Differentiating celiac disease from other diseases: Difference between revisions

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! rowspan="2" |Lab findings
! rowspan="2" |Lab findings
! rowspan="2" |Additional finding
! rowspan="2" |Additional finding
! rowspan="2" |Cause
! rowspan="2" |Gold standard dignosis
! rowspan="2" |Gold standard dignosis
|-
|-
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| +/-
| +/-
| +/-
| +/-
|
|Childhood
 
Adult
| +
| +
| +
| +
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* Signs of the fat-soluble [[Vitamin A|vitamins A]], [[Vitamin D|D]], E, and K deficiency
* Signs of the fat-soluble [[Vitamin A|vitamins A]], [[Vitamin D|D]], E, and K deficiency
|
|
* [[IgA]] [[endomysial antibod]]<nowiki/>y (IgA EMA)
* IgA tissue [[transglutaminase]] antibody (IgA tTG)
* [[IgG]] tissue transglutaminase antibody (IgG tTG)
* IgA deamidated [[gliadin]] [[peptide]] (IgA DGP)
* IgG deamidated gliadin peptide (IgG DGP)
|
|
* [[Gluten-free diet]]
* [[Gluten-free diet]]
|
|
* [[IgA]] tissue [[transglutaminase]] Ab
* HLA-DQ2 and/or DQ8 [[gene mutation]]
* Innate responses to [[wheat proteins]]
|
* [[Immunoglobulin A]] (IgA) anti-tissue transglutaminase (TTG) antibody
|-
|-
|[[Lactose intolerance]]
|[[Lactose intolerance]]
| +
| +
| -
| -
|
|Adult
| -
| -
| -
| -
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* [[Abdominal tenderness]]
* [[Abdominal tenderness]]
|
|
* Stool [[osmotic]] gap of >125 mOsm/kg 
* Stool pH <6 
|
|
* Avoidance of dietary [[lactose]]
* Avoidance of [[Dietary|dietar]]<nowiki/>y [[lactose]]
* Substitution to maintain nutrient intake
* Substitution to maintain nutrient intake
* Regulation of [[calcium]] intake
* Regulation of [[calcium]] intake
* Use of [[enzyme]] [[lactase]]
* Use of [[enzyme]] [[lactase]]
|
|
* Intestinal [[biopsy]]
* Acquired primary [[lactase deficiency]]
** Adult-type [[hypolactasia]]
** Lactase nonpersistence)
|
* [[Lactose breath hydrogen test]]
|-
|-
|[[Cystic fibrosis]]
|[[Cystic fibrosis]]
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| +
| +
|
|
* Digital clubbing
* [[Digital clubbing]]
* Respiratory rale, wheeze, and crunckles
* Respiratory [[Rales|rale]], [[wheeze]], and crunckles
* Abdominal pain
* [[Abdominal pain]]
* Cyanosis
* Cyanosis
|
|
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* Evaluated nasal transepithelial potential difference (NPD)
* Evaluated nasal transepithelial potential difference (NPD)
|
|
* Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein
* Disease manifestations in multiple organ systems:
* Disease manifestations in multiple organ systems:
** Diabetes
** Diabetes
** Recurrent upper and lower respiratory tract infections
** Recurrent upper and lower respiratory tract infections
** Infertility
** Infertility
|Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein
|
|
* Elevated sweat chloride ≥60 mmol/L
* Elevated sweat chloride ≥60 mmol/L
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| +
| +
| -
| -
|After childhood
|<nowiki>+/-</nowiki>
| -
| +/-
|
|
* enhanced gastrointestinal motility and gastrointestinal sound
* Mild abdominal tenderness
* Abdominal bloating
|
|
* Hypokalemia 
* Metabolic alkalosis
* Hypermagnesemia(in case of magnesium laxative usage)
|<nowiki>-</nowiki>
|Laxative drug abuse
|
|
|
* laxative screening on a stool for:
|
** Diphenolic laxatives (eg, bisacodyl)
|
** Polyethylene glycol-containing laxatives
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|-
|-
|[[Crohns disease|Crohns]]
|[[Crohns disease|Crohns disease]]
| +
| +
| -
| -
|
|Young adults
 
(20th)
| +
| +
|
|
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*[[Hypotension]]
*[[Hypotension]]
|
|
* Anemia
* Iron deficiency
* Elevated white blood cell count
* Vitamin B12 deficiency
* Elevated erythrocyte sedimentation rate
* Elevated CRP
|
|
* Topical mucosamine and [[corticosteroids]] are preferred
* Topical mucosamine and [[corticosteroids]] are preferred
* [[Mesalamine]] and [[sulfasalazine]] are used for remission
* [[Mesalamine]] and [[sulfasalazine]] are used for remission
|Abnormal immune response to self antigens
|
|
* [[Colonoscopy]] with [[biopsy]]
* [[Colonoscopy]] with [[biopsy]]
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|
|
*  
*  
|
|
|
* [[TSH]] with [[T3]] and [[T4]]
* [[TSH]] with [[T3]] and [[T4]]
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* [[Nausea]], [[vomiting]]
* [[Nausea]], [[vomiting]]
* [[Flushing]]
* [[Flushing]]
|
|
|
* Elevated [[VIP]] levels
* Elevated [[VIP]] levels
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* [[Osmotic]] [[laxatives]] such as [[polyethylene glycol]], [[sorbitol]], and [[lactulose]]
* [[Osmotic]] [[laxatives]] such as [[polyethylene glycol]], [[sorbitol]], and [[lactulose]]
* [[Antispasmodic]] drugs (e.g. [[Anticholinergic|anticholinergics]] such as [[hyoscyamine]] or [[dicyclomine]])
* [[Antispasmodic]] drugs (e.g. [[Anticholinergic|anticholinergics]] such as [[hyoscyamine]] or [[dicyclomine]])
|
|
|
* [[Diagnosis|Clinical diagnosis]]
* [[Diagnosis|Clinical diagnosis]]
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* [[Flatulence]]
* [[Flatulence]]
* Symptoms begin mainly after ingestion of [[lactose]]
* Symptoms begin mainly after ingestion of [[lactose]]
|
|
|
|[[Hydrogen Breath Test|Lactose breath hydrogen test]]
|[[Hydrogen Breath Test|Lactose breath hydrogen test]]
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* [[Skin hyperpigmentation]]
* [[Skin hyperpigmentation]]
* [[Arthralgias]]
* [[Arthralgias]]
|
|Upper [[endoscopy]] with [[biopsies]] of the [[small intestine]] for ''[[Tropheryma whipplei|T. whipplei]]'' testing ([[histology]] with [[Periodic acid-Schiff stain|PAS staining]], [[polymerase chain reaction]] [[[PCR]]] testing, and [[immunohistochemistry]])
|Upper [[endoscopy]] with [[biopsies]] of the [[small intestine]] for ''[[Tropheryma whipplei|T. whipplei]]'' testing ([[histology]] with [[Periodic acid-Schiff stain|PAS staining]], [[polymerase chain reaction]] [[[PCR]]] testing, and [[immunohistochemistry]])
|-
|-
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* triggered by cow's milk protein
* triggered by cow's milk protein
* profuse, repetitive vomiting
* profuse, repetitive vomiting
|
|oral food challenge (OFC)
|oral food challenge (OFC)
|-
|-
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* one-half of patients have other allergic diseases
* one-half of patients have other allergic diseases
* associated with an identifiable dietary antigen
* associated with an identifiable dietary antigen
|
|eosinophilic infiltration of the gastrointestinal tract on biopsy
|eosinophilic infiltration of the gastrointestinal tract on biopsy
|-
|-
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** Arthritis
** Arthritis
** Uveitis
** Uveitis
|
|
|
* A colonoscopy with mucosal biopsy with mononuclear infiltrates:
* A colonoscopy with mucosal biopsy with mononuclear infiltrates:
** Collagenous colitis is characterized by a colonic subepithelial collagen band >10 micrometers in diameter
** Collagenous colitis is characterized by a colonic subepithelial collagen band >10 micrometers in diameter
** Lymphocytic colitis is characterized by ≥20 intraepithelial lymphocytes (IEL) per 100 surface epithelial cells
** Lymphocytic colitis is characterized by ≥20 intraepithelial lymphocytes (IEL) per 100 surface epithelial cells
|-
! rowspan="2" |Cause
! colspan="2" |Diarrhea
! rowspan="2" |Age of onset
! colspan="3" |History
! rowspan="2" |Physical exam
! rowspan="2" |Lab findings
! rowspan="2" |Additional finding
! rowspan="2" |Gold standard dignosis
|-
!Watery
!Fatty
!Weight loss
!FTT
!Abdominal pain
|-
|-
|Congenital chloride diarrhea
|Congenital chloride diarrhea
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* Mutations in the ''SLC26A3'' gene
* Mutations in the ''SLC26A3'' gene
** Encodes for an epithelial anion exchanger 
** Encodes for an epithelial anion exchanger 
|
|
|
* Excessive fecal secretion of chloride
* Excessive fecal secretion of chloride
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|
|
* May be associated with choanal or anal atresia
* May be associated with choanal or anal atresia
|
|
|
|-
|-
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* Dehydration
* Dehydration
* Symptomatic as long as the diet includes lactose or its hydrolysis products, glucose and galactose
* Symptomatic as long as the diet includes lactose or its hydrolysis products, glucose and galactose
|
|
|
* positive glucose breath hydrogen test + normal intestinal biopsy
* positive glucose breath hydrogen test + normal intestinal biopsy
|-
|-
|Congenital sucrase-isomaltase deficiency 
|Abetalipoproteinemia
| -
| +
|Infancy
| +
| +
| +
|Abdominal distention
Impaired visual acuity and visual field defects
 
Dysarthria 
|Low triglyceride
Low total cholesterol levels 
 
Acanthocytes 
 
Low vitamin E levels
|Clumsiness
vision impairment
 
Ataxia
|
|
* autosomal recessive disorder caused by mutations encoding the microsomal triglyceride transfer protein (MTP)
|Clinical findings and low triglyceride and cholesterol level
|-
|Primary bile acid malabsorption
| +
| +/-
|Childhood Adolescents
| +
| +
| +/-
| -
|
|
|Disease hetergenicity lead to varying presentation from chronic diarrhea without significant fat malabsorption to severe watery diarrhea and steatorrhea with malnutrition
|
|
* genetic defects in ''SLC10A2'' (solute carrier family 10 member 2 gene)
|
|
|
* Total and specific bile acids from stool
|
* Gamma emitter selenium-75-homocholic acid taurine (SeHCAT)
|
|-
|
! rowspan="2" |Cause
|
! colspan="2" |Diarrhea
* Symptoms start with consumption of sucrose-containing formulas or foods
! rowspan="2" |Age of onset
|
! colspan="3" |History
! rowspan="2" |Physical exam
! rowspan="2" |Lab findings
! rowspan="2" |Additional finding
! rowspan="2" |Cause
! rowspan="2" |Gold standard dignosis
|-
!Watery
!Fatty
!Weight loss
!FTT
!Abdominal pain
|-
|Gastrinoma (Zollinger-Ellison syndrome)
| +
| -
|between the ages of 20 and 50
| +
| +/-
| +
|Mild to moderate upper abdominal tenderness
|Positive secretin stimulation test
Elevated serum chromogranin A
|heartburn
|Gastrin producing tumor mainly in duodenum
|elevated basal or stimulated serum gastrin more than 1000 pg/mL
|}
|}
(solute-linked carrier family 26 member A3)  
(solute-linked carrier famly 26 member A3)  


oral food challenge (OFC):   
oral food challenge (OFC):   

Revision as of 23:12, 12 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Differentiating Celiac Disease from Other Diseases

The table below summarizes the findings that differentiate causes of chronic diarrhea[1][2][3][4][5][6][7]

Cause Diarrhea Age of onset History Physical exam Lab findings Additional finding Cause Gold standard dignosis
Watery Fatty Weight loss FTT Abdominal pain
Celiac disease +/- +/- Childhood

Adult

+ + +
Lactose intolerance + - Adult - - +
  • Stool osmotic gap of >125 mOsm/kg 
  • Stool pH <6 
Cystic fibrosis - + Infancy and childhood + + +
  • Positive DNA analysis for CFTR multimutation method
  • Evaluated nasal transepithelial potential difference (NPD)
  • Disease manifestations in multiple organ systems:
    • Diabetes
    • Recurrent upper and lower respiratory tract infections
    • Infertility
 Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein
  • Elevated sweat chloride ≥60 mmol/L
Laxative overuse + - After childhood +/- - +/-
  • enhanced gastrointestinal motility and gastrointestinal sound
  • Mild abdominal tenderness
  • Abdominal bloating
  • Hypokalemia 
  • Metabolic alkalosis
  • Hypermagnesemia(in case of magnesium laxative usage)
 - Laxative drug abuse
  • laxative screening on a stool for:
    • Diphenolic laxatives (eg, bisacodyl)
    • Polyethylene glycol-containing laxatives
Crohns disease + - Young adults

(20th)

+ +
  • Anemia
  • Iron deficiency
  • Elevated white blood cell count
  • Vitamin B12 deficiency
  • Elevated erythrocyte sedimentation rate
  • Elevated CRP
 Abnormal immune response to self antigens
Hyperthyroidism + -
VIPoma + - +
  • Elevated VIP levels
  • Followed by imaging
Irritable bowel syndrome + -
lactose intolerance - + Lactose breath hydrogen test
Whipple disease - + + - +
Upper endoscopy with biopsies of the small intestine for T. whipplei testing (histology with PAS staining, polymerase chain reaction [[[PCR]]] testing, and immunohistochemistry)
Allergic enteropathy/Food protein-induced enterocolitis syndrome (FPIES) + - Infancy +/- +/- +
  • Nausea
  • Vomiting
  • Abdominal distention
 S/E:
  • Blood-tinged and mucusy
  • Polymorphonuclear leukocytes presence
  • triggered by cow's milk protein
  • profuse, repetitive vomiting
 oral food challenge (OFC)
Eosinophilic gastroenteritis  + - 3rd decade +/- +/- +
  • Nausea
  • Vomiting
  • Abdominal distention
  • elevated serum IgE levels
  • abnormal D-xylose test
  • one-half of patients have other allergic diseases
  • associated with an identifiable dietary antigen
 eosinophilic infiltration of the gastrointestinal tract on biopsy
Microscopic colitis + - 6th decde + - +
  • Abdominal tenderness
  • autoantibodies include:
    • RF
    • ANA
    • AMA
    • ANCA
  • Fecal urgency
  • Incontinence
  • My be associated with extraintestinal symptoms, such as:
    • Arthralgia
    • Arthritis
    • Uveitis
  • A colonoscopy with mucosal biopsy with mononuclear infiltrates:
    • Collagenous colitis is characterized by a colonic subepithelial collagen band >10 micrometers in diameter
    • Lymphocytic colitis is characterized by ≥20 intraepithelial lymphocytes (IEL) per 100 surface epithelial cells
Congenital chloride diarrhea + - Neonate + + - -
  • Hyponatremia
  • Hypochloremia
  • Metabolic alkalosis
  • History of polyhydramnios
  • Mutations in the SLC26A3 gene
    • Encodes for an epithelial anion exchanger 
  • Excessive fecal secretion of chloride
Congenital sodium diarrhea + - Neonate + + - - S/E:
  • Alkaline
  • Fecal sodium concentrations

Serum:

  • Metabolic acidosis
  • Hyponatremia
  • May be associated with choanal or anal atresia
Glucose-galactose malabsorption + - Infancy + +/- + Abdominal tenderness
  • severe life-threatening diarrhea
  • Dehydration
  • Symptomatic as long as the diet includes lactose or its hydrolysis products, glucose and galactose
  • positive glucose breath hydrogen test + normal intestinal biopsy
Abetalipoproteinemia - + Infancy + + + Abdominal distention

Impaired visual acuity and visual field defects

Dysarthria 

Low triglyceride

Low total cholesterol levels 

Acanthocytes 

Low vitamin E levels

Clumsiness

vision impairment

Ataxia

  • autosomal recessive disorder caused by mutations encoding the microsomal triglyceride transfer protein (MTP)
 Clinical findings and low triglyceride and cholesterol level
Primary bile acid malabsorption + +/- Childhood Adolescents + + +/- - Disease hetergenicity lead to varying presentation from chronic diarrhea without significant fat malabsorption to severe watery diarrhea and steatorrhea with malnutrition
  • genetic defects in SLC10A2 (solute carrier family 10 member 2 gene)
  • Total and specific bile acids from stool
  • Gamma emitter selenium-75-homocholic acid taurine (SeHCAT)
Cause Diarrhea Age of onset History Physical exam Lab findings Additional finding Cause Gold standard dignosis
Watery Fatty Weight loss FTT Abdominal pain
Gastrinoma (Zollinger-Ellison syndrome) + - between the ages of 20 and 50 + +/- + Mild to moderate upper abdominal tenderness Positive secretin stimulation test

Elevated serum chromogranin A

heartburn Gastrin producing tumor mainly in duodenum elevated basal or stimulated serum gastrin more than 1000 pg/mL

(solute-linked carrier famly 26 member A3)

oral food challenge (OFC):

References

  1. ↑ Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR; et al. (2005). "Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology". Can J Gastroenterol. 19 Suppl A: 5A–36A. PMID 16151544.
  2. ↑ Sauter GH, Moussavian AC, Meyer G, Steitz HO, Parhofer KG, Jüngst D (2002). "Bowel habits and bile acid malabsorption in the months after cholecystectomy". Am J Gastroenterol. 97 (7): 1732–5. doi:10.1111/j.1572-0241.2002.05779.x. PMID 12135027.
  3. ↑ Maiuri L, Raia V, Potter J, Swallow D, Ho MW, Fiocca R; et al. (1991). "Mosaic pattern of lactase expression by villous enterocytes in human adult-type hypolactasia". Gastroenterology. 100 (2): 359–69. PMID 1702075.
  4. ↑ RUBIN CE, BRANDBORG LL, PHELPS PC, TAYLOR HC (1960). "Studies of celiac disease. I. The apparent identical and specific nature of the duodenal and proximal jejunal lesion in celiac disease and idiopathic sprue". Gastroenterology. 38: 28–49. PMID 14439871.
  5. ↑ Hertzler SR, Savaiano DA (1996). "Colonic adaptation to daily lactose feeding in lactose maldigesters reduces lactose intolerance". Am J Clin Nutr. 64 (2): 232–6. PMID 8694025.
  6. ↑ Briet F, Pochart P, Marteau P, Flourie B, Arrigoni E, Rambaud JC (1997). "Improved clinical tolerance to chronic lactose ingestion in subjects with lactose intolerance: a placebo effect?". Gut. 41 (5): 632–5. PMC 1891556. PMID 9414969.
  7. ↑ BLACK-SCHAFFER B (1949). "The tinctoral demonstration of a glycoprotein in Whipple's disease". Proc Soc Exp Biol Med. 72 (1): 225–7. PMID 15391722.

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