Differentiating celiac disease from other diseases: Difference between revisions

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! rowspan="2" |Cause
! rowspan="2" |Cause
! colspan="2" |Diarrhea
! colspan="2" |Diarrhea
! colspan="2" |Osmotic gap
! rowspan="2" |Age of onset
! colspan="4" |History
! colspan="3" |History
! rowspan="2" |Physical exam
! rowspan="2" |Physical exam
! rowspan="2" |Age onset
! rowspan="2" |Lab findings
! rowspan="2" |Additional findind
! rowspan="2" |Additional finding
! rowspan="2" |Gold standard dignosis
! rowspan="2" |Gold standard dignosis
!
|-
|-
!Watery
!Watery
!Fatty
!Fatty
!< 50 mOsm per kg
!> 50 mOsm per kg*
!Weight loss
!Weight loss
!FTT
!Abdominal pain
!Abdominal pain
!FTT
!Anemia
!Lab findings
|-
|-
|[[Celiac disease (patient information)|Celiac disease]]
|[[Celiac disease (patient information)|Celiac disease]]
| +/-
| +/-
| +/-
| +/-
| -
|
| +
| +
| +
| +
| +
| +
| +
|<nowiki>+</nowiki>
|
|
* [[Abdominal distention]]
* [[Abdominal distention]]
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|
|
* [[IgA]] tissue [[transglutaminase]] Ab
* [[IgA]] tissue [[transglutaminase]] Ab
|
|-
|-
|[[Lactose intolerance]]
|[[Lactose intolerance]]
| +
| +
| -
| -
|
| -
| -
|<nowiki>+</nowiki>
| -
| -
| +
| +
| -
|
:-
|
|
* [[Abdominal tenderness]]
* [[Abdominal tenderness]]
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|
|
* Intestinal [[biopsy]]
* Intestinal [[biopsy]]
|
|-
|-
|[[Cystic fibrosis]]
|[[Cystic fibrosis]]
| -
| -
| +
| +
|
|Infancy and childhood
|
| +
| +
| +
| +
| +
| +
| +
|
|
* Digital clubbing
* Respiratory rale, wheeze, and crunckles
* Abdominal pain
* Cyanosis
|
|
* Positive DNA analysis for CFTR multimutation method
* Evaluated nasal transepithelial potential difference (NPD)
|
|
* Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein
* Disease manifestations in multiple organ systems:
** Diabetes
** Recurrent upper and lower respiratory tract infections
** Infertility
|
|
|
* Elevated sweat chloride ≥60 mmol/L
|-
|-
|[[Laxative abuse|Laxative overuse]]
|[[Laxative abuse|Laxative overuse]]
| +
| +
| -
| -
|
|
|
|
|
|
|
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|
|
|-
|-
|Congenital chloride diarrhea
|
|
|
|
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|
|
|
|
|Neonate
|
|
* History of polyhydramnios
* Mutations in the ''SLC26A3'' gene
** Encodes for an epithelial anion exchanger 
*
|
|
* Excessive fecal secretion of chloride
|hyponatremia, hypochloremia, and metabolic alkalosis
|-
|-
|[[Crohns disease|Crohns]]
|[[Crohns disease|Crohns]]
| +
| +
| -
| -
|<nowiki>+</nowiki>
|
|<nowiki>-</nowiki>
| +
| +
|
| +
| +
|
|
* [[Abdominal pain]] followed by [[diarrhea]]
|
|
* [[Abdominal]] [[tenderness ]]when palpated in severe [[disease]]
* [[Abdominal]] [[tenderness ]]when palpated in severe [[disease]]
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|
|
* [[Colonoscopy]] with [[biopsy]]
* [[Colonoscopy]] with [[biopsy]]
|
|-
|-
|[[Hyperthyroidism]]
|[[Hyperthyroidism]]
| +
| +
| -
| -
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|
|
|
|
|
|
|
|
* Excessive [[sweating]]
* Heat intolerance
* [[Hypermotility|Increased bowel movements]]
|
|
* Lump in the neck
* Lump in the neck
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* Increased DTR
* Increased DTR
|
|
*
|
|
* [[Carbimazole]]  and [[methimazole]]
*  
* [[Beta blockers]] like [[propylthiouracil]]
* [[Iodine-131]]
|
|
* [[TSH]] with [[T3]] and [[T4]]
* [[TSH]] with [[T3]] and [[T4]]
|
|-
|-
|[[VIPoma]]
|[[VIPoma]]
| +
| +
| -
| -
|
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| -
|
|
|
|
|
|
* Watery [[diarrhea]]
* [[Dehydration]]  ([[thirst]], [[dry skin]], [[dry mouth]], [[tiredness]], [[headaches]], and [[dizziness]])
* [[Lethargy]], [[muscle weakness]]
* [[Nausea]], [[vomiting]]
* Crampy [[abdominal pain]]
* [[Weight loss]]
* [[Flushing]]
|
|
* [[Tachycardia]]  
* [[Tachycardia]]  
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* [[Abdominal tenderness]] in the right upper abdominal quadrant
* [[Abdominal tenderness]] in the right upper abdominal quadrant
|
|
*
|
|
* [[Sandostatin]] or [[chemotherapy]] for [[malignant tumors]]
* [[Dehydration]]  
* Surgical removal of the [[tumor]]
* [[Lethargy]], [[muscle weakness]]
* [[Nausea]], [[vomiting]]
* [[Flushing]]
|
|
* Elevated [[VIP]] levels
* Elevated [[VIP]] levels
* Followed by imaging
* Followed by imaging
|
|-
|-
|[[Irritable bowel syndrome]]
|[[Irritable bowel syndrome]]
| +
| +
| -
| -
| -
| -
|
|
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|
|
|
|
[[Abdominal pain]] or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following:
* Improves with [[defecation]]
* Onset associated with change in frequency of [[stool]]
* Onset associated with change in appearance of stool
* 25% of [[Bowel movement|bowel movements]] are loose stools
History of straining is also common
|
|
* [[Abdominal tenderness]]
* [[Abdominal tenderness]]
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** ROME III criteria
** ROME III criteria
** [[Pharmacological|Pharmacologic]] studies based criteria
** [[Pharmacological|Pharmacologic]] studies based criteria
|
|-
|-
|[[lactose intolerance]]
|[[lactose intolerance]]
| -
| +
| -
| -
| +
| +
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|
|
|
|
* [[Bloating|Bloating,]]
* [[Flatulence]]
* [[Abdominal pain]], and/or [[chronic diarrhea]]
* after ingestion of [[lactose]]
|
|
* [[Abdominal]] [[tenderness ]]when palpated in severe [[disease]]
* [[Abdominal]] [[tenderness ]]when palpated in severe [[disease]]
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* [[Nausea and vomiting]]
* [[Nausea and vomiting]]
|
|
|Restriction of  [[lactose]] and  maintain [[calcium]] and [[vitamin D]] intake.
* [[Bloating|Bloating,]]
* [[Flatulence]]
* Symptoms begin mainly after ingestion of [[lactose]]
|
|[[Hydrogen Breath Test|Lactose breath hydrogen test]]
|[[Hydrogen Breath Test|Lactose breath hydrogen test]]
|-
|[[Whipple's disease|Whipple disease]]
| -
| +
|
|
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|
*
|
* [[Leukocytopenia]]
* [[Thrombocytopenia]]
|
* [[Skin hyperpigmentation]]
* [[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]])
|-
|-
|[[Whipple's disease|Whipple disease]]
|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
|-
! 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
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|Neonate
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* 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
|-
|Congenital sucrase-isomaltase deficiency 
|
|
|
|
|
|
|
|
|
|
|
* [[Arthralgias]]
* [[Weight loss]]
* [[Diarrhea]]
* [[Abdominal pain]]
|
|
* [[Leukocytopenia]]
* [[Thrombocytopenia]]
* [[Skin hyperpigmentation]]
|
|
|[[Doxycycline]] and [[hydroxychloroquine]] are [[bactericidal]]
* Symptoms start with consumption of sucrose-containing formulas or foods
|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]])
|
|
|}
|}
(solute-linked carrier family 26 member A3)  
(solute-linked carrier family 26 member A3)  
oral food challenge (OFC): 


==References==
==References==

Revision as of 22:07, 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 Gold standard dignosis
Watery Fatty Weight loss FTT Abdominal pain
Celiac disease +/- +/- + + +
Lactose intolerance + - - - +
Cystic fibrosis - + Infancy and childhood + + +
  • Digital clubbing
  • Respiratory rale, wheeze, and crunckles
  • Abdominal pain
  • Cyanosis
  • Positive DNA analysis for CFTR multimutation method
  • Evaluated nasal transepithelial potential difference (NPD)
  • Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein
  • Disease manifestations in multiple organ systems:
    • Diabetes
    • Recurrent upper and lower respiratory tract infections
    • Infertility
  • Elevated sweat chloride ≥60 mmol/L
Laxative overuse + -
Crohns + - + +
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
Cause Diarrhea Age of onset History Physical exam Lab findings Additional finding Gold standard dignosis
Watery Fatty Weight loss FTT Abdominal pain
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
Congenital sucrase-isomaltase deficiency 
  • Symptoms start with consumption of sucrose-containing formulas or foods

(solute-linked carrier family 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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