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Alexander E, Stahl M, Weaver A, Devara J, Fahey LM, Singh A, Leonard MM, Weisbrod V, Shull M, Silvester J, Kramer Z, Kerzner B, Liu E, Absah I. The Spectrum of Duodenal Histologic Findings in Patients With Trisomy 21: A Multicenter Study. J Pediatr Gastroenterol Nutr 2023; 77:184-190. [PMID: 37184455 DOI: 10.1097/mpg.0000000000003825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVES Patients with Trisomy 21 (T21) commonly have gastrointestinal symptoms and diseases that prompt evaluation with esophagogastroduodenoscopy (EGD). Our objective is to characterize duodenal histological abnormalities in these patients when undergoing EGD. A secondary aim is to explore associations of histologic findings with different therapies. METHODS Patients 30 years old or younger with T21 who underwent EGD from 2000 to 2020 at 6 hospitals were included in this retrospective cohort study. Duodenal biopsies were categorized based on reported histopathology findings as normal or abnormal. Abnormal pathology reports were reviewed and categorized into villous atrophy (VA) and duodenitis without VA. The VA group was further categorized based on the presence or absence of celiac disease (CD). RESULTS We identified 836 patients with T21 who underwent EGD, 419 (50.1%) of whom had duodenal histologic abnormalities. At the time of the first (index) abnormal duodenal biopsy, 290 of 419 had VA and of those, 172 of 290 met CD diagnostic criteria, while 118 of 290 did not meet CD criteria (nonspecific VA). Among the patients with an abnormal biopsy, acid suppression at the time of the index biopsy was less common in patients with VA-CD compared to patients without VA or patients with nonspecific VA (12.2% vs 45.7% vs 44.9%). CONCLUSIONS Half of the T21 patients in this cohort had abnormal duodenal biopsies including a subgroup with nonspecific VA. In this cohort, acid suppression use was more prevalent in patients with abnormalities other than CD.
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Affiliation(s)
- Erin Alexander
- From the Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic Children's Center, Rochester, MN
| | - Marisa Stahl
- the Digestive Health Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Amy Weaver
- the Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Janaki Devara
- From the Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic Children's Center, Rochester, MN
| | - Lisa M Fahey
- the Division of Gastroenterology, Hepatology, & Nutrition, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Arunjot Singh
- the Division of Gastroenterology, Hepatology, & Nutrition, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Maureen M Leonard
- the Center for Celiac Research and Treatment, Division of Pediatric Gastroenterology and Nutrition, Mass General Hospital for Children, Harvard Medical School, Boston, MA
| | - Vanessa Weisbrod
- Harvard Celiac Research Program, Boston Children's Hospital, Boston, MA
| | - Mary Shull
- the Digestive Health Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jocelyn Silvester
- Harvard Celiac Research Program, Boston Children's Hospital, Boston, MA
- the Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Zachary Kramer
- the Celiac Disease Program, Division of Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, Washington, DC
| | - Benny Kerzner
- the Celiac Disease Program, Division of Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, Washington, DC
| | - Edwin Liu
- the Digestive Health Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Imad Absah
- From the Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic Children's Center, Rochester, MN
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Behl S, Khan MR, Ismail Y, Swantek C, Chen ZME, Murray JA, Absah I. The Characteristics of Isolated Bulb Celiac Disease in Children. J Pediatr Gastroenterol Nutr 2023; 77:79-85. [PMID: 37084335 DOI: 10.1097/mpg.0000000000003799] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
OBJECTIVES Mucosal injury in celiac disease (CD) patients can be patchy, and up to 12% of CD patients can have mucosal changes limited to the duodenal bulb. Hence, recent guidelines recommend obtaining bulb biopsies in addition to distal duodenum. This study aimed to describe a cohort of children with isolated bulb CD and assess the benefit of separating bulb biopsies. METHODS A retrospective chart review between January 2011 and January 2022 at 2 medical centers was conducted. We included children with CD who underwent endoscopy with separated biopsies from the bulb and distal duodenum. A blinded pathologist performed Marsh-Oberhuber grading on selected cases. RESULTS We identified 224 CD patients, of which 33 (15%) had histologically confirmed isolated bulb CD. Patients with isolated bulb CD were older at diagnosis (10 vs 8 years; P = 0.03). Median anti-tissue transglutaminase immunoglobulin A (TTG IgA) level was lower in isolate bulb CD (2.8 vs 16.7 times the upper limit of normal [ULN], P < 0.001). Almost 88% (29/33) of isolated bulb CD patients had an anti-TTG IgA value of less than 10 times the ULN. Time to anti-TTG IgA normalization (mean 14 months) was similar between the 2 groups. A pathologist review of diagnostic biopsies could not distinguish between the bulb and distal duodenum biopsies in approximately one-third of the reviewed samples. CONCLUSIONS Separating bulb from distal duodenum biopsies can be considered during CD diagnosis, particularly in children with anti-TTG IgA levels less than 10 times the ULN. Larger prospective cohorts are needed to decide whether isolated bulb CD is a unique cohort or an early stage of the conventional CD.
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Affiliation(s)
- Supriya Behl
- From the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Muhammad Rehan Khan
- the Division of Pediatric Gastroenterology, Hepatology & Nutrition, University of Illinois College of Medicine at Peoria; Children's Hospital of Illinois, Peoria, IL
| | - Yasmine Ismail
- the Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Courtney Swantek
- the Department of Pediatrics/Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL
| | | | - Joseph A Murray
- the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Imad Absah
- the Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
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Kröger S, Repo M, Hiltunen P, Vornanen M, Huhtala H, Kivelä L, Kurppa K. Differential diagnosis and long-term outcomes of non-atrophic duodenal changes in children. Front Pediatr 2022; 10:982623. [PMID: 36105857 PMCID: PMC9464825 DOI: 10.3389/fped.2022.982623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/11/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES AND STUDY Gastrointestinal endoscopy is often performed when investigating abdominal complaints in children. While atrophic changes of the duodenal mucosa are usually caused by celiac disease, the prevalence and clinical significance of non-atrophic duodenal changes are less clear. We studied these issues in a large pediatric endoscopic cohort. METHODS Comprehensive data on clinical features, diagnostic findings and long-term outcomes of children who had undergone upper gastrointestinal endoscopy with systematic duodenal sampling were collected. Study variables were compared between children with non-atrophic changes and normal histology, and between those with non-atrophic changes who did and did not receive a diagnosis. RESULTS The study comprised 1,170 consecutive children, of whom 51 (4.4%) had non-atrophic and 315 (26.9%) atrophic duodenal changes and 804 (68.7%) normal histology. The most common non-atrophic findings were non-specific inflammation (n = 19) and intraepithelial lymphocytosis (n = 14). Patients with non-atrophic changes presented more often with blood in stools (23.5 vs. 11.3%; p = 0.009), anemia (43.2 vs. 36.5%; p = 0.028) and positive celiac serology (34.3 vs. 12.9%; p < 0.001) than those with a normal duodenum. Twenty-four (44%) of those with non-atrophic changes received an initial diagnosis, the most common of which were inflammatory bowel disease (IBD) (n = 8), Helicobacter pylori infection (n = 3) and food allergy (n = 3). The prevalence of the diagnoses did not differ from those with a normal duodenum. Those who received a diagnosis had more often blood in stools (37.5 vs. 11.1%; p = 0.027), anemia (70.6 vs. 20.0%; p = 0.002) and negative celiac serology (50.0 vs. 7.7%; p = 0.013) than those without diagnosis. During a follow-up of 6.1-13.3 years, five of the 12 initially undiagnosed seropositive patients developed celiac disease, and one patient also developed ulcerative colitis. CONCLUSION Non-atrophic duodenal changes are relatively common and associated with anemia, blood in stools, and positive celiac disease serology. Excluding potential celiac disease, those without an initial diagnosis have a favorable long-term prognosis.
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Affiliation(s)
- Sofia Kröger
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland.,Celiac Disease Research Center, Tampere University, Tampere, Finland
| | - Marleena Repo
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland.,Celiac Disease Research Center, Tampere University, Tampere, Finland
| | - Pauliina Hiltunen
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland
| | - Martine Vornanen
- Department of Pathology, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Laura Kivelä
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland.,Celiac Disease Research Center, Tampere University, Tampere, Finland.,Children's Hospital and Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Kalle Kurppa
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland.,Celiac Disease Research Center, Tampere University, Tampere, Finland.,Seinäjoki Central Hospital, University Consortium of Seinäjoki, Seinäjoki, Finland
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