Javier A. Villafuerte-Galvez

Celiac Disease or Non-Celiac Gluten Sensitivity? An Approach to Clinical Differential Diagnosis

OBJECTIVES:Differentiating between celiac disease (CD) and non-celiac gluten sensitivity (NCGS) is important for appropriate management but is often challenging.METHODS:We retrospectively reviewed records from 238 patients who presented for the evaluation of symptoms responsive to gluten restriction without prior diagnosis or exclusion of CD. Demographics, presenting symptoms, serologic, genetic, and histologic data, nutrient deficiencies, personal history of autoimmune diseases, and family history of CD were recorded. NCGS was defined as symptoms responsive to a gluten-free diet (GFD) in the setting of negative celiac serology and duodenal biopsies while on a gluten-containing diet or negative human leukocyte antigen (HLA) DQ2/DQ8 testing.RESULTS:Of the 238 study subjects, 101 had CD, 125 had NCGS, 9 had non-celiac enteropathy, and 3 had indeterminate diagnosis. CD subjects presented with symptoms of malabsorption 67.3% of the time compared with 24.8% of the NCGS subjects (P<0.0001). In addition, CD subjects were significantly more likely to have a family history of CD (P=0.004), personal history of autoimmune diseases (P=0.002), or nutrient deficiencies (P<0.0001). The positive likelihood ratio for diagnosis of CD of a >2× upper limit of normal IgA trans-glutaminase antibody (tTG) or IgA/IgG deaminated gliadan peptide antibody (DGP) with clinical response to GFD was 130 (confidence interval (CI): 18.5–918.3). The positive likelihood ratio of the combination of gluten-responsive symptoms and negative IgA tTG or IgA/IgG DGP on a regular diet for NCGS was 9.6 (CI: 5.5–16.9). When individuals with negative IgA tTG or IgA/IgG DGP also lacked symptoms of malabsorption (weight loss, diarrhea, and nutrient deficiencies) and CD risk factors (personal history of autoimmune diseases and family history of CD), the positive likelihood ratio for NCGS increased to 80.9.CONCLUSIONS:On the basis of our findings, we have developed a diagnostic algorithm to differentiate CD from NCGS. Subjects with negative celiac serologies (IgA tTG or IgA/IgG DGP) on a regular diet are unlikely to have CD. Those with negative serology who also lack clinical evidence of malabsorption and CD risk factors are highly likely to have NCGS and may not require further testing. Those with equivocal serology should undergo HLA typing to determine the need for biopsy.

Factors governing long-term adherence to a gluten-free diet in adult patients with coeliac disease.

A strict gluten‐free diet is the cornerstone of treatment for coeliac disease. Studies of gluten‐free diet adherence have rarely used validated instruments. There is a paucity of data on long‐term adherence to the gluten‐free diet in the adult population.

The role of medical students in the fight to control neglected tropical diseases: a view from Peru.

Neglected tropical diseases (NTDs) is a term that might not ring a bell among the majority of our fellow medical students. The World Health Organization (WHO) defines NTDs through a list of 15 diseases, all of them infectious, ancient, and debilitating [1]. Despite vast consensus on which are and which are not considered NTDs, the precise inclusion criteria are as hard to define as global health [2]. Nevertheless, we believe that three basic features that characterize NTDs are high burden of disease in certain specific contexts, neglected from prevention and control—including drug development, and long-term impairment among those suffering from them. Neglect is the central idea, because not only do these diseases sicken the historically neglected populations, but they also have long been neglected from the axis of research, innovation, and production. The objective of this essay is to describe and promote training opportunities on NTDs to medical students, especially in Peru and Latin America. We will describe two medical student organizations and how they are organized to address NTDs. Finally, we will suggest three methods—curriculum, research, and information dissemination—of raising awareness of NTDs among medical students in Peru. Defining the NTDs through globally applicable and locally sensible criteria, instead of a rigid pre-specified list, could eventually improve the struggle against them. In this effort, medical students should play an important role. The Peruvian National Institute of Health, by establishing long-neglected diseases specific to Peru—such as Carrion disease due to Bartonella bacilliformis [3] and hydatidosis [4]—as national public health priorities for research, has shown the imperative of the need for a local NTD agenda [5].

Prospective randomized controlled study on the effects of Saccharomyces boulardii CNCM I-745 and amoxicillin-clavulanate or the combination on the gut microbiota of healthy volunteers

ABSTRACT Probiotics are believed to be beneficial in maintaining a healthy gut microbiota whereas antibiotics are known to induce dysbiosis. This study aimed to examine the effects of the probiotic Saccharomyces boulardii CNCM I-745 (SB), the antibiotic Amoxicillin-Clavulanate (AC) and the combination on the microbiota and symptoms of healthy humans. Healthy subjects were randomized to one of 4 study groups: SB for 14 days, AC for 7 days, SB plus AC, Control (no treatment). Participants gave stool samples and completed gastro-intestinal symptom questionnaires. Microbiota changes in stool specimens were analyzed using 16s rRNA gene pyrosequencing (bTEFAP). Only one subject withdrew prematurely due to adverse events. Subjects treated by S boulardii + AC had fewer adverse events and tolerated the study regimen better than those receiving the AC alone. Control subjects had a stable microbiota throughout the study period. Significant microbiota changes were noted in the AC alone group during antibiotic treatment. AC associated changes included reduced prevalence of the genus Roseburia and increases in Escherichia, Parabacteroides, and Enterobacter. Microbiota alterations reverted toward baseline, but were not yet completely restored 2 weeks after antibiotherapy. No significant shifts in bacterial genera were noted in the SB alone group. Adding SB to AC led to less pronounced microbiota shifts including less overgrowth of Escherichia and to a reduction in antibiotic-associated diarrhea scores. Antibiotic treatment is associated with marked microbiota changes with both reductions and increases in different genera. S. boulardii treatment can mitigate some antibiotic-induced microbiota changes (dysbiosis) and can also reduce antibiotic-associated diarrhea.

Utility of CT in the emergency department in patients with ulcerative colitis.

Background:Computed tomography (CT) is used in the emergency department (ED) for triage of patients with gastrointestinal complaints. Patients with inflammatory bowel disease undergo radiologic studies for gastrointestinal symptoms and are at risk for excessive ionizing radiation exposure; however, the utility of CT in the ED in patients with ulcerative colitis (UC) is not clear. In this study, we assess the frequency and risk factors for clinically significant CT findings in patients with UC in the ED. Methods:We retrospectively reviewed 163 consecutive cases of patients with UC who presented to a tertiary care ED and underwent abdominopelvic CT between June 2008 and December 2011. Using logistic regression, we identified predictors of significant CT findings and derived a model to predict CT scans without clinically significant findings. Results:Of note, 63.2% (103/163) of CT scans had no clinically significant findings. Less than 2% of scans revealed complications related to UC. Predictors of CT scans without clinically significant findings included rectal bleeding or diarrhea (P < 0.001), use of 5-aminosalicylate (P = 0.011), or immunomodulator (P = 0.032). Alternatively, predictors of clinically significant CT findings included nausea and vomiting (P < 0.001), history of colectomy (P < 0.001), history of abdominal or pelvic surgery (P < 0.001), surgery within 1 month (P < 0.001), age (P = 0.004), elevated white blood cell count (P = 0.003), and no UC medications (P = 0.001). Conclusions:Most patients with UC who presented to the ED and underwent CT had no clinically significant findings. We devised a model to predict lack of clinically significant CT findings, which may assist in reducing cost and radiation exposure in patients with UC.

Lack of adherence to SHEA-IDSA treatment guidelines for Clostridium difficile infection is associated with increased mortality

Objectives The objective of this study was to determine our institutions compliance with 2010 Society for Healthcare Epidemiology of America and IDSA Clostridium difficile infection (CDI) treatment guidelines and their respective outcomes. Methods We collected clinical parameters, laboratory values, antibiotic therapy and clinical outcomes from the electronic medical records for all patients hospitalized at our institution with a diagnosis of CDI from December 2012 to November 2013. We specifically evaluated whether SHEA-IDSA treatment guidelines were followed and evaluated the associations between guideline adherence and severe outcomes including mortality. Results We identified 230 patients with CDI meeting inclusion criteria during the study period. Of these, 124 (54%) were appropriately treated, 46 (20%) were under-treated and 60 (26%) were over-treated. All-cause 90 day mortality was 17.4% overall; 43.5% in the under-treated group versus 12.9% in those appropriately treated (P < 0.0001) and 10.9% in those appropriately treated plus over-treated (P < 0.0001). Similarly, 90 day mortality attributed to CDI was 21.7% in those under-treated versus 8.9% in those appropriately treated (P = 0.03) and 8.2% in those either appropriately treated or over-treated (P = 0.015). Severe-complicated CDI occurred in 46 patients. In this subgroup, there was a non-significant trend towards increased mortality in under-treated patients (56.7%) compared with appropriately treated patients (37.5%, P = 0.35). Under-treatment was also associated with a higher rate of CDI-related ICU transfer (17.4% versus 4.8% in those appropriately treated, P = 0.023). Conclusions Adherence to CDI treatment guidelines is associated with improved outcomes especially in those with severe disease. Increased emphasis on provision of appropriate, guideline-based CDI treatment appears warranted.

Colonoscopic Findings in Peruvian Patients with Chronic Diarrhea

Objective To report the colonoscopic and pathological findings in patients with chronic diarrhea from a gastroenterology unit during approximately 3 years in a general teaching hospital located in Lima-Peru. Materials and Methods Patients with chronic diarrhea as the motive for colonoscopy from March 2008 to December 2010 were selected from the colonoscopy report computerized database. Colonoscopic findings were registered. Biopsies taken during the procedure were prospectively reviewed. Results 226 patients were included, of which 162 (71.7%) had a colon biopsy available. The average age of the patients was 53.6±16.36. 85.8% of patients were reported to have a normal colon. 14.8% of patients were found to have a normal colonic mucosa or mucosal edema, 35.8% of patients had lymphocytic colitis and 28.4% had paucicelular colitis. Conclusions The majority of colonoscopies were reported with unremarkable macroscopic findings. Lymphocytic colitis was unusually frequent compared to previous reports.

CONSIDERACIÓN DE LAS PUBLICACIONES CIENTÍFICAS PARA EL INGRESO A LA RESIDENCIA MÉDICA EN EL PERÚ

Sr Editor. El sistema actual de admision al residentado medico (Programa de Segunda Especializacion en Medicina Humana) en el Peru, tiene como criterios de calificacion a: 1) el examen de conocimientos, 2) el orden de merito de egreso de pregrado y 3) un puntaje de bonificacion por el desempeno del Servicio Rural y Urbano Marginal de Salud (SERUMS) segun el quintil de carencias de servicios basicos del fondo Nacional de Cooperacion para el Desarrollo de la zona donde el postulante haya realizado este servicio (1).

Proton pump inhibitors and risk of Clostridium difficile infection: association or causation?

Purpose of review The rising burden of Clostridium difficile infection (CDI) requires urgent identification of preventable risk factors. Observational studies suggest an association between proton-pump inhibitor (PPI) use and CDI risk. Recent findings Key historical literature on PPI and CDI associations is reviewed as a prelude to evaluating the plausibility of a causative association. Impactful literature from the past 18 months is examined in detail and critically appraised through the lens of the Bradford Hill Criteria for determination of causality. The PPI and CDI association has been studied extensively and is valid. Nonetheless, causality is not proven due to extensive and difficult to control confounding in observational studies of CDI patient populations with complex comorbidities. Summary In the authors’ opinion, systematic discontinuation of PPIs in patients at risk for CDI is not warranted based on current evidence. Well controlled prospective human studies are needed. Careful and repeated consideration should be given to all PPI prescriptions to avoid potential adverse effects.

Editorial: adherence in coeliac disease – those that can will and those that can't won't (and need support)! authors’ reply

evaluate dietary compliance in patients with coeliac disease. Br J Nutr 2009; 102: 882–7. 8. Sharkey LM, Corbett G, Currie E, et al. Optimising delivery of care in coeliac disease comparison of the benefits of repeat biopsy and serological follow-up. Aliment Pharmacol Ther 2013; 38: 1278–91. 9. Ciacci C, Ciclitira P, Hadjivassiliou M, et al. The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis. United European Gastroenterol J 2015; 3: 121–35.