Allergic and dietetic colitis and gastroenteritis

Gastroenterology

Clinicals - History

Fact Explanation
An infant Food related allergic gastroenteritis is a spectrum of hypersensitivity disorders, occurring commonly in infancy and they outgrow from it. An infant
Food related allergic gastroenteritis is a spectrum of hypersensitivity disorders, occurring commonly in infancy and they outgrow from it.
An adult Adult onset allergic gastropathies are rare but associated with possibly fatal outcomes . Some present as an incidental finding while investigating for diarrhea and abdominal pain. An adult
Adult onset allergic gastropathies are rare but associated with possibly fatal outcomes . Some present as an incidental finding while investigating for diarrhea and abdominal pain.
An identifiable risk factor The common hypersensitivity cause is cows' milk protein. Others are soy milk, peanuts, corn, carrots, rye, wheat, white of the egg, cod, and chicken. An identifiable risk factor
The common hypersensitivity cause is cows' milk protein. Others are soy milk, peanuts, corn, carrots, rye, wheat, white of the egg, cod, and chicken.
Diarrhea One of the commonest presentations . This is due to Ig-E mediated hypersensitivity in children and T lymphocyte-mediated (i.e. non-IgE associated) in young adults. Some can present with constipation too, rarely. Diarrhea
One of the commonest presentations . This is due to Ig-E mediated hypersensitivity in children and T lymphocyte-mediated (i.e. non-IgE associated) in young adults. Some can present with constipation too, rarely.
Blood in stools Due to allergic procto-colitis. Blood in stools
Due to allergic procto-colitis.
Vomiting Another major symptom, probably due to the same pathophysiology of diarrhea. Once the offending food item has been re-introduced, vomiting is the first symptom to appear. Vomiting
Another major symptom, probably due to the same pathophysiology of diarrhea. Once the offending food item has been re-introduced, vomiting is the first symptom to appear.
Weight loss There can be significant weight loss, and in the case of infants, failure to thrive is possible. Due to dehydration and malabsorption. Weight loss
There can be significant weight loss, and in the case of infants, failure to thrive is possible. Due to dehydration and malabsorption.
Abdominal pain Another common presentation. Abdominal pain
Another common presentation.
Association with other allergic phenomena The allergic gastroenteritis can be associated with other atopic conditions. i.e. atopic dermatitis, food allergy, rhinitis, bronchial asthma. But gastrointestinal disorders manifest independent of the type of allergic reactions inducing atopic manifestations. Association with other allergic phenomena
The allergic gastroenteritis can be associated with other atopic conditions. i.e. atopic dermatitis, food allergy, rhinitis, bronchial asthma. But gastrointestinal disorders manifest independent of the type of allergic reactions inducing atopic manifestations.
Family history of atopy The risk of atopy increases if a parent or sibling has atopic disease (20–40% and 25–35%, respectively), and is higher still if both parents are atopic (40–60%). Family history of atopy
The risk of atopy increases if a parent or sibling has atopic disease (20–40% and 25–35%, respectively), and is higher still if both parents are atopic (40–60%).

Clinicals - Examination

Fact Explanation
Loss of weight Due to dehydration and mal-absorption. Weight should be plotted in a standard growth chart to identify failure to thrive in infants. Loss of weight
Due to dehydration and mal-absorption. Weight should be plotted in a standard growth chart to identify failure to thrive in infants.
Features of dehydration i.e. decreased peripheral perfusion (indicated by capillary refilling time) , deep breathing, decreased skin turgor, sunken eyes, dry mouth, sunken fontanelle and absence of tears. Due to recurrent vomiting and diarrhea. Features of dehydration
i.e. decreased peripheral perfusion (indicated by capillary refilling time) , deep breathing, decreased skin turgor, sunken eyes, dry mouth, sunken fontanelle and absence of tears. Due to recurrent vomiting and diarrhea.
Blood pressure Continuous vomiting and diarrhea can be associated with hypovolemic shock. Blood pressure
Continuous vomiting and diarrhea can be associated with hypovolemic shock.
Pallor Due to blood loss with stools. Pallor
Due to blood loss with stools.
Abdominal examination Diffuse tenderness has been reported. In severe cases where malnourishment is prominent, fluid in peritoneal cavity can also be noticed. Abdominal examination
Diffuse tenderness has been reported. In severe cases where malnourishment is prominent, fluid in peritoneal cavity can also be noticed.

Investigations - Diagnosis

Fact Explanation
Complete blood count Peripheral blood eosinophilia is expected due to the hypersensitivity reaction. Where there has been significant blood loss with stools, anemia also can be expected. Complete blood count
Peripheral blood eosinophilia is expected due to the hypersensitivity reaction. Where there has been significant blood loss with stools, anemia also can be expected.
Skin prick test (SPT) To diagnose the presence of distinguishable allergens. Appropriate and specific allergen extracts should be used, with using normal saline pricks as negative controls. Interpretation of the tests should be done after 15 - 20 minutes of application. Positive results are defined as a wheal ≥3 mm diameter. Skin prick test (SPT)
To diagnose the presence of distinguishable allergens. Appropriate and specific allergen extracts should be used, with using normal saline pricks as negative controls. Interpretation of the tests should be done after 15 - 20 minutes of application. Positive results are defined as a wheal ≥3 mm diameter.
Endoscopy Diffuse hyperemia and edema are features of inflammatory reaction in the mucosa. Can take biopsies at the same time. Endoscopy
Diffuse hyperemia and edema are features of inflammatory reaction in the mucosa. Can take biopsies at the same time.
Histology Infiltration of GI mucosa with eosinophils. Histology
Infiltration of GI mucosa with eosinophils.
Serum electrolytes To exclude hypernatremia or hypokalemia, which should be addressed in management if present, and rule out acute renal failure. Serum electrolytes
To exclude hypernatremia or hypokalemia, which should be addressed in management if present, and rule out acute renal failure.
Blood urea and serum creatinine Blood urea and serum creatinine are markers of acute renal failure. Blood urea and serum creatinine
Blood urea and serum creatinine are markers of acute renal failure.

Investigations - Management

Fact Explanation
Complete blood count To exclude anemia, infection and thrombocytopenia before the surgical management option. Complete blood count
To exclude anemia, infection and thrombocytopenia before the surgical management option.
Renal functions i.e. serun electrolytes, blood urea, serum creatinine. To see the evidence of renal function after correction of the dehydration. Renal functions i.e. serun electrolytes, blood urea, serum creatinine.
To see the evidence of renal function after correction of the dehydration.
Chest X-ray To exclude respiratory illness prior to surgery. Chest X-ray
To exclude respiratory illness prior to surgery.
12-lead elecrocardiogram To exclude cardiac diseases prior to surgery. 12-lead elecrocardiogram
To exclude cardiac diseases prior to surgery.
Fasting blood sugar To exclude asymptomatic hyperglycemia before surgery. Fasting blood sugar
To exclude asymptomatic hyperglycemia before surgery.

Management - Supportive

Fact Explanation
Avoid offending food item Avoid the offending food item till the patient is clinically well and hypersensitivity to it is excluded by skin prick test. In cases of cows' milk hypersensitivity in infants, Elimination of cow's milk protein from the infant's or mother's diet and challenges are the gold standard for diagnosis. Avoid offending food item
Avoid the offending food item till the patient is clinically well and hypersensitivity to it is excluded by skin prick test. In cases of cows' milk hypersensitivity in infants, Elimination of cow's milk protein from the infant's or mother's diet and challenges are the gold standard for diagnosis.
Hydration To prevent hypovolemia. Hydration
To prevent hypovolemia.
Education of the parents and helathcare workers Education about the nature of the illness, predisposing factors and the importance about the dietary management. i.e. avoidance of the offending food itme, using substitutes. Education of the parents and helathcare workers
Education about the nature of the illness, predisposing factors and the importance about the dietary management. i.e. avoidance of the offending food itme, using substitutes.

Management - Specific

Fact Explanation
Amino acid formula (AAF) For infants who have failure to thrive, suffer from macronutrient deficiencies or have pain. AAF is hypoallergenic, minimises the risk of failure on an eHF and further weight loss. Amino acid formula (AAF)
For infants who have failure to thrive, suffer from macronutrient deficiencies or have pain. AAF is hypoallergenic, minimises the risk of failure on an eHF and further weight loss.
Corticosteroids The drug of choice for anti-inflammatory effect on the GI mucosa. Combined together with avoidance of offending food item, can cause complete recovery. Corticosteroids
The drug of choice for anti-inflammatory effect on the GI mucosa. Combined together with avoidance of offending food item, can cause complete recovery.
Other drugs These are not widely used, but some benefits have been proven than using corticosteroids because of the side effects of them. i.e. proton pump inhibitors, mast cell stabilizers, ketotifen, leukotriene antagonists and octreotide. Other drugs
These are not widely used, but some benefits have been proven than using corticosteroids because of the side effects of them. i.e. proton pump inhibitors, mast cell stabilizers, ketotifen, leukotriene antagonists and octreotide.
Surgical resection Resection of involved intestinal segments can be done in refractory cases. Surgical resection
Resection of involved intestinal segments can be done in refractory cases.

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