Anti-endomysial and anti-gliadin antibodies in screening for coeliac disease in children at greater risk of developing coeliac disease.

AIMS: To determine the prevalence of coeliac disease in selected groups of children presenting to a paediatric department. METHODS: Children presenting to the Paediatric Department at Christchurch Hospital were enrolled upon identification of one or more factors associated with increased risk of coeliac disease. All subjects were screened with anti-endomysial antibody and antigliadin antibody tests. Those children with positive tests underwent small bowel biopsy. RESULTS: 36 of 153 children had abnormal antibody tests. Seven (4.5%) of 34 children who underwent small bowel biopsies were found to have histological findings consistent with coeliac disease. Five of these children had presented with symptoms not classically ascribed to coeliac disease (failure to gain weight or non-specific abdominal pain). CONCLUSIONS: The possibility of coeliac disease should be considered in children with atypical symptoms and the diagnosis excluded by appropriate testing. Recognition of the variable presentations associated with coeliac disease in children is clinically relevant.

Adult coeliac disease: prevalence and clinical significance.

BACKGROUND AND AIMS: Although coeliac disease is a common condition, the role of population screening is not clear. The aim of this study was to determine the prevalence and clinical significance of coeliac disease in the adult population of Christchurch, New Zealand. METHODS: A total of 1064 adults randomly selected from the 1996 Christchurch electoral rolls were enlisted. The subjects were screened for coeliac disease using the anti-endomysial antibody test (EMA), and all those with positive tests were reviewed and underwent a small bowel biopsy. RESULTS: Twelve of the 1064 persons tested (1.1%) were EMA positive and all had small bowel biopsy histology consistent with coeliac disease. Two of the 12 subjects were previously known to be EMA positive although neither had a small bowel biopsy. One additional subject with known and treated coeliac disease was also enrolled but was EMA negative. Thus, the overall prevalence of coeliac disease was 13 of 1064 subjects (1.2%, or 1:82), 10 of whom were newly diagnosed (0.9%, or 1:106) and three were previously known or suspected to have coeliac disease (0.3%, or 1:355). The prevalence in both sexes was similar. Nine of the 12 EMA-positive coeliac disease subjects identified by the use of screening reported symptoms, of which tiredness and lethargy were the most common. The subjects were of normal stature, although females tended to be lean. None of the subjects were anaemic, but four were iron deficient and four folate deficient. Five of the 12 had sustained bone fractures. Bone mineral density was reduced in males but not in females. CONCLUSIONS: The prevalence of coeliac disease in the adult population of Christchurch, New Zealand, is 1.2%. Unrecognized coeliac disease which was detected by population screening was three-fold more common than proven or suspected coeliac disease. Population screening may identify subjects who could benefit from treatment.

The prevalence of viral hepatitis (HAV, HBV and HCV) in the Christchurch community.

AIM: To determine the prevalence of hepatitis A (HAV), hepatitis B (HBV) and hepatitis C (HCV) in adults randomly selected from the Christchurch community. METHODS: A list of names was randomly generated from the Christchurch electoral roll and subjects were sequentially contacted and invited to participate. A blood sample was taken and tested for hepatitis A (IgG anti-HAV antibody), hepatitis B (HBsAg and anti-HBc) and HCV (anti-HCV antibody) using Abbott Elisa kits. Subjects positive for HBsAg were also tested for HBeAg/HBV DNA. Those positive for anti-HBc were tested for anti-HBs. HCV antibody positive samples were tested for HCV RNA using PCR. RESULTS: 1064 subjects (30.3% of those invited) participated in the study. The prevalence of HAV antibodies was 27.9%, and increased with age. The overall prevalence of HBV markers was 42/1064 (4.2%), and of these 0.3% were HBsAg positive and 3.9% were considered immune. No gender or ethnic differences in these proportions were observed. The seroprevalence of HVC antibody was 3/1064 (0.3%), two of whom were also PCR positive for HCV RNA. CONCLUSION: In the Christchurch community there was a high prevalence of antibodies to HAV, which increased with age. The prevalence of HBsAg and antibody to HCV were both low at 0.3%.

Seroprevalence of Helicobacter pylori in the adult population of Christchurch: risk factors and relationship to dyspeptic symptoms and iron studies.

AIM: To determine the prevalence of Helicobacter pylori infection in subjects randomly selected from the Christchurch population and to determine the risk factors and symptoms related to the infection. METHODS: A list of names was randomly generated from the 1996 electoral roll and subjects were sequentially contacted and invited to participate. A questionnaire on dyspeptic symptoms was completed and the subject's serum was analysed for H. pylori antibodies using the Roche method. Equivocal samples were retested by the Meridian method. RESULTS: One thousand and sixty-four subjects participated in the study. In four subjects results for H. pylori were indeterminate and these subjects were excluded from analysis. Of the remaining 1060 subjects, 254 (24.0%) were seropositive for H. pylori. The seropositivity in males (n=444) was 25.9% and in females (n=616) 22.6%. On multivariate analysis age, ethnicity, low income and smoking > 20 cigarettes per day were all independent predictors of H. pylori seropositivity. H. pylori positive subjects had shorter stature compared to those who were seronegative. The symptom scores for dyspepsia were similar in both the seropositive and seronegative subjects. In males the serum iron levels were lower in seropositive subjects but there were no significant differences in serum ferritin in either males or females between seropositive and seronegative subjects. CONCLUSION: H. pylori is a common infection in the Christchurch community with the prevalence increasing significantly with age. H. pylori positive subjects had shorter stature and in males lower serum iron levels were observed. Infection was not associated with an increased risk of dyspeptic symptoms.

The fate of ingested 14C-urea in the urea breath test for Helicobacter pylori infection.

The metabolic fate of the radioactive carbon in the 14C-urea breath test for Helicobacter pylori was investigated in 18 subjects. After ingestion of labelled urea, breath was sampled for 24 h, and urine was collected for 3 days. Subjects were designated high or low expirers on the basis of their breath counts, and this agreed well with H. pylori serologic analyses. When given 185 or 37 kBq of 14C-urea, 51% (SD = 16%, n = 11) of the label was recovered from the breath of high expirers, and 7% (SD = 3%, n = 7) from the breath of low expirers. The mean combined urinary and breath recovery for high expirers was 86% (SD = 7%), and for low expirers it was 97% (SD = 3%). It is concluded that the long-term retention of 14C from ingested 14C-urea is low. The results enable a more accurate estimation to be made of radiation exposure resulting from the 14C-urea breath test.

Comparison of endoscopic forceps biopsies and capsule biopsies in determining disaccharidase activity in the duodenum.

Endoscopic biopsy is an accepted technique for obtaining samples of small bowel mucosa for histological examination. In this study a comparison between endoscopic forceps biopsies and capsule biopsies in estimating disaccharidase enzyme activity in the small bowel was evaluated. Disaccharidase levels on 168 consecutive small bowel biopsies obtained by either endoscopic biopsy or capsule biopsy were reviewed retrospectively. There was no significant difference in enzyme activity in samples collected by either method. Another 18 patients had simultaneous endoscopic and capsule biopsies from the second part of the duodenum. Again, there was no difference in enzyme activity between samples collected by either technique at the same level in the duodenum. The disaccharidase activity in forceps biopsies taken from the second part of the duodenum is equivalent to those obtained by capsule biopsy.

Colonoscopically detected colorectal cancer missed on barium enema.

The radiographs and clinical records of 26 patients with colorectal cancer missed on barium enema, and subsequently detected at colonoscopy, were reviewed to determine the cause of radiological error. Twenty (77%) of the patients were female. In 24 of 26 patients, anemia and/or rectal bleeding was a presenting feature. Fourteen of the 26 (54%) missed cancers were in the sigmoid colon, 10 (38%) in the ascending colon or hepatic flexure, and two (8%) in the rectum. Tumor size ranged from 20-100 mm. Fifteen were polyps, and 11 annular cancers. Fourteen (54%) were Dukes C or D tumors. Twenty-eight barium enemas in 23 patients were available for review: 86% were double-contrast studies. In 18 (76%), the cancer could be seen in retrospect and, in over half, the tumor was obvious. The dominant perceptive error was due to missing the lesion in the barium pool. Other major errors were missing the lesion en face or in overlapping loops. As most cancers were missed because of observer perceptive error, by both experienced and inexperienced radiologists, the authors recommend double reporting of all barium enemas.

Defenestration of hepatic sinusoids as a cause of hyperlipoproteinaemia in alcoholics.

The hepatic sinusoidal endothelium separates sinusoidal blood from hepatocytes; changes in the porosity of this endothelium may affect the passage of chylomicrons into hepatocytes and influence lipid metabolism. Chronic exposure to ethanol reduces the porosity of the endothelium; this mechanism may underlie the hyperlipoproteinaemia observed in some people who drink heavily.

Dientamoeba fragilis: a bowel pathogen?

Although many patients infected with Dientamoeba fragilis suffer gastrointestinal symptoms, controversy still surrounds the pathogenic role of this intestinal protozoan. We describe three patients infected with D fragilis who had gastrointestinal symptoms. In the first patient symptoms resolved with therapy before the protozoan was eradicated from the stool, however in the second, symptoms persisted unabated despite clearing of the organism. In the third patient, symptoms resolution was associated with effective treatment. We discuss the life cycle, diagnosis and treatment of this organism and its role as a pathogen.

Colonoscopy and bacteraemia: an experience in 50 patients.

There is little consensus concerning the incidence of bacteraemia during colonoscopy and the need for antibiotic prophylaxis in susceptible patients. Hepatic abscesses in one patient which may have been related to prior colonoscopic examinations led the authors to carry out a prospective study of 50 patients undergoing colonoscopy. Multiple blood cultures were carried out to maximise the positive yield of transient bacteraemia and to attempt to determine the time when bacteraemia is most likely to occur. Five patients had positive blood cultures. In two patients S epidermidis was isolated, but only from the precolonoscopic blood sample. In three subjects enteric organisms were cultured from blood samples obtained during the procedure. In one of these three the same organism was cultured from the preendoscopic blood sample so that in only two patients (4%) could the bacteraemia be attributed to the colonoscopy. These results would suggest that the risk of bacteraemia during colonoscopy is low.

Halothane hepatitis: toxicity or hypersensitivity?

A 32 year old female developed a severe hepatitis (serum bilirubin 544 mumol/l) one week after a halothane anaesthetic. Six months later a general anaesthetic was administered via a halothane free circuit without incident. A year later a further non halothane anaesthetic was administered this time utilising the routine circuit after briefly flushing the rubber tubing with oxygen. That evening she became febrile and the following day abnormal liver function tests were documented. She remained asymptomatic.

Familial short stature and coeliac disease: a family case report.

A case of coeliac disease associated with growth retardation and pubertal failure in a 19 year old female is reported. Diagnosis was delayed by use of the term 'undiagnosed short stature'. Investigations confirmed severe malabsorption, osteoporosis and marked delay in bone growth associated with small bowel mucosal atrophy. HLA screening of the patient's family led to the identification of coeliac disease in her brother aged 12 years and her asymptomatic mother both of whom were short in stature. The institution of a gluten free diet, appropriate vitamin and mineral supplements has restored growth and sexual development to normal in the affected children. These cases emphasize the variable nature of coeliac disease, its familial occurrence and the need to exclude the disorder in cases of undiagnosed (familial) short stature.

Clostridium difficile-associated colitis: cross infection in predisposed patients with renal failure.

Four men with renal failure developed Clostridium difficile-associated diarrhoea while being cared for in the same ward at about the same time. Cross infection appeared to play a role. All patients had received antibiotics; three were treated for chest infections and one for a urinary tract infection. The antibiotics implicated were cefoxitin alone in two patients, cefoperazone alone in one patient and cloxacillin, cefoperazone and amoxycillin in the last patient. Two patients had received immunosuppressive agents as well. Clostridium difficile cytotoxin was detected in stools from all patients using a cell culture assay. Pseudomembranous colitis was demonstrated in two patients at sigmoidoscopy and in one at post mortem. All patient were given oral vancomycin. Two died with the disease, one following relapse in the absence of antibiotics, and two patients were cured only to die later of unrelated diseases. Isolation of affected patients seems prudent as the disease may be infectious.

Comparison of three methods to estimate steatorrhoea.

Faecal fat excretion was estimated in 24 patients using three methods. Quantitative estimations of fat excretion were calculated from both a three day faecal fat collection and a twenty-four hour faecal collection corrected for excretion of a cuprous thiocyanate marker. Breath 14CO2 excretion was measured after ingestion of a liquid meal containing 2.5 microCi of 14C-triolein in an arachis oil emulsion. Peak concentrations of 14CO2 in breath were used as an estimate of the degree of fat absorption. Correlation between the two quantitative measures of faecal fat was good (r = 0.87), 17 patients having steatorrhoea of more than 7 g fat per day by both estimations. Results of the breath test were disappointing. With the standard meal containing 20 g arachis oil the lowest peak 14CO2 excretion rate seen in subjects without steatorrhoea, 3 percent of the dose per hour, was taken as the lower limit of normal. Seven subjects with steatorrhoea as shown by faecal collections excreted normal amounts of 14CO2. When the size of the fat meal was increased to 1.0 g arachis oil per kg body weight in 16 of the subjects previously studied, all patients with proven steatorrhoea excreted less than 3 percent of the dose per hour but three of the subjects without steatorrhoea gave abnormal breath excretion results. It is concluded that the collection of a 24 hour faecal specimen using a cuprous thiocyanate marker provides a more reliable estimate of faecal fat excretion than the 14C-triolein breath test.

Skin testing for coeliac disease.

Subfractions of gluten from two genetically different New Zealand wheats were injected intradermally in 16 patients with coeliac disease and 20 healthy controls. The coeliac patients as a group exhibited greater skin reactions when examined at seven hours than the controls. However, the skin test did not give sufficient discrimination to make it clinically useful as a screening test for coeliac disease.

Serum bile acids and rountine liver function tests in patients with chronic liver disease and cholestasis.

Serum bile acids were measured in 28 patients with established liver disease. The peak serum level after a meal was as sensitive an index of liver disease as a combination of serum bilirubin, aspartate amino transferase, alkaline phosphatase and gamma glutamyl transpeptidase and was more often abnormal than any one of the four tests. Serum bile acid measurements may be of most value in detecting cirrhosis when the activity of disease is minimal.