody as predictor of villous atrophy. RESULTS 100% specificity and ∞ positive likelihood ratio for duodenal atrophy was observed at a cut-off value of tissue-transglutaminase antibody 5 times higher than the upper limit of normal. CD diagnosis was confirmed by concordance with antiendomysial antibodies, and by reduction of t-TG titre in all patients and improvement of duodenal histology in 80% during gluten-free diet. CONCLUSIONS Tissue-transglutaminase antibody level 5-folds the upper limit of normal is 100% specific for duodenal atrophy and using this cut-off biopsy could by avoided in 1/3 of patients. Diagnostic criteria of celiac disease in adults need revision.

Characteristics of coeliac disease (CD) in a cohort of elderly patients

Introduction CD is increasingly being diagnosed in elderly patients, but little information is available on clinical characteristics and on response to gluten free diet (GFD) in elderly CD. Methods To characterise CD in patients aged ≥65 years by comparison with patients aged 18–65 years and to assess the effects of GFD. Information on clinical, serological and histological characteristics collected before and during GFD were retrieved retrospectively from CD database of patients attending our Clinic from 1991 to 2010. We identified two cohorts of patients: Group A, age ≥65 years (n= 59 patients); Group B, age range 18–64 years (n= 1166). Results Elderly patients represented 5% of patients in our database. Mean ± SEM age was 70±0.6 years (range 65-83) in group A and 35.2±0.3 (range 18–64) in group B; male/female ratio was 1/2.7in both Groups. body mass index (BMI) was 22.5±0.7 in group A and 21.6±0.1 in group B respectively (p=0.1). Prevalence of diarrhoea (49% vs 41 %, p=0.3) and abdominal pain (27% vs 31 %, p=0.6) was similar, but weight loss (37% vs 21% p=0.005) and dyspepsia (22% vs 12%; p=0.04) were more frequent in group A than B. Incidence at diagnosis of non-Hodgkin lymphoma (NHL) was higher in group A (5%) than group B (0.3%, p=0.003). Differences before and during GFD on selected parameters are summarised in table 1. Table 1 PTU-049 Neuropsychological tests in CD patients (Group A) and in Control subjects (Group B) Before GFD During GFD Group A Group B p Group A Group B p Haemoglobin (mg/dl) 12.12°0.3 12.73°0.1 0.02 13.12°0.31 13.3°0.05 0.5 Albumin (g/dl) 57.59°0.92 61.19°0.15 <0.0001 58.47°1.17 62.26°0.15 <0.0001 Calcium (mg/dl) 8.72°0.2 9.1°0.03 0.0043 9.1°0.17 9.28°0.02 0.06 Vitamin D (ng/ml) 15.48°2.02 20.9°0.45 0.01 21.88°3.43 23.3°0.77 0.7 Vitamin B12 (pg/ml) 463.9°86 348.6°6.3 0.0007 373.3°29.3 385.1°6.84 0.7 Parathyroid hormone (pg/ml) 91.45°16.7 67.2°2.5 0.05 60.71°6.37 50.5°1.16 0.1 Bone ALP (U/l) 89.19°16.66 42.69°2.2 <0.0001 43.25°5.62 28.8°0.77 0.004 T-score lumbosacral −3.01°0.37 −1.01°0.07 <0.0001 −2.62°0.79 −0.82°0.08 0.0006 Marsh III 81% 93% 0.2 21% 19% 0.5 Conclusion CD is a common disease in the elderly and can be diagnosed in patients as old as 83 years of age. Clinical presentation is similar in the elderly as in younger patients, but elderly patients present more frequently with weight loss and bone disease. NHL is already present at time of CD diagnosis in a substantial proportion of elderly patients, emphasizing the importance of early diagnosis. Histological improvement during GFD is similar in elderly as in younger patients, but improvement of laboratory parameters is less marked in elderly CD.

P.43 TISSUE-TRANSGLUTAMINASE ANTIBODIES LEVEL (T-TGA) AS PREDICTOR OF VILLOUS ATROPHY AMONG ADULT UNSELECTED PATIENTS WITH SUSPECTED CELIAC DISEASE (CD)

their first re-evaluation. To avoid any bias, to both patient and doctor, the questionnarie was administered by a second operator, just before taking duodenal biopsies, except for 6 cases (maximum time elapse: 3 months). The score obtained was compared with persistence of both villous atrophy (VA) and endomysial antibodies (EMA) tested on monkey oesophagus. Results: The questionnaire was fulfilled in less than one minute. The table shows that patients scoring the lowest results were more frequent among the patients with persistence of both VA and positive EMA.