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A case of asymptomatic gastritis nodular HP-related and coeliac disease
Abstracts / Digestive and Liver Disease 46 (2014) e85–e127
AN UNCOMMON DIAGNOSIS OF CELIAC DISEASE IN A THALASSEMIC GIRL Monica Montuori 1,∗ , Maria Paola Smacchia 2 , Donatella Iorfida 1 , Stefania Leoni 1 , Chiara Maria Trovato 1 , Silvia Gatti 1 , Ilaria Celletti 1 , Francesco Valitutti 1 , Michela Capogna 2 , Caterina Anania 1 , Salvatore Cucchiara 1 1 UOC Gastroenterologia ed Epatologia Pediatrica, Sapienza Università di Roma, Roma, Italy 2 Presidio Regionale Malattie Ereditarie, Sapienza-Università di Roma, Roma, Italy
Celiac disease (CD) has a heterogeneous clinical expression. This report describes an uncommon CD diagnosis in a 21 year old girl, affected by thalassemia major and followed at our Hematology Unit. Her ferritin levels used to range between 700 and 1000 g/L when she was on deferoxamine (40 mg/kg/day s.c.), therefore replaced with deferosilax (30–40 mg/kg/day per os) with stabilization of values around 400 g/L. After EBV infection, recurrent abdominal pains and diarrhea appeared. Few months later, ferritin levels decreased stepwise to 120 g/L albeit the same daily iron intake (blood transfusions) and the same drug dose, leading hematologists to reduce deferosilax up to 13 mg/kg/day. Her values increased up to 300 g/L. Thereafter, she was sent at our Gastroenterology and Hepatology Unit because of persisting gastrointestinal symptoms. Screening for CD showed anti-transglutaminase IgA > 100 UA/mL (<16) and positive antiendomysial antibodies. A reduction in number and height of folds was found in bulb and duodenum at upper gastrointestinal endoscopy and histological examination confirmed CD diagnosis (MarshOberhuber 3a-3b). Once on gluten-free diet (GFD) ferritin levels rose to 568 g/L, thus requiring to increase deferosilax dose. This report suggests to consider undiagnosed CD in thalassemic patients when ferritin levels unexpectedly decrease demanding a lower iron chelator dose, perhaps due to un underlying malabsorption. Although the GFD leads to increased ferritin levels, it remains essential in order to prevent the risk of CD complication in organs such as liver, pancreas, thyroid, bone and heart, already potentially damaged by hematological condition. http://dx.doi.org/10.1016/j.dld.2014.07.138 A CASE OF ASYMPTOMATIC GASTRITIS NODULAR HP-RELATED AND COELIAC DISEASE Elvira Difrancisca ∗ , Maria Letizia Lospalluti, Giuseppe Iacono Azienda Ospedaliera di Rilievo Nazionale ad Alta Specializzazione- Civico, G. Di Cristina Benfratelli, Palermo, Italy Objective: Demonstrate the importance of esophagogastroduodenoscopy (EGDS) in asymptomatic patient with family history of celiac disease, tissue transglutaminase antibodies (tTG) and endomisium antibodies (EMA) positive, to highlight macroscopic and histological alterations and related disease. Methods: We report a case of an overweight (BMI 27) child 12 years old, asymptomatic, with a celiac brother, presenting tTG, EMA, HLA DQ2 positive. Results: Esophagogastroduodenoscopy with biopsy showed a picture of nodular antral gastritis Helicobacter Pylori (HP) related, urease test positive, scalloping and depletion of duodenal folds. At the stereomicroscopy there was absence of normal leafy vegetations and a honeycomb appearance. Histology showed a picture of marked villous atrophy and increased intraepithelial lympho-
e117
cytes with MARSH type 3c. The research of the fecal antigen of HP was positive. The patient started gluten-free diet and therapy with amoxicillin-clavulanate, clarithromycin and proton pump inhibitors. After three months the fecal HP antigen was negative, tTG and EMA were decreased. Few vanishing symptoms of intestinal discomfort like belching and bloating, that after were described, currently disappeared. Conclusions: Celiac disease can occur in many ways. The overweight should not be an exclusion criterion to further diagnostic. The EGDS is also necessary to diagnose related pathologies that, if not revealed, could interfere the success of the dietotherapy. This case-report underlines the importance of careful history to catch vanishing symptoms of disease. http://dx.doi.org/10.1016/j.dld.2014.07.139 PHYSICIAN PERCEPTIONS ON PROBIOTICS: RESULTS OF A MULTINATIONAL SURVEY Christian Boggio Marzet 1,∗ , Andras Arato 2 , Roberto Berni Canani 3 , Serhat Bor 4 , Ener Dinleyici 5 , Uday Ghoshal 6 , Francisco Guarner 7 , Aldo Maruy 8 , Annalisa Passariello 3 , Ettair Said 9 , Sohail Thobani 10 , Lin Zhang 11 1 Pediatric Gastroenterology & Nutrition Section, Hospital Gral. de Agudos “Dr. I. Pirovano”, CABA, Argentina 2 Pediatric Gastroenterology, Semmelweis University, Budapest, Hungary 3 Department of Translational Medical Science, University of Naples “Federico II”, Naples, Italy 4 Tıp Fakültesi Gastroenteroloji Klini˘ gi, Ege Üniversitesi, Izmir, Turkey 5 Department of Pediatrics, Eskisehir Osmangazi University, Eskisehir, Turkey 6 Department of Gastroenterology, S.G.P.G.I., Lucknow, India 7 Digestive System Research Unit, Vall d’Hebron Research Institute, Barcelona, Spain 8 Gastroenterología Pediátrica, Hospital Nacional Cayetano Heredia, Lima, Peru 9 Pediatric Gastroenterology, Department of Pediatrics, Rabat University, Rabat, Morocco 10 Department of Pediatric Gastroenterology, South City Hospital, Karachi, Pakistan 11 Department of Pediatrics, 3rd Hospital of Hebei Medical University, Hebei, China
Objective: The aim of this study was to evaluate the knowledge, attitudes and current practices of physicians with regards to probiotics in 10 countries. Methods: A closed-ended structured questionnaire was implemented in 10 different countries (Argentina, Peru, Spain, Italy, Hungary, Morocco, Turkey, Pakistan, India and China). Target and sample size: 90–190 physicians interviewed per country (general practitioners, GP; pediatricians, P; gastroenterologists, G). Total sample: 1670. Representativeness: adapted criteria according to each country’s reality (quota method). Results: 85% doctors in 10 countries felt that they were somewhat or absolutely informed about probiotics, with the highest prevalence among G in China (100%) and GP in China (93%), India (91%). However 39% Moroccan physicians expressed a lack of information. Concerning probiotic definition 94% of Turkish doctors responded according to FAO/WHO criteria while in Pakistan only 39% of doctors did. Saccharomyces boulardii and Lactobacillus rham-
AN UNCOMMON DIAGNOSIS OF CELIAC DISEASE IN A THALASSEMIC GIRL Monica Montuori 1,∗ , Maria Paola Smacchia 2 , Donatella Iorfida 1 , Stefania Leoni 1 , Chiara Maria Trovato 1 , Silvia Gatti 1 , Ilaria Celletti 1 , Francesco Valitutti 1 , Michela Capogna 2 , Caterina Anania 1 , Salvatore Cucchiara 1 1 UOC Gastroenterologia ed Epatologia Pediatrica, Sapienza Università di Roma, Roma, Italy 2 Presidio Regionale Malattie Ereditarie, Sapienza-Università di Roma, Roma, Italy
Celiac disease (CD) has a heterogeneous clinical expression. This report describes an uncommon CD diagnosis in a 21 year old girl, affected by thalassemia major and followed at our Hematology Unit. Her ferritin levels used to range between 700 and 1000 g/L when she was on deferoxamine (40 mg/kg/day s.c.), therefore replaced with deferosilax (30–40 mg/kg/day per os) with stabilization of values around 400 g/L. After EBV infection, recurrent abdominal pains and diarrhea appeared. Few months later, ferritin levels decreased stepwise to 120 g/L albeit the same daily iron intake (blood transfusions) and the same drug dose, leading hematologists to reduce deferosilax up to 13 mg/kg/day. Her values increased up to 300 g/L. Thereafter, she was sent at our Gastroenterology and Hepatology Unit because of persisting gastrointestinal symptoms. Screening for CD showed anti-transglutaminase IgA > 100 UA/mL (<16) and positive antiendomysial antibodies. A reduction in number and height of folds was found in bulb and duodenum at upper gastrointestinal endoscopy and histological examination confirmed CD diagnosis (MarshOberhuber 3a-3b). Once on gluten-free diet (GFD) ferritin levels rose to 568 g/L, thus requiring to increase deferosilax dose. This report suggests to consider undiagnosed CD in thalassemic patients when ferritin levels unexpectedly decrease demanding a lower iron chelator dose, perhaps due to un underlying malabsorption. Although the GFD leads to increased ferritin levels, it remains essential in order to prevent the risk of CD complication in organs such as liver, pancreas, thyroid, bone and heart, already potentially damaged by hematological condition. http://dx.doi.org/10.1016/j.dld.2014.07.138 A CASE OF ASYMPTOMATIC GASTRITIS NODULAR HP-RELATED AND COELIAC DISEASE Elvira Difrancisca ∗ , Maria Letizia Lospalluti, Giuseppe Iacono Azienda Ospedaliera di Rilievo Nazionale ad Alta Specializzazione- Civico, G. Di Cristina Benfratelli, Palermo, Italy Objective: Demonstrate the importance of esophagogastroduodenoscopy (EGDS) in asymptomatic patient with family history of celiac disease, tissue transglutaminase antibodies (tTG) and endomisium antibodies (EMA) positive, to highlight macroscopic and histological alterations and related disease. Methods: We report a case of an overweight (BMI 27) child 12 years old, asymptomatic, with a celiac brother, presenting tTG, EMA, HLA DQ2 positive. Results: Esophagogastroduodenoscopy with biopsy showed a picture of nodular antral gastritis Helicobacter Pylori (HP) related, urease test positive, scalloping and depletion of duodenal folds. At the stereomicroscopy there was absence of normal leafy vegetations and a honeycomb appearance. Histology showed a picture of marked villous atrophy and increased intraepithelial lympho-
e117
cytes with MARSH type 3c. The research of the fecal antigen of HP was positive. The patient started gluten-free diet and therapy with amoxicillin-clavulanate, clarithromycin and proton pump inhibitors. After three months the fecal HP antigen was negative, tTG and EMA were decreased. Few vanishing symptoms of intestinal discomfort like belching and bloating, that after were described, currently disappeared. Conclusions: Celiac disease can occur in many ways. The overweight should not be an exclusion criterion to further diagnostic. The EGDS is also necessary to diagnose related pathologies that, if not revealed, could interfere the success of the dietotherapy. This case-report underlines the importance of careful history to catch vanishing symptoms of disease. http://dx.doi.org/10.1016/j.dld.2014.07.139 PHYSICIAN PERCEPTIONS ON PROBIOTICS: RESULTS OF A MULTINATIONAL SURVEY Christian Boggio Marzet 1,∗ , Andras Arato 2 , Roberto Berni Canani 3 , Serhat Bor 4 , Ener Dinleyici 5 , Uday Ghoshal 6 , Francisco Guarner 7 , Aldo Maruy 8 , Annalisa Passariello 3 , Ettair Said 9 , Sohail Thobani 10 , Lin Zhang 11 1 Pediatric Gastroenterology & Nutrition Section, Hospital Gral. de Agudos “Dr. I. Pirovano”, CABA, Argentina 2 Pediatric Gastroenterology, Semmelweis University, Budapest, Hungary 3 Department of Translational Medical Science, University of Naples “Federico II”, Naples, Italy 4 Tıp Fakültesi Gastroenteroloji Klini˘ gi, Ege Üniversitesi, Izmir, Turkey 5 Department of Pediatrics, Eskisehir Osmangazi University, Eskisehir, Turkey 6 Department of Gastroenterology, S.G.P.G.I., Lucknow, India 7 Digestive System Research Unit, Vall d’Hebron Research Institute, Barcelona, Spain 8 Gastroenterología Pediátrica, Hospital Nacional Cayetano Heredia, Lima, Peru 9 Pediatric Gastroenterology, Department of Pediatrics, Rabat University, Rabat, Morocco 10 Department of Pediatric Gastroenterology, South City Hospital, Karachi, Pakistan 11 Department of Pediatrics, 3rd Hospital of Hebei Medical University, Hebei, China
Objective: The aim of this study was to evaluate the knowledge, attitudes and current practices of physicians with regards to probiotics in 10 countries. Methods: A closed-ended structured questionnaire was implemented in 10 different countries (Argentina, Peru, Spain, Italy, Hungary, Morocco, Turkey, Pakistan, India and China). Target and sample size: 90–190 physicians interviewed per country (general practitioners, GP; pediatricians, P; gastroenterologists, G). Total sample: 1670. Representativeness: adapted criteria according to each country’s reality (quota method). Results: 85% doctors in 10 countries felt that they were somewhat or absolutely informed about probiotics, with the highest prevalence among G in China (100%) and GP in China (93%), India (91%). However 39% Moroccan physicians expressed a lack of information. Concerning probiotic definition 94% of Turkish doctors responded according to FAO/WHO criteria while in Pakistan only 39% of doctors did. Saccharomyces boulardii and Lactobacillus rham-