Anuj Walia*, BR Thapa**, KK Prasad***, CK Nain****, B Nagi *****
Division of Pediatric Gastroenterology, Dept of Gastroenterology,
Post Graduate Institute of Medical Education & Research *, Division of Pediatric Gastroenterology, Dept of Gastroenterology,
Post Graduate Institute of Medical Education & Research **, Division of Pediatric Gastroenterology, Dept of Gastroenterology,
Post Graduate Institute of Medical Education & Research ***, Division of Pediatric Gastroenterology, Dept of Gastroenterology,
Post Graduate Institute of Medical Education & Research ****, Division of Pediatric Gastroenterology, Dept of Gastroenterology,
Post Graduate Institute of Medical Education & Research *****
Celiac disease is the commonest cause of malabsorption in children in North India. There is no study on mucosal enzyme analysis in celiacs from India.
- To study the clinical profile, role of serology, duodenal biopsy and gluten free diet in celiac disease
- To study intestinal mucosal enzyme activities of brush border enzymes (disaccharidases and alkaline phosphatase).
Materials and Methods: This is a prospective study conducted in 72 children diagnosed as celiac disease (CD) based on modified ESPGAN criteria, seen from Jan 2003 to Apr 2005 in a tropical country. The detailed clinical history, examination, hemogram, LFT, upper gastrointestinal endoscopy, duodenal biopsy and tissue transglutaminase levels (TG2) were done in all patients. Five duodenal punch biopsies were taken (3 for histopathology and 2 for enzyme assay). 14 cases of GERD acted as control for enzyme analysis. In 56 CD patients, the enzyme activity of disaccharidases and alkaline phosphatase was measured according to the method of Dehiquist (1964) and Teitz (1983) respectively. Student test was used for stastistical analysis.
Results: Male to female ratio was 1.4:1. Age of onset of symptoms was 3.12 ± 2.33 years and mean age of presentation was 6.11 ± 2.73 years. The clinical presentation was with anemia in 79.16%, chronic diarrhea in 76.38% and failure to thrive in 68.05%. Abdominal distension was noted in 43.05% and 25% had associated pain in abdomen. In addition clubbing was seen in 26.38%, signs of vitamin deficiencies in 20.83% and rickets in 8.33%. Mean hemoglobin at presentation was 8.4 ± 1.8 g/dl, out of which microcytic hypochromic anemia accounted for 80.71% while dimorphic anemia accounted for 19.29%. AST/ALT more than two fold were seen in 23.61% of the cases. On endoscopy, duodenal grooving and scalloping was seen in 98.61% and on histopathology 73.61% had subtotal villous atrophy while 26.38% had partial villous atrophy. The TG2 IgA antibodies were positive in 97.22% while 2 patients were IgA deficient. All patients showed response to gluten free diet. The mucosal enzyme studies revealed the mean lactase levels of 4.68 ± 0.40 IU/g of protein in CD patients and 15.42 ± 0.31 IU/g of protein levels in controls. (p <0.001). The mean sucrase levels in CD patients were 9.90 ± 0.76 IU/g of protein and the mean level in controls was 35.32 ± 0.43 IU/g of protein (p <001). The mean maltase levels in CD patients was 22.28 ± 1.50 IU/g of protein and that in controls was 54.42 ± 0.54 IU/g of protein (p <0.001). The mean alkaline phosphatase levels in CD patients was 654.59 ± 32.88 IU/g of protein and the levels observed in controls was 1359.34 ± 5.13 IU/g of protein. (p <0.01).
Conclusions: Modified ESPGAN criteria are helpful in diagnosis of CD. The TG2 levels were raised in 97.22% and the 2.77% who did not have them raised were found to be IgA deficient. On endoscopy duodenal grooving was found in 98.61% of the cases. There was a significant reduction in the levels of disaccharidases and alkaline phosphatase levels in CD as compared to the controls. These changes could be responsible for the chronic diarrhea, vitamin deficiencies, malabsorption and the resultant failure to thrive seen in our children.
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