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Avitzur Y, Jimenez L, Martincevic I, Acra S, Courtney-Martin G, Gray M, Hope K, Muise A, Prieto Jimenez PM, Taylor N, Thiagarajah JR, Martín MG. Diet management in congenital diarrheas and enteropathies - general concepts and disease-specific approach, a narrative review. Am J Clin Nutr 2024; 120:17-33. [PMID: 38734141 PMCID: PMC11251218 DOI: 10.1016/j.ajcnut.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/27/2024] [Accepted: 05/06/2024] [Indexed: 05/13/2024] Open
Abstract
Congenital diarrheas and enteropathies (CODE) are a group of rare, heterogenous, monogenic disorders that lead to chronic diarrhea in infancy. Definitive treatment is rarely available, and supportive treatment is the mainstay. Nutritional management in the form of either specialized formulas, restrictive diet, or parenteral nutrition support in CODE with poor enteral tolerance is the cornerstone of CODE treatment and long-term growth. The evidence to support the use of specific diet regimens and nutritional approaches in most CODE disorders is limited due to the rarity of these diseases and the scant published clinical experience. The goal of this review was to create a comprehensive guide for nutritional management in CODE, based on the currently available literature, disease mechanism, and the PediCODE group experience. Enteral diet management in CODE can be divided into 3 distinct conceptual frameworks: nutrient elimination, nutrient supplementation, and generalized nutrient restriction. Response to nutrient elimination or supplementation can lead to resolution or significant improvement in the chronic diarrhea of CODE and resumption of normal growth. This pattern can be seen in CODE due to carbohydrate malabsorption, defects in fat absorption, and occasionally in electrolyte transport defects. In contrast, general diet restriction is mainly supportive. However, occasionally it allows parenteral nutrition weaning or reduction over time, mainly in enteroendocrine defects and rarely in epithelial trafficking and polarity defects. Further research is required to better elucidate the role of diet in the treatment of CODE and the appropriate diet management for each disease.
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Affiliation(s)
- Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Centre, SickKids Hospital, Toronto, ON, Canada; Division of Gastroenterology, Hepatology and Nutrition, SickKids Hospital, University of Toronto, Toronto, ON, Canada.
| | - Lissette Jimenez
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Congenital Enteropathy Program, Boston Children's Hospital, Boston, MA, United States;; Harvard Digestive Disease Center, Boston MA, United States
| | - Inez Martincevic
- Division of Gastroenterology, Hepatology and Nutrition, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Sari Acra
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Centre, SickKids Hospital, Toronto, ON, Canada; Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Megan Gray
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Kayla Hope
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Aleixo Muise
- Division of Gastroenterology, Hepatology and Nutrition, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Paula M Prieto Jimenez
- Division of Gastroenterology and Nutrition, Department of Pediatrics, Mattel Children's Hospital and the David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Nancy Taylor
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jay R Thiagarajah
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Congenital Enteropathy Program, Boston Children's Hospital, Boston, MA, United States;; Harvard Digestive Disease Center, Boston MA, United States
| | - Martín G Martín
- Division of Gastroenterology and Nutrition, Department of Pediatrics, Mattel Children's Hospital and the David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States.
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Barut D, Kıran Taşcı E, Kunay B, Güven B, Aksoy B, Çağan Appak Y, Karakoyun M, Çetin F, Selimoğlu A, Onay H, Aydoğdu S. Congenital sucrase-isomaltase deficiency in Türkiye; a single center experience. Scand J Gastroenterol 2024; 59:647-651. [PMID: 38459691 DOI: 10.1080/00365521.2024.2324961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/25/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Congenital sucrase-isomaltase deficiency (CSID) is a rare inherited carbohydrate malabsorption disorder caused by sucrase-isomaltase (SI) gene variants. In CSID, an autosomal recessively inherited disease, symptoms can also be seen in individuals with heterozygous mutations. METHODS The variant spectrum was evaluated retrospectively in individuals who presented with chronic diarrhea between 2014 and 2022 and had undergone genetic testing of the SI gene considering CSID due to diet-related complaints. RESULTS Ten patients with chronic diarrhea were genetically evaluated with SI gene sequencing. In patients diagnosed with CSID and whose symptoms improved with enzyme replacement therapy, the genetic mutation zygosity was found to be heterozygous at a rate of 90%. In 10% of the patients, the mutation was homozygous. Limiting consuming sucrose and isomaltose foods reduced the patients' complaints, but the symptoms did not disappear completely. With the initiation of sacrosidase enzyme replacement therapy, the patient's complaints completely disappeared. CONCLUSION In CSID, defined as an autosomal recessive disease, clinical symptoms can also be seen in heterozygous cases previously described as carriers, and these patients also benefit from sacrosidase enzyme replacement therapy. In light of these findings, the autosomal recessive definition of CSID does not fully characterize the disease.What is Known:CSID is a rare inherited carbohydrate malabsorption disorder caused by sucrase-isomaltase gene variants.In congenital sucrase-isomaltase deficiency, an autosomal recessively inherited disorder, symptoms can also be seen in individuals with heterozygous mutations.What is new:Severe disease symptoms can also be seen in heterozygous cases, which were thought to be carriers because the disease was previously described as autosomal recessive.Sacrosidase enzyme replacement therapy also eliminates the disease symptoms in patients with heterozygous CSID mutations.This is the second study on sucrase-isomaltase enzyme deficiency pediatric groups in Türkiye and Europe.
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Affiliation(s)
- Doğan Barut
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition Disease, Medical School of Ege University, Izmir, Turkey
| | - Ezgi Kıran Taşcı
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition Disease, Medical School of Ege University, Izmir, Turkey
| | - Bora Kunay
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition Disease, Medical School of Ege University, Izmir, Turkey
| | - Burcu Güven
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Betül Aksoy
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Izmir Katip Çelebi University, İzmir, Turkey
| | - Yeliz Çağan Appak
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Izmir Katip Çelebi University, İzmir, Turkey
| | - Miray Karakoyun
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition Disease, Medical School of Ege University, Izmir, Turkey
| | - Funda Çetin
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition Disease, Medical School of Ege University, Izmir, Turkey
| | - Ayşe Selimoğlu
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition Disease, Medical School, Memorial Ataşehir/Bahçelievler Hospital, İstanbul, Turkey
| | - Huseyin Onay
- Department of Medical Genetics, Ege University Hospital, Izmir, Turkey
| | - Sema Aydoğdu
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition Disease, Medical School of Ege University, Izmir, Turkey
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Smith H, Romero B, Flood E, Boney A. The patient journey to diagnosis and treatment of congenital sucrase-isomaltase deficiency. Qual Life Res 2021; 30:2329-2338. [PMID: 33772704 PMCID: PMC8298246 DOI: 10.1007/s11136-021-02819-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 11/12/2022]
Abstract
Purpose Congenital sucrase-isomaltase deficiency (CSID) is a rare genetic disorder characterized by a deficiency of the sucrase-isomaltase (SI) enzyme complex within the brush border membrane of the small intestine. Mutations in the SI gene result in abnormal synthesis and/or incorrect transport of the SI enzyme. Patients with CSID generally have reduced sucrase activity, but levels of isomaltase activity range from absent to almost normal. This study sought to better understand the experience of patients with CSID prior to, during, and after their diagnosis and its subsequent treatment with sacrosidase. Methods This was a cross-sectional interview study conducted in conjunction with a longitudinal, observational study of US patients prescribed and taking sacrosidase for at least three consecutive months as treatment for CSID. The observational study included both children and adults. Results This qualitative interview study explored the experiences of 43 adult and pediatric patients (n = 8 adults and n = 35 children/adolescents) with CSID pre-, during, and post-diagnosis. Findings suggest that a CSID diagnosis is particularly problematic given the disparate range of more commonly understood gastrointestinal (GI) disorders. After diagnosis and treatment with sacrosidase, participants reported considerable improvement in symptoms and health-related quality of life (HRQL), yet symptoms persist that continue to affect daily life, indicating areas of potential unmet need. Conclusion Educating clinicians about CSID may help improve the overall diagnosis experience. As this research is the first of its kind in CSID, additional research, qualitative and quantitative, will be important to furthering the understanding of HRQL impact and unmet need experienced by this population and identifying ways to best meet those needs.
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Rathod S, Friesen CA, Radford K, Colombo JM. Sucrase Breath Testing in Children Presenting With Chronic Abdominal Pain. Clin Pediatr (Phila) 2020; 59:1191-1194. [PMID: 32686473 DOI: 10.1177/0009922820942183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Sucrase deficiency has been implicated in chronic abdominal pain. Testing for sucrase deficiency generally involves invasive procedures or lengthy clinical visits, but now noninvasive kits that allow home testing are available to test for sucrase deficiency. In order to assess feasibility and utility of at-home testing, we reviewed our experience in 75 consecutive patients. All patients seen in the abdominal pain clinic had histories obtained in a standardized fashion and all had sucrase breath tests completed at home utilizing a commercially available kit. Testing was completed by 46 patients (61.3%). Tests were abnormal indicating sucrase deficiency in 34.8% of those completing testing. No symptoms were predictive of a positive test although there were trends of an association of an abnormal test with diarrhea and bloating. Our findings suggest that sucrase deficiency occurs frequently enough that more widespread testing and/or an empiric trial of sucrose and starch restriction should be considered.
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Affiliation(s)
- Sandeep Rathod
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
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Abstract
PURPOSE OF REVIEW Disaccharidase testing, as applied to the evaluation of gastrointestinal disturbances is available but it is not routinely considered in the diagnostic work-up. The purpose of this review was to determine if disaccharidase testing is clinically useful and to consider how the results could alter patient management. RECENT FINDINGS Indicate that carbohydrate maldigestion could contribute functional bowel disorders and negatively impact the fecal microbiome. Diagnostic techniques include enzyme activity assays performed on random endoscopically obtained small intestinal biopsies, immunohistochemistry, stable isotope tracer and nonenriched substrate load breath testing, and genetic testing for mutations. More than 40 sucrase--isomaltase gene variants coding for defective or reduced enzymatic activity have been reported and deficiency conditions are more common than previously thought. SUMMARY The rationale for disaccharidase activity testing relates to a need to fully assess unexplained recurrent abdominal discomfort and associated symptoms. All disaccharidases share the same basic mechanism of mucosal expression and deficiency has far reaching consequences. Testing for disaccharidase expression appears to have an important role in symptom evaluation, but there are accuracy and logistical issues that should be considered. It is likely that specific recommendations for patient management, dietary modification, and enzyme supplementation would come from better testing methods.
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Affiliation(s)
- Antone R. Opekun
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX, USA
- Section of Gastroenterology, Hepatology and Nutrition, Texas Children’s Hospital, Houston, TX, USA
| | - Bruno P. Chumpitazi
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX, USA
- Section of Gastroenterology, Hepatology and Nutrition, Texas Children’s Hospital, Houston, TX, USA
| | - Mustafa M. Abdulsada
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Buford L Nichols
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX, USA
- Director Emeritus, USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
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