11/24/2017 0 Comments C.Diff Guidelines Diet![]() Clostridium difficle (or C. What is C Diff? It causes up to 500,000 infections and 15,000 fatalities per year in the USA alone. Find answers here for your C Diff questions. Clostridium difficile, also known as C. The infection most commonly affects people. Diagnosis and Management of Celiac Disease. Alberto Rubio- Tapia, MD1, Ivor D. Hill, MD2, Ciar. Kelly, MD3, Audrey H. Calderwood, MD4 and Joseph A. Murray, MD1. 1Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA; 2. Department of Pediatrics, Wake Forest University School of Medicine, Winston- Salem, North Carolina, USA; 3.
Celiac Center, Division of Gastroenterology, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA; 4. Gastroenterology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USAAm J Gastroenterol 2. April 2. 01. 3Received 8 January 2. February 2. 01. 3Correspondence: Joseph A. Murray, MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 2. Street SW, Rochester, Minnesota 5. USA. E- mail: murray. Abstract. This guideline presents recommendations for the diagnosis and management of patients with celiac disease. Celiac disease is an immune- based reaction to dietary gluten (storage protein for wheat, barley, and rye) that primarily affects the small intestine in those with a genetic predisposition and resolves with exclusion of gluten from the diet. There has been a substantial increase in the prevalence of celiac disease over the last 5. Celiac disease can present with many symptoms, including typical gastrointestinal symptoms (e. Indeed, many individuals with celiac disease may have no symptoms at all. Celiac disease is usually detected by serologic testing of celiac- specific antibodies. The diagnosis is confirmed by duodenal mucosal biopsies. Both serology and biopsy should be performed on a gluten- containing diet. The treatment for celiac disease is primarily a gluten- free diet (GFD), which requires significant patient education, motivation, and follow- up. Non- responsive celiac disease occurs frequently, particularly in those diagnosed in adulthood. Persistent or recurring symptoms should lead to a review of the patient’s original diagnosis to exclude alternative diagnoses, a review of the GFD to ensure there is no obvious gluten contamination, and serologic testing to confirm adherence with the GFD. In addition, evaluation for disorders associated with celiac disease that could cause persistent symptoms, such as microscopic colitis, pancreatic exocrine dysfunction, and complications of celiac disease, such as enteropathy- associated lymphoma or refractory celiac disease, should be entertained. Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice. Given the incomplete response of many patients to a GFD- free diet as well as the difficulty of adherence to the GFD over the long term, development of new effective therapies for symptom control and reversal of inflammation and organ damage are needed. The prevalence of celiac disease is increasing worldwide and many patients with celiac disease remain undiagnosed, highlighting the need for improved strategies in the future for the optimal detection of patients. Introduction. This clinical guideline addresses the diagnosis, treatment, and overall management of patients with celiac disease (CD), including an approach to the evaluation of non- responsive CD. While it is primarily directed at the care of adult patients, variations pertinent to the pediatric population have been included. Each section will provide specific recommendations based on the current literature and a summary of the evidence supporting those recommendations. The GRADE system was used to evaluate the quality of supporting evidence (1) (Table 1). A “strong” recommendation is made when the benefits clearly outweigh the negatives and the result of no action. The quality of the evidence is graded from high to low. Criteria for assigning grade of evidence. Type of evidence. Randomized trial=high. Observational study=low. Any other evidence=very low. Decrease grade if. Serious (. CD is one of the most common causes of chronic malabsorption (2). This results from injury to the small intestine with loss of absorptive surface area, reduction of digestive enzymes, and consequential impaired absorption of micronutrients such as fat- soluble vitamins, iron, and potentially B1. In addition, the inflammation exacerbates symptoms of malabsorption by causing net secretion of fluid that can result in diarrhea. The failure of absorption of adequate calories leads to weight loss, and the malabsorption results in abdominal pain and bloating (3). These are common symptoms associated with CD (4,5). CD remains underdiagnosed in the United States (6). CD may present in many ways (7). Currently, active case- finding (serologic testing for CD in patients with symptoms or conditions closely associated with CD) is the favored strategy to increase detection of CD (8). Active case- finding may increase detection of CD among patients with symptoms attending a primary- care office, although this strategy is insufficient to detect most patients with CD (7). There is no consensus regarding which symptoms, laboratory abnormalities, and/or associated diseases require evaluation for CD. The frequency of CD in common clinical scenarios varies from modestly elevated, such as irritable bowel syndrome, to substantially elevated, such as unexplained iron- deficiency anemia (Table 2) (9,1. Table 2. Conditions in which CD occurs more frequently than in the general population and/or for whom a GFD may be bene. The prevalence of biopsy- proven CD in patients with dyspepsia is 1%, similar to that of the general population (1. CD is not recommended based on disease prevalence alone. How- ever, treatment for dyspepsia can be a clinical challenge (1. CD will readily respond to the gluten- free diet (GFD) (4,1. Thus, mucosal biopsies of the duodenum should be considered in patients with dyspepsia who undergo investigation with upper endoscopy because of persistent symptoms despite initial therapy, are aged > 5. The frequency of CD is substantially increased in patients who have a first- degree family member affected with CD (1. The precise risk is highest in monozygous twins, next in human leuko- cyte antigen (HLA)- matched siblings, siblings, and finally parents and children of patients with CD (1. A lower rate probably applies to second- degree relatives (1. Members of families who have more than one individual already identified with CD are at higher risk of CD and recommendations for screening should extend to all other family members, including second- degree relatives (1. The estimates of prevalence of CD in family members vary substantially, with one large multicenter study in the United States showing a rate as low as 5% in both first- and second- degree relatives (1. Other studies, especially those that are community- based, show a rate that is substantially higher, affecting up to 2. The clinical implications are that newly diagnosed patients with CD should inform their first- degree family members of the potential increased risk for CD and the recommendation for testing. In addition, health- care providers should determine whether there is a family history of CD in patients with symptoms or signs suggestive of CD and if so consider screening the patient. Testing of truly symptomless first- degree relatives is reasonable but controversial. Even those patients who initially thought themselves to be without symptoms on direct questioning at the time of detection often report improved health after adapting to the GFD because of disappearance of symptoms that may not have been previously explained (2. Others may have symptoms that they did not consider abnormal until after they initiated a GFD and these symptoms resolve (2. Asymptomatic patients detected by screening do not experience new symptoms after onset of a GFD (2. The majority of patients with CD identified on the basis of screening reported dietary adherence and improvements in quality of life on the GFD (2. A small proportion of patients, however, reported increased health- related anxiety after diagnosis (2. Overall satisfaction with the diagnosis was high (9. Abnormal liver blood tests, in particular elevations of alanine aminotransferase and aspartate aminotransferase, are commonly seen in clinical care, although the prevalence of clinically significant liver disease is low (2. In CD, hypertransaminasemia is often a subclinical finding that is gluten dependent (2. Patients with unexplained elevation of liver enzymes should be assessed for CD (2. There are reasonable data to show that gluten- dependent hypertransaminasemia will normalize in most patients (> 9. GFD (2. 7). Rarely, CD can be associated with severe liver disease (2. There is evidence that CD is substantially more common in patients with Type I DM than in the general Caucasian population. The estimates vary between 3 and 1. In children, it has been suggested that yearly or every- other- year screening for CD be undertaken utilizing serology. Patients with Type I DM who are undergoing upper endoscopy should undergo duodenal biopsies to rule out CD if they have never been tested previously. After gastrointestinal symptoms, the second most common manifestation of CD in patients with Type I DM is diminished or impaired bone mineralization. There is some evidence suggesting that there is added disease burden to patients already struggling with the management of Type I DM. In addition, there is good evidence that gastrointestinal symptoms present at diagnosis will respond to a GFD with overall improvement in quality of life related to GI symptoms. The impact of the treatment of CD on the management of Type I DM is mixed (3. Some data suggest an increase in absorption, leading to the need for increased insulin doses. Other data suggest improvement of DM controlled by reduction of hypoglycemic events, especially postprandial. Testing for CD in asymptomatic patients with Type I DM is controversial.
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