Effect of Celiac Disease on Outcomes After Posterior Lumbar Fusion: A Matched Cohort Study.

OBJECTIVE: The purpose of this study was to analyze if celiac disease (CD) is associated with increased postoperative complications following single-level posterior lumbar fusion (PLF). METHODS: A retrospective database review was performed using the PearlDiver dataset. The study population included all patients older than 18 years who underwent elective PLF with diagnosis of CD using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes. Study patients were compared with controls for 90-day medical complications and 2-year surgical complications including 5-year reoperation rates. A multivariate logistic regression was used to determine the independent effect of CD on the postoperative outcomes. RESULTS: A total of 909 patients with CD and 4483 patients in the matched control group who underwent primary single-level PLF were included in this study. CD patients had a significantly increased risk of 90-day emergency department (ED) visit (OR 1.28; P = 0.020). CD patients also demonstrated higher rates of 2-year pseudarthrosis and instrument failure, but they were statistically comparable (P > 0.05). There was no difference in 5-year reoperation rate. There were also no significant differences in 90-day medical complication rate and 2-year surgical complication rate between the two groups. In addition, there were no differences in procedure cost and 90-day cost. CONCLUSIONS: For CD patients undergoing PLF, the current study demonstrated increased rate of 90-day ED visit. Our findings may be useful for patient counseling and surgical planning for those with this condition.

Small bowel enteroscopy - A joint clinical guideline by the Spanish and Portuguese small-bowel study groups

The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small-bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication, and its diagnostic and therapeutic yield. A set of recommendations was issued accordingly

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Glioblastoma Multiforme in a Patient with Celiac Disease: Management of Seizures After Gross Total Tumor Resection.

BACKGROUND: A 55-year-old woman with a history of celiac disease presented with focal seizures and a mass lesion located at the left frontal lobe. Management of seizures in these patients is challenging. CASE DESCRIPTION: The patient underwent a navigation-assisted tumor resection. A week later, she returned to her regular diet, but 12 days after surgery she started the same pattern seizures. CONCLUSION: A patient suffering from glioblastoma multiforme who presents with seizures and has a history of celiac disease must be treated more aggressively than usual, with dual or triple anticonvulsant scheme therapy, and provided a strict gluten-free diet after tumor resection.

Serendipity in Refractory Celiac Disease: Full Recovery of Duodenal Villi and Clinical Symptoms after Fecal Microbiota Transfer.

Treatment of refractory celiac disease type II (RCD II) and preventing the development of an enteropathy associated T-cell lymphoma in these patients is still difficult. In this case report, we describe a patient with RCD II who received fecal microbiota transfer as treatment for a recurrent Clostridium difficile infection, and remarkably showed a full recovery of duodenal villi and disappearance of celiac symptoms. This case suggests that altering the gut microbiota may hold promise in improving the clinical and histological consequences of celiac disease and/or RCD II.

'Pre-endoscopy point of care test (Simtomax- IgA/IgG-Deamidated Gliadin Peptide) for coeliac disease in iron deficiency anaemia: diagnostic accuracy and a cost saving economic model'.

BACKGROUND: International guidelines recommend coeliac serology in iron deficiency anaemia, and duodenal biopsy for those tested positive to detect coeliac disease. However, pre-endoscopy serology is often unavailable, thus committing endoscopists to take routine duodenal biopsies. Some endoscopists consider duodenal biopsy mandatory in anaemia to exclude other pathologies. We hypothesise that using a point of care test at endoscopy could fill this gap, by providing rapid results to target anaemic patients who require biopsies, and save costs by biopsy avoidance. We therefore assessed three key aspects to this hypothesis: 1) the availability of pre-endoscopy serology in anaemia; 2) the sensitivities and cost effectiveness of pre-endoscopy coeliac screening with Simtomax in anaemia; 3) whether other anaemia-related pathologies could be missed by this targeted-biopsy approach. METHODS: Group 1: pre-endoscopy serology availability was retrospectively analysed in a multicentre cohort of 934 anaemic patients at 4 UK hospitals. Group 2: the sensitivities of Simtomax, endomysial and tissue-transglutaminase antibodies were compared in 133 prospectively recruited patients with iron deficiency anaemia attending for a gastroscopy. The sensitivities were measured against duodenal histology as the reference standard in all patients. The cost effectiveness of Simtomax was calculated based on the number of biopsies that could have been avoided compared to an all-biopsy approach. Group 3: the duodenal histology of 153 patients presenting to a separate iron deficiency anaemia clinic were retrospectively reviewed. RESULTS: In group 1, serology was available in 361 (33.8 %) patients. In group 2, the sensitivity and negative predictive value (NPV) were 100 % and 100 % for Simtomax, 96.2 % and 98.9 % for IgA-TTG, and 84.6 % and 96.4 % for EMA respectively. In group 3, the duodenal histology found no causes for anaemia other than coeliac disease. CONCLUSION: Simtomax had excellent diagnostic accuracy in iron deficiency anaemia and was comparable to conventional serology. Duodenal biopsy did not identify any causes other than coeliac disease for iron deficiency anaemia, suggesting that biopsy avoidance in Simtomax negative anaemic patients is unlikely to miss other anaemia-related pathologies. Due to its 100 % NPV, Simtomax could reduce unnecessary biopsies by 66 % if only those with a positive Simtomax were biopsied, potentially saving £3690/100 gastroscopies. TRIAL REGISTRATION: The group 2 study was retrospectively registered with clinicaltrials.gov. Trial registration date: 13(th) July 2016; TRIAL REGISTRATION NUMBER: NCT02834429 .

Surgery in (pre)malignant celiac disease.

AIM: To report the outcome of surgery in patients with (pre)malignant conditions of celiac disease (CD) and the impact on survival. METHODS: A total of 40 patients with (pre)malignant conditions of CD, ulcerative jejunitis (n = 5) and enteropathy associated T-cell lymphoma (EATL) (n = 35), who underwent surgery between 2002 and 2013 were retrospectively evaluated. Data on indications, operative procedure, post-operative morbidity and mortality, adjuvant therapy and overall survival (OS) were collected. Eleven patients with EATL who underwent chemotherapy without resection were included as a control group for survival analysis. Patients were followed-up every three months during the first year and at 6-mo intervals thereafter. RESULTS: Mean age at resection was 62 years. The majority of patients (63%) underwent elective laparotomy. Functional stenosis (n = 13) and perforation (n = 12) were the major indications for surgery. In 70% of patients radical resection was performed. Early postoperative complications, mainly due to leakage or sepsis, occurred in 14/40 (35%) of patients. Eight patients required reoperation. More patients who underwent resection in the acute setting (n = 3, 20%) died compared to patients treated in the elective setting. With a median follow-up of 20 mo, seven patients (18%) required reoperation due to long-term complications. Significantly more patients who underwent acute surgery could not be treated with adjuvant chemotherapy. Patients who first underwent surgical resection showed significantly better OS than patients who received chemotherapy without resection. CONCLUSION: Although the complication rate is high, the preferred first step of treatment in (pre)malignant CD consists of local resection as early as possible to improve survival.

Surgical aspects of celiac disease.

Celiac disease, characterized by intestinal inflammation and malabsorption, occurs in 1 per cent of the population and is often undiagnosed. These patients are at increased risk for surgical procedures resulting from symptoms, associated intestinal disorders, and malignancy. Our aim was to determine the incidence and outcome of abdominal operations in patients with celiac disease. Records of 512 adult patients with celiac disease evaluated over a 22-year period were reviewed. Operations were classified as related or unrelated to celiac disease. One hundred eighty-eight (36%) of 512 patients underwent abdominal operations. One hundred twenty-seven (68%) of the 188 patients had unrelated procedures. Sixty-one (32%) had operations considered related to celiac disease. Twenty-six (43%) of 61 with related procedures were diagnosed preoperatively. Procedures were performed for pain, obstruction, motility disorders, and malignancy. Six patients had recurrent pancreatitis. Seven patients underwent liver transplantation. Thirty-five (57%) related procedures led to the diagnosis of celiac disease including "unmasking" (n = 25) and diagnostic findings (n = 10). One-third of patients with celiac disease undergo abdominal operations of which one-third are related to celiac disease. Operations are related to complications of celiac disease and often lead to the initial diagnosis.

Hematopoietic stem cell transplantation for non-malignant gastrointestinal diseases.

Both, autologous and allogeneic hematopoietic stem cell transplantation (HSCT) can be used to cure or ameliorate a variety of malignant and non-malignant diseases. The rationale behind this strategy is based on the concept of immunoablation using high-dose chemotherapy, with subsequent regeneration of naive T-lymphocytes derived from reinfused hematopoietic progenitor cells. In addition, the use of HSCT allows for the administration of high-dose chemotherapy (whether or not combined with immunomodulating agents such as antithymocyte globulin) resulting in a prompt remission in therapy-refractory patients. This review gives an update of the major areas of successful uses of HSCT in non-malignant gastrointestinal disorders. A Medline search has been conducted and all relevant published data were analyzed. HSCT has been proved successful in treating refractory Crohn's disease (CD). Patients with refractory celiac disease type II and a high risk of developing enteropathy associated T-cell lymphoma have shown promising improvement. Data concerning HSCT and mesenchymal SCT in end-stage chronic liver diseases are encouraging. In refractory autoimmune gastrointestinal diseases high-dose chemotherapy followed by HSCT seems feasible and safe and might result in long-term improvement of disease activity. Mesenchymal SCT for a selected group of CD is promising and may represent a significant therapeutic alternative in treating fistulas in CD.

Liver abnormalities in bowel diseases.

Liver abnormalities are often seen in bowel diseases. Whether these represent aspects of two separate diseases, or if one is causing the other, is not always easy to decide. Extraintestinal manifestations of inflammatory bowel disease (IBD) or coeliac disease are frequently observed. Of these extraintestinal manifestations, hepatic disorders are among the most common. Primary sclerosing cholangitis (PSC) and primary biliary cirrhosis are the most frequent hepatic disorders in IBD and coeliac disease, respectively. Genetic studies have lately elucidated the associations between IBD and PSC, but there is still a long way until we have complete understanding of the molecular aetiology and pathophysiology of these conditions. There is no curative treatment available for PSC, besides liver transplantation. Steatosis and cholelithiasis are also common in IBD, as are signs of hepatic injury due to IBD treatment. Less common liver abnormalities include liver abscesses, hepatic thromboembolic events, granulomatous liver disease and hepatic amyloidosis.

Endoscopic and histological pitfalls in the diagnosis of celiac disease: a multicentre study assessing the current practice / Dificultades endoscópicas e histológicas en el diagnóstico de la enfermedad celiaca: un estudio multicéntrico para valorar la práctica actual

Background and aims: the diagnosis of celiac disease requires small bowel biopsies to identify the characteristic mucosal changes. The current biopsy practice among endoscopists for celiac disease is in most part unknown. The aim of this study was to compare the different diagnostic policies in various centers in their current practice. Method: information from a total of 931 confirmed celiac disease patients was retrospectively obtained retrospectively from nine centers in European and Middle Eastern countries. The number of small-bowel biopsies obtained from the duodenal bulb and the second part of the duodenum was compared among different centers. Results: the most frequent stage of mucosal changes amongst Iranian subjects was Marsh IIIa whereas in the rest of the study population was Marsh IIIc. Marsh I and Marsh II were more prevalent in adults (P < 0.05) and Marsh IIIc was significantly higher in pediatric ages between 1 and 15 (P < 0.05). The most common number of biopsy specimens obtained from Romanian subjects was 1 (52% of cases), followed by 2 for Iranian (56%), 3 for Lithuanian (66.7%) and British patients (65%) and 4 for Italian patients (48.3%). For majority of cases, anemia was the most prevalent symptom (18.7%) followed by malabsorption (10.5%), diarrhea (9.3%) and dyspepsia (8.2%), respectively. Conclusions: despite the evidence-based recommendations, this study revealed a poor compliance with major guidelines on diagnosis of celiac disease. We emphasize that taking adequate number of duodenal biopsies should be implemented for an accurate diagnosis and also for the exclusion of celiac disease(AU)

[Intraoperative ultrasound duplex scanning in the diagnosis and assessment of results of surgical treatment of patients with celiac compression syndrome].

The authors have performed an analysis of main indicators of celiac duplex scanning in 180 patients with celiac compression syndrome before operation, during decompression and at the postoperative period. All the patients underwent surgical celiac trunk decompression. The indicators of the intraoperative celiac duplex scanning (stenosis degree, linear peak systolic circulation rate) of the celiac trunk shower hemodynamic reliable stenosis and were sufficiently different from preoperative findings. The stenosis degree and linear peak systolic circulation rate were less during intraoperative examination than before the operation. Intraoperative, duplex canning allowed compressive stenosis of the seliac trunk to be differentatied in some patients from intravasal one (atherosclerosis and arteritis), and its adequate decompression to be performed. When performing the celiac trunk decompression it is thought to be necessary to fulfill its intraoperative ultrasound duplex scanning before and after elimination of the compression.

Síndrome del ganglio linfático mesentérico cavitado: una rara complicación de la enfermedad celiaca / Cavitating mesenteric lymph node syndrome: a rare complication of celiac disease

Dentro de las numerosas complicaciones de la enfermedad celiaca, el síndrome del ganglio linfático mesentérico cavitado se considera una de las más infrecuentes, siendo escasas las series de casos publicadas en la literatura. Su etiología y su mecanismo fisiopatológico se desconocen pero debido a su alta tasa de mortalidad, situada en torno al 50%, es conveniente reconocerla de forma precoz para así instaurar un tratamiento adecuado lo antes posible(AU)

Among the many complications of celiac disease, mesenteric lymph node syndrome cavitated is considered one of the rarest, there is few case series published in the literature. The etiology and pathophysiology are unknown but because of its high mortality rate, estimated to be around 50%, it should recognize at an early stage in order to institute appropriate therapy as soon as possible(AU)

Accuracy in celiac disease diagnostics by controlling the small-bowel biopsy process.

OBJECTIVES: In a Swedish celiac disease screening study (Exploring the Iceberg of Celiacs in Sweden), we systematically reviewed the clinical diagnostic procedures with the aim to evaluate the diagnostic accuracy and to take advantage of lessons learned for improving diagnostic routines. MATERIALS AND METHODS: A school-based celiac disease screening study involving 5 Swedish centers, with 10,041 invited 12-year-olds with 7567 consenting participation. All 192 children with elevated serological markers were recommended to undergo small-bowel biopsy, performed and evaluated according to local clinical routines. All of the mucosal specimens were reevaluated by 1 and, when needed, 2 expert pathologists to reach diagnostic consensus. RESULTS: Small-bowel biopsies were performed in 184 children: 130 by endoscopy and 54 by suction capsule. Endoscopic biopsies were inconclusive in 0.6%, compared with 7.4% of biopsies by suction capsule. A patchy enteropathy was found in 9.1%. Reevaluation by the expert pathologist resulted in 6 additional cases with celiac disease and 1 cleared. Sixteen children with normal or inconclusive biopsies, 4 after endoscopy, and 12 after suction capsule were endoscopically rebiopsied, resulting in another 8 cases. The celiac disease prevalence of 30 of 1000 (95% confidence interval 26-34) was not statistically different from that previously reported. CONCLUSIONS: The present review revealed the importance of controlling each step of the diagnostic procedure. Several cases would have been missed by relying only on local routines. To improve the quality of childhood celiac disease diagnostics, we recommend multiple endoscopic biopsies from both proximal and distal duodenum and standardized evaluation by a pathologist with good knowledge of celiac disease.

Management of cerebral venous thrombosis in a patient with Lane-Hamilton syndrome and coeliac disease, epilepsy and cerebral calcification syndrome.

We describe a case of cerebral venous thrombosis presenting in a patient with Lane-Hamilton syndrome and coeliac disease epilepsy cerebral calcification syndrome. This is a first reported occurrence of this combination. Delayed anticoagulation with early external ventricular drain insertion for life-threatening raised intracranial pressure resulted in a successful outcome.

Percutaneous embolization of periduodenal varix due to portal hypertension in a patient with kidney-pancreas transplantation: a case report.

Kidney-pancreas transplantation is a valid therapeutic option for patients with insulin-dependent diabetes mellitus. However, vascular complications associated with pancreas transplantation are not uncommon. Herein we have reported a 32-year-old woman with a history of insulin-dependent diabetes mellitus and celiac disease. She underwent liver transplantation for acute hepatitis. After 7 years, the patient developed end-stage kidney disease beginning hemodialysis and being listed for a kidney-pancreas transplantation, which was successfully performed when she was 29 years old with enteric diversion (Roux intestinal loop reconstruction). Five years after kidney-pancreas transplantation, she was admitted to our hospital with serious intestinal bleeding and poor liver function. The ultrasound showed a pattern like a arteriovenous fistula near the head of the pancreas. Computed Tomography was not diagnostic; an arteriogram showed the presence of a mesenteric varix and a mesenteric-caval shunt through the duodenum of the pancreatic graft. The liver biopsy and portal pressure gradient showed portal hypertension and liver cirrhosis. To obtain time a waiting a new liver, the patient underwent percutaneous embolization of the mesenteric varix through jugular access. The procedure was uneventful. The patient was successfully transplanted 2 months later. Pancreas function was always satisfactory.

Celiac disease serology in patients with different pretest probabilities: is biopsy avoidable?

AIM: To establish the diagnostic performance of several serological tests, individually and in combination, for diagnosing celiac disease (CD) in patients with different pretest probabilities, and to explore potential serological algorithms to reduce the necessity for biopsy. METHODS: We prospectively performed duodenal biopsy and serology in 679 adults who had either high risk (n = 161) or low risk (n = 518) for CD. Blood samples were tested using six assays (enzyme-linked immunosorbent assay) that detected antibodies to tissue transglutaminase (tTG) and deamidated gliadin peptide (DGP). RESULTS: CD prevalence was 39.1% in the high-risk population and 3.3% in the low-risk group. In high-risk patients, all individual assays had a high diagnostic efficacy [area under receiving operator characteristic curves (AU ROC): 0.968 to 0.999]. In contrast, assays had a lower diagnostic efficacy (AU ROC: 0.835 to 0.972) in the low-risk group. Using assay combinations, it would be possible to reach or rule out diagnosis of CD without biopsy in 92% of cases in both pretest populations. We observed that the new DGP/tTG Screen assay resulted in a surplus compared to more conventional assays in any clinical situation. CONCLUSION: The DGP/tTG Screen assay could be considered as the best initial test for CD. Combinations of two tests, including a DGP/tTG Screen, might be able to diagnose CD accurately in different clinical scenarios making biopsy avoidable in a high proportion of subjects.

An unusual case of intussusception.

Intussusception is not an uncommon diagnosis in the pediatric emergency department. Although most commonly occurring near the ileocecal junction, we describe a case of a small-bowel-small-bowel intussusception.