Role of IgG anti-β-lactoglobulin antibody in the diagnosis of cow’s milk protein intolerance in India

Objective: Little is known about cow’s milk protein intolerance (CMPI) in India. This study was aimed at finding CMPI cases and determining the role of IgG anti-β-lactoglobulin antibody in the diagnosis of this condition in India. Methods: From June 2004 to December 2005, 30 children with presumptive diagnosis of CMPI, based on endoscopic rectal or duodenal biopsy showing excess eosinophils and response to milk withdrawal, were enrolled and studied prospectively. Definite diagnosis was made in 20 children on the basis of positive milk challenge. IgG anti-β-lactoglobulin antibodies were tested in children with CMPI before and after stopping milk and after milk challenge. Antibody levels were also studied in 27 age-matched disease controls and 50 healthy adults. Results: The median age of 20 children (16 boys) with CMPI was 16.5 (6–36) months. Of them, 18 presented with diarrhea (12 bloody) and 2 had rectal bleeding. The presumptive diagnosis was most often (85%) based on colonic or rectal biopsy findings. Rectal biopsy was diagnostic in all 20 cases irrespective of the mode of presentation compared with duodenal biopsy which was diagnostic in 3 cases (p<0.0001). There was no difference in antibody levels between cases and controls; the antibody level decreased significantly after milk withdrawal (p<0.005), but did not rise significantly after milk rechallenge. Conclusions: CMPI is a common cause of chronic diarrhea in children in northern India. Sigmoidoscopy and rectal biopsy help in establishing the diagnosis in most cases. IgG anti-lactoglobulin antibody test is not useful in diagnosing CMPI in the Indian setting

Effect of a gluten-free diet on growth and small-bowel histology in children with celiac disease in India

Background and Aim: Follow-up studies on growth and histological recovery of children with celiac disease (CD) while on a gluten-free diet (GFD) are lacking from Asia. We therefore assessed the effects of this diet. Methods: Forty-two children with CD were enrolled. Weight and height were expressed as weight for height (WfH) and height standard deviation scores (HSDS), respectively. Twenty-five children had repeated duodenal biopsies after 1-2 years and 14 had a third biopsy after 3-7 years of GFD. Compliance was checked by regular interview and IgA antiendomysial antibody estimation (EMA). Results: At diagnosis (n = 25), mean HSDS was -3.3 ± 1.6 with 76% having a HSDS of <-2; 60% were undernourished (WfH mean 81.6 ± 5.7). Over a mean follow up of 3.7 years, HSDS improved to -1.3 ± 1.7 and 84% cases achieved normal nutrition. Mean height velocity was 13.9 cm during first year and 5.6 cm in subsequent years. Small-bowel biopsies at diagnosis showed subtotal villous atrophy (Marsh IIIb) in 18 (72%) and partial villous atrophy (Marsh IIIa) in seven (28%) patients. Repeat biopsy at 1-2 years showed shift from subtotal to partial villous atrophy in 94% (n = 17/18) and normalization in one patient. In patients with Marsh IIIa improvement of partial villous atrophy was observed in all. Immunoglobulin A endomysial antibody was negative in 81%. Repeat biopsies at 5 years of GFD showed improvement to Marsh I-II, but none normalized. Conclusion: The majority of children with CD show normalization of nutrition and growth after GFD. Small-bowel histology improves markedly but does not normalize even after 5 years of GFD

Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations

Acute variceal bleeding (AVB) is a medical emergency and associated with a mortality of 20% at 6 weeks. Significant advances have occurred in the recent past and hence there is a need to update the existing consensus guidelines. There is also a need to include the literature from the Eastern and Asian countries where majority of patients with portal hypertension (PHT) live. The expert working party, predominantly from the Asia-Pacific region, reviewed the existing literature and deliberated to develop consensus guidelines. The working party adopted the Oxford system for developing an evidence-based approach. Only those statements that were unanimously approved by the experts were accepted. AVB is defined as a bleed in a known or suspected case of PHT, with the presence of hematemesis within 24 h of presentation, and/or ongoing melena, with last melanic stool within last 24 h. The time frame for the AVB episode is 48 h. AVB is further classified as active or inactive at the time of endoscopy. Combination therapy with vasoactive drugs (< 30 min of hospitalization) and endoscopic variceal ligation (door to scope time < 6 h) is accepted as first-line therapy. Rebleeding (48 h of T (0)) is further sub-classified as very early rebleeding (48 to 120 h from T (0)), early rebleeding (6 to 42 days from T (0)) and late rebleeding (after 42 days from T (0)) to maintain uniformity in clinical trials. Emphasis should be to evaluate the role of adjusted blood requirement index (ABRI), assessment of associated comorbid conditions and poor predictors of non-response to combination therapy, and proposed APASL (Asian Pacific Association for Study of the Liver) Severity Score in assessing these patients. Role of hepatic venous pressure gradient in AVB is considered useful. Antibiotic (cephalosporins) prophylaxis is recommended and search for acute ischemic hepatic injury should be done. New guidelines have been developed for management of variceal bleed in patients with non-cirrhotic PHT and variceal bleed in pediatric patients. Management of acute variceal bleeding in Asia-Pacific region needs special attention for uniformity of treatment and future clinical trials