chronic diarrhea in young lady

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chronic diarrhea in young lady

  1. 1. An intresting case of gastroentrology
  2. 2. Patient details: <ul><li>Patient Ms. S </li></ul><ul><li>Age 40 years </li></ul><ul><li>Resident of Central India </li></ul>
  3. 3. Presenting complaints <ul><li>Pain & discomfort in abdomen- 30 years </li></ul><ul><li>Frequent loose motions – 30 years </li></ul><ul><li>Feeling of weakness and malaise- 25 years </li></ul><ul><li>Low grade fever- 20 years </li></ul><ul><li>Body ache and Joints pain- 20 years </li></ul><ul><li>Dark Patches over face- 5 years </li></ul>
  4. 4. H/O Present illness <ul><li>Patient is not comfortable about her abdomen since her remembrance . she feels bloating of abdomen, gurgling and pain on and off . </li></ul><ul><ul><li>Pain is generalized, with no diurnal variation and not associated with vomiting. </li></ul></ul><ul><ul><li>Pain is aggravated after food consumption and is not relieved after motion </li></ul></ul>
  5. 5. <ul><ul><li>She is also having loose motions on and off . It is generally semisolid </li></ul></ul><ul><li>Associated with mucus </li></ul><ul><li>Never had blood in stool </li></ul><ul><li>Some time mal odorous </li></ul><ul><li>Frequency 6 to 8 per day </li></ul><ul><li>some time quantity is large </li></ul>
  6. 6. Symptoms aggravated by <ul><li>Milk </li></ul><ul><li>Spicy food </li></ul><ul><li>High calorie food </li></ul><ul><li>Fried and junk food </li></ul>
  7. 7. <ul><li>Patient and her relative noticed a yellowness in her complexion </li></ul><ul><li>She feels exhausted most of the time </li></ul><ul><li>Her weight is always on lower side </li></ul><ul><li>Since last 10 years she also complaining of generalized body ache and joint pains. Which involves small joints of fingers wrist elbow and shoulders. Which is associated with morning stiffness, More in winters . </li></ul>
  8. 8. History of past illness <ul><li>No h/o diabetes, hypertension, hyperuricemia, blood transfusions </li></ul><ul><li>Family history </li></ul><ul><li>Mother – Severe Rheumatoid arthritis </li></ul><ul><li>Personal history </li></ul><ul><li>Nothing significant </li></ul>
  9. 9. General examination <ul><li>G.C- Good Pallor + </li></ul><ul><li>Pulse- 72/min Resp- 18/min </li></ul><ul><li>BP- 106/74 mm of Hg N.V.-Not engorged </li></ul><ul><li>N.G. –Not palpable JVP – Not raised </li></ul><ul><li>No edema, Jaundice, cyanosis or clubbing </li></ul><ul><li>Pigmentation over forehead and face. </li></ul>Systemic examination <ul><li>GIT- NAD R/s –NAD </li></ul><ul><li>CVS- NAD CNS - NAD </li></ul>
  10. 10. Investigations - blood picture <ul><li>Hb- 8.4 gm % </li></ul><ul><li>TRBC - 3.9 million cu.mm </li></ul><ul><li>TWBC – 10500 </li></ul><ul><li>DWBC – P-47, L-51, m-2% E- nil </li></ul><ul><li>Platelets – adequate </li></ul><ul><li>Anemia typing- Normocytic hyprochomic </li></ul><ul><li>No immature cells seen </li></ul><ul><li>No MP seen </li></ul>
  11. 11. <ul><li>Stool- Fat +ve Mucus & Blood -ve </li></ul><ul><li>USG –NAD </li></ul><ul><li>Urine –NAD </li></ul><ul><li>X-Ray chest- Normal </li></ul><ul><li>Serum Uric Acid- 4.1 mg/dl </li></ul><ul><li>R.A Factor –ve </li></ul><ul><li>HIV- Nonreactive </li></ul><ul><li>Thyroid function tests – WNL </li></ul><ul><li>Serum Calcium- 7.8 (Normal 8.5 to 10.5 mg/dl) </li></ul><ul><li>High sensitivity C-reactive protein- 0.47 mg/dl ( Normal less than 0.3 mg/dl) </li></ul>
  12. 12. Anti CCP
  13. 13. Anti nuclear antibody
  14. 14. Hemoglobin elecrophoresis
  15. 15. Tissue Transglutaminase antibody
  16. 16. Vit. B-12 level
  17. 17. Upper & Lower GI endoscopies
  18. 18. Biopsy from IInd part of duodenum
  19. 19. What can be the diagnosis
  20. 20. Coeliac disease with early sero negative rheumatoid arthritis <ul><li>Final Diagnosis </li></ul>
  21. 21. Coeliac disease- Introduction <ul><li>CD is a common chronic inflammatory bowel condition characterized by mal absorption abnormal small bowel histology and intolerance to gluten and prolamines found in wheat, barley and rye. </li></ul><ul><li>Gliadin is a protein found in wheat and barley is water insoluble </li></ul><ul><li>The disease multifaceted in nature with variable clinical presentation ranging from GI manifestation to asymptomatic silent and extra intestinal forms </li></ul><ul><li>It may present from first year of life till 8 th decade </li></ul><ul><li>CD in children and non tropical sprue in adults are probably the same entity </li></ul><ul><li>Dermatitis Herpetiformis a bullous skin disease is also known to be induce by Gluten. </li></ul><ul><li>Untreated CD is associated with high morbidity and increase mortality </li></ul>
  22. 22. Coeliac disease <ul><li>Coeliac disease is not an allergy or simple food intolerance. In fact it's an autoimmune disease, where the body's immune system attacks its own tissues. In people with coeliac disease this immune reaction is triggered by gluten, a collective name for a type of protein found in the cereals wheat, barley and prolamines in rye. A few people are also sensitive to oats. In coeliac disease, eating gluten causes the lining of the gut (small bowel) to become damaged and may affect other parts of the body . </li></ul>
  23. 23. Possible symptoms include: <ul><li>bloating, abdominal pain, nausea, diarrhoea, excessive wind, heartburn, indigestion, constipation </li></ul><ul><li>any combination of iron, vitamin B12 or folic acid deficiency </li></ul><ul><li>tiredness, headaches </li></ul><ul><li>weight loss (but not in all cases) </li></ul><ul><li>recurrent mouth ulcers </li></ul><ul><li>hair loss (alopecia) </li></ul><ul><li>skin rash (dermatitis herpetiformis-  'DH' ) </li></ul><ul><li>defective tooth enamel </li></ul><ul><li>osteoporosis </li></ul><ul><li>depression </li></ul><ul><li>infertility </li></ul><ul><li>recurrent miscarriages </li></ul><ul><li>joint or bone pain </li></ul><ul><li>neurological (nerve) problems such as ataxia (poor muscle co-ordination) and neuropathy (numbness and tingling in the hands and feet). </li></ul>
  24. 24. Median age for diagnosis of CD <ul><li>In adults- 4 th and 5 th decade </li></ul><ul><li>Median delay in diagnosis ranges from – </li></ul><ul><li>5-11 years in developed countries </li></ul><ul><li>In India 30-40 years </li></ul>
  25. 25. Etiology <ul><li>Unknown </li></ul><ul><li>Environmental </li></ul><ul><li>Immunologic and Genetic factors contributes to the disease. </li></ul>
  26. 26. Types <ul><li>Classic Type- </li></ul><ul><li>Silent or Atypical form present with non specific abdominal pain, esophageal reflux, osteoporosis, Cryptogenic hypertrans aminasimia, insulin dependent DM or Neurological symptoms </li></ul>
  27. 27. Diagnosis of CD
  28. 28. Prevalence <ul><li>0.5 to 1 % </li></ul><ul><li>1 in 113 people in Europe </li></ul><ul><li>Most Common in Whites of North European ancestry </li></ul><ul><li>PGI Chandigarh data is around 1% in India </li></ul><ul><li>Ratio of undiagnosed to diagnosed in children is 7:1 and in adult is 68:1 </li></ul><ul><li>The prevalence of CD was 1:22 for first degree relative and 1:39 for second degree relatives. </li></ul><ul><li>All Patients with CD express HLA-DQ2 ALLELE though only a minority of patients express DQ2 have CD </li></ul><ul><li>Absence of DQ2 excludes the diagnosis of CD </li></ul>
  29. 29. Serological Markers <ul><li>IgA and IgG anti Glidnin anti bodies (Predictive values +ve and –ve more than 96%) </li></ul><ul><li>IgA antiendomysial antibody( 92 to 95 % ) </li></ul><ul><li>IgA tissue transglutaminasse antibody </li></ul><ul><li>Antibody negative CD also exist if patients are IgA deficient (6.4% of all cases) </li></ul>
  30. 30. Histopathological findings <ul><li>Gold standard for diagnosis is villous atrophy on duodenal biopsy </li></ul><ul><li>Marsh’s histological grade </li></ul><ul><li>Grade 0- Normal duodenal mucosa </li></ul><ul><li>Grade-I – Increased intraepithelial </li></ul><ul><li>lymphocyte count </li></ul><ul><li>Grade-II- Grade I + Crypt Hyperplasia </li></ul><ul><li>Grade III- Grade I+ grade II+ villous atrophy </li></ul>
  31. 31. Course of the disease <ul><li>Started with anaprashan </li></ul><ul><li>Spontaneous remission </li></ul><ul><li>Reappears in second decade of life. </li></ul><ul><li>Remission and exacerbation known </li></ul>
  32. 32. Treatment <ul><li>Gluten free diet </li></ul><ul><li>Supportive and symptomatic </li></ul>
  33. 33. Gluten Containing foods
  34. 34. complications <ul><li>GI and Non Gi neoplasams </li></ul><ul><li>Intestinal lymphomas </li></ul><ul><li>intestinal ulcers </li></ul><ul><li>collegenous sprue </li></ul>
  35. 35. Many faces of CD
  36. 36. Symptoms of Malabsorptive disorders
  37. 37. Tests useful in diagnosis of Malabsorption
  38. 38. My experience
  39. 39. Thanks I can also win

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