Key Points

Figure 38-31 Diverticula. (Courtesy Dr. Perry Pernicano.)

episode of diverticulitis has been shown to prevent recurrence in more than 70% of patients followed up for more than 5 years.

The decision of whether to proceed with inpatient or outpatient treatment of diverticulitis depends on the clinical judgment of the physician, the severity of the disease process, and likelihood that the patient's condition will respond to outpatient therapy. Patients who are able to tolerate a diet, who do not have systemic symptoms, and who do not have significant peritoneal signs may be treated on an outpatient basis with TMP-SMX or a fluoroquinolone plus metronidazole (Gilbert et al., 2009).

Primary resection and anastomosis without a protective stoma has become the surgical treatment of choice for

• Tests to consider in testing for celiac disease include transglutaminase IgA, antiendomysial antibody, antigliadin antibody, and the genetic test HLA DQ2/DQ8.

• A negative HLA DQ2/DQ8 test is most helpful in ruling out celiac disease. A positive test does not rule it in but is associated with an increased risk.

• Consider an elimination/challenge diet for 2 weeks. If symptoms improve, a rechallenge with gluten-containing foods will cause a recurrence of symptoms.

• The antibody tests (TTG IgA, antiendomysial, antigliadin) can become negative after elimination of gluten protein and may be false negative.

Adult presentation of celiac disease is characterized by weight loss, diarrhea, fatigue, and anemia. Children frequently present with failure to thrive, vomiting, diarrhea, muscle wasting, signs of hypoproteinemia including possible ascites, and general irritability. Common comorbidities include type 1 diabetes mellitus, cerebral calcifications, Sjogren's syndrome, and thyroid disease. Celiac disease should be considered in cases of unexplained folic acid, iron or B12 deficiency, reduced serum albumin, osteoporosis, and osteomalacia.

Other presentations may include infertility or recurrent miscarriage. Splenic atrophy commonly occurs in celiac sprue, and pneumococcal immunization should be administered in these patients.

Immunoglobulin A (IgA) antiendomysial antibodies are currently the most accurate serologic test for diagnosing celiac sprue with a sensitivity of 97% to 100% and specificity of 98% to 99%. Antigliadin antibodies are also usually quantified. Enzyme tissue transglutaminase, the antigen for antiendomysial antibodies, has a sensitivity of 95% and specificity of 94% in diagnosing celiac disease (AGA, 2006). HLA testing can now be done to evaluate persons at risk for celiac disease. About 95% of celiac patients are positive for HLA-DQ2 and 5% for HLA-DQ8. The majority of people who test positive for HLA-DQ2/DQ8 are at risk, but only 2% to 3% actually develop celiac disease. Celiac disease is rarely seen with a negative test, and thus this test is most useful when negative. A positive test does not make the diagnosis. A CBC, comprehensive biochemical profile including serum albumin concentration, transferrin saturation, serum or RBC folate, vitamin B12, and liver function tests should also be obtained on diagnosis. Deficiencies of iron, folic acid, calcium, and vitamins B12 and D frequently often correct after initiating a gluten-free diet, without the need for vitamin supplementation.

The diagnostic standard for celiac disease is a small intestinal biopsy using endoscopy, although this is usually not necessary to establish an accurate diagnosis. Characteristic changes include damage to the normal villous morphology with decreased villous height/crypt depth, decreased epithelial surface cell height, and increased lymphocytic infiltration of the intestinal mucosa. The accepted AGA diagnostic criteria state that small intestinal mucosa should be abnormal while patients continue on a gluten diet. A repeat biopsy should be taken 4 to 6 months after induction of treatment, and if there has been no improvement in the small intestinal mucosal morphology, the original diagnosis should be questioned. Many gastroenterologists do not obtain a subsequent biopsy specimen, and the cost-effectiveness of this approach has not been demonstrated. A gluten challenge is recommended if there is any doubt concerning the correct diagnosis (AGA, 2006).

The AGA guidelines state that the cornerstone of treatment of celiac disease and its resultant complications is gluten-free diet therapy under a nutritionist's guidance. Patients should completely omit wheat, rye, barley, beer, and breakfast cereals from their diet. It is important to explain the disease process and toxicity of gluten-containing foods to the patient, including the potential for the reversal of current celiac-related problems, including anemia, depression, and infertility. Gluten-free breads, pasta, and other products are commercially available and should be recommended as substitutes. Patients with celiac disease usually experience rapid symptomatic improvement within weeks of the exclusion of dietary gluten, providing additional diagnostic confirmation. Monitoring of antiendomysial or tissue transglutaminase antibody (TTG IgA) titers, which usually normalize with the institution of a gluten-free diet, may prove useful to check dietary compliance, but have neither become standard practice nor been cost-effective. Life-threatening hypokalemia or hypomagnesemia rarely occurs and should be appropriately corrected. Expert panels suggest that yearly weight, CBC, ferritin, folate, calcium, and ALP levels should be obtained for disease monitoring. Oral corticosteroids may be used in unresponsive patients, but only when other causes of small intestinal villous atrophy have been excluded (AGA, 2006).

Dermatitis herpetiformis is a common extraintestinal manifestation of gluten-sensitive enteropathy, characterized by a pruritic, blistering, and vesicular rash. The diagnosis is made with immunofluorescent staining of granular IgA after skin biopsy. Treatment involves oral dapsone and a gluten-free diet, and with sufficient symptom relapse after 6 months, dapsone can be withdrawn and the gluten-free diet continued indefinitely. Osteopenia and osteoporosis, as well as bone pain, pseudofractures, and orthopedic deformities, are common features of celiac disease. Osteoporosis carries a significant fracture risk, and thus dual-energy x-ray absorptiometry (DEXA) screening of patients with celiac disease is recommended yearly. If osteoporosis is discovered, measures include strict adherence to a gluten-free diet, calcium supplementation of up to 1500 mg/day, bisphosphonate or calcitonin therapy, or consideration of hormone replacement therapy in postmenopausal women. Smoking cessation should be encouraged and an exercise regimen advised in all patients. Ulcerative jejunitis is a serious complication of celiac disease that carries a high mortality risk after intestinal hemorrhage, perforation, or obstruction in patients with a history of significant malnutrition. Diagnosis can be challenging, and small intestine radiography often is not helpful. If small intestinal ulceration or lymphoma is suspected, enteroscopy may be used to obtain biopsy specimens for histologic assessment. Surgical resection of the ulcer, especially if localized to one part of the intestine, can be curative. Again, a strict gluten-free diet should be initiated, and treatment with steroids has shown significant benefit. If a diagnosis of enteropathy-associated T-cell lymphoma is made, the patient should be referred to an oncologist for appropriate chemotherapy.

Overall mortality risks are higher in patients with celiac disease, attributed to malignant intestinal lymphoma and adenocarcinoma. One study found a fivefold increased risk of developing malignancy in patients with celiac disease, with a relative risk of 40 for developing non-Hodgkin's lymphoma. These risks decreased to the level of the normal population after patients maintained a gluten-free diet for 5 years (AGA, 2006).

Managing Diverticular Disease

Managing Diverticular Disease

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