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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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Thapaliya I, Yadav J. Hypocalcaemic tetany linked to vitamin D deficiency and hypomagnesemia in primary intestinal lymphangiectasia: a literature review. Ann Med Surg (Lond) 2024; 86:2049-2057. [PMID: 38576918 PMCID: PMC10990415 DOI: 10.1097/ms9.0000000000001850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/11/2024] [Indexed: 04/06/2024] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder in children causing protein-losing enteropathy. Vitamin D deficiency and hypomagnesemia contributed to the tetany. The literature review reflects the importance of screening for these deficiencies and regular serum magnesium monitoring in PIL cases with neuromuscular or ionic abnormalities.
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Safari Vejin T, Zepeda ME, Yglesias BS, Devito P. Newfound features associated with Hennekam Syndrome ( Intestinal Lymphangiectasia-Lymphedema-Intellectual-Disability Syndrome) complicated with comorbid Waldmann's Disease resulting in Celiac Disease. Clin Case Rep 2023; 11:e7891. [PMID: 38028107 PMCID: PMC10651965 DOI: 10.1002/ccr3.7891] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 08/17/2023] [Accepted: 08/28/2023] [Indexed: 12/01/2023] Open
Abstract
Key Clinical Message Adequate evaluation of patients with Hennekam Syndrome (HS) is challenging for physicians, because of multi-organ involvement and complex pathophysiology. We report the first case in an African American with lymphedema, who developed protein-losing enteropathy (PLE) and was successfully diagnosed with HS from cause-and-effect complications by Waldmann's Disease (WD) and comorbid Celiac Disease (CD). Abstract As far as we know, this is the 51st case of HS worldwide and the first one in an African American. The examined patient met all diagnostic criteria for HS, suggesting a dysfunction in the development of the lymphatic system, with associated comorbidities including developmental delay, gastrointestinal pathologies, facial and hearing abnormalities, and cardiac defects. Primary intestinal lymphangiectasia (WD) is a consequence of HS, which ultimately results in PLE and worsening interstitial lymph buildup. Based on our findings, CD, a complication not yet reported in HS, may arise from WD. Other autoimmune diseases may be seen in HS: a previous report demonstrated positive anti-thyroid stimulating hormone antibodies in HS patients. We propose that in HS, increased interstitial lymph (WD, if intestinal) with protein loss induces TNF-α- and IL-6-mediated immune reactions in the affected visceral organs, causing autoimmune pathologies. The interstitial lymph fluid-induced TNF-α and IL-6-mediated immunopathogenic reactions lead to inflammation and subsequent destruction of the intestinal mucosa. The chronic inflammatory increase in TGF-β causes gastric mucosa hypertrophy, which results in gastric fold thickening. Eventually, wider tight junctions develop, increasing gastric mucosa permeability, and leading to gastropathy. Considering the examined patient's history of gastroenteritis and the literature stating that CD is a non-mucosal cause of gastropathy and PLE, it is suggested that sequelae of GI complications occur in a cause-and-effect chain in HS. HS results in WD, which causes CD, resulting in hypertrophic gastropathy and loss of parietal and chief cells, eventually leading to malabsorption and PLE (Figure 1). HS primarily affects various organs due to inflammatory-mediated damage and accumulation of lymph fluid. Other findings for HS include keratoconjunctivitis sicca (dry eye disease), fibrous lymphedema exhibiting lymphorrhea, chylous ascites, anemia, and parathyroid abnormalities. Immune impairment in HS predisposes patients to autoimmune disorders, therefore autoimmunity (CD) and WD are concomitant comorbidities of HS. HS-associated comorbidities are primarily due to inflammation and damage to immune cell transport or underlying health conditions affecting proper lymphatic function. However, it is suggested that HS mutations may disrupt the development of the lymphatic system leading to further complication. complications can be compound heterozygous, and there is a need for further research to identify nearby genes that can cause concomitant co-morbidity.
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Affiliation(s)
- Tannaz Safari Vejin
- Department of SurgeryTrumbull Regional Medical CenterWarrenOhioUSA
- AUA College and MedicineAntigua and Barbuda
| | | | | | - Peter Devito
- Department of SurgeryTrumbull Regional Medical CenterWarrenOhioUSA
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Jablonski SA. Pathophysiology, Diagnosis, and Management of Canine Intestinal Lymphangiectasia: A Comparative Review. Animals (Basel) 2022; 12:ani12202791. [PMID: 36290177 PMCID: PMC9597800 DOI: 10.3390/ani12202791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Intestinal lymphangiectasia was first described in the dog over 50 years ago. Despite this, canine IL remains poorly understood and challenging to manage. Intestinal lymphangiectasia is characterized by variable intestinal lymphatic dilation, lymphatic obstruction, and/or lymphangitis, and is a common cause of protein-losing enteropathy in the dog. Breed predispositions are suggestive of a genetic cause, but IL can also occur as a secondary process. Similarly, both primary and secondary IL have been described in humans. Intestinal lymphangiectasia is definitively diagnosed via intestinal histopathology, but other diagnostic results can be suggestive of IL. Advanced imaging techniques are frequently utilized to aid in the diagnosis of IL in humans but have not been thoroughly investigated in the dog. Management strategies differ between humans and dogs. Dietary modification is the mainstay of therapy in humans with additional pharmacological therapies occasionally employed, and immunosuppressives are rarely used due to the lack of a recognized immune pathogenesis. In contrast, corticosteroid and immunosuppressive therapies are more commonly utilized in canine IL. This review aims toward a better understanding of canine IL with an emphasis on recent discoveries, comparative aspects, and necessary future investigations.
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Affiliation(s)
- Sara A Jablonski
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, MI 48824, USA
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Meng MM, Liu KL, Xue XY, Hao K, Dong J, Yu CK, Liu H, Wang CH, Su H, Lin W, Jiang GJ, Wei N, Wang RG, Shen WB, Wu J. Endoscopic classification and pathological features of primary intestinal lymphangiectasia. World J Gastroenterol 2022; 28:2482-2493. [PMID: 35979262 PMCID: PMC9258282 DOI: 10.3748/wjg.v28.i22.2482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/09/2021] [Accepted: 04/28/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The appearance of the intestinal mucosa during endoscopy varies among patients with primary intestinal lymphangiectasia (PIL).
AIM To classify the endoscopic features of the intestinal mucosa in PIL under endoscopy, combine the patients’ imaging and pathological characteristics of the patients, and explain their causes.
METHODS We retrospectively analyzed the endoscopic images of 123 patients with PIL who were treated at the hospital between January 1, 2007 and December 31, 2018. We compared and analyzed all endoscopic images, classified them into four types according to the endoscopic features of the intestinal mucosa, and analyzed the post-lymphographic computed tomography (PLCT) and pathological characteristics of each type.
RESULTS According to the endoscopic features of PIL in 123 patients observed during endoscopy, they were classified into four types: nodular-type, granular-type, vesicular-type, and edematous-type. PLCT showed diffuse thickening of the small intestinal wall, and no contrast agent was seen in the small intestinal wall and mesentery in the patients with nodular and granular types. Contrast agent was scattered in the small intestinal wall and mesentery in the patients with vesicular and edematous types. Analysis of the small intestinal mucosal pathology revealed that nodular-type and granular-type lymphangiectasia involved the small intestine mucosa in four layers, whereas ectasia of the vesicular- and edematous-type lymphatic vessels largely involved the lamina propria mucosae, submucosae, and muscular layers.
CONCLUSION Endoscopic classification, combined with the patients’ clinical manifestations and pathological examination results, is significant and very useful to clinicians when scoping patients with suspected PIL.
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Affiliation(s)
- Ming-Ming Meng
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Kui-Liang Liu
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Xin-Ying Xue
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Kun Hao
- Departments of Lymphatic Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Jian Dong
- Departments of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Chun-Kai Yu
- Departments of Pathology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Hong Liu
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Cang-Hai Wang
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Hui Su
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Wu Lin
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Guo-Jun Jiang
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Nan Wei
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Ren-Gui Wang
- Departments of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Wen-Bin Shen
- Departments of Lymphatic Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Jing Wu
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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Prajapati S, Bohara S, Mainali G, Karki S, Thapa S, Aryal N. Diagnostic dilemma in diagnosing rare cause of protein losing enteropathy: Waldmann's disease. Clin Case Rep 2022; 10:e5992. [PMID: 35769238 PMCID: PMC9211774 DOI: 10.1002/ccr3.5992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022] Open
Abstract
Waldmann's disease, or primary intestinal lymphangiectasia, is an unusual cause of protein-losing enteropathy primarily characterized by lymphopenia, hypoalbuminemia, and hypogammaglobulinemia. However, variable clinical presentations result dilemmas in diagnosis and effective management. We present a toddler diagnosed with Waldmann's disease managed with a high-protein diet and medium-chain triglyceride supplementation.
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Affiliation(s)
- Sarita Prajapati
- Department of PediatricsBirendra Military HospitalKathmanduNepal
| | - Sujan Bohara
- Department of General and Gastrointestinal SurgeryNepal Mediciti HospitalLalitpurNepal
| | - Gaurab Mainali
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | | | - Sharan Thapa
- Lekhnath City Hospital Private LimitedPokharaNepal
| | - Nirjala Aryal
- Department of PediatricsBirendra Military HospitalKathmanduNepal
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Creed HA, Sanfelippo AN, Reyna AJ, Chakraborty A, Rutkowski JM. Impact of High Fat Diet and Bolus Feeding on Chyle Accumulation in a Mouse Model of Generalized Lymphatic Anomaly. Lymphat Res Biol 2021; 20:358-367. [PMID: 34748416 PMCID: PMC9422780 DOI: 10.1089/lrb.2021.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Generalized lymphatic anomalies (GLA) are complex vessel malformations that can impair lymphatic function. Potential GLA complications include lipid-rich lymph in the thoracic space or peritoneal cavity, respectively chylothorax and chylous ascites. To reduce the potential for chyle accumulation, GLA patients limit dietary fats. We hypothesized that dietary fatty acid composition impacts the potential for lymphatic dysfunction and chyle accumulation in GLA. Methods and Results: Adipose-specific overexpression of lymphatic growth factors has demonstrated lethal chylothorax in mice. Here, we utilized mice with inducible adipocyte overexpression of vascular endothelial growth factor-D (VD mice) to mimic lymphatic proliferation in GLA and assessed the incidence of chyle accumulation on a mixed high fat diet (HFD), high saturated fat diet (HSFD), or high unsaturated fat diet (HUSFD). Lipid transport was assessed by uptake rates of bolus oral triglyceride load and mesenteric fat analysis. Lymphatic expansion and inflammation were determined by whole mount immunofluorescence and gene expression. Body composition was assessed by MRI. HSFD 2-month wildtype groups resulted in an increase in TNF-α, IL-6, and IL-10 expression compared with chow-fed controls. The chyle accumulation incidence was highest in HFD-fed mice compared with either HSFD or HUSFD. Strikingly, increased mortality was observed irrespective of which high fat diet was consumed after administration of a bolus lipid load. Conclusion: Chronic HFD increases risk of chyle accumulation, however increased mortality was driven particularly by a bolus lipid load in VD mice. These findings suggest that although chronic HFD increases chyle accumulation risk, a single large meal feeding may increase risk of lethal chylothorax instances for GLA patients.
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Affiliation(s)
- Heidi A Creed
- Division of Lymphatic Biology, Department of Medical Physiology, Texas A&M University College of Medicine, Bryan, Texas, USA
| | - Ashley N Sanfelippo
- Division of Lymphatic Biology, Department of Medical Physiology, Texas A&M University College of Medicine, Bryan, Texas, USA
| | - Andrea J Reyna
- Division of Lymphatic Biology, Department of Medical Physiology, Texas A&M University College of Medicine, Bryan, Texas, USA
| | - Adri Chakraborty
- Division of Lymphatic Biology, Department of Medical Physiology, Texas A&M University College of Medicine, Bryan, Texas, USA
| | - Joseph M Rutkowski
- Division of Lymphatic Biology, Department of Medical Physiology, Texas A&M University College of Medicine, Bryan, Texas, USA
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8
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Vignes S, Bellanger J. Lymphangiectasies intestinales primitives (maladie de Waldmann). Rev Med Interne 2018; 39:580-585. [DOI: 10.1016/j.revmed.2017.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 07/24/2017] [Indexed: 12/17/2022]
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Martins CR, Gagnaire A, Rostain F, Lepage C. Waldmann's disease: a rare cause of protein losing enteropathy in an adult patient. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 109:385-388. [PMID: 28376626 DOI: 10.17235/reed.2017.4593/2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Primary intestinal lymphangiectasia or Waldmann's disease is an uncommon cause of protein losing enteropathy with an unknown etiology and is usually diagnosed during childhood. It is characterized by dilation and leakage of intestinal lymph vessels leading to hypoalbuminemia, hypogammaglobulinemia and lymphopenia. Differential diagnosis should include erosive and non-erosive gastrointestinal disorders, conditions involving mesenteric lymphatic obstruction and cardiovascular disorders that increase central venous pressure. Since there are no accurate serological or radiological available tests, enteroscopy with histopathological examination based on intestinal biopsy specimens is currently the gold standard diagnostic modality of intestinal lymphangiectasia. We report a rare case of a primary intestinal lymphangiectasia in a 60-year-old Caucasian female who presented with asymptomatic hypoalbuminemia and hypogammaglobulinemia. After the diagnosis of a protein losing enteropathy, the patient underwent an enteroscopy and biopsies were taken, whose histological examination confirmed dilated intestinal lymphatics with broadened villi of the small bowel. Secondary causes of intestinal lymphangiectasia were excluded and the diagnosis of Waldmann's disease was recorded. The patient was put on a high-protein and low-fat diet with medium-chain triglyceride supplementation with improvement.
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Li S, Liu X, He Y, Li Q, Ji L, Shen W, Tong G. Nutritional therapy and effect assessment of infants with primary intestinal lymphangiectasia: Case reports. Medicine (Baltimore) 2017; 96:e9240. [PMID: 29390480 PMCID: PMC5758182 DOI: 10.1097/md.0000000000009240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
RATIONALE Intestinal lymphangiectasia (IL) is a rare enteropathy involving the expansion and rupture of intestinal lymphatic channels. Although several reports have studied cases of primary IL (PIL), this condition is very rare, and is even less commonly encountered in infants. This study aimed to investigate the nutritional therapy and effect assessment of chylous reflux disorder caused by PIL in infants. PATIENT CONCERNS Infantile patients were enrolled in the Affiliated Beijing Shijitan Hospital of the Capital Medical University between January 2012 and March 2014. The minimum age of onset was 4 months and the maximum age of onset was 16 months, with an average age of 4.9 months. DIAGNOSES All children were inpatient who had been diagnosed with chylous reflux syndrome (chylothorax and/or chylic abdomen) caused by PIL. INTERVENTIONS Retrospective analysis and individualized nutrition therapy of these cases were carried out. Finally, nutritional therapy and prognosis of PIL were assessed and summarized. OUTCOMES All the children survived, showed improvement in the serum total protein, albumin, and HGB levels after nutritional therapy. After comprehensive nutritional therapy, we were able to achieve diarrhea control for all the 9 patients, and after treatment, the children passed soft, yellow stools 1 to 2 times/d. After treatment, the height and weight of all patients increased to within the normal ranges of the World Health Organization standard chart. The mean serum albumin level reached 41.3 g/L. All nutrition-related indicators were found to have significant improvement compared with the baseline levels. LESSONS The results revealed that nutritional therapy for the 9 children with PIL was effective, and it may be able to improve the clinical syndromes and symptoms of children with PIL and promote recovery.
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Affiliation(s)
- Suyun Li
- Department of Nutrition, Beijing Shijitan Hospital, Capital Medical University
| | - Xiaoqian Liu
- Department of Nutrition, Beijing Shijitan Hospital, Capital Medical University
| | - Yuan He
- Department of Nutrition, Beijing Shijitan Hospital, Capital Medical University
| | - Qianyu Li
- Department of Nutrition, Beijing Shijitan Hospital, Capital Medical University
| | - Linlin Ji
- Department of Nutrition, Beijing Shijitan Hospital, Capital Medical University
| | - Wenbin Shen
- Department of Lymphatic Surgery, Beijing Shijitan Hospital, Capital Medical University
| | - Guansheng Tong
- Department of Nuclear Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Levitt DG, Levitt MD. Protein losing enteropathy: comprehensive review of the mechanistic association with clinical and subclinical disease states. Clin Exp Gastroenterol 2017; 10:147-168. [PMID: 28761367 PMCID: PMC5522668 DOI: 10.2147/ceg.s136803] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Protein losing enteropathy (PLE) has been associated with more than 60 different conditions, including nearly all gastrointestinal diseases (Crohn’s disease, celiac, Whipple’s, intestinal infections, and so on) and a large number of non-gut conditions (cardiac and liver disease, lupus, sarcoidosis, and so on). This review presents the first attempt to quantitatively understand the magnitude of the PLE in relation to the associated pathology for three different disease categories: 1) increased lymphatic pressure (e.g., lymphangiectasis); 2) diseases with mucosal erosions (e.g., Crohn’s disease); and 3) diseases without mucosal erosions (e.g., celiac disease). The PLE with lymphangiectasis results from rupture of the mucosal lymphatics, with retrograde drainage of systemic lymph into the intestinal lumen with the resultant loss of CD4 T cells, which is diagnostic. Mucosal erosion PLE results from macroscopic breakdown of the mucosal barrier, with the epithelial capillaries becoming the rate-limiting factor in albumin loss. The equation derived to describe the relationship between the reduction in serum albumin (CP) and PLE indicates that gastrointestinal albumin clearance must increase by at least 17 times normal to reduce the CP by half. The strengths and limitations of the two quantitative measures of PLE (51Cr-albumin or α1-antitrypsin [αAT] clearance) are reviewed. αAT provides a simple quantitative diagnostic test that is probably underused clinically. The strong, unexplained correlation between minor decreases in CP and subsequent mortality in seemingly healthy individuals raises the question of whether subclinical PLE could account for the decreased CP and, if so, could the mechanism responsible for PLE play a role in the increased mortality? A large-scale study correlating αAT clearance with serum albumin concentrations will be required in order to determine the role of PLE in the regulation of the serum albumin concentration of seemingly healthy subjects.
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Affiliation(s)
- David G Levitt
- Department of Integrative Biology and Physiology, University of Minnesota
| | - Michael D Levitt
- Research Service, Veterans Affairs Medical Center, Minneapolis, MN, USA
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12
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Isa HM, Al-Arayedh GG, Mohamed AM. Intestinal lymphangiectasia in children. A favorable response to dietary modifications. Saudi Med J 2017; 37:199-204. [PMID: 26837404 PMCID: PMC4800920 DOI: 10.15537/smj.2016.2.13232] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Intestinal lymphangiectasia (IL) is a rare disease characterized by dilatation of intestinal lymphatics. It can be classified as primary or secondary according to the underlying etiology. The clinical presentations of IL are pitting edema, chylous ascites, pleural effusion, acute appendicitis, diarrhea, lymphocytopenia, malabsorption, and intestinal obstruction. The diagnosis is made by intestinal endoscopy and biopsies. Dietary modification is the mainstay in the management of IL with a variable response. Here we report 2 patients with IL in Bahrain who showed positive response to dietary modification.
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Affiliation(s)
- Hasan M Isa
- Department of Pediatrics, Salmaniya Medical Complex, Manama, Bahrain. E-mail.
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13
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Huber T, Paschold M, Eckardt AJ, Lang H, Kneist W. Surgical therapy of primary intestinal lymphangiectasia in adults. J Surg Case Rep 2015; 2015:rjv081. [PMID: 26169531 PMCID: PMC4499709 DOI: 10.1093/jscr/rjv081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder, especially in adults. It causes a local disruption of chylus transport and is part of the exudative gastroenteropathies. Conservative therapy includes dietary measures or somatostatin medication. Taking the differential diagnosis of PIL into consideration is a major challenge, since patients suffering from PIL may present with diarrhoea and lymphedema or chylous ascites. This can be explained by the chronic lymphedema of the bowel leading to dilation of the vessels (intraluminal loss) and sometimes even to a rupture (peritoneal loss). Push–pull enteroscopy and capsule endoscopy are the proper interventional diagnostic tools to discover PIL. Exploratory laparoscopy may be useful in unclear cases. Surgical resection of the altered intestine has been described with positive results. Exploratory laparoscopy may even be a diagnostic tool in unclear cases. Resection of the altered intestine is a treatment option in symptomatic and treatment-refractory cases.
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Affiliation(s)
- Tobias Huber
- Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Markus Paschold
- Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Alexander J Eckardt
- Department of Gastroenterology, DKD Helios Klinik Wiesbaden, Wiesbaden, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Werner Kneist
- Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
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Takada J, Araki H, Kubota M, Ibuka T, Shiraki M, Shimizu M, Moriwaki H. Protein-losing enteropathy cured by resection of adenomatous goiter: report of a case. Clin J Gastroenterol 2015; 8:120-5. [PMID: 25845937 DOI: 10.1007/s12328-015-0565-z] [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: 02/17/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
Abstract
A 51-year-old Japanese woman presented to our hospital with systemic edema and general fatigue. Her serum albumin level was very low (1.5 g/dL). Technetium-99 m-human serum albumin ((99m)Tc-HSA) scintigraphy showed albumin leakage from the upper small bowel. Magnetic resonance lymphangiography showed dilated lymphatic vessels in the chest, whereas double-balloon enteroscopy (DBE) showed white villi and chyle leakage in the deeper part of the duodenal mucosa. A duodenal mucosa biopsy specimen revealed lymphangiectasia. She was diagnosed with protein-losing enteropathy (PLE). Treatment with a fat-restricted diet and tranexamic acid--previously reported to be effective against PLE--was attempted, but was ineffective. A thyroid tumor was simultaneously detected in her left neck, and was found to extend to the mediastinum on computed tomography. The tumor (size, >5 cm) was resected, and a pathological diagnosis of adenomatous goiter was made. The patient's serum albumin level increased to normal levels within 1 month postoperatively. After 6 months, (99m)Tc-HSA scintigraphy showed no albumin leakage from the gastrointestinal tract, and disappearance of white villi and chyle leakage on DBE. No lymphangiectasia was noted in the biopsy specimen. Adenomatous goiter was thus considered the cause of the PLE, possibly through lymph flow obstruction in the mediastinum.
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Affiliation(s)
- Jun Takada
- Department of Gastroenterology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan,
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Butcher RO, Kinsey L, Lee HY, Foster L, McGrath SM, Willert RP. An unusual cause of ankle swelling. Endosc Int Open 2014; 2:E262-4. [PMID: 26135105 PMCID: PMC4423299 DOI: 10.1055/s-0034-1377382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 06/03/2014] [Indexed: 10/27/2022] Open
Affiliation(s)
- Rhys O. Butcher
- Department of Gastroenterology, Central Manchester University Hospitals, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Laura Kinsey
- Department of Gastroenterology, Central Manchester University Hospitals, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Hui Y. Lee
- Department of Gastroenterology, Central Manchester University Hospitals, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Lucy Foster
- Department of Gastroenterology, Central Manchester University Hospitals, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Stephen M. McGrath
- Department of Histopathology, Central Manchester University Hospitals, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Robert P. Willert
- Department of Gastroenterology, Central Manchester University Hospitals, Manchester Royal Infirmary, Manchester, United Kingdom,Corresponding author Robert P. Willert Department of GastroenterologyCentral Manchester University HospitalsManchester Royal InfirmaryOxford RoadManchester M13 9WLUnited Kingdom+44-161-2767992
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Ingle SB, Hinge (Ingle) CR. Primary intestinal lymphangiectasia: Minireview. World J Clin Cases 2014; 2:528-533. [PMID: 25325063 PMCID: PMC4198405 DOI: 10.12998/wjcc.v2.i10.528] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/28/2014] [Accepted: 07/29/2014] [Indexed: 02/05/2023] Open
Abstract
Primary idiopathic intestinal lymphangiectasia is an unusual disease featured by the presence of dilated lymphatic channels which are located in the mucosa, submucosa or subserosa leading to protein loosing enteropathy.Most often affected were children and generally diagnosed before third year of life but may be rarely seen in adults too. Bilateral pitting oedema of lower limb is the main clinical manifestation mimicking the systemic disease and posing a real diagnostic dilemma to the clinicians to differentiate it from other common systemic diseases like Congestive cardiac failure, Nephrotic Syndrome, Protein Energy Malnutrition, etc. Diagnosis can be made on capsule endoscopy which can localise the lesion but unable to take biopsy samples. Thus, recently double-balloon enteroscopy and biopsy in combination can be used as an effective diagnostic tool to hit the correct diagnosis. Patients respond dramatically to diet constituting low long chain triglycerides and high protein content with supplements of medium chain triglyceride. So early diagnosis is important to prevent untoward complications related to disease or treatment for the sake of accurate pathological diagnosis.
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Update March 2013. Lymphat Res Biol 2013. [DOI: 10.1089/lrb.2013.1113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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