High anion gap metabolic acidosis caused by D-lactate: mind the time of blood collection

Introduction: D-lactic acidosis is an uncommon cause of high anion gap acidosis. Materials and methods: A 35-year old woman was admitted to the emergency room with somnolence, drowsiness, dizziness, incoherent speech and drunk appearance. Her past medical history included a Roux-en-Y bypass. Point-of-care venous blood analysis revealed a high anion gap acidosis. Based on the clinical presentation, routine laboratory results and negative toxicology screening, D-lactate and 5-oxoprolinuria were considered as the most likely causes of the high anion gap acidosis. Urine organic acid analysis revealed increased lactate, but no 5-oxoproline. Plasma D-lactate was < 1.0 mmol/L and could not confirm D-lactic acidosis. What happened: Further investigation revealed that the blood sample for D-lactate was drawn 12 hours after admission, which might explain the false-negative result. Data regarding the half-life of D-lactate are, however, scarce. During a second admission, one month later, D-lactic acidosis could be confirmed with an anion gap of 40.7 mmol/L and a D-lactate of 21.0 mmol/L measured in a sample collected at the time of admission. Main lesson: The time of blood collection is of utmost importance to establish the diagnosis of D-lactic acidosis due to the fast clearance of D-lactate in the human bod

High anion gap metabolic acidosis caused by D-lactate: mind the time of blood collection

Introduction: D-lactic acidosis is an uncommon cause of high anion gap acidosis. Materials and methods: A 35-year old woman was admitted to the emergency room with somnolence, drowsiness, dizziness, incoherent speech and drunk appearance. Her past medical history included a Roux-en-Y bypass. Point-of-care venous blood analysis revealed a high anion gap acidosis. Based on the clinical presentation, routine laboratory results and negative toxicology screening, D-lactate and 5-oxoprolinuria were considered as the most likely causes of the high anion gap acidosis. Urine organic acid analysis revealed increased lactate, but no 5-oxoproline. Plasma D-lactate was < 1.0 mmol/L and could not confirm D-lactic acidosis. What happened: Further investigation revealed that the blood sample for D-lactate was drawn 12 hours after admission, which might explain the false-negative result. Data regarding the half-life of D-lactate are, however, scarce. During a second admission, one month later, D-lactic acidosis could be confirmed with an anion gap of 40.7 mmol/L and a D-lactate of 21.0 mmol/L measured in a sample collected at the time of admission. Main lesson: The time of blood collection is of utmost importance to establish the diagnosis of D-lactic acidosis due to the fast clearance of D-lactate in the human body.status: publishe

Celiac Disease Remission With Tofacitinib: A Case Report

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Acute abdomen due to intestinal angioedema induced by ACE inhibitors : not so rare ?

During the last 5 years we identified 7 patients with a history of episodic acute abdominal pain and subobstruction due to intestinal angioedema secondary to the use of Angiotensin Converting Enzyme (ACE) inhibitors. These cases were all diagnosed in one gastroenterology department. This is thereby the largest single centre case series of ACE inhibitor-induced angioedema that has been published until now. Our findings suggest that this syndrome is far more frequent than international literature would let us believe. We also describe one of the first male cases diagnosed with this entity for which there is a significant female predominance. In the presence of an appropriate history and suggestive findings on CT scan, this diagnosis can relatively easily he made if one is sufficiently intent on it. An appropriate diagnosis can save these patients a lot of unnecessary diagnostic procedures and discomfort. (Acta gastroenterol. belg., 2009, 72, 455-457).status: publishe

Serological diagnosis of celiac disease: comparative analysis of different strategies

Different serologic tests are available for the diagnosis of celiac disease (CD).status: publishe

Defining Thresholds of Antibody Levels Improves Diagnosis of Celiac Disease

BACKGROUND & AIMS: The European Society for Pediatric Gastroenterology and Nutrition proposed guidelines for the diagnosis of celiac disease, stating that duodenal biopsy is no longer needed if patients have symptoms and levels of immunoglobulin A anti-tissue transglutaminase (IgA anti-tTG) more than 10-fold the cut-off value. We evaluated the accuracy of this guideline in a well-characterized population using different commercial assays. METHODS: We analyzed levels of IgA anti-tTG in serum samples from 104 consecutive pediatric and adult patients who were not deficient in IgA and were diagnosed with celiac disease from August 1, 2000, to December 31, 2009. We also analyzed serum samples from 537 consecutive patients without celiac disease (controls), collected from May 1, 2004, to October 12, 2006, who underwent intestinal biopsy analysis. Serum levels of antibodies were quantified using assays from Bio-Rad, INOVA, Genesis, and Thermo Fisher. RESULTS: The likelihood ratio (probability of a specific result in patients divided by the probability of the same result in controls) for celiac disease increased with levels of IgA anti-tTG in all assays. Depending on the assay, the likelihood ratio for levels greater than 10-fold the cut-off value ranged from 111 to 294. The percentage of patients with celiac disease with levels of IgA anti-tTG greater than 10-fold the cut-off value ranged from 41% to 61%, depending on the assay. For levels of anti-tTG greater than 10-fold the cut-off value, the post-test probabilities for celiac disease (probability of disease, based on pretest probability and test result) were, depending on the assay, 89%-96% and 53%-75% for pretest probabilities (probability of disease depending on symptoms) of 7% and 1%, respectively. CONCLUSIONS: To diagnose celiac disease based on serologic factors, it might be best to define thresholds for levels of IgA anti-tTG based on a predefined likelihood ratio or post-test probability, instead of a multiple of a cut-off value. Patients with a high pretest probability and levels of anti-tTG greater than 10-fold the cut-off value have a high probability for having celiac disease, aiding clinical decision making.status: publishe