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Celiac Disease: Updates on Pathology and Differential Diagnosis.
Dai, Y, Zhang, Q, Olofson, AM, Jhala, N, Liu, X
Advances in anatomic pathology. 2019;(5):292-312
Abstract
Celiac disease is a gluten-triggered immune-mediated disorder, characterized by inflammation of the enteric mucosa following lymphocytic infiltration and eventually resulting in villous blunting. There have been many developments in refining diagnostic laboratory tests for celiac disease in the last decade. Biopsy-sparing diagnostic guidelines have been proposed and validated in a few recent prospective studies. However, despite these developments, histologic evaluation of duodenal mucosa remains one of the most essential diagnostic tools as it helps in the diagnosis of celiac disease in individuals who do not fulfill the biopsy-sparing diagnostic criteria and in those not responding to a gluten-free diet. Histologic evaluation also allows for the assessment of mucosal recovery after treatment and in the identification of concurrent intestinal diseases. Therefore, pathologists should be familiar with the histologic spectrum of celiac disease and need to be aware of other disorders with similar symptoms and histopathology that may mimic celiac disease. This review aims to provide pathologists with updates on celiac laboratory testing, biopsy-sparing diagnostic criteria, histopathology, complications, and differential diagnoses of celiac disease.
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Recent understanding of the pathophysiology of functional dyspepsia: role of the duodenum as the pathogenic center.
Miwa, H, Oshima, T, Tomita, T, Fukui, H, Kondo, T, Yamasaki, T, Watari, J
Journal of gastroenterology. 2019;(4):305-311
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Abstract
Over almost 30 years since functional dyspepsia (FD) was defined, researchers have endeavored to elucidate the pathophysiology of functional gastrointestinal disorders. Now a consensus is emerging that the gastric symptoms of FD are caused mainly by gastric motility abnormalities and gastric hypersensitivity. The involvement of other causative factors including acid, Helicobacter pylori, psychological factors, and diet has been debated, but how they are involved in the manifestation of dyspeptic symptoms remains unclear. We believe that most of those factors cause FD symptoms by inducing gastric motility abnormalities and gastric hypersensitivity via the duodenum. Here, we discuss 2 possible reasons why patients with FD experience chronic upper abdominal symptoms: (1) the possibility that the contents of the duodenum of patients with FD differ from those of healthy persons and the different contents stimulate the duodenum, and (2) the possibility that the duodenum of patients with FD is more sensitive to noxious stimuli because of low-grade inflammation and increased mucosal permeability.
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Intraepithelial lymphocytes, scores, mimickers and challenges in diagnosing gluten-sensitive enteropathy (celiac disease).
Sergi, C, Shen, F, Bouma, G
World journal of gastroenterology. 2017;(4):573-589
Abstract
The upper digestive tract is routinely scoped for several causes of malabsorption, and the number of duodenal biopsy specimens has increased notably in the last 10 years. Gluten-sensitive enteropathy (GSE) is an autoimmune disease, which shows an increasing prevalence worldwide and requires a joint clinico-pathological approach. The classical histopathology of GSE with partial or total villous blunting is well recognized, but the classification of GSE is not straightforward. Moreover, several mimickers of GSE with intraepithelial lymphocytosis have been identified in the last 20 years, with drug interactions and medical comorbidities adding to the conundrum. In this review, we report on the normal duodenal mucosa, the clinical presentation and laboratory diagnosis of GSE, the duodenal intraepithelial lymphocytes and immunophenotype of GSE-associated lymphocytes, the GSE mimickers, the differences "across oceans" among guidelines in diagnosing GSE, and the use of a synoptic report for reporting duodenal biopsies in both children and adults in the 21st century.
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Hydrothermal Duodenal Mucosal Resurfacing: Role in the Treatment of Metabolic Disease.
Cherrington, AD, Rajagopalan, H, Maggs, D, Devière, J
Gastrointestinal endoscopy clinics of North America. 2017;(2):299-311
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Abstract
The duodenum has become recognized as a metabolic signaling center that is involved in regulating insulin action and, therefore, insulin resistance states such as type 2 diabetes. Bariatric surgery and other manipulations of the upper intestine, in particular the duodenum, have shown that limiting nutrient exposure or contact in this key region exerts powerful metabolic effects. Early human clinical trial data suggest that endoscopic hydrothermal duodenal mucosal resurfacing is well tolerated in human subjects and has an acceptable safety profile. This article describes the rationale for this endoscopic approach and its early human use, including safety, tolerability, and early efficacy.
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Salivary and fecal microbiota and metabolome of celiac children under gluten-free diet.
De Angelis, M, Vannini, L, Di Cagno, R, Cavallo, N, Minervini, F, Francavilla, R, Ercolini, D, Gobbetti, M
International journal of food microbiology. 2016;:125-132
Abstract
Celiac disease (CD) is an inflammatory autoimmune disorder resulting from the combination of genetic predisposition and gluten ingestion. A life-long gluten free diet (GFD) is the only therapeutic approach. Dysbiosis, which can precede the CD pathogenesis and/or persist when subjects are on GFD, is reviewed and discussed. Salivary microbiota and metabolome differed between healthy and celiac children treated under GFD (T-CD) for at least two years. The type of GFD (African- vs Italian-style) modified the microbiota and metabolome of Saharawi T-CD children. Different studies showed bacterial dysbiosis at duodenal and/or fecal level of patients with active untreated CD (U-CD) and T-CD compared to healthy subjects. The ratio of protective anti-inflammatory bacteria such as Lactobacillus-Bifidobacterium to potentially harmful Bacteroides-Enterobacteriaceae was the lowest in U-CD and T-CD children. In agreement with dysbiosis, serum, fecal and urinary metabolome from U-CD and T-CD patients showed altered levels of free amino acids and volatile organic compounds. However, consensus across studies defining specific bacteria and metabolites in U-CD or T-CD patients is still lacking. Future research efforts are required to determine the relationships between CD and oral and intestinal microbiotas to improve the composition of GFD for restoring the gut dysbiosis as a preventative or therapeutic approach for CD.
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Biliopancreatic Diversion with Duodenal Switch: Surgical Technique and Perioperative Care.
Biertho, L, Lebel, S, Marceau, S, Hould, FS, Julien, F, Biron, S
The Surgical clinics of North America. 2016;(4):815-26
Abstract
The goal of this article is to present an overview of selection criteria, surgical technique, and perioperative outcomes of biliopancreatic diversion with duodenal switch. The standard follow-up requirements, including vitamin supplementation, and long-term risks associated with metabolic surgery are also discussed. Most of the data reported here are based on the authors' experience with 4000 biliopancreatic diversions with duodenal switch performed in their institution since 1990.
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Contemporary celiac disease diagnosis: is a biopsy avoidable?
Mills, JR, Murray, JA
Current opinion in gastroenterology. 2016;(2):80-5
Abstract
PURPOSE OF REVIEW The duodenal biopsy is the gold standard for the diagnosis of celiac disease. However, given improvements in the performance of serological testing, the possibility of accurately diagnosing celiac disease without the need of a biopsy has attracted interest. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition has revised its recommendations to include a diagnostic algorithm that includes sequential serological testing and human leukocyte antigen genotyping for symptomatic children which would enable a diagnosis of celiac disease to be made in the absence of a confirmatory intestinal biopsy. RECENT FINDINGS Recent studies have evaluated the ESPGHAN guidelines and have mostly corroborated that celiac disease can be accurately diagnosed in specific pediatric patient populations without the need of a biopsy. However, two cautionary points have been raised that warrant further consideration - the success of this approach is highly dependent targeting a population with a high pretest probability of celiac disease, as well, the performance of serology assays must be established and the appropriate use of cutoffs is essential. SUMMARY The duodenal biopsy will remain the gold standard for diagnosing celiac disease in a majority of patients. However, as serology assays evolve and as a greater understanding of the genetic risk factors of celiac disease is achieved, more patients may be accurately diagnosed without the need for a biopsy.
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Gastroduodenal mucosal defense mechanisms.
Said, H, Kaji, I, Kaunitz, JD
Current opinion in gastroenterology. 2015;(6):486-91
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Abstract
PURPOSE OF REVIEW To highlight recent developments in the field of gastroduodenal mucosal defense with emphasis on lumen-gut interactions. RECENT FINDINGS There has been a growing interest in the physiological functions of luminal chemosensors present from tongue to colon that detect organic molecules in the luminal content associated with nutrient ingestion, usually associated with specialized cells, in particular the enteroendocrine cells. These receptors transduce the release of peptide hormones, in particular proglucagon-derived products such as the glucagon-like peptides (GLPs), which have profound effects on gut function and on metabolism. Luminal chemosensors transduce GLP release in response to changes in the cellular environment, as part of the mechanism of nutrient chemosensing. GLP-2 has important trophic effects on the intestinal mucosa, including increasing the proliferation rate of stem cells and reducing transmucosal permeability to ions and small molecules, in addition to increasing the rate of duodenal bicarbonate secretion. GLP-1, although traditionally considered an incretin that enhances the effect of insulin on peripheral tissues, also has trophic effects on the intestinal epithelium. SUMMARY A better understanding of the mechanisms that mediate GLP release can further illuminate the importance of nutrient chemosensing as an important component of the mechanism that mediates the trophic effects of luminal nutrients. GLP-1 and GLP-2 are already in clinical use for the treatment of diabetes and intestinal failure. Improved understanding of the control of their release and their end-organ effects will identify new clinical indications and interventions that enhance their release.
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Intramural duodenal hematoma after submucosal injection of epinephrine for a bleeding ulcer: case report and review.
Dibra, A, Këlliçi, S, Çeliku, E, Draçini, X, Maturo, A, Çeliku, E
Il Giornale di chirurgia. 2015;(1):29-31
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Abstract
We present a case of intramural duodenal hematoma as a complication of endoscopic therapy for a bleeding duodenal ulcer in an adult patient with no evidence of other pathologies. A 18-year-old man was admitted in emergency room with gastrointestinal bleeding manifested by melena. Previous medical history revealed that he had endoscopic sclerotherapy for bleeding duodenal ulcer 5 months before. Endoscopy revealed a Forrest 2a ulcer in the duodenal bulb and sclerotherapy was performed by injecting 10 ml of 0.2% epinephrine and 20 ml of Na- Cl 0.9% solution. Upper occlusion's signs appeared 36 hours after the procedure. The hematoma, that was identified by endoscopy and confirmed by MRI and CT scan of the abdomen, caused transient duodenal obstruction. Combined conservative management with nasogastric tube and total parenteral nutrition resulted in reduction of obstructive symptoms within 4 weeks.
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What a practitioner needs to know about celiac disease?
Garg, K, Gupta, RK
Indian journal of pediatrics. 2015;(2):145-51
Abstract
Celiac disease (CD) is an immune-mediated systemic disorder elicited by gluten and related prolamines in genetically susceptible individuals and is characterized by the presence of a variable combination of gluten-dependent clinical manifestations, CD-specific antibodies, HLA-DQ2 or HLA-DQ8 haplotypes and enteropathy. CD is triggered by wheat gluten and related prolamines in barley and rye. Worldwide, the disease affects approximately 1 % of the general population. Clinical features of CD vary considerably. Intestinal symptoms are more common in young children. In older children extra intestinal manifestations affecting almost all organs are seen. IgA tTG antibody, upper GI endoscopy with histological analysis of multiple biopsies of the duodenum and in selected cases HLA DQ2 and DQ8 positivity and endomysial antibodies (EMA) are needed for diagnosis. Currently, the only treatment for CD is a life-long gluten-free diet (GFD). Strict avoidance of wheat, rye, barley and their derivatives will result in intestinal healing and relief of symptoms for the majority of individuals with CD. The GFD is simple in principle, however, completely eliminating all foods and ingredients containing wheat, rye, barley, and most commercial oats can be very challenging. Newly diagnosed CD children should undergo testing and treatment for micronutrient deficiencies specially iron, folic acid, vitamin D, and vitamin B12. Long-term monitoring and follow up of patients with CD is necessary.