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Mo1975 A Diagnostic Approach to Patients With Suspected Lactose Malabsorption
AGA Abstracts
Mo1972
Mo1974
Role of SeHCAT Scanning in Diagnosis of Bile Salt Malabsorption: a University Hospital Experience Usman I. Aujla, Rabia Arfan, Aneel N. Nimba, Asif Mahmood, Sameer Zar
Clinical Utility of the Disaccharidase Immunoassay: A Three-Year Retrospective Study Michelle Ewart, Elizabeth Richards
Introduction: Chronic diarrhoea is a very common presentation in the gastroenterology clinics. Majority of patients with negative investigations for organic disease are often labelled with a diagnosis of irritable bowel syndrome with diarrhoea (IBS-D). Bile salt malabsorption (BMA) is not an uncommon cause of chronic diarrhoea. In clinical practice mostly an empirical trail of bile acid sequestrants is used to diagnose this condition which lacks diagnostic accuracy. 23-seleno-25-homo-tauro-cholic acid (SeHCAT) scan is a reliable, simple and non invasive investigation to detect and treat this condition but has been underutilized in most centres in the United Kingdom (UK). Aims & Methods: We aimed to evaluate the usefulness of SeHCAT scan in evaluating patients with chronic diarrhoea. We retrospectively reviewed all patients who had SeHCAT scan over a two year period in a University Hospital. The integrated hospital electronic database system was reviewed and analysed for the following: clinical details, radiology, biochemistry, endoscopy and histology. BMA was defines as SeHCAT retention of less than 15% (mild 10-15%; moderate 5-10% and severe <5%). Results: 118 patients referred to gastroenterology clinic for chronic diarrhoea underwent SeHCAT testing over the review period. 42 M; 76 F, mean age 51 y (range 16-89). SeHCAT test was positive for BMA in 51/118(43%) of patients. Among positive SeHCAT tests, 27 (53%) had severe, 15 (29%) had moderate and, 9 (17%) had mild BAM. 12 (23%) had type 1 (6 terminal ileal resection and 6 Crohn's Disease), 28 (55%) had type 2 (Idiopathic) and 11 (21.5%) had type 3 (7 cholecystectomy, 2 diabetes, 2 coeliac) BAM. Out of 51 with confirmed BMA on SeHCAT testing, treatment information in the notes was available for 35(68%) of the patients. These patients were treated with bile acid sequestrants, either with colesevalam (n=7) or with cholestyramine (n=28). Colesevalam was well tolerated with 100% good response. In cholestyramine group 12(43%) had good response, 4(7%) partial and 7(25%) showed poor response. All patients with poor response discontinued treatment and 4 (57%) of this group stopped cholestyramine early due to unpleasant side effects. No treatment response was documented in the notes for 5 patients. Overall, colesevalam had excellent response rates with no reported side effects. Conclusion: SeHCAT scan is probably an underutilized test for diagnosing bile salt malabsorption. In patients presenting with chronic diarrhoea SeHCAT scanning must be considered to diagnose this probably under recognised cause of chronic diarrhoea. Colesevalam has better tolerability and response rates and must be considered in group of patients intolerant to cholestyramine.
Background: The disaccharidase immunoassay directly measures disaccharidase activity in small bowel biopsies. Though the panel can detect abnormalities in several disaccharidase enzymes its most common use is in diagnosing lactase deficiency. The current gold standard for detecting lactase deficiency is the lactose-hydrogen breath test, which measures hydrogen levels at various intervals after ingestion of a lactose load. In contrast to the disaccharidase immunoassay, which is an invasive send-out test, the lactose-hydrogen breath test can be done in-house and is non-invasive. Design: Utilizing Clinical Looking Glass software, surgical pathology reports for small bowel biopsies during 2010-2012 were identified that included disaccharidase panel results. Two panels were included: one that measures lactase, sucrase, palatinase and glucoamylase, and another that measures lactase, sucrase, palatinase and maltase. Results from each surgical pathology report were read and recorded in Excel. All reports were reviewed twice, on separate occasions, and correlated with the Excel spreadsheet for accuracy. Results: A cohort of 308 patients with disaccharidase panel results was found for the years 2010-2012. The patient population was 55.8% (172) female and 44.2% (136) male. The population was primarily pediatric/adolescent with 99.7% (307) of patients ranging in age from infant to 21 years old, with one adult, 54-year-old, patient. The majority of patients, 67.2 % (207), were found to have lactase deficiency, with 60.1% (185) having lactase deficiency only and normal alpha-glucosidase activities. A subset of patients, 32.8% (101) had normal disaccharidase activity and 6.5% (20) of patients had a global decrease in disaccharidases. Other deficiencies, 1.6% (5), found were: isolated sucrase deficiency, isolated glucoamylase deficiency, sucrase and palatinase deficiency, and two patients with combined lactase, sucrase and glucoamylase deficiencies. Conclusions: For a small subset of patients with hereditary disaccharidase deficiencies, such as sucrase-isomaltase deficiency or glucoamylase deficiency, the disaccharidase immunoassay is a necessary and important diagnostic tool. Many clinicians order the disaccharidase panel as a routine add-on test to most small bowel biopsies. The intent is to prevent repeat biopsies in the event that a disaccharidase analysis is needed in the future. Each test costs $201.50 . Over three years, this adds up to over $60,000. The cost of the breath test in comparison may be as low as $115.00 . As our institution is an accountable care organization, it would be beneficial to implement a new testing algorithm that emphasizes lactose-hydrogen breath test as the first line diagnostic modality, and reserves the disaccharidase immunoassay for second line testing or cases in which non-lactase disaccharidase deficiencies are suspected.
Mo1973 Prevalence of Bile Acid Malabsorption As a Cause of Diarrhoea in Consecutive New Patient Referrals to a Gastroenterology Clinic Uday N. Shivaji, Fahmid U. Chowdhury, Alexander C. Ford Background: Diarrhoea is a common presenting complaint in the Gastroenterology outpatient department. The potential causes are numerous, but include irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), coeliac disease, and colorectal cancer. Interest in bile acid malabsorption (BAM) as a cause of diarrhoea has increased recently. However, guidelines from the British Society of Gastroenterology do not recommend routine exclusion of this condition using 23-seleno-25-homo-tauro-cholic acid (SeHCAT) scanning. Methods: Review of consecutive unselected new patient referrals to a single Gastroenterologists' outpatient clinic during a 3-year period, from January 2010 to December 2012. All clinic letters were reviewed retrospectively, and symptoms reported by the patient at the initial consultation were recorded. Radiology, endoscopy, chemical pathology, and histopathology databases were then cross-examined in order to ascertain the final diagnosis following full investigation, to the level deemed appropriate by the consulting physician. We defined BAM using a SeHCAT retention value of <15% at 7 days. Results: Of 613 consecutive unselected new patient referrals to a single Gastroenterologist between January 2010 and December 2012, 151 (24.6%) reported diarrhoea. After investigation the final diagnoses are listed in Table 1. The second commonest cause of diarrhoea, after IBS, was BAM. Nine (45.0%) of 20 patients with BAM reported lower abdominal pain or discomfort. In 13 (65.0%) patients there was no obvious cause of BAM, and these were classified as idiopathic, or type II, BAM. Conclusions: BAM was the commonest underlying cause of diarrhoea after IBS. Idiopathic BAM was commoner than coeliac disease. Almost 50% of patients with BAM reported lower abdominal pain or discomfort, which may lead to misdiagnosis as IBS unless further investigations are performed. BAM should be considered as a likely diagnosis in all patients with diarrhoea, and SeHCAT scanning should be moved up the hierarchy of diagnostic tests in such patients.
AGA Abstracts
Mo1975 A Diagnostic Approach to Patients With Suspected Lactose Malabsorption Tsachi Tsadok Perets, Einav Shporn, Shoshana Aizic, Yelena Kelner, Sigal Levy, Yaron Niv, Ram Dickman Background: The lactose breath test (LBT) is the standard technique for the diagnosis of lactose malabsorption. However, it is time-consuming, strenuous for the patient and was reported to have low sensitivity. The Lactose Intolerance Quick Test (LIQT) measures lactase activity in duodenal biopsies and may be performed as part of upper gastrointestinal endoscopy. Aim: To assess the role of the LBT and LIQT in the case management of suspected lactose malabsorption. Methods: The study group included 69 consecutive patients evaluated by the LBT followed by the LIQT. The test results were compared, and the sensitivity, specificity, and predictive values of the LBT were calculated. Results: Patients' mean age was 54.4 years; male:female ratio was 1:3; mean body mass index (BMI) was 25.2 kg/m2. None had celiac disease on duodenal biopsy. The LIQT was positive for hypolactasia in 55 patients (80%): mild in 14 (25%) and severe in 41 (75%). Ten (18%) patients were symptomatic during the LBT. The LBT was positive for lactose malabsorption in 32 (46%) of 69 patients. Of the 37 remaining patients with normal findings on the LBT, 24 (65%) had positive findings on the LIQT: 11 (30%) mild hypolactasia, and 13 (35%) severe hypolactasia. In one case, the LBT was positive and the LIQT was negative. The LBT had a sensitivity of 56%, specificity 93%, positive predictive value 97%, and negative predictive value 35%. Conclusions: The LBT may serve as a diagnostic screening tool for lactose malabsorption. Symptomatic patients with negative LBT results should be referred for second-line testing with the LIQT.
S-706
Mo1972
Mo1974
Role of SeHCAT Scanning in Diagnosis of Bile Salt Malabsorption: a University Hospital Experience Usman I. Aujla, Rabia Arfan, Aneel N. Nimba, Asif Mahmood, Sameer Zar
Clinical Utility of the Disaccharidase Immunoassay: A Three-Year Retrospective Study Michelle Ewart, Elizabeth Richards
Introduction: Chronic diarrhoea is a very common presentation in the gastroenterology clinics. Majority of patients with negative investigations for organic disease are often labelled with a diagnosis of irritable bowel syndrome with diarrhoea (IBS-D). Bile salt malabsorption (BMA) is not an uncommon cause of chronic diarrhoea. In clinical practice mostly an empirical trail of bile acid sequestrants is used to diagnose this condition which lacks diagnostic accuracy. 23-seleno-25-homo-tauro-cholic acid (SeHCAT) scan is a reliable, simple and non invasive investigation to detect and treat this condition but has been underutilized in most centres in the United Kingdom (UK). Aims & Methods: We aimed to evaluate the usefulness of SeHCAT scan in evaluating patients with chronic diarrhoea. We retrospectively reviewed all patients who had SeHCAT scan over a two year period in a University Hospital. The integrated hospital electronic database system was reviewed and analysed for the following: clinical details, radiology, biochemistry, endoscopy and histology. BMA was defines as SeHCAT retention of less than 15% (mild 10-15%; moderate 5-10% and severe <5%). Results: 118 patients referred to gastroenterology clinic for chronic diarrhoea underwent SeHCAT testing over the review period. 42 M; 76 F, mean age 51 y (range 16-89). SeHCAT test was positive for BMA in 51/118(43%) of patients. Among positive SeHCAT tests, 27 (53%) had severe, 15 (29%) had moderate and, 9 (17%) had mild BAM. 12 (23%) had type 1 (6 terminal ileal resection and 6 Crohn's Disease), 28 (55%) had type 2 (Idiopathic) and 11 (21.5%) had type 3 (7 cholecystectomy, 2 diabetes, 2 coeliac) BAM. Out of 51 with confirmed BMA on SeHCAT testing, treatment information in the notes was available for 35(68%) of the patients. These patients were treated with bile acid sequestrants, either with colesevalam (n=7) or with cholestyramine (n=28). Colesevalam was well tolerated with 100% good response. In cholestyramine group 12(43%) had good response, 4(7%) partial and 7(25%) showed poor response. All patients with poor response discontinued treatment and 4 (57%) of this group stopped cholestyramine early due to unpleasant side effects. No treatment response was documented in the notes for 5 patients. Overall, colesevalam had excellent response rates with no reported side effects. Conclusion: SeHCAT scan is probably an underutilized test for diagnosing bile salt malabsorption. In patients presenting with chronic diarrhoea SeHCAT scanning must be considered to diagnose this probably under recognised cause of chronic diarrhoea. Colesevalam has better tolerability and response rates and must be considered in group of patients intolerant to cholestyramine.
Background: The disaccharidase immunoassay directly measures disaccharidase activity in small bowel biopsies. Though the panel can detect abnormalities in several disaccharidase enzymes its most common use is in diagnosing lactase deficiency. The current gold standard for detecting lactase deficiency is the lactose-hydrogen breath test, which measures hydrogen levels at various intervals after ingestion of a lactose load. In contrast to the disaccharidase immunoassay, which is an invasive send-out test, the lactose-hydrogen breath test can be done in-house and is non-invasive. Design: Utilizing Clinical Looking Glass software, surgical pathology reports for small bowel biopsies during 2010-2012 were identified that included disaccharidase panel results. Two panels were included: one that measures lactase, sucrase, palatinase and glucoamylase, and another that measures lactase, sucrase, palatinase and maltase. Results from each surgical pathology report were read and recorded in Excel. All reports were reviewed twice, on separate occasions, and correlated with the Excel spreadsheet for accuracy. Results: A cohort of 308 patients with disaccharidase panel results was found for the years 2010-2012. The patient population was 55.8% (172) female and 44.2% (136) male. The population was primarily pediatric/adolescent with 99.7% (307) of patients ranging in age from infant to 21 years old, with one adult, 54-year-old, patient. The majority of patients, 67.2 % (207), were found to have lactase deficiency, with 60.1% (185) having lactase deficiency only and normal alpha-glucosidase activities. A subset of patients, 32.8% (101) had normal disaccharidase activity and 6.5% (20) of patients had a global decrease in disaccharidases. Other deficiencies, 1.6% (5), found were: isolated sucrase deficiency, isolated glucoamylase deficiency, sucrase and palatinase deficiency, and two patients with combined lactase, sucrase and glucoamylase deficiencies. Conclusions: For a small subset of patients with hereditary disaccharidase deficiencies, such as sucrase-isomaltase deficiency or glucoamylase deficiency, the disaccharidase immunoassay is a necessary and important diagnostic tool. Many clinicians order the disaccharidase panel as a routine add-on test to most small bowel biopsies. The intent is to prevent repeat biopsies in the event that a disaccharidase analysis is needed in the future. Each test costs $201.50 . Over three years, this adds up to over $60,000. The cost of the breath test in comparison may be as low as $115.00 . As our institution is an accountable care organization, it would be beneficial to implement a new testing algorithm that emphasizes lactose-hydrogen breath test as the first line diagnostic modality, and reserves the disaccharidase immunoassay for second line testing or cases in which non-lactase disaccharidase deficiencies are suspected.
Mo1973 Prevalence of Bile Acid Malabsorption As a Cause of Diarrhoea in Consecutive New Patient Referrals to a Gastroenterology Clinic Uday N. Shivaji, Fahmid U. Chowdhury, Alexander C. Ford Background: Diarrhoea is a common presenting complaint in the Gastroenterology outpatient department. The potential causes are numerous, but include irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), coeliac disease, and colorectal cancer. Interest in bile acid malabsorption (BAM) as a cause of diarrhoea has increased recently. However, guidelines from the British Society of Gastroenterology do not recommend routine exclusion of this condition using 23-seleno-25-homo-tauro-cholic acid (SeHCAT) scanning. Methods: Review of consecutive unselected new patient referrals to a single Gastroenterologists' outpatient clinic during a 3-year period, from January 2010 to December 2012. All clinic letters were reviewed retrospectively, and symptoms reported by the patient at the initial consultation were recorded. Radiology, endoscopy, chemical pathology, and histopathology databases were then cross-examined in order to ascertain the final diagnosis following full investigation, to the level deemed appropriate by the consulting physician. We defined BAM using a SeHCAT retention value of <15% at 7 days. Results: Of 613 consecutive unselected new patient referrals to a single Gastroenterologist between January 2010 and December 2012, 151 (24.6%) reported diarrhoea. After investigation the final diagnoses are listed in Table 1. The second commonest cause of diarrhoea, after IBS, was BAM. Nine (45.0%) of 20 patients with BAM reported lower abdominal pain or discomfort. In 13 (65.0%) patients there was no obvious cause of BAM, and these were classified as idiopathic, or type II, BAM. Conclusions: BAM was the commonest underlying cause of diarrhoea after IBS. Idiopathic BAM was commoner than coeliac disease. Almost 50% of patients with BAM reported lower abdominal pain or discomfort, which may lead to misdiagnosis as IBS unless further investigations are performed. BAM should be considered as a likely diagnosis in all patients with diarrhoea, and SeHCAT scanning should be moved up the hierarchy of diagnostic tests in such patients.
AGA Abstracts
Mo1975 A Diagnostic Approach to Patients With Suspected Lactose Malabsorption Tsachi Tsadok Perets, Einav Shporn, Shoshana Aizic, Yelena Kelner, Sigal Levy, Yaron Niv, Ram Dickman Background: The lactose breath test (LBT) is the standard technique for the diagnosis of lactose malabsorption. However, it is time-consuming, strenuous for the patient and was reported to have low sensitivity. The Lactose Intolerance Quick Test (LIQT) measures lactase activity in duodenal biopsies and may be performed as part of upper gastrointestinal endoscopy. Aim: To assess the role of the LBT and LIQT in the case management of suspected lactose malabsorption. Methods: The study group included 69 consecutive patients evaluated by the LBT followed by the LIQT. The test results were compared, and the sensitivity, specificity, and predictive values of the LBT were calculated. Results: Patients' mean age was 54.4 years; male:female ratio was 1:3; mean body mass index (BMI) was 25.2 kg/m2. None had celiac disease on duodenal biopsy. The LIQT was positive for hypolactasia in 55 patients (80%): mild in 14 (25%) and severe in 41 (75%). Ten (18%) patients were symptomatic during the LBT. The LBT was positive for lactose malabsorption in 32 (46%) of 69 patients. Of the 37 remaining patients with normal findings on the LBT, 24 (65%) had positive findings on the LIQT: 11 (30%) mild hypolactasia, and 13 (35%) severe hypolactasia. In one case, the LBT was positive and the LIQT was negative. The LBT had a sensitivity of 56%, specificity 93%, positive predictive value 97%, and negative predictive value 35%. Conclusions: The LBT may serve as a diagnostic screening tool for lactose malabsorption. Symptomatic patients with negative LBT results should be referred for second-line testing with the LIQT.
S-706