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Morning Report

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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.