Tropical sprue laboratory findings: Difference between revisions

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Latest revision as of 00:30, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S [3]

Overview

Tropical sprue is a diagnosis of exclusion and there are no specific laboratory findings. Blood smear will show megaloblastic changes in chronic phase of tropical sprue. All the etiologies of malabsorption must be ruled out to consider the diagnosis of tropical sprue.

Laboratory Findings

Tropical sprue is diagnosed based on the following criteria:^[1]

Clinical presentation with chronic non bloody diarrhea with malabsorption
Presence of malabsorption for two different substances
Abnormal small intestinal histological findings
Exclusion of other causes of malabsorption
Response to treatment with tetracycline and folic acid

All the patients with celiac disease unresponsive to gluten free diet, a diagnosis of tropical sprue must be considered. The lab findings are not specific for tropical sprue as it is a diagnosis of exclusion. ^[2]

Patients with ileal involvement will have low vitamin B12 and folate levels.^[3]
Normal transglutaminase, immunoglobulin levels are present.
Peripheral blood smear will demonstrate megaloblastic picture.

Approach to a Patient With Malabsorption in Tropical Region

Clinical suspicion of malabsorption syndrome

Initial screening perform:
•Stool microscopy to rule out infectious causes
•D-xylose test to test for the presence of intestinal enterocyte dysfunction
•Fecal fat test for detection of steatorrhea

If D-Xylose and feacal fat tests are positive, confirmatory tests for malabsoption should be done

•Positive antiendomysial antibodies and villous atrophy suggests celiac disease
•Positive breath hydrogen test suggests lactase deficiency
•Positive microscopy and culture of jejunal aspirate suggests small bowel bacterial overgrowth
•Low serum immunoglobulin suggests B-cell deficiency
•HIV serology for HIV infection
•CT enterography to rule out intestinal inflammatory conditions
•Abdomen CT to rule out chronic pancreatitis

Once other possibilities are ruled out, suspect diagnosis of tropical sprue

Start tetracycline therapy
Improvement of symptoms with tetracycline confirms the diagnosis

Laboratory Investigations in Patient with Malabsorption

Stool microscopy will demonstrate the presence of protozoa like giardia, ova, cyst and other infective agents.
Fecal fat study to diagnose steatorrhea.
Low elastase and chymotrypsin is an indicator of pancreatic insufficiency.^[4]
IgA tissue transglutaminase or IgA antiendomysium assay for gluten sensitive enteropathy.
Blood tests may reveal anaemia, high ESR or low albumin.
D-Xylose test is useful in determining enterocyte function.
CT abdomen is helpful in the diagnosis of inflammatory bowel disease and pancreatitis.

References

↑ Walker MM (2003). "What is tropical sprue?". J Gastroenterol Hepatol. 18 (8): 887–90. PMID 12859716.
↑ Bonnefoy S, Chauvin A, Galéano-Cassaz C, Camilleri-Broet S, Jacquet SF, Carmoi T; et al. (2012). "[Tropical sprue in an expatriate]". Rev Med Interne. 33 (5): 284–7. doi:10.1016/j.revmed.2012.01.015. PMID 22405324.
↑ Misra RC, Kasthuri D, Chuttani HK (1967). "Correlation of clinical, biochemical, radiological, and histological findings in tropical sprue". J Trop Med Hyg. 70 (1): 6–10. PMID 6016817.
↑ Thomas P, Forbes A, Green J, Howdle P, Long R, Playford R, Sheridan M, Stevens R, Valori R, Walters J, Addison G, Hill P, Brydon G (2003). "Guidelines for the investigation of chronic diarrhoea, 2nd edition". Gut. 52 Suppl 5: v1–15. PMID 12801941.[1].

Template:WS Template:WH

[pmid12859716-1] Walker MM (2003). "What is tropical sprue?". J Gastroenterol Hepatol. 18 (8): 887–90. PMID 12859716.

[pmid22405324-2] Bonnefoy S, Chauvin A, Galéano-Cassaz C, Camilleri-Broet S, Jacquet SF, Carmoi T; et al. (2012). "[Tropical sprue in an expatriate]". Rev Med Interne. 33 (5): 284–7. doi:10.1016/j.revmed.2012.01.015. PMID 22405324.

[pmid6016817-3] Misra RC, Kasthuri D, Chuttani HK (1967). "Correlation of clinical, biochemical, radiological, and histological findings in tropical sprue". J Trop Med Hyg. 70 (1): 6–10. PMID 6016817.

[4] Thomas P, Forbes A, Green J, Howdle P, Long R, Playford R, Sheridan M, Stevens R, Valori R, Walters J, Addison G, Hill P, Brydon G (2003). "Guidelines for the investigation of chronic diarrhoea, 2nd edition". Gut. 52 Suppl 5: v1–15. PMID 12801941.[1].

[1]

[2]

[3]

[4]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Tropical sprue}}
-{{CMG}}
+{{CMG}}; {{AE}}  {{AKI}}
 ==Overview==
+[[Tropical sprue]] is a diagnosis of exclusion and there are no specific laboratory findings. Blood smear will show [[Megaloblastic Anemias|megaloblastic]] changes in chronic phase of [[tropical sprue]]. All the etiologies of [[malabsorption]] must be ruled out to consider the diagnosis of [[tropical sprue]].
 ==Laboratory Findings==
-Routine tests for TS:
+[[Tropical sprue]] is diagnosed based on the following criteria:<ref name="pmid12859716">{{cite journal| author=Walker MM| title=What is tropical sprue? | journal=J Gastroenterol Hepatol | year= 2003 | volume= 18 | issue= 8 | pages= 887-90 | pmid=12859716 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12859716  }} </ref>
-* Hemoglobin
+*Clinical presentation with chronic non bloody [[diarrhea]] with [[malabsorption]]
-* Mean corpuscular volume
+*Presence of [[malabsorption]] for two different substances
-* LDH
+*Abnormal small intestinal [[histological]] findings
-* Folic acid
+*Exclusion of other causes of [[malabsorption]]
-* Vitamin B12
+*Response to treatment with [[tetracycline]] and [[Folic Acid|folic acid]]
-Serological findings:
+All the patients with [[celiac disease]] unresponsive to gluten free diet, a diagnosis of [[tropical sprue]] must be considered. The lab findings are not specific for [[tropical sprue]] as it is a diagnosis of exclusion. <ref name="pmid22405324">{{cite journal| author=Bonnefoy S, Chauvin A, Galéano-Cassaz C, Camilleri-Broet S, Jacquet SF, Carmoi T et al.| title=[Tropical sprue in an expatriate]. | journal=Rev Med Interne | year= 2012 | volume= 33 | issue= 5 | pages= 284-7 | pmid=22405324 | doi=10.1016/j.revmed.2012.01.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22405324  }} </ref>
-* Anti-gliadin antibodies
+*Patients with ileal involvement will have low [[vitamin B12]] and [[folate]] levels.<ref name="pmid6016817">{{cite journal| author=Misra RC, Kasthuri D, Chuttani HK| title=Correlation of clinical, biochemical, radiological, and histological findings in tropical sprue. | journal=J Trop Med Hyg | year= 1967 | volume= 70 | issue= 1 | pages= 6-10 | pmid=6016817 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6016817  }} </ref>
-* Anti-endomysial antibodies
+*Normal [[transglutaminase]], [[immunoglobulin]]  levels are present.
-* Anti-tissue transgltaminase antibodies
+*[[Peripheral blood smear]] will demonstrate [[Megaloblastic anemia|megaloblastic picture.]]
-* Testing for other antibodies.
-Tropical Sprue can be diagnosed using the following tests and exams:
-===Stool Examination===
-* The stools are usually increased in volume and are either watery, or semiformed.
-* The finding of fat globules in stool is very suggestive of the presence of steatorrhea.
-* It is also helpful to exclude some of the parasites causing chronic diarrhea such as Giardia Lamblia, Entamoeba Histolytic.
-===Sigmoidoscopy===
+===Approach to a Patient With Malabsorption in Tropical Region===
-* Performed in all patients with chronic diarrhea to exclude lesions other than sprue such as amebiasis.
+{{familytree/start}}
-* In sprue, there is hyperemia of the colonic mucosa without ulcerations.
+{{familytree | | | | | | | | | | | | | | |  A01 | A01= Clinical suspicion of [[malabsorption]] syndrome}}
+{{familytree | | | | | | | | | | | | | | | |!| | }}
+{{familytree | boxstyle=text-align: left;| | | | | | | | | | | | | | | B01 | |B01= Initial screening perform: <br>•[[Stool microscopy]] to rule out infectious causes <br>•D-xylose test to test for the presence of intestinal enterocyte dysfunction <br>•[[Fecal fat test]] for detection of [[steatorrhea]]}}
+{{familytree | | | | | | | | | | | | | | | |!| |}}
+{{familytree | | | | | | | | | | | | | | | C01 | | | | | | | | C01= If D-Xylose and feacal fat tests are positive, confirmatory tests for [[malabsoption]] should be done}}
+{{familytree | | | | | | | | | | | | | | | |!| |}}
+{{familytree |boxstyle=text-align: left; | | | | | | | | | | | | | | | D01 | |D01=•Positive [[antiendomysial]] antibodies and villous atrophy suggests [[celiac disease]] <br>•Positive [[breath hydrogen test]] suggests [[lactase deficiency]] <br>•Positive microscopy and culture of jejunal aspirate suggests [[small bowel bacterial overgrowth]] <br>•Low [[serum immunoglobulin]] suggests [[B-cell deficiency]] <br>•[[HIV]] serology for HIV infection <br>•[[CT]] enterography to rule out intestinal inflammatory conditions <br>•Abdomen [[CT]] to rule out [[chronic pancreatitis]]}}
+{{familytree | | | | | | | | | | | | | | | |!| |}}
+{{familytree | | | | | | | | | | | | | | | E01 | | E01= Once other possibilities are ruled out, suspect diagnosis of [[tropical sprue]]}}
+{{familytree | | | | | | | | | | | | | | | |!| |}}
+{{familytree | | | | | | | | | | | | | | | F01 | | F01 = Start [[tetracycline]] therapy <br> Improvement of symptoms with [[tetracycline]] confirms the diagnosis}}
+{{familytree/end}}
-===Gastric biopsy===
+===Laboratory Investigations in Patient with Malabsorption===
-* Shows achlorhydria and changes ranging from superficial gastritis through chronic gastritis to complete gastric atrophy.
+*Stool microscopy will demonstrate the presence of protozoa like [[giardia]], [[ova]], [[cyst]] and other infective agents.
+*[[Fecal fat|Fecal fat study]] to diagnose [[steatorrhea]].
-===Absorption studies===
+*Low [[elastase]] and [[chymotrypsin]] is an indicator of pancreatic insufficiency.<ref>{{cite journal |author=Thomas P, Forbes A, Green J, Howdle P, Long R, Playford R, Sheridan M, Stevens R, Valori R, Walters J, Addison G, Hill P, Brydon G |title=Guidelines for the investigation of chronic diarrhoea, 2nd edition |journal=Gut |volume=52 Suppl 5 |issue= |pages=v1-15 |year=2003 |pmid=12801941}}[http://www.bsg.org.uk/pdf_word_docs/cd_body.pdf].
-* Steatorrhea may be essential for the diagnosis of TS.
+</ref>
+*[[IgA]] tissue [[transglutaminase]] or [[IgA]] antiendomysium assay for [[Celiac disease|gluten sensitive enteropathy.]]
+*Blood tests may reveal [[anaemia]], high [[ESR]] or low [[albumin]].
-*[[Bone density]] test
+*D-Xylose test is useful in determining [[enterocyte]] function.
-* CHEM 20
+*[[CT]] abdomen is helpful in the diagnosis of [[inflammatory bowel disease]] and [[pancreatitis]].
-*[[Complete blood count]] (CBC)
-*[[Comprehensive metabolic panel]]
-*[[Enteroscopy]]
-*[[Folate]] level (serum)
-*[[Iron]] level (serum)
-*[[Stool]] examination for [[bacteria]] and [[parasites]]
-*Upper [[endoscopy]]
-*[[Upper GI series]]
-*[[Vitamin B12]] level (serum)
-*[[Vitamin D]] level
 ==References==
 {{Reflist|2}}
-[[Category:Gastroenterology]]
 {{WS}}
 {{WH}}
+[[Category:Emergency mdicine]]
+[[Category:Disease]]
+[[Category:Up-To-Date]]
+[[Category:Infectious disease]]
+[[Category:Gastroenterology]]