y***d
发帖数: 33 | 1 在板上潜水有一会了，好像发case的不多啊。是不是这儿attending太多，都没时间写
case了呢？我来抛砖引玉好了。
从今天开始，每星期我会上一个case。 周一history, 周二physical， 周三initial
labs/work up, 周四additional work-up, 周五final diagnosis. 欢迎大家跟贴讨论
。这些case基本上是面向内科resident的。不过attending们也可以复习一下哈。如果
受欢迎的话我会一直贴下去。废话到此为止。 先上第一个case试试反响如何。
CC: bilateral leg swelling and diarrhea
HPI: 72 yo f h/o HTN, diarrhea and pneumatosis intestinalis of unclear
etiology presented to ER for worsening bilateral lower extremity edema and
ongoing diarrhea.
Initially presented 2 month PTA with persistent diarrhea x2 month and weight
loss after an episode of gastroenteritis (husband also had it).Subsequently
underwent extensive workup including multiple stool cultures, O&P, and a
colonoscopy with inconclusive result. Tried lactose free diet w/o
improvement. CT showed pneumatosis intestinalis.An ex-lap confirmed the CT
finding but could not identify the cause.
During previous hospitalization 1 week PTA was noted to have LE edema. It
was felt to be secondary to venous insufficiency vs. stopping outpatient
HCTZ. Patient discharged on spiranolactone with outpt TTE but came back 2/2
worsening LE edema and ongoing diarrhea. Diarrhea is watery, large volume,
occurs 1-2 times a day, 8-9 hours after eating.
ROS: 40-50 lb weight loss in past 3-4 months, generalized weakness,
occasional nausea/vomiting past week and flatulence. Also reports finger
turning blue when cold. No abdominal pain, melena, hematochezia, fevers,
chills, decreased appetite, chest pain, dyspnea or PND.
PMH: HTN, persistent hypokalemia, anemia. Exploratory laparoscopy showed
pneumatosis intestinalis of terminal ileum and proximal jejunum without
signs of perforation or ischemia. Colonoscopy showed unremarkable ileum
biopsy.
Meds: Benicar, spironolactone
All: NKDA
SH: originally from Istanbul, lives with husband. No tob, rare ETOH, no
drugs.
FH: Mom had Addison’s disease.
大家想到什么说什么。明天上physical exam。 | a*********1
发帖数: 872 | 2 欢迎欢迎！一天贴一部分，很吊胃口
看完history,没什么头绪。是不是SLE? | S******9
发帖数: 2837 | 3 MEN?
metastatic carcinoid syndrome? | b*******l
发帖数: 856 | | z*******2
发帖数: 2643 | | A*******s
发帖数: 9638 | 6 Thank you, Dr.Yiled.
So excited to see the case presentation.
Ok, I would suggest: For each day, we raise questions related to the topic
the host wants to discuss. Monday would be the day for the history, for
example.
Any history of recent travel? | V*****G
发帖数: 337 | 7 Amyloidosis
Hypothyroidism
Parasite infection, e.g. schistosomiasis
Celiac sprue, tropic sprue
Polyglandular autoimmune syndrome
Other autimmune diseases: e.g. Systemic sclerosis
Binecar SE?
How long has she been having hypokalemia?
Hypokalemia:
if started same time as hypertension = primary aldosteronism
if started after HCTZ = SE
if started after diarrhea = due to GI loss
Raynaud syndrome:
if on beta blocker for HTZ, could be SE
systemic sclerosis
Will modify based on day to day update......
【在 y***d 的大作中提到】
: 在板上潜水有一会了，好像发case的不多啊。是不是这儿attending太多，都没时间写
: case了呢？我来抛砖引玉好了。
: 从今天开始，每星期我会上一个case。 周一history, 周二physical， 周三initial
: labs/work up, 周四additional work-up, 周五final diagnosis. 欢迎大家跟贴讨论
: 。这些case基本上是面向内科resident的。不过attending们也可以复习一下哈。如果
: 受欢迎的话我会一直贴下去。废话到此为止。 先上第一个case试试反响如何。
: CC: bilateral leg swelling and diarrhea
: HPI: 72 yo f h/o HTN, diarrhea and pneumatosis intestinalis of unclear
: etiology presented to ER for worsening bilateral lower extremity edema and
: ongoing diarrhea.
| m*********6
发帖数: 609 | 8 with FH of autoimmune disease, can it be some kind of autoantibody-related disease?
【在 y***d 的大作中提到】
: 在板上潜水有一会了，好像发case的不多啊。是不是这儿attending太多，都没时间写
: case了呢？我来抛砖引玉好了。
: 从今天开始，每星期我会上一个case。 周一history, 周二physical， 周三initial
: labs/work up, 周四additional work-up, 周五final diagnosis. 欢迎大家跟贴讨论
: 。这些case基本上是面向内科resident的。不过attending们也可以复习一下哈。如果
: 受欢迎的话我会一直贴下去。废话到此为止。 先上第一个case试试反响如何。
: CC: bilateral leg swelling and diarrhea
: HPI: 72 yo f h/o HTN, diarrhea and pneumatosis intestinalis of unclear
: etiology presented to ER for worsening bilateral lower extremity edema and
: ongoing diarrhea.
| w*****i
发帖数: 220 | 9 Diarrhea looks like secretory so I would add one more guess: VIPomma?
Hypokalemia & LE could both be explained by diarrhea per se. but pneumatosis
intestinalis w/o signs of ischemia is really odd. | S******9
发帖数: 2837 | 10 pneumatosis intestinalis can be explained by the long-term diarrhea from
Vipoma.
pneumatosis
【在 w*****i 的大作中提到】
: Diarrhea looks like secretory so I would add one more guess: VIPomma?
: Hypokalemia & LE could both be explained by diarrhea per se. but pneumatosis
: intestinalis w/o signs of ischemia is really odd.
| | | J********0
发帖数: 19 | 11 How come everybody is proposing something relatively rare? How about the
possibility of bowel ischemia which is compatible with abdominal pain,
diarrhea, and especially pneumatosis intestinitis and likely DVT of lower
extremities. Is there any thing to explain the pneumatosis? Otherwise, bowel
ischemia has to be in the differential. Bilateral lower extremity edema is
consistent with DVT from blood clot. Is there a dupplex doppler study? Is
there atrial fibrillation which is the #1 cause of showering emboli to all
over the places. | A*******s
发帖数: 9638 | 12 Victor, can you tell us why you put amyloidosis at the first place? This
reminds me of a case with nephrotic syndrome(BLE edema) 2nd to amyloidosis.
【在 V*****G 的大作中提到】
: Amyloidosis
: Hypothyroidism
: Parasite infection, e.g. schistosomiasis
: Celiac sprue, tropic sprue
: Polyglandular autoimmune syndrome
: Other autimmune diseases: e.g. Systemic sclerosis
: Binecar SE?
: How long has she been having hypokalemia?
: Hypokalemia:
: if started same time as hypertension = primary aldosteronism
| S******9
发帖数: 2837 | 13 这个病人有多腺体病的表现，有Hx免疫病，有raynaud表现这些。他是不是考虑淀粉样
变性可以累积多个器官？
【在 A*******s 的大作中提到】
: Victor, can you tell us why you put amyloidosis at the first place? This
: reminds me of a case with nephrotic syndrome(BLE edema) 2nd to amyloidosis.
| a*********1
发帖数: 872 | 14 给第一个给出正确diagnosis的人发包子奖励怎么样？
【在 A*******s 的大作中提到】
: Thank you, Dr.Yiled.
: So excited to see the case presentation.
: Ok, I would suggest: For each day, we raise questions related to the topic
: the host wants to discuss. Monday would be the day for the history, for
: example.
: Any history of recent travel?
| A*******s
发帖数: 9638 | 15 我想是这样。 Enterocolitis可以是infectious or inflammatory。与edema应该是没
什么直接关系（dehydration更可能）。 所以说systemic disease makes more sense.
我们可能是在找zebra。
【在 S******9 的大作中提到】
: 这个病人有多腺体病的表现，有Hx免疫病，有raynaud表现这些。他是不是考虑淀粉样
: 变性可以累积多个器官？
| A*******s
发帖数: 9638 | 16 当然， 好的分析贴也要奖励。
【在 a*********1 的大作中提到】
: 给第一个给出正确diagnosis的人发包子奖励怎么样？
| I****a
发帖数: 407 | 17 cryoglobulinemia
vasculitis
plasma cell dyscrasia | y***d
发帖数: 33 | 18 Glad there's a lot of discussion already.
Exam:
T 36.4 P 78 BP 149/87 RR 16 O2sat 98% RA
Gen – NAD
HEENT: NCAT, neck supple, EOMI, o/p clear
CV – RRR, no m/r/g, no JVD
Resp – CTA b/l, no c/r/g
Abd – hyperactive BS, soft, NT, some distension, no HSM
Ext – 4+ pitting edema up to low back. Some scaling and mild erythema noted
on bilateral lower shins.
Neuro – A&Ox3, grossly nonfocal
And to answers some questions posted above:
1. Exploratory laparoscopy showed pneumatosis intestinalis of terminal ileum
and proximal jejunum without signs of perforation or ischemia.
2. Patient was hospitalized three times in period of 2 month. First was for
diarrhea and hypokalemia. CT found pneumatosis intestinalis. She was
asymptomatic. So was treated with bowel rest and discharged for outpt workup
.She had a normal colonoscopy outpatient. Her diarrhea got worse ->
hospitaliztion for woese diarrhea and abdominal pain. Found to be
hypokalemia again. Had the ex-lap which wasn't that helpful. During that
hospitalization LE edema was noted and she was started on aldactone. She
came back within a week because her edema got worse. This is when I had her.
Questions to think about: What issue is primary and what issues are
secondary? How would you work her up? I will give only the lab results asked
for tomorrow. | V*****G
发帖数: 337 | 19 The thinking about amyloidosis is as follows:
From what LZ described "extensive workup including multiple stool cultures,
O&P, and a
colonoscopy with inconclusive result. Tried lactose free diet w/o
improvement." I am leaving the common GI disorders (but still with common GI
disorders in mind), e.g. IBD, IBS, Common Gastroenteritis (except
salmonella etc unusual bugs), ischemic enteropathy, lactose intolerance. But
there is pneumonatis instestinalis, so GI is indeed involved. So I am
thinking systemic disease involving GI, plus LE edema etc. Since patients
were admitted 3 times, I would assume all common diseases have been sought
after by all doctors.
【在 A*******s 的大作中提到】
: Victor, can you tell us why you put amyloidosis at the first place? This
: reminds me of a case with nephrotic syndrome(BLE edema) 2nd to amyloidosis.
| V*****G
发帖数: 337 | 20 I have to ask you some more questions about history, since you didn't
mention abd pain in the 1st post, now you said there is abd pain, this
potentially changed the whole picture.
I still need more info about history if you don't mind.
For history:
Abd Pain: OCDFPPLIQRAAA all needed
Diarrhea: OCDFPPAAA ABCO, blood?
Other GI symptoms: nausea, vomit, jaundice, abd bloating, if there is
constipation, relationship between constipation and diarrhea
Edema: OCDFPPAAA, esp aggravating and alleviating factors, e.g. standing vs
raising leg,
Other LE changes: skin, temperature, sensation, movement,
Any edema at other places of the body (you mentioned abd distension later on
, is there fluid in there?)
Medication history, when HCTZ started, when stopped, esp relationship with
hypokalemia and edema, when other medications started..
Hypokalemia: anything else, from your description, only found out about 2
month ago, which is about same time as diarrhea. Was HCTZ stopped 2 month
ago? When was HCTZ stopped? What other medication is started and when?
Any other symptoms.
PE:
Abd: shifting fluid
Thyroid,
Lower ext: pulses, sensation, motor, relfex, temperature, skin, pitting
edema
Mouth and throat: any special smell?
Lab:
1. Biopsy of GI and exact findings on colonoscopy, since colonoscopy have
been done several times
2. Stool Clostridium difficile toxin x3, leukocyte, O&Px3, culturex3, SOBT,
3. Blood albumin, protein, BUN, Cr, TSH, Free T4, electrolyte,
4. CBC, CMP, ABG, LFT
5. UA,
6. Doppler U/S for Lower Ext
7. Any other biopsy conducted
8. Antibody screening, ANA, Anti-Scl 70, Anti-dsDNA,
9. CT abd
I have to say, please please give complete info, as complete as possible when presenting a case here, since we got no chance to see the patient.
noted
【在 y***d 的大作中提到】
: Glad there's a lot of discussion already.
: Exam:
: T 36.4 P 78 BP 149/87 RR 16 O2sat 98% RA
: Gen – NAD
: HEENT: NCAT, neck supple, EOMI, o/p clear
: CV – RRR, no m/r/g, no JVD
: Resp – CTA b/l, no c/r/g
: Abd – hyperactive BS, soft, NT, some distension, no HSM
: Ext – 4+ pitting edema up to low back. Some scaling and mild erythema noted
: on bilateral lower shins.
| | | V*****G
发帖数: 337 | 21 I thought about it, but since LZ didn't say there is abd pain, I leave it
out.
But since LZ now told us there is abd pain, I would put these on the list
too.
【在 I****a 的大作中提到】
: cryoglobulinemia
: vasculitis
: plasma cell dyscrasia
| I****a
发帖数: 407 | 22 What issue is primary? What issues are secondary?
It is hard to pinpoint at this moment for me w/o knowing any lab values.
This is likely a systemic process with multiple organ system involvement: GI
, vascular and possible renal and heme. I would guess diagnosis is
eventually made by a pivotal biopsy.
How would you work her up?
I would focus on elucidating the cause of anasarca and hypokalemia,
specifically UA, urine protein/creatinin ratio, urine lytes to calculate
transtubular potassium gradient, serum albumin level. Since you mentioned
patient also has anemia, red cell indices, a reticount, smear would be nice
to get. In reality, she should have all common labs done, it is also not
unreasonable to invoke broader work up such as getting a body CT, SPEP,
serologies for autoimmune dx. and viral hepatitis.
Nice case.
noted
【在 y***d 的大作中提到】
: Glad there's a lot of discussion already.
: Exam:
: T 36.4 P 78 BP 149/87 RR 16 O2sat 98% RA
: Gen – NAD
: HEENT: NCAT, neck supple, EOMI, o/p clear
: CV – RRR, no m/r/g, no JVD
: Resp – CTA b/l, no c/r/g
: Abd – hyperactive BS, soft, NT, some distension, no HSM
: Ext – 4+ pitting edema up to low back. Some scaling and mild erythema noted
: on bilateral lower shins.
| A*******s
发帖数: 9638 | 23 Primary issues are weight loss and diarrhea.
Secondary issues are hypokalemia and edema.
I would order:
CBC, CMP.
24 hr urine protein.
somatostatin receptor scintigraphy
doppler for DVT of LEs. | y***d
发帖数: 33 | 24 Let me answer some of the questions that were posed...
For history:
Abd Pain: OCDFPPLIQRAAA all needed
--She did not have abdominal pain when I saw her. She mostly compainted of
bloating and mild distension. I don't have the details of her abdominal pain
from before. All I knew was that it was generalized and not that bad.
Diarrhea: OCDFPPAAA ABCO, blood?
--1-2 times a day, watery, large volume. Unclear if it was greasy. No
visible blood. No constipation. No tenesmus.
Other GI symptoms: nausea, vomit, jaundice, abd bloating, if there is
constipation, relationship between constipation and diarrhea
--1-2 days of nausea with couple episodes of vomiting after colonoscopy but
was not an issue when I saw her. NBNB. No jaundice. Sort of pale, unclear if
it was her natural skin color.
Edema: OCDFPPAAA, esp aggravating and alleviating factors, e.g. standing vs
raising leg,
Other LE changes: skin, temperature, sensation, movement,
Any edema at other places of the body (you mentioned abd distension later on
, is there fluid in there?)
--edema as described in exam. Accumulation was gradual. No orthopnea, PND.
Medication history, when HCTZ started, when stopped, esp relationship with
hypokalemia and edema, when other medications started..
Hypokalemia: anything else, from your description, only found out about 2
month ago, which is about same time as diarrhea. Was HCTZ stopped 2 month
ago? When was HCTZ stopped? What other medication is started and when?
Any other symptoms.
--HCTZ was an outpt med, duration unclear. Was stopped first hospitalization
(2 month ago) due to concerns of hypokalemia and volume depletion. At
discharge of second hospitalization was started on aldactone. No other
medication changes. | y***d
发帖数: 33 | 25 OK, labs:
I was hoping that people would ask for more stool studies, but maybe people
just assume that since she's had extensive work up, all the stool data would
be available. Anyway, here are the labs from this hospitalization and from
before. If a lab is not listed, then it wasn't done. The stool studies were
mostly done on a low residue, lactose free diet.
Several people asked for LE dopper and echo. We didn't do them bacause based
on her H&P along with labs, the patient's anasarca is more consistant with
malnutrition.
Question for today:
1. your interpretation of the lab? ( How would the stool studies help you?)
2. next step in diagnosis?
3. why is she still having diarrhea?
Na 142 TB 0.3 WBC 2.7
K 2.8 AST 30 Hgb 9.3
Cl 107 ALT 41 Hct 29.1
HCO3 29 ALP 114 PLT 170
BUN 16 TP 5.6 Poly 60
Cr 1 Alb 2.0 Lymph 22
Glc 91 Pre-alb 10.7 Mono 15
Ca 7 Mg 1.4
Phos 2.4
PT 15.3 CPK 69
CKMB 0.9
INR 1.2 %MB 1.3
Trop I <0.04
NT-BNP 961
Ferritin 329
Iron 23
TIBC 65
Iron sat 35%
B12 653
Folate 10
Retic 1.2%
Cort stim 17->36
TSH 1.382
ESR 73
Vit A 16 (38-98)
Vit D <4
Vit E 16.4
Stool O&P: neg x2 Stool Giardia neg
Fecal WBC: neg C. diff neg
Stool lytes: Na 35.2 K 29 Cl 10
Stool PH 4 (<5.6 suggest CHO malabsorption)
Fecal fat: normal FOBT: trace pos
VIP level: 48 (20-42)
Stool alpha1 antitrypsin <25 (>55 suggest pancreatic insufficiency)
IgA 122
Anti endomysial IgA: neg
Anti tissue transglutaminase IgA: neg | c*******s
发帖数: 399 | 26 This is a chronic diarrhea case, let me try the the red book algorithm
stool osmotic gap = 290-(Na+K)=162
with osmotic gap more then 50, positive fecal fat positive, it is likely
secondary to malabsorption/ osmotice cause.
with all available test result as above , should we further do
1. mucosal biospy?
2. check xvlose test for bacterial overgrowth
3. any evidence of cholestasis, cirrhosis. ERCP, ABD U
/S
people
would
from
were
based
with
【在 y***d 的大作中提到】
: OK, labs:
: I was hoping that people would ask for more stool studies, but maybe people
: just assume that since she's had extensive work up, all the stool data would
: be available. Anyway, here are the labs from this hospitalization and from
: before. If a lab is not listed, then it wasn't done. The stool studies were
: mostly done on a low residue, lactose free diet.
: Several people asked for LE dopper and echo. We didn't do them bacause based
: on her H&P along with labs, the patient's anasarca is more consistant with
: malnutrition.
: Question for today:
| V*****G
发帖数: 337 | 27 Nice to see the lab.
Majority consistent to GI loss (malnutrition/malabsorption)
Edema is due to hypoalbumin and low protein. Originally lower extremity edema was thought to be due to systemic involvement. But when I saw "4+ pitting edema up to low back" on PE on day 2, I knew it could be due to low protein level. I appreciate the good PE you did. :)
Hypokalemia is most likely due to GI loss too.
Other lab abnormalities suggested:
Group 1: Low VitD, low phosphate, low calcium = Vit D deficiency, PT>14 = vit K difficiency? Low Vit A ==== malabsorption/malnutrition
Group 2: low magnesium, low K = malnutrition/malabsorption
Group 3: low Total protein, low albumin = malnutritution/malabsorption
Group 4: low WBC, (need to do ELISA for HIV?), low Hb, Hct and RBC, with iron study results = Anemia of chronic disease, I think we need to rule out lymphoma here (and plus chronic diarrhea, and FOBT trace positive).
Group 5: stool lytes: stool osmolar gap = 290- 2x(35.2+29) = 161, Stool PH 4 (<5.6 suggest CHO malabsorption, thanks LZ)
>100 suggests osmotic diarrhea, < 100 suggests secretory diarrhea
Stool Osmolal Gap = Stool Osm - (2 * (Na + K) )
Causes of osmotic diarrhea include:
Bile salt deficiency
Pancreatic insufficiency
Celiac/Tropical Sprue
Whipple's Dz
Intestinal Lymphoma
Medications
Lactose Intolerance
Laxative abuse (depending on the type of laxative)
Causes of secretory diarrhea include:
Laxative abuse (depending on the type of laxative)
Hormonal, Endocrine Tumors (e.g., carcinoid, VIPomas),
Causes of inflmmatory diarreha:
IBD, infection,
After the edema and hypokalemia explained by diarrhea, the case becomes a purely chronic diarrhea case to me.
Chronic diarrhea:
■ Insidious onset with > 4 weeks of symptoms.
Differential and workup will change the gear a little bit:
From stool osmotic gap, it appears to be malabsorption. and all other labs are consistent with the malabsorption too. Only thing is fecal fat is normal.
Stool osmotic gap is not consistent with secretary diarrhea, but VIP is slightly higher (I don't know 48 means what here).
Inflammatory diarrhea is not likely to me, since fecal WBC is negative, culture negative, O&P negative. Colonoscopy is negative.
Some possibilities are not likely due to negative lab results (e.g. thyroid, celiac sprue).
So I will change differential to:
Causes of osmotic diarrhea
Bile salt deficiency (since liver enzyme is slightly increased)
Pancreatic insufficiency (do stool elastase study)
Celiac/Tropical Sprue (ask travel history and do small instine biopsy)
Whipple's Dz (biopsy)
Intestinal Lymphoma (biopsy)
Medications (not likely)
Lactose Intolerance (not likely)
Laxative abuse (depending on the type of laxative) (???)
VIPoma (do CT abdomen)
Carcinoid syndrome
Amyloidosis
Workup plan:
Biopsy of small bowel (upper endoscopy) and [colon biopsy with colonoscopy, maybe hold until upper endoscopy done]
Stool elastase study
CT abdomen/MRI for VIPoma and carcinoid syn, liver etc.
D-xylose test and 72 hour fecal fat quantitation
Test of bile salt absorption
ELISA HIV antibody
HBsAg, Anti-HCV
(urine 5-HIAA)?
people
would
from
were
based
with
【在 y***d 的大作中提到】
: OK, labs:
: I was hoping that people would ask for more stool studies, but maybe people
: just assume that since she's had extensive work up, all the stool data would
: be available. Anyway, here are the labs from this hospitalization and from
: before. If a lab is not listed, then it wasn't done. The stool studies were
: mostly done on a low residue, lactose free diet.
: Several people asked for LE dopper and echo. We didn't do them bacause based
: on her H&P along with labs, the patient's anasarca is more consistant with
: malnutrition.
: Question for today:
| I****a
发帖数: 407 | 28 Unexplained bicytopenia for an elderly, a bone marrow biopsy is recommended
after nutritional and viral causes are r/o.
Agree with upper GI endoscopy with biopsy, pan CT.
Waldenstrome jumped into my mind given age, cytopenia, Raynaud's phenomenon and enteropathy. A SPEP would be nice. Since patient comes from Turkey, mediterranean lymphoma with alpha heavy chain is possible although patients are generally younger. LZ has not mentioned UA and urine protein quantification yet. | y***d
发帖数: 33 | 29 UA was basically normal. We didn't do SPEP/UPEP because she did not have a
globulin gap. We thought it was reasonable to recheck CBC when her
nutritional status got better.
Thanks VictorG for the detailed analysis of the case. The only thing I would
correct is that we usually us stool osm > 125 for cut off of osmotic
diarrhea and < 50 for secretory diarrhea. In between values are none-
diagnostic. Here is a link to the AGA guideline. Don't tell UCSF ;)
http://gidiv.ucsf.edu/course/things/1AGADiarrhea.pdf
So we consulted GI, who did do an EGD with small bowel biopsy. We also
started her on TPN and a trial of rifaximin. Her EGD showed normal stomach,
diffuse moderately scalloped mucosa at 2nd part of the duodenum, and mild
inflammation in the duodenal bulb.
Duodenum biopsy: increased intraepithelial lymphocytosis >30/100 surface
epithelial cells. Crypt hyperplasia and marked atrophy of normal villous
architecture. Marsh stage 3B.
At that point we were 90% sure about what she had. Does anybody want to
venture a guess? We also sent two more confirmatory tests after we had the
EGD findings. Final results tomorrow. | a*********1
发帖数: 872 | | | | c*******s
发帖数: 399 | 31 Given the anti transglutaminase and anti endomysial are negative,
I would think the diagnose is more likly tropic spru.
【在 a*********1 的大作中提到】
: celiac disease
| V*****G
发帖数: 337 | 32 If there is no travel history to tropical area, celiac disease is the
diagnosis.
(Supporting evidence for celiac disease is the pathology and clinical
presentation. Only thing is antibody is negative, . Test Sensitivity and
Specificity for celiac diseases: IgG, IgA anti-gliadin antibody 70% 97%;
IgA anti-endomysial antibody 85-98% 97-100% ; IgA anti-tissue
transglutaminase antibody 95-98%)
It there is travel history to tropical area with husband, tropical disease
is the more likely diagnosis.
Tropical Sprue
Responds to anti-microbial therapy
Lacks anti-endomysial antibodies
If no info about travel history to tropical area, I will go for CELIAC DIEASE!!!
Wait for the FINALE!!!
【在 c*******s 的大作中提到】
: Given the anti transglutaminase and anti endomysial are negative,
: I would think the diagnose is more likly tropic spru.
| A*******s
发帖数: 9638 | 33 I have asked about the travel history. But apparently LZ ignored it. So it
is unlikely there was a travel history.
【在 V*****G 的大作中提到】
: If there is no travel history to tropical area, celiac disease is the
: diagnosis.
: (Supporting evidence for celiac disease is the pathology and clinical
: presentation. Only thing is antibody is negative, . Test Sensitivity and
: Specificity for celiac diseases: IgG, IgA anti-gliadin antibody 70% 97%;
: IgA anti-endomysial antibody 85-98% 97-100% ; IgA anti-tissue
: transglutaminase antibody 95-98%)
: It there is travel history to tropical area with husband, tropical disease
: is the more likely diagnosis.
: Tropical Sprue
| c*******s
发帖数: 399 | 34 Is not she originally from Istanbul?
it
【在 A*******s 的大作中提到】
: I have asked about the travel history. But apparently LZ ignored it. So it
: is unlikely there was a travel history.
| A*******s
发帖数: 9638 | 35 Possible 72 years ago. :)
【在 c*******s 的大作中提到】
: Is not she originally from Istanbul?
:
: it
| c*******s
发帖数: 399 | 36 That is right, what I am saying is that the possiblity of travling back home
exists.
after all, the chronic diarrhea start after an acute episode, the the anti
glutaminase test has a very high sensitivity and specificity.
we need more detailed history.
is there any way to differentiate two diseases based on the path of biospy?
Thanks.
【在 A*******s 的大作中提到】
: Possible 72 years ago. :)
| S******9
发帖数: 2837 | 37 small intestinal biopsy can tell the difference among celiac disease ,
whipple's disease and tropical sprue
home
【在 c*******s 的大作中提到】
: That is right, what I am saying is that the possiblity of travling back home
: exists.
: after all, the chronic diarrhea start after an acute episode, the the anti
: glutaminase test has a very high sensitivity and specificity.
: we need more detailed history.
: is there any way to differentiate two diseases based on the path of biospy?
: Thanks.
| V*****G
发帖数: 337 | 38 Thank you, you are very generous.
【在 a*********1 的大作中提到】
: celiac disease
| A*******s
发帖数: 9638 | 39 I am lost. I guess that's why we need GI consult.
home
【在 c*******s 的大作中提到】
: That is right, what I am saying is that the possiblity of travling back home
: exists.
: after all, the chronic diarrhea start after an acute episode, the the anti
: glutaminase test has a very high sensitivity and specificity.
: we need more detailed history.
: is there any way to differentiate two diseases based on the path of biospy?
: Thanks.
| y***d
发帖数: 33 | 40 It is celiac disease indeed. We put her on strict gluten free diet and her
diarrhea resolved. Because her anti-endomysial AB and anti-tTG were negative
, we sent deaminated gliaden peptide (DGP) IgA and IgG, which are supposed
to be newer and more sensitive. Unfortunately the DGP antibiodies were also
negative. However, she did have the HLA DQ2 gene on gene, which is one of
the two genetic predispositions of getting celiac disease. Looking back, her
case is somewhat atypical given the age of onset and negative serologies.
That's probably why it took so long to diagnose her. Good job every one. | | | A*******s
发帖数: 9638 | 41 Interesting case, and thank you, Dr.Yiled..
I almost jump on the boat of IBS since almost everything was negative. :)
negative
also
her
【在 y***d 的大作中提到】
: It is celiac disease indeed. We put her on strict gluten free diet and her
: diarrhea resolved. Because her anti-endomysial AB and anti-tTG were negative
: , we sent deaminated gliaden peptide (DGP) IgA and IgG, which are supposed
: to be newer and more sensitive. Unfortunately the DGP antibiodies were also
: negative. However, she did have the HLA DQ2 gene on gene, which is one of
: the two genetic predispositions of getting celiac disease. Looking back, her
: case is somewhat atypical given the age of onset and negative serologies.
: That's probably why it took so long to diagnose her. Good job every one.
| A*******s
发帖数: 9638 | 42 aquafina111 and Victor deserve the BZs. | y***d
发帖数: 33 | 43 Initially, IBS was an attractive diagnosis to us as well. But our GI consult
told us that IBS is basically a functional disease. And functional diseases
should never lead to weight loss or malnutrition.
【在 A*******s 的大作中提到】
: Interesting case, and thank you, Dr.Yiled..
: I almost jump on the boat of IBS since almost everything was negative. :)
:
: negative
: also
: her
| V*****G
发帖数: 337 | 44 Very nice case, thank you!
negative
also
her
【在 y***d 的大作中提到】
: It is celiac disease indeed. We put her on strict gluten free diet and her
: diarrhea resolved. Because her anti-endomysial AB and anti-tTG were negative
: , we sent deaminated gliaden peptide (DGP) IgA and IgG, which are supposed
: to be newer and more sensitive. Unfortunately the DGP antibiodies were also
: negative. However, she did have the HLA DQ2 gene on gene, which is one of
: the two genetic predispositions of getting celiac disease. Looking back, her
: case is somewhat atypical given the age of onset and negative serologies.
: That's probably why it took so long to diagnose her. Good job every one.
| V*****G
发帖数: 337 | 45 Thnaks, BanZhus!
【在 A*******s 的大作中提到】
: aquafina111 and Victor deserve the BZs.
| A*******s
发帖数: 9638 | 46 Victor， 先别谢我。 你就不敢challenge GI的diagnosis？
【在 V*****G 的大作中提到】
: Thnaks, BanZhus!
| A*******s
发帖数: 9638 | 47 大家给Dr. Yiled 提点问题， 好问题有包子侍候。
我们要尊重权威， 也要挑战权威。 ：） | V*****G
发帖数: 337 | 48 I do have a few questions to ask:
1st about the diagnosis: is diagnosis clear when the biopsy result is clear
or when gluten free diet worked? To me, it's the later. It will be more
helpful to ask patient if there is traveling history to Caribean, India,
Southeast Asia etc.If no such a history, then giving diagnosis when biopsy
result is clear might be reasonable to me. Maybe LZ said this somewhere in
the description that I missed. Anyway I am not clear no this at this point.
The other thing is how to rule out lymphocytic colitis at 1st and 2nd
hospitalization? Biopsy should have been done when they do colonoscopy. What
will be the pathology result for lymphoma? We have a lot of pathologists
here, please help. :) And it would be very helpful to illustrate the biopsy
result in depth among celiac sprue, tropical sprue, and lymphoma (the last
one should be easier I think.).
2nd: causes of leukopenia and anemia? Malnutrition or lymphoma or other
related diseases to celiac disease? This needs to be followed.
3rd: HTN, aldactone might not be enough to control blood pressure. I think
either add calcium blocker (since she also has raynaud syn) or put her back
on HTCZ when Potassium is back to normal.
4th: It is known that celiac disease is related to autoimmune disease and
blood malignance. Should we screen auto-antibody for systemic sclerosis etc.
since she has raynaud?
【在 A*******s 的大作中提到】
: 大家给Dr. Yiled 提点问题， 好问题有包子侍候。
: 我们要尊重权威， 也要挑战权威。 ：）
| y***d
发帖数: 33 | 49 I don't think there was a travel history. That was screened during her first
hospitalisation and we didn't go back and ask those questions again whenwe
got the path results back. Would have hake the case better if we did.
About when the diagnosis is confirmed, it was when she got better on gluten
free diet. before that we were highly suspicious but there was still a
little doubt because of those negative serologies. Our GI fellow told her
that he was 90% sure. Then she got better with gluten free diet and her HLA
DQ2 was positive. That convinced me that she has celiac sprue.
Her colonoscopy did also include random biopsy of the colon and terminal
ileum.I should have mentioned. That was my bad. However, diarrhea from the
colon is generally high frequency and low volume. And her diarrhea was low
frequency and high volume, which suggested a small bowel origin.If you look
at the malabsorption patter, that is also more consistent with small bowel.
I'm no pathologist, so I can't comment on the pathology question. As far as
I know both celiac sprue and the tropical sprue cause villi atrophy, along
with a list of other diseases such as lactose intolerance. I don't know if
there are subtle pathologic differences. Calling for a pathologist.
Her pancytopenia completely recovered by the time she was discharged from
the SNF.I think it was purely due to malnutrition.
She hasn't followed up with her PCP yet, so I'm not sure if she will get
screened for other autoimmune diseases or what anti-HTN would have worked
better. My personal opion is not to hunt for those things as long as she is
asymptomatic (as from Raynauds).Why, because you are not going to put her on
steroids just because her finger turns white and she has a positive ANA. SS
is more of a clinical diadnosis anyway. She should absolutely be screened for
those symptoms everytime she follows up though.
clear
.
What
【在 V*****G 的大作中提到】
: I do have a few questions to ask:
: 1st about the diagnosis: is diagnosis clear when the biopsy result is clear
: or when gluten free diet worked? To me, it's the later. It will be more
: helpful to ask patient if there is traveling history to Caribean, India,
: Southeast Asia etc.If no such a history, then giving diagnosis when biopsy
: result is clear might be reasonable to me. Maybe LZ said this somewhere in
: the description that I missed. Anyway I am not clear no this at this point.
: The other thing is how to rule out lymphocytic colitis at 1st and 2nd
: hospitalization? Biopsy should have been done when they do colonoscopy. What
: will be the pathology result for lymphoma? We have a lot of pathologists
| A*******s
发帖数: 9638 | 50 Thanks for the answer.
I am no GI fellow so please pardon me for naive questions:
The diagnosis is more clinic than scientic to me. The important thing is
the patient has improved with the gluten free diet.
What about non-celiac gluten intolerance? People with non-celiac gluten
intolerance may experience similar symptoms to those with celiac disease
encounter.
HLA DQ2 is not specific.
first
whenwe
gluten
HLA
【在 y***d 的大作中提到】
: I don't think there was a travel history. That was screened during her first
: hospitalisation and we didn't go back and ask those questions again whenwe
: got the path results back. Would have hake the case better if we did.
: About when the diagnosis is confirmed, it was when she got better on gluten
: free diet. before that we were highly suspicious but there was still a
: little doubt because of those negative serologies. Our GI fellow told her
: that he was 90% sure. Then she got better with gluten free diet and her HLA
: DQ2 was positive. That convinced me that she has celiac sprue.
: Her colonoscopy did also include random biopsy of the colon and terminal
: ileum.I should have mentioned. That was my bad. However, diarrhea from the
| | | V*****G
发帖数: 337 | 51 I had this question for a long time. When a patient was admitted , shouldn't
we take care of majority of his/her problems, ideally all problems? Why do
we leave problems (eg her HTN) WHEN Discharged? I know this is kind of
common practice, isn't? Why?
first
whenwe
gluten
HLA
【在 y***d 的大作中提到】
: I don't think there was a travel history. That was screened during her first
: hospitalisation and we didn't go back and ask those questions again whenwe
: got the path results back. Would have hake the case better if we did.
: About when the diagnosis is confirmed, it was when she got better on gluten
: free diet. before that we were highly suspicious but there was still a
: little doubt because of those negative serologies. Our GI fellow told her
: that he was 90% sure. Then she got better with gluten free diet and her HLA
: DQ2 was positive. That convinced me that she has celiac sprue.
: Her colonoscopy did also include random biopsy of the colon and terminal
: ileum.I should have mentioned. That was my bad. However, diarrhea from the
| y***d
发帖数: 33 | 52 A++, I'm no GI fellow either. I agree with you that the diagnosis in this
case is very much clinic. However her being HLA-DQ2 positive certainly did
not hurt.(It'll be very hard to convince people that she had celiac dz if
her HLA typing were negative.) From my understanding, there are three
components to diagnosis of celiac disease: 1. positive serology, 2.
confirmatory biopsy, and 3. improvement on gluten free diet. It would be
nice for her to have all three but the one that I really care about is #3.
I'm not sure what kind of non-celiac gluten intolerance you are referring to
. Are you talking about similar GI symptom but minimal pathologic change on
SB biopsy or are you talking about extra-GI symptoms like dermatitis
herpetiformis? If you are talking about the former, I guess it depends on
how you define celiac disease. One can call those people asymptomatic celiac
disease or non-celiac gluten intolerance. I'm not sure what the official
title is.
【在 A*******s 的大作中提到】
: Thanks for the answer.
: I am no GI fellow so please pardon me for naive questions:
: The diagnosis is more clinic than scientic to me. The important thing is
: the patient has improved with the gluten free diet.
: What about non-celiac gluten intolerance? People with non-celiac gluten
: intolerance may experience similar symptoms to those with celiac disease
: encounter.
: HLA DQ2 is not specific.
:
: first
| y***d
发帖数: 33 | 53 Ideally, one would want to take care of all problems before discharging the
patient. In reality, some of the more chronic issues take time to treat and
fine-tune. I'm not sure how your hospital is, but in my hospital, in-patient
service are covered by residents and hospitalists, who do not follow the
patient when they leave. So most of the time, non-urgent issues such as mild
HTN are left for the primary to take care off. Most of the primary docs in
our hospital system prefer it that way. If you were the primary, I'd imagine
that you would prefer the patient be started on the antihypertensive agent
you like the best and have the most personal experience with rather than
something the resident picked after knowing your patient for 2 hours.
There's also a practicel component. Most people's blood pressure or blood
glucose are not the same in the hospital compared to their average at home.
When we see them, they are sick, or dry, or nauseated, or stressed, or
eating healthier, or eating less than home or all of the above. If we were
to tailor their chronic meds to their numbers in the hospital, we may
overshoot or undershoot. If the patient is not good about follow up, it may
be dangerous. So I've gotten into the habit of not mess with the outpatient
meds too much unless it is absolutely necessary.
The other practical thing is that a lot of the labs don't cross over if the
PCP is not electronically linked to the hospital. I've cut down the number
of iron panel and Vit D levels I order in the hospital because it's just a
waste of money if the PCP doesn't get the result.
I could go on and on about this, but I guess I'll stop whining.
't
do
【在 V*****G 的大作中提到】
: I had this question for a long time. When a patient was admitted , shouldn't
: we take care of majority of his/her problems, ideally all problems? Why do
: we leave problems (eg her HTN) WHEN Discharged? I know this is kind of
: common practice, isn't? Why?
:
: first
: whenwe
: gluten
: HLA
| V*****G
发帖数: 337 | 54 Thanks for the info.
For 1st paragraph, I took it as too busy to do. I somewhat can buy it since
it happens in reality. As to relationship with PCP, I will discuss later.
For 2nd paragraph, it sounds like for bp and glucose, hospitalization maybe
affect it differently. Do we have any evidence? You know we all talk about
evidence based medicine. Is this in any guideline, or is it in gray zone?
For 3rd paragraph, it is unfortunate reality. This is where communication
matters. PCP need to be , ideally, kept in the loop. Necessary adjustment in
treatment of bp is a common practice during hospitalization, I think. I
agree that no need to change outpatient medication if not necessary. But I
would change others that are related to the hospitalization and keep PCP
informed, or discuss with PCP before making these changes.
the
and
patient
mild
in
imagine
agent
【在 y***d 的大作中提到】
: Ideally, one would want to take care of all problems before discharging the
: patient. In reality, some of the more chronic issues take time to treat and
: fine-tune. I'm not sure how your hospital is, but in my hospital, in-patient
: service are covered by residents and hospitalists, who do not follow the
: patient when they leave. So most of the time, non-urgent issues such as mild
: HTN are left for the primary to take care off. Most of the primary docs in
: our hospital system prefer it that way. If you were the primary, I'd imagine
: that you would prefer the patient be started on the antihypertensive agent
: you like the best and have the most personal experience with rather than
: something the resident picked after knowing your patient for 2 hours.
| A*******s
发帖数: 9638 | 55 Thanks you, Dr.Yiled.
I don't know how to define non-celiac gluten intolerance either. I guess
just general gluten allergy w/o specific pathologic findings.
As a private practitioner, I am little bothered by the extensive workup for
the celiac disease. Retrospectively, should we just try gluden free diet at
the first place? I know academia is a totally different thing.
Waiting for more interesting cases.
to
on
【在 y***d 的大作中提到】
: A++, I'm no GI fellow either. I agree with you that the diagnosis in this
: case is very much clinic. However her being HLA-DQ2 positive certainly did
: not hurt.(It'll be very hard to convince people that she had celiac dz if
: her HLA typing were negative.) From my understanding, there are three
: components to diagnosis of celiac disease: 1. positive serology, 2.
: confirmatory biopsy, and 3. improvement on gluten free diet. It would be
: nice for her to have all three but the one that I really care about is #3.
: I'm not sure what kind of non-celiac gluten intolerance you are referring to
: . Are you talking about similar GI symptom but minimal pathologic change on
: SB biopsy or are you talking about extra-GI symptoms like dermatitis
|
|
