Novel Therapies for Celiac Disease: A Clinical Review Article.

Celiac disease is emerging as an autoimmune disorder with increasing prevalence and incidence. The mean age of presentation is also increasing with the passage of time. The delay in diagnosis is partly attributable to the asymptomatic state in which most patients present. The diagnosis of the disease is primarily based on biopsy, but serology can also be included for possible screening purposes. Although the primary management strategy is to eliminate gluten from the diet of such patients; however, compliance with the diet and follow-up to detect healing might be difficult to maintain. Therefore, there is a need to investigate further management therapies that can be easily administered and monitored. The aim of the review is to discuss the epidemiology, clinical presentation, and novel therapies being investigated for celiac disease.

A Rare Case of Colonic Sarcoidosis Presenting as a Mass.

INTRODUCTION: Sarcoidosis is a common multisystem chronic inflammatory disease of an unidentified inciting etiology. The most common initial manifestations of this disease involve the pulmonary system, and involvement of the gastrointestinal tract is rare. Sarcoidosis of the gastrointestinal tract occurs in an oral-anal gradient, with the esophagus and stomach being the most commonly involved sites, while colonic involvement remains extremely rare. Case Presentation. We present a case of a 24-year-old African American man who was evaluated for persistent abdominal pain, chronic diarrhea, and weight loss. Workup for infectious etiologies and celiac disease was unrevealing. An inflammatory mass in the hepatic flexure was found during colonoscopy, and a computed tomography (CT) scan of the abdomen was significant for circumferential thickening of the cecum and ascending colon, along with nodular thickening of the peritoneum without enhancement. Malignancy and inflammatory bowel disease were the initial differentials. A peritoneal biopsy was also performed. Pathology of the colon and peritoneal biopsy was significant for the presence of noncaseating granulomas and confluent granulomatous inflammation. The patient was diagnosed with colonic sarcoidosis, and treatment with corticosteroids was initiated. Symptoms resolved with treatment, and a follow-up colonoscopy five months later showed interval healing. CONCLUSION: Although rare, colonic sarcoidosis should be considered as one of the differential diagnoses when evaluating a patient with chronic diarrhea and a mass on colonoscopy. Histopathology is the key to diagnosis as it distinguishes malignancy from sarcoidosis. Corticosteroids remain as an option for treating colonic sarcoidosis.

Advances in the Diagnosis of Venous Thromboembolism: A Literature Review.

The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.

Reevaluation of the Efficacy of First Line Regimen for Helicobacter pylori.

BACKGROUND: Helicobacter pylori is a common cause of gastritis, peptic ulcer disease, and non-ulcer dyspepsia, and is also associated with gastric adenocarcinoma and mucosa associated lymphoid tissue lymphoma. Despite being known about for more than 30 years, finding an effective therapeutic strategy against it remains a challenge. AIM: There are no US studies evaluating the efficacy of a Levofloxacin based therapy for H. pylori infection. We here intend to study the efficacy of Levofloxacin based triple antibiotic regimen as compared to Clarithromycin based triple therapy and Bismuth based quadruple therapy in our patient population. METHODS: This is a retrospective single center observational study. Patients with Helicobacter pylori infection who underwent treatment for H. pylori with one of the three therapies, i.e. Clarithromycin triple, Bismuth Quadruple or Levofloxacin triple, were included in the study and the eradication rates were compared. The confirmation of the H. pylori was done 4 weeks after the completion of anti-microbial therapy. RESULTS: A total of 177 individuals underwent the H. pylori treatment in our retrospective review. Of these, 54% (n=97) of patients were treated with Clarithromycin based triple therapy (Group 1), 35% (n=63) were treated with Levofloxacin based regimen (Group 2), and the remaining 11% (n=17) were treated with Bismuth based quadruple therapy (Group 3). The eradication rates were significantly higher in patients treated with Clarithromycin based triple therapy as compared to Levofloxacin based triple therapy and Bismuth quadruple therapy (78.3% vs 49.2% vs 41.1% P=0.001). CONCLUSION: In conclusion, our study shows significantly lower eradication rates with Levofloxacin triple therapy among a selected US population. Thus, it may not be a good first-line therapy among this US population and the Clarithromycin based regimen may still be used successfully.

Parotid tumor presenting with hemifacial spasm.

A 47-year-old man presented with right parotid swelling and a history of frequent attacks of hemifacial spasm. MRI of the brain and neck showed a mass in the right parotid gland. Fine needle aspiration biopsy of the mass revealed a pleomorphic adenoma of the parotid gland, which was confirmed after total right parotidectomy. His attacks of hemifacial spasm did not improve after surgery and 8 months postoperatively, he received botulinum toxin-A injections, which improved his symptoms. Clinicians need to be aware that patients with occult parotid tumors can present like patients with classic hemifacial spasm.