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Collagenous Sprue
1.
2. V I L L O U S A T R O P H Y
D I F F E R E N T C A U S E S
Presented by :
Dr. Waleed Mahrous
3. Patient profile
47 year old Saudi male
Referred at 31/12/2012 to our clinic for
further management
4. Case Presentation
47 year old male patient NOT known to have any
medical illness
The patient had been healthy until he developed severe
central abdominal pain colicky in nature not radiating
His symptoms progressed to nausea and emesis after
2–3 weeks. The abdominal pain & emesis usually
occurred 30 minutes after eating, 1–5 times per
day, was bilious in nature, and was associated with
bloating.
5. No history of diarrhea , mucus discharge
, melena , or fresh blood .
No experienced of nocturnal symptoms.
Case Presentation
6. Case Presentation
Patient look for medical advice in KFH in AL Medina
After some investigations was done for him with some
image pt was Dx with partial intestinal
obstruction
Treated with IVF, Abx, was kept NPO for sometimes
and NGT free drain
Pt has much improvement after that .
7. Case Presentation
Pt started to have watery diarrhea after that, on
and off but no blood with it also with mild abdominal
pain.
Pt had significant weight loss from 105kg to
78kg since first presentation (around 5-6 months)
No other symptoms associated with his presentation
So, pt referred to our clinic for further management
8. Case Presentation
No hx of fever , constipation , or PR bleeding
No hx of hematemsis or melena
No hx of skin discoloration or skin lesion
No hx of eating from outside or use of antibiotics
Wt loss with no change in his appetite since his presentation
No eye symptoms or similar condition,
No hx of joint pain or swelling .
9. Case Presentation
Patient is NOT known to have any medical illness
before
with no previous hospitalization except for his early
presentation
No past surgical history
NOT known to have any allergy
NOT using any medication
• Past history
10. Case Presentation
No similar condition in the family
No chronic illness in the family
• Family history
11. Case Presentation
Living in Medina with his family
Medium class, NOT smoker or alcoholic
Married with no extramarital activity
• Social history
• Systemic review
Unremarkable
15. Case Presentation
Patient was conscious, alert, oriented to time place
and person, NOT in distress, NOT in pain and lying
comfortable in bed, NOT cachectic, NO muscle
wasting No palpable LN
Vital sign :
T : 36.9
BP: 116 67 HR : 87
RR : 17
SPO2 99% room air
• On Examination
16. Case Presentation
Abdominal
Soft and lax with no tenderness
No Organomegally - Spleen was NOT
palpable, Liver around 12 cm span
PR Exa. was Normal
• On Examination
17. Case Presentation
C.V.S
No scar or deformity of the chest
S1 + S2 + o , No palpable or audible murmure
• On Examination
Respiratory
Fair air entry bilaterally
No wheezs or crepeatation
28. CT abdomen and pelvis with IV contrast
FINDINGS :
Multiple mesenteric lymphadenopathies
, largest one measuring 1.7cm.
Mild hepatomegaly.
Jejunization of the ileum
33. Case Presentation
• Upper endoscopy + single balloon
From duodenum to >1 Meter inside jejunum:
Nodularity , scallooping and ulceration.
Biopsy taken for AFB C/S and histopathology.
34. Case Presentation
• Colonoscopy (with Terminal Ileum intubation)
RECTUM: 2 small flat polyps seen, removed with
biopsy forcips, no complications.
SIGMOID to CECUM: No abnormalities seen.
TERMINAL ILEUM: Diffuse nodularity with mild
erythema, no ulcers or lesions.
multiple biopsies taken.
37. Case Presentation
Duodenal Histopathology :
The villous architecture is remarkably
distorted with shortening and focal
complete villous atrophy.
No remarkable increase in the number of
CD3+ lymphocytes in the epithelium.
38. The lamina propria is expanded by a mixed
inflammatory infiltrate, of a
lymphoplasmacytic
There is glandular distortion, apoptosis &
regenerative changes
No definite malignant cells, granulomas or
infectious organisms detected
Suggestive of crohn's disease is high
Case Presentation
41. Work up ….
Villous Atrophy and Negative Celiac Serology
Villous Atrophy and Negative Enterocyte Antibody
Villous Atrophy and Negative ASCA
Case Presentation
45. Start Steroid Rx
Prednisolone 40 mg po od for 2/52 then tapper
gradual until seen in clinic
Seen in clinic at 6/52 where Imuran 200 mg
po od started and continue tapering steroid until
D/C
Patient symptoms improved dramatically
Case Presentation
47. Patient present to ER with:
- Diarrhea 10 times > 3/52
- Recurrent Vomiting 15 times
2>52
- Loss Appetite
- Loss weight > 10 kg in 1/12
- Generalized weakness
Case Presentation
54. Comparison to the previous study done
on January 2013, there is still significa
nt mesenteric lymphadenopathy.
No hepatomegaly or splenomegaly is se
en
55. Radiology Impression :
The overall picture is compatible with severe in
flammatory process of small bowel
The differential diagnosis may include :
- Active Crohn's disease
- Infectious Enterocolitis
Case Presentation
57. Colonoscopy
up to Terminal
Ileum : Only
seen nodular
ulcerated
mucosa of TI
other colon
normal
Biopsy taken to r/o
TB CULTURE &
CMV
Case Presentation
59. EGD : Thickened
edematous with
few superficial
ulceration at
gastric area
Nodular with
large patchy
area of deep
ulcerated small
bowel
Case Presentation
2ed duodenal Part
60. Methylprednisolone 20 mg iv bid
initiated
&
TPN - Total Parenteral Nutrition
Case Presentation
65. Duodenal Histopathology :
The villous architecture is markedly
districted with shorting and focal
complete villous atrophy but without a
remarkable increase in number of CD 3
lymphocyte in epithelium.
Trichrome stain demonstrate a thick
collagenous subepithelial band
suggestive of collagenous sprue
Case Presentation
69. Gluten Free Diet
&
Anti - TNF – Adalimumab
initiated
Case Presentation
70. Patient seen in clinic 6 weeks from discharge
Improved symptoms
- No more diarrhea
- No more vomiting
- Feeling some time abdominal discomfort and
pain
- Increase weight by 5 kg since discharge
- Normal Lab
- Normal Albumin 43
Case Presentation
71.
72. INTRODUCTION
Collagenous sprue is a severe
malabsorptive disorder, histologically
characterized by small intestinal
villous and crypt atrophy, and a
subepithelial collagen deposit, thicker
than 12 µm, that entraps lamina propria
cellular elements.
REV ESP ENFERM DIG 2013; 105 (3): 171-174
73. Collagenous sprue is a rare disease
entity, with only about small No. of
sporadic cases reported worldwide since
it was first described in 1947.
Its exact etiology is still under
investigation, and its relationship with
classic celiac disease and other
refractory, spruelike intestinal disorders
remains controversial.
REV ESP ENFERM DIG 2013; 105 (3): 171-174
74. CS affects the small intestine (mainly
duodenum and proximal jejunum)
in a patchy way and with variable
intensity .
Severity of symptoms correlates with
the overall length of bowel affected
rather than with the degree of
histological alterations.
REV ESP ENFERM DIG 2013; 105 (3): 171-174
75. Those endoscopic findings, that is,
the reduction of folds, scalloping,
mucosal nodularity, are
suggestive, but nonspecific, of
collagenous sprue because they can
also be seen in classic celiac disease.
REV ESP ENFERM DIG 2013; 105 (3): 171-174
76. Treatment
The management of CS is very
problematic. Thus far, there are no long-
term follow-up data available to compare
the most effective treatment regimens.
Celiac sprue must be ruled out, and
dietary investigations should be
considered to detect unusual allergies
causing refractory sprue.
REV ESP ENFERM DIG 2013; 105 (3): 171-174
77. Dietary gluten restriction should be the
first step even though patients are often
partially or totally unresponsive to gluten-free
diet, as previously reported.
Parenteral nutrition has been proposed as
the best therapy because corticosteroid-
related complications such as osteopenia are
magnified in a chronic malabsorptive disorder.
REV ESP ENFERM DIG 2013; 105 (3): 171-174
78. Total parenteral nutrition allows for
time to use immunosuppressives
that have been used to treat
refractory CD, to consider dietary
investigations, and to detect
unusual allergies.
REV ESP ENFERM DIG 2013; 105 (3): 171-174
79. Long-term high-dose corticosteroids
remain the most effective
treatment option for CS, but the
dosing, tapering period, and side-effect
management needs to be investigated.
Other options that have been used to
treat refractory CD may be useful in
the treatment of CS.
80. A combination of nutrition
support, steroids, and
immunosuppressors such as
azathioprine, 6-mercaptopurine,
cyclosporine, or tumor necrosis
factor antibodies may be useful,
but lack clinical trials.
REV ESP ENFERM DIG 2013; 105 (3): 171-174
81. Infliximab treatment in refractory
collagenous sprue: report of a case and
review of the literature
27-year-old man developed watery diarrhea with
weight loss and abdominal pain. Duodenal
biopsies showed a subtotal villous atrophy with
an extensive subepithelial layer of collagenous
fibers.
An apparent GFD did not reduce symptoms.
Z Gastroenterol 2009; 47(6): 575-578
82. High dose steroid treatment (75 mg
prednisone) in combination with
azathioprine (150 mg) reduced diarrhea
but did not induce complete remission.
Based on strongly elevated mucosal TNF-
alpha transcript concentrations we
introduced infliximab (5 mg/kg body
weight) into therapy.
Z Gastroenterol 2009; 47(6): 575-578
83. After two applications the patient's
symptoms quickly improved.
During the following year no recurrence
of diarrhea has been observed.
This case suggests that infliximab is an
effective treatment in complicated
cases of collagenous sprue.
Z Gastroenterol 2009; 47(6): 575-578
84. V I L L O U S A T R O P H Y
D I F F E R E N T C A U S E S