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Sheppard R, Evanson B, Campbell I, Shand A. Chronic diarrhoea, weight loss and a positive anti-tissue transglutaminase antibody: A case report of olmesartan-induced enteropathy. BMJ Case Rep 2024; 17:e255407. [PMID: 38719261 PMCID: PMC11085927 DOI: 10.1136/bcr-2023-255407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024] Open
Abstract
Olmesartan is an angiotensin II receptor blocker licensed for the treatment of hypertension. It can cause a sprue-like enteropathy (SLE), characterised by chronic diarrhoea, weight loss and villous atrophy. Transiently raised anti-tissue transglutaminase (ATTG) antibody has also been rarely reported in the literature.We describe the case of a woman in her mid-50s, who presented with a history of intermittent loose stools over 1 year, associated with significant weight loss. She had two marginally raised serum ATTG antibody tests during her work-up.After extensive investigations, she was diagnosed with olmesartan-induced enteropathy. On subsequent follow-up, her symptoms had resolved with cessation of her olmesartan therapy.This case adds to existing literature, highlighting the importance of considering olmesartan as a possible differential diagnosis for SLE. It also reports the presence of a raised ATTG antibody which is infrequently reported in this context.
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Affiliation(s)
| | | | | | - Alan Shand
- Gastroenterology Unit, NHS Lothian, Edinburgh, UK
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2
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Schiepatti A, Minerba P, Puricelli M, Maimaris S, Arpa G, Biagi F, Sanders DS. Systematic review: Clinical phenotypes, histopathological features and prognosis of enteropathy due to angiotensin II receptor blockers. Aliment Pharmacol Ther 2024; 59:432-444. [PMID: 38185985 DOI: 10.1111/apt.17855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/21/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Although enteropathy due to angiotensin II receptor blockers (ARBs) has been known for over 10 years, clinicians' awareness of this condition is still low. AIMS To systematically review the literature about clinical phenotypes, distribution of mucosal changes throughout the gastrointestinal tract and prognosis of enteropathy due to ARBs. METHODS According to PRISMA guidelines, we searched PubMed and Embase for relevant articles up to November 6, 2023. We included full-text papers, letters, case reports and case series describing enteropathy due to ARBs. Patients were classified into subgroups based on endoscopic and histological findings of different regions of the gastrointestinal tract. The protocol was registered with Open Science Framework (https://doi.org/10.17605/OSF.IO/TK67C). RESULTS We included 94 articles reporting 183 cases (101 female, mean age at diagnosis 69 ± 10 years). The clinical picture at diagnosis was characterised by severe diarrhoea (97%) and weight loss (84%, median -13 kg), leading to hospital admission in 167 (95%) patients. Olmesartan (90%) was most frequently implicated. Villous atrophy (VA) was reported in 164/183 (89%) patients. One hundred and nine had only VA, 12 had pan-gastrointestinal involvement, 23 had VA and gastric involvement and 19 had VA and colon involvement (predominantly microscopic colitis). Outcomes were reported for 178/183 (97%) patients, who all recovered clinically on ARBs withdrawal. Histological recovery occurred in all 96 patients with VA at baseline who underwent follow-up duodenal biopsy. CONCLUSIONS Enteropathy due to ARBs is characterised by severe malabsorption often requiring hospital admission and can involve the entire gastrointestinal tract. Clinician awareness can lead to prompt diagnosis and excellent prognosis.
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Affiliation(s)
- Annalisa Schiepatti
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - Paolo Minerba
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Michele Puricelli
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Stiliano Maimaris
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - Giovanni Arpa
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia, Italy
- Unit of Anatomic Pathology, ICS Maugeri-IRCCS SpA SB, Pavia, Italy
| | - Federico Biagi
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
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3
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Alexander D, Abdelazeem B, Alnounou M. Olmesartan-Induced Ischemic Enteritis Complicated With Bowel Perforation: A Case Report and Literature Review. Cureus 2023; 15:e36660. [PMID: 37101993 PMCID: PMC10124147 DOI: 10.7759/cureus.36660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 04/28/2023] Open
Abstract
Olmesartan is a relatively new angiotensin receptor blocker used widely to control hypertension. Cases have been reported previously of enteropathy induced by olmesartan. Here, the authors report a case of olmesartan-induced ischemic enteritis complicated by bowel perforation. A 52-year-old male patient, during the treatment with olmesartan, developed severe abdominal pain of five-day duration. He underwent exploratory laparotomy for bowel perforation and surgical resection of the ischemic bowel segment. On a two-month follow-up after the discontinuation of olmesartan and the emergency surgery, the patient was symptom-free and functioning well. This rare report focuses on ischemic enteritis associated with olmesartan, describes the symptoms, and records the progression of this side effect and the corresponding treatment. Our case aims to raise awareness amongst physicians about the possibility of this severe complication and to point out that more research is still needed on its pathophysiology to better understand this drug.
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Affiliation(s)
- Dheeraj Alexander
- Internal Medicine, McLaren Health Care, Flint/Michigan State University, Flint, USA
| | - Basel Abdelazeem
- Internal Medicine, McLaren Health Care, Flint/Michigan State University, Flint, USA
| | - Mustafa Alnounou
- Gastroenterology, McLaren Health Care, Flint/Michigan State University, Flint, USA
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4
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Kajihara Y. An unusual cause of severe watery diarrhea. Eur J Intern Med 2022; 102:110-111. [PMID: 35589497 DOI: 10.1016/j.ejim.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Yusaku Kajihara
- Department of Gastroenterology, Fuyoukai Murakami Hospital, 3-3-14 Hamada, Aomori 030-0843, Japan.
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5
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Costetti M, Schiepatti A, Fraticelli S, Costa S, Maimaris S, Lenti MV, Villani L, Bianchi PI, Di Sabatino A, Corazza GR, Vanoli A, Biagi F. Clinical and gastro-duodenal histopathological features of enteropathy due to angiotensin II receptor blockers. Dig Liver Dis 2021; 53:1262-1267. [PMID: 34330666 DOI: 10.1016/j.dld.2021.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/01/2021] [Accepted: 07/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical elements differentiating enteropathy due to angiotensin II-receptor-blockers (ARBs-E) from coeliac disease (CD) are poorly defined. The histopathological features on duodenal and gastric biopsies in these patients still need to be investigated. AIMS To describe the clinical phenotype of ARBs-E in comparison to CD, and the histological findings of gastric and duodenal biopsies in ARBs-E. METHODS Clinical data of patients with ARBs-E and CD diagnosed between 2013 and 2020 were retrospectively reviewed. Baseline presenting symptoms and demographics were compared (Fisher's exact test and t-test). Gastric and duodenal histology in ARBs-E were revised by two independent pathologists. RESULTS 14 ARBs-E and 112 CD patients were enroled. Weight loss (p < 0.01), acute onset of diarrhoea (p < 0.01), hospitalization (p < 0.01), and older age at diagnosis (p < 0.01) were more common in ARBs-E. Duodenal histology in ARBs-E showed intraepithelial lymphocytosis in 71%, increased mucosal eosinophilic count in 57%, with preserved neuroendocrine, Paneth and goblet cells in all patients. Gastric histologic lesions at baseline, including lymphocytic gastritis, eosinophilic gastritis, chronic active gastritis, and metaplastic atrophic gastritis patterns were observed in 73% of patients, without Helicobacter pylori infection. CONCLUSIONS ARBs-E showed a severe clinical phenotype, often requiring hospital admission. Gastric involvement at diagnosis is very common, and this could further support this diagnosis.
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Affiliation(s)
- Martina Costetti
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Annalisa Schiepatti
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy.
| | - Sara Fraticelli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia, and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefania Costa
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Stiliano Maimaris
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Laura Villani
- Pathology Unit, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Italy
| | | | - Antonio Di Sabatino
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Alessandro Vanoli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia, and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federico Biagi
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
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O'Morain N, Shannon E, McManus J, Warner V, Leeson H, O'Donovan H, Egan B, Byrnes V. Coeliac disease enteropathy and symptoms may be aggravated by angiotensin receptor blockers in patients on a gluten-free diet. United European Gastroenterol J 2021; 9:973-979. [PMID: 34185963 PMCID: PMC8498406 DOI: 10.1002/ueg2.12117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/11/2021] [Indexed: 12/20/2022] Open
Abstract
Background Angiotensin receptor blocker‐associated enteropathy (ARB‐e) is an increasingly recognised clinical entity with symptoms and histological findings identical to coeliac disease (CD). There is evidence to suggest immune‐mediated mucosal injury in ARB‐e with a high prevalence of DQ2/DQ8; however, as IgA anti‐tissue transglutaminase (anti‐TTG) is usually negative, an insult other than TTG‐mediated injury is suspected. The impact of ARBs on disease activity in patients with CD is not known. Objective To assess the effect of ARB exposure on patients with established CD. Methods A patient record search of 1142 individual patients attending a dedicated coeliac clinic from 2010 to the present identified 59 patients treated with ARB. Those with CD confirmed by serology (TTG + ve/EMA + ve) and histopathology (Marsh criteria) were included (n = 40, 0.52%). Data collected included disease duration, compliance with gluten‐free diet (GFD), reported symptoms (diarrhoea, weight loss and abdominal pain), surrogate markers of absorption (Vitamin D, Iron, Calcium and Haemoglobin), in addition to anti‐TTG titre and histological grade at last follow up. Patients were age and sex‐matched in a 1:2 ratio with CD patients not taking ARBs (controls), with comparable rates of disease duration and compliance with GFD. Results The ARB and control groups were matched in terms of age (mean 66.2 years) and gender (female 63%). Strict compliance with GFD was reported in 55% and 56%, respectively. Persistent symptoms were reported in 10/40 (25%) of the ARB group compared with 7/82 (9%) of controls (p = 0.0181). There were lower rates of mucosal healing (Marsh grade 0) in the ARB group (36% n = 11) compared to controls (55%, n = 33). There was no significant difference in anti‐TTG titres. Surrogate markers of absorption were comparable across the groups, except for Vitamin D which was lower in those taking olmesartan (p = 0.0015). Conclusions ARBs may aggravate the enteropathy and lead to increased symptoms in patients with bone fide diagnosed CD following a GFD.
Summarise the estabished knowledge on this subject
Angiotensin receptor blocker‐associated enteropathy (ARB‐e) is an increasingly recognised clinical entity with symptoms and histological findings identical to coeliac disease (CD). The exact cause of mucosal injury in ARB‐e is unknown however there is evidence to suggest immune‐mediated mucosal injury in ARB‐e with a high prevalence of DQ2/DQ8, however as anti‐tissue transglutaminase (TTG) is usually negative, an insult other than TTG‐mediated injury is suspected. The impact of ARBs on disease activity in patients with CD is not known. What are the significance and/or new findins of this study? Coeliac patients who take ARBs are more likely to have persistent symptoms and lower rates of mucosal healing than their age‐matched coeliac controls. This observation appears to be independent of TTG mediated injury, akin to that reported in non‐coeliac populations. ARB use in patients with established coeliac disease may confound the interpretation of clinical and histological response to a gluten‐free diet.
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Affiliation(s)
- Neil O'Morain
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
| | - Eileen Shannon
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
| | - John McManus
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
| | - Vanessa Warner
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
| | - Hilary Leeson
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
| | - Helen O'Donovan
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
| | - Brian Egan
- Department of Gastroenterology, Mayo General Hospital, Castlebar, Ireland
| | - Valerie Byrnes
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
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Shukla N, Moore K, Gabb GM. Olmesartan-associated duodenal villous atrophy, an emerging clinical issue. Intern Med J 2021; 50:624-626. [PMID: 32431039 DOI: 10.1111/imj.14834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 11/30/2022]
Abstract
Duodenal villous atrophy with olmesartan was described in 2012, 10 years following registration of olmesartan. Clinical features are severe watery diarrhoea, usually occurring in association with weight loss. Onset is delayed, with a mean duration of prior exposure to olmesartan of 3 years. Diagnosis may be delayed. Symptoms resolve over weeks following cessation of olmesartan. Epidemiological studies suggest increased risk with olmesartan, rather than a class effect of all angiotensin receptor blockers. Post-marketing surveillance for drug safety remains important.
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Affiliation(s)
- Nupur Shukla
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Kylies Moore
- Drug Information Service, Pharmacy, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Genevieve M Gabb
- Acute and Urgent Care, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Cardiology, Flinders Medical Centre, Adelaide, South Australia, Australia.,Discipline of Medicine, School of Medicine, Faculty of Health Science, University of Adelaide, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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8
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Malik A, Inayat F, Malik MI, Afzal M, Azrak MF. Olmesartan-Induced Spruelike Enteropathy: An Emerging Cause of Small Bowel Injury. Cureus 2020; 12:e9347. [PMID: 32850220 PMCID: PMC7444891 DOI: 10.7759/cureus.9347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Olmesartan-induced spruelike enteropathy is a rare clinical entity that is characterized by unexplained chronic diarrhea and weight loss. Prompt recognition of this adverse event may be challenging due to clinical and histologic similarities with other small intestinal pathologies. We hereby delineate the case of an elderly female with a 14-month clinical history of non-bloody diarrhea and weight loss. After extensive diagnostic workup and exclusion of probable etiologies, the patient was diagnosed with olmesartan-associated enteropathy. A dramatic clinical and histologic recuperation was achieved after discontinuation of olmesartan. This paper illustrates the overarching need for a detailed clinical history focusing on medication review in patients presenting with chronic diarrhea with no obvious cause. The spruelike enteropathy associated with olmesartan is an emerging cause of small bowel injury. Clinicians should maintain a high index of suspicion for this adverse drug reaction. Early and correct diagnosis carries paramount importance in sparing these patients from unnecessary diagnostic investigations and therapeutic delays.
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Abstract
PURPOSE OF REVIEW To evaluate recently published information about the frequency of maldigestion and malabsorption in older individuals, likely diagnoses causing these problems, and the diagnostic scheme when these diagnoses are being considered. RECENT FINDINGS Although the prevalence of malnourishment and frank malnutrition may be increasing among older adults admitted to the hospital, this appears to be due to reduced food intake rather than maldigestion or malabsorption. The mechanisms of food digestion and absorption seem to be resilient, even in old age, but concurrent illness may produce malabsorption in older individuals. Illnesses that may be more common among the elderly include small intestinal bacterial overgrowth, exocrine pancreatic insufficiency, enteropathies, vascular disease, diabetes, and certain infections, such as Whipple's disease. In addition, older adults may have had previous surgeries or exposure to medicines which may induce malabsorption. The presentation of maldigestion and malabsorption in the elderly may be different than in younger individuals, and this may contribute to delayed recognition, diagnosis, and treatment. Diagnostic testing for maldigestion and malabsorption generally is similar to that used in younger patients. Maldigestion and malabsorption occur in older individuals and require a high level of suspicion, especially when weight loss, sarcopenia, or nutrient deficiencies are present.
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Affiliation(s)
- Lawrence R Schiller
- Baylor University Medical Center, 260 Wadley Tower, 3500 Gaston Avenue, Dallas, TX, 75246, USA.
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10
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Makri A, Florentin M, Elisaf MS, Liamis G. Significant Weight Loss in a Patient Taking Olmesartan: An Unusual Case Report. Curr Drug Saf 2019; 14:238-241. [PMID: 30848210 PMCID: PMC6865051 DOI: 10.2174/1574886314666190307142111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/22/2022]
Abstract
Objective: Olmesartan-induced enteropathy consists a syndrome that mimics celiac disease both clinically and histologically. Cases of this entity have sporadically been reported since 2012 and are usually characterized by severe diarrhea and malabsorption, followed by significant weight loss. Case Report: Herein, we report an uncommon case of this syndrome, where weight loss preceded several months the onset of gastrointestinal symptoms. Discussion and Conclusion: Physicians should be aware of unexplained weight loss in patients taking olmesartan, as prompt discontinuation of the drug may prevent the deleterious consequences of malabsorption.
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Affiliation(s)
- Andromachi Makri
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Matilda Florentin
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Moses S. Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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11
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Association of sprue-like enteropathy and angiotensin receptor-1 antagonists. Wien Klin Wochenschr 2019; 131:493-501. [DOI: 10.1007/s00508-019-01539-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 07/06/2019] [Accepted: 08/02/2019] [Indexed: 02/06/2023]
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12
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Kamal A, Fain C, Park A, Wang P, Gonzalez-Velez E, Leffler DA, Hutfless SM. Angiotensin II receptor blockers and gastrointestinal adverse events of resembling sprue-like enteropathy: a systematic review. Gastroenterol Rep (Oxf) 2019; 7:162-167. [PMID: 31217979 PMCID: PMC6573796 DOI: 10.1093/gastro/goz019] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/10/2019] [Accepted: 03/28/2019] [Indexed: 12/27/2022] Open
Abstract
Background Olmesartan, an angiotensin II receptor blocker (ARB), is associated with gastrointestinal symptoms resembling sprue-like enteropathy. Some have proposed that enteropathy may be a class effect rather than olmesartan-specific. We performed a systematic review to identify literature of sprue-like enteropathy for all ARBs. Methods Case reports, case series and comparative studies of ARBs were searched on PubMed and Embase databases through 21 November 2018 and then assessed. Results A total of 82 case reports and case series as well as 5 comparative studies, including 248 cases, were selected and analysed. The ARBs listed in the case reports were olmesartan (233 users; 94.0%), telmisartan (5 users; 2.0%), irbesartan (4 users; 1.6%), valsartan (3 users; 1.2%), losartan (2 users; 0.8%) and eprosartan (1 user; 0.4%). The periods between ARB initiation and onset of symptoms ranged from 2 weeks to 13 years. Histologic results were reported in 218 cases, in which 201 cases (92.2%) were villous atrophy and 131 cases (60.1%) were intraepithelial lymphocytosis. Human leucocyte antigen (HLA) testing was performed in 147 patients, among whom 105 (71.4%) had HLA-DQ2 or HLA-DQ8 haplotypes. Celiac-associated antibodies were tested in 169 patients, among whom 167 (98.8%) showed negative results. Gluten exclusion from the diet failed to relieve symptoms of enteropathy in 127 (97.7%) of 130 patients with information. Complete remission of symptoms after discontinuation of ARB was reported in 233 (97.4%) of the 239 patients with information. Seven cases (2.8%) reported recurrence of symptoms after restarting olmesartan; rechallenge was not reported for the non-olmesartan ARBs. The retrospective studies conducted worldwide had inconsistent study designs (e.g. differences in periods of study and case definition) and findings. Conclusions Although enteropathy is rare, clinicians should remain vigilant of this potential adverse event even years after medication initiation.
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Affiliation(s)
- Ayesha Kamal
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA
| | - Christopher Fain
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA
| | - Angela Park
- Johns Hopkins, Department of Surgery and Surgical Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Peiqi Wang
- Johns Hopkins, Department of Surgery and Surgical Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Eduardo Gonzalez-Velez
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Susan M Hutfless
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Abstract
PURPOSE OF REVIEW We reviewed the current 'state of the art' on autoimmune enteropathy and small-bowel mucosal atrophy, with the aim of supporting clinicians in a frequently challenging diagnosis through different therapeutic options and prognosis. RECENT FINDINGS The diagnosis of small-bowel diseases has radically changed over the last 10 years. The possibility to 'easily' obtain bioptic samples from the jejunum and ileum by means of the enteroscopic techniques (particularly, device-assisted enteroscopy) and the novel cross-sectional imaging studies have opened the window to new insights on intestinal disorders. Consequentially, the detection of small-bowel mucosal atrophy has become a frequent finding in patients undergoing endoscopic investigation and its differential diagnosis can be challenging at times. Among the 'typical' causes of mucosal atrophy, autoimmune enteropathy has become more frequent than previously thought. However, the final diagnosis of autoimmune enteropathy is a 'puzzle' composed by serological, endoscopic, histological and molecular markers, which should be correctly dealt with in order to reach a certain diagnosis. SUMMARY In conclusion, there is an emerging body of literature about autoimmune enteropathy and small-bowel atrophy. The herein presented practical review on autoimmune enteropathy can be of help to clinicians in their daily practice.
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Abstract
Differential diagnosis and management of enteropathies found in the context of seronegative villous atrophy (VA) are still a clinical challenge. Although seronegative coeliac disease may be the most frequent cause of serology-negative VA, other conditions must be taken into account in the differential diagnosis of seronegative VA. The rarity of these enteropathies with frequent overlapping of histological features may result in misclassification of such patients as affected by a seronegative or a refractory form of coeliac disease with consequent inappropriate treatments and long-term morbidity. The aim of this review is to summarize the current knowledge and to provide an evidence base and practical algorithmic approach for the investigation and management of seronegative VA.
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Sadki A, Le Besnerais M, Héron F, Marie I. Traitement par olmésartan et entéropathie : à propos de deux cas et revue de la littérature. Rev Med Interne 2019; 40:112-116. [DOI: 10.1016/j.revmed.2018.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/22/2018] [Accepted: 08/15/2018] [Indexed: 01/04/2023]
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16
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Fuchs V, Kurppa K, Huhtala H, Laurila K, Mäki M, Collin P, Salmi T, Luostarinen L, Saavalainen P, Kaukinen K. Serology-based criteria for adult coeliac disease have excellent accuracy across the range of pre-test probabilities. Aliment Pharmacol Ther 2019; 49:277-284. [PMID: 30592070 DOI: 10.1111/apt.15109] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 10/25/2018] [Accepted: 12/02/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The revised paediatric criteria for coeliac disease allow omission of duodenal biopsies in symptomatic children who have specific serology and coeliac disease-associated genetics. It remains unclear whether this approach is also applicable for adults with various clinical presentations. AIM To evaluate the accuracy of serology-based criteria in adults with variable pre-test probabilities for coeliac disease. METHODS Three study cohorts comprised adults with high-risk clinical coeliac disease suspicion (n = 421), moderate-risk family members of coeliac disease patients (n = 2357), and low-risk subjects from the general population (n = 2722). Serological and clinical data were collected, and "triple criteria" for coeliac disease comprised transglutaminase 2 antibodies >10× the upper limit of normal, positive endomysium antibodies, and appropriate genetics without requirement of symptoms. The diagnosis was based on intestinal biopsy. RESULTS The diagnosis of coeliac disease was established in 274 subjects. Of these, 59 high-risk subjects, 17 moderate-risk subjects, and 14 low-risk subjects fulfilled the "triple criteria". All had histologically proven coeliac disease, giving the criteria a positive predictive value of 100%. Altogether, 90 (33%) of all 274 newly diagnosed patients could have avoided biopsy, including 37% among high-risk, 20% among moderate-risk, and 48% among low-risk patients. No histological findings other than coeliac disease were found in the biopsies of "triple positive" subjects. CONCLUSIONS Coeliac disease can reliably and safely be diagnosed without biopsy in adults fulfilling the "triple criteria" regardless of the pre-test probability. Revised criteria would enable the number of endoscopies to be reduced by one-third.
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Affiliation(s)
- Valma Fuchs
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Kalle Kurppa
- Tampere Center for Child Health Research, University of Tampere, and Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Tampere Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Kaija Laurila
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Markku Mäki
- Tampere Center for Child Health Research, University of Tampere, and Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Pekka Collin
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Teea Salmi
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Dermatology, Tampere University Hospital, Tampere, Finland
| | - Liisa Luostarinen
- Department of Neurology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Päivi Saavalainen
- Research Programs Unit, Immunobiology, and Haartman Institute, Department of Medical Genetics, University of Helsinki, Helsinki, Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
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17
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Ghaith J, Raslan IA, Szilagyi A, Alameldin M. Case of olmesartan-associated enteropathy and transient positive antitissue transglutaminase serology. BMJ Case Rep 2018; 11:11/1/e225518. [PMID: 30567230 PMCID: PMC6301511 DOI: 10.1136/bcr-2018-225518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Olmesartan-associated enteropathy (OAE) is increasingly being recognised as a major differential diagnosis in patients with villous atrophy and negative coeliac disease (CD) serology. OAE and positive coeliac markers have rarely been reported. We report a case of diarrhoea and small bowel villous blunting associated with a transient elevation of antitissue transglutaminase antibody (ATTG). On discontinuation of olmesartan, symptoms improved, repeat biopsies were normal and levels of ATTG also returned normal. We discuss a possible explanation for the transient elevation in ATTG and the significance of considering OAE/CD overlap.
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Affiliation(s)
- Jenan Ghaith
- Internal Medicine Residency Program, University of McGill, Montreal, Quebec, Canada
| | - Ismail A Raslan
- Internal Medicine Residency Program, University of McGill, Montreal, Quebec, Canada
| | - Andrew Szilagyi
- Medicine Division of Gastroenterology, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Mona Alameldin
- Department of Pathology, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Canada
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