The invisible part of “ICEBERG”:Extraintestinal findings and celiac diseas

Year 2022, , 64 - 70, 26.03.2022

Serdar Karakaya , İbrahim Karadağ , Aslıhan Mete , Oktay Bulur , Metin Uzman , Esin Beyan

https://doi.org/10.18663/tjcl.1039075

Abstract

Aim: Clinical manifestations of celiac disease (CD) can be quite different and varying. The number of CDs presenting with atypical symptoms is increasing day by day. Hence, we aimed to determine how many patients with CD were atypical celiac through examining their admission complaints, clinical characteristics, laboratory results, endoscopic findings, and pathological findings.
Material and Methods: Eighty-nine patients with CD aged over 18 years who were followed-up in Ankara Kecioren Training and Research Hospital Internal Medicine Clinic between 2007 and 2014 were included in the study. The files of the patients were reviewed retrospectively. Sex, age, hospital admission complaints, clinical characteristics, laboratory results, endoscopy findings, and pathology results of the patients were recorded.
Results: The median age of the patients in the study was 36, and 68.5% of them were female. The most common symptoms of the patients were fatigue (49.4%), anorexia (33.7%), and dyspepsia (22.5%), while diarrhea (19.1%), which is among the classical symptoms, was less common. 7.8% of the patients had no complaints at the time of admission, whereas 47.1% of them had only extraintestinal symptoms. At admission, 47% of the patients had anemia, 73.4% had iron deficiency, and 55.4% of them had vitamin B12 deficiency. When hemoglobin, ferritin, and vitamin B12 levels were compared before and after a gluten-free diet, a significant increase was determined. Transaminase elevation was detected in 25.3% of our patients at the time of diagnosis. When pre-treatment and post-treatment values were compared, a significant decrease was determined in those with high transaminase levels. In the pre-treatment serological test results of the patients, Ig A EMA positivity was the most common finding with a rate of 90.2%, followed by IgG EMA with 88.9%. In terms of pre-treatment endoscopy findings, 50.2% of our patients had normal appearance, 25.4% had a mosaic pattern, 12.6% had effacement of the duodenal folds, 12.6% had a nodular appearance, and 9.5% had a scalloping of the duodenal folds. When the pathology results of our patients were examined, 83.4% of them were at the advanced stage and with Marsh Type 3.
Conclusion: CD may present with atypical complaints such as extraintestinal findings, as in more than half of the patients in this study. Celiac disease should be taken into consideration, particularly in conditions such as iron deficiency, osteoporosis, and transaminase elevations, which are prevalent in the community. The prevalence of CD in our country is estimated to be around 1-2%; however, it is considered that there are more asymptomatic patients with atypical celiac disease. When diagnosing CD, the most crucial step is to consider the potential presence of CD during pre-diagnoses. Thus, CD should be included in the differential diagnosis, specifically in patients presenting with atypical symptoms.

Keywords

Atypical Celiac, Celiac Disease, extraintestinal findings

Buzdağının görünmeyen yüzü: Ekstraintestinal Bulgular ve Çölyak Hastalığı

Abstract

Amaç: Çölyak hastalığı (ÇH) kliniği oldukça farklı ve değişken olabilir. Atipik semptomlarla başvuran ÇH sayısı gün geçtikçe artmaktadır. Bu nedenle ÇH tanısı alan bireylerin hastaneye başvuru şikayetleri, klinik özellikleri, laboratuvar bulguları, endoskopik bulguları, patolojik bulguları inceleyerek hastaların ne kadarının atipik çölyak olduğunu saptamayı amaçladık.
Gereç ve Yöntemler: Çalışmaya Ankara Keçiören Eğitim ve Araştırma Hastanesi İç Hastalıları kliniğine 2007-2014 tarihleri arasında takip edilen 18 yaş üstü tüm ÇH tanısı alan 89 hasta dahil edildi. Hastaların dosyaları retrospektif tarandı. Hastaların cinsiyetleri, yaşları, hastaneye başvuru şikayetleri, klinik özellikleri, laboratuvar tetkikleri, endoskopi bulguları, patoloji sonuçları kaydedildi.
Bulgular: Çalışmadaki hastaların median yaşı 36 ve % 68.5’i kadındı. Hastalarda en sık halsizlik (%49.4), iştahsızlık (%33.7) ve dispepsi (%22.5) görülürken klasik semptomlardan diare (%19.1) daha az sıklıkla görüldü. Hastaların %7.8’inde başvuru anında herhangi bir şikayeti yokken %47.1’inde yalnızca ekstrainestinal semptomlar mevcuttu. Başvuruda hastaların %47’sinde anemi, %73.4’ünde demir eksikliği, %55.4’ünde vitamin B12 eksikliği vardı. Glutensiz diyet öncesi ve sonrası hemoglobin, ferritin, vitamin B12 değerleri karşılaştırıldığında istatiksel anlamlı artış saptandı. Hastalarımızın tanı anında %25.3’ünde transaminaz yüksekliği saptandı. Tedavi öncesi ve sonrası karşılaştırıldığında transaminaz seviyesi yüksek olanlarda istatiksel anlamlı düşüş gözlendi. Hastaların tedavi öncesi serolojik testlerinde en sık Ig A EMA %90.2, Ig G EMA %88.9 pozitifliği vardı. Hastalarımızın tedavi öncesi endoskopi bulguları %50.2 normal görünüm, %25.4’ünde mozaik patern, %12.6’sında foldlarda silinme, %12.6’sında nodüler görünüm ve %9.5’inde tarak sırtı görünümü mevcuttu. Hastalarımızın patoloji raporları incelendiğinde %83.4’ü ileri evre olup Marsh Tip 3’tü.
Sonuç: Sonuç olarak ÇH bu çalışmadaki hastaların yarısından fazlasında olduğu gibi extraintestinal bulgular gibi atipik şikayetlerle başvurabilir. Özellikle toplumda sık görülen demir eksikliği, osteoporoz, transaminaz yükseklikleri gibi durumlarda çölyak hastalığı göz önünde bulundurulmalıdır. Ülkemizde ÇH prevelansının %1-2 civarında olduğu tahmin edilmekte ancak bundan daha fazla atipik çölyak hastalığı asemptomatik hastaların olduğu düşünülmektedir. ÇH tanı koyarken en önemli aşama ön tanılarda akılda bulundurmaktır. Bu yüzden özellikle atipik semptomlarla başvuran hastalarda ÇH ayırıcı tanılar arasında bulundurulmalıdır.

Keywords

Atipik Çölyak, Çölyak Hastalığı, ekstraintestinal bulgular

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