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Gastroesophageal Reflux Disease (GERD) 

GERD Gluten Celiac Disease
Arrows Show Abnormal Movement of Gastric Acid in Gastroesophageal Reflux Disease.

What Is Gastroesophageal Reflux Disease (GERD)?

GERD is an upper digestive disorder that is characterized by a decrease in lower esophageal sphincter pressure (LES,) which allows the abnormal reflux or backflow of stomach contents into the esophagus. It is also called erosive esophagitis or reflux esophagitis and is the most common disorder of the esophagus.

The esophagus is a muscular tube that transports swallowed substances to the stomach. It begins at the cricoid cartilage (Adam’s apple) as a continuation of the pharynx and ends at the lower esophageal sphincter (LES).

The lower esophageal sphincter is located at the junction of the esophagus and the stomach. It functions like a circular band to tighten after food is ingested in order to prevent its going back up the esophagus.

Q: How does reflux damage the esophagus?

A: Damage to the lining of the esophagus is induced by the caustic, chemical action of acid and pepsin in gastric juice and, in severe cases, also bile salts, that back upwards from the stomach through an impaired LES. Gastric acid combined with pepsin or bile salts seems to be more harmful to the esophageal epithelial layers than gastric acid alone.1

Pepsin is normally produced by the stomach to dissolve protein in swallowed food. Unfortunately, when the esophagus is inflamed, pepsin will act on it to break down the protein in its sore wall. These sores are called erosions.

Importantly, refluxate to the esophagus in patients with acid suppression therapy is different from those in patients without. Higher levels of secondary bile acids are detected in patients with acid suppression therapy. Even if acid suppression is successful, weakly acidic reflux with bile acids can damage the esophagus.1

Damage starts at the luminal surface (inside where food passes through) of the squamous epithelium (tough surface cells) and progresses through the underlying layers into the submucosa.

One of the primary functions of the esophageal epithelium is to protect the underlying tissue from mechanical and chemical damage by acting as a barrier. The epithelial layers of the distal esophagus need to withstand reflux from the stomach and its contents. When the epithelium fails to protect the underlying tissue from this damage, it leads to erosions, esophagitis, and may lead to Barrett’s esophagus.1

Barrett’s esophagus and esophageal small cell cancer are severe complications of GERD that can be fatal.

GERD can result from too much, or more commonly, too little stomach acid.

What Is Gastroesophageal Reflux Disease (GERD) In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Chen X, Oshima T, Tomita T, Fukui H, Watari J, Matsumoto T, Miwa H. Acidic bile salts modulate the squamous epithelial barrier function by modulating tight junction proteins. Am J Physiol Gastrointest Liver Physiol. 2011 Aug;301(2):G203-9. doi: 10.1152/ajpgi.00096.2011. Epub 2011 May 26. [↩] [↩] [↩]

Penicillin V Impaired Absorption in Children 

osteomalacic myopathy in celiac diseaseWhat Is Osteomalacic Myopathy?

O steomalacic myopathy is a major feature of osteomalacia that is characterized by painful muscle weakness involving the thighs and upper arms and hyperreflexia.

Q: What is hyperreflexia?

A: Hyperreflexia means the action of reflexes is increased. Reflex action is an involuntary, or automatic, response to a stimulus. A reflex action is complicated but essentially depends on  a normal responding muscle which is altered in osteomalacia.

Osteomalacic myopathy is diagnosed on bloodwork that shows deficient levels of vitamin D and elevated levels of parathyroid hormone and alkaline phosphatase, a bone enzyme.

What Is Osteomalacic Myopathy In Celiac Disease and/or Gluten Sensitivity?

Celiac Disease After Childbirth (Puerperium)  

erythema elevatum diutinum of forearmWhat Is Erythema Elevatum Diutinum?

E rythema elevatum diutinum is a rare leucocytoclastic vasculitis thought to be caused by an immune response that is characterized by inflammation, a rash, and scarring of small blood vessels of the skin.

A characteristic poorly defined rash develops symmetically in the skin of extremities where the vessels are inflamed. Nodules and plaques are yellowish red and crust on healing, leaving darkened areas (hyperpigmentation).

Q: What is leucocytoclastic vasculitis?

A: Leucocytoclastic vasculitis is the most common form of vasculitis (inflammation of blood vessels) of the skin and usually results from deposition of immune complexes at the vessel wall. It presents in different forms and in association with different diseases. Diagnosis is made by skin biopsy with immunofluorescence.1

Erythema elevatum diutinum may be caused by inflammatory disease, certain infections such as HIV, immunological disease, malignancy, and drugs.

Corticosteroids are indicated when there are signs of incipient skin necrosis or when the disease is severe. Otherwise, treatment is with Colchicine or Dapsone medications.2

What Is Erythema Elevatum Diutinum In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Sunderkötter C, Bonsmann G, Sindrilaru A, Luger T. Management of leukocytoclastic vasculitis. J Dermatolog Treat. 2005;16(4):193-206. [↩]
  2. Sunderkötter C, Bonsmann G, Sindrilaru A, Luger T. Management of leukocytoclastic vasculitis. J Dermatolog Treat. 2005;16(4):193-206. [↩]

Cystic Fibrosis 

stages of melanoma
The dark brown coloring represents the progression of melanoma as it begins to grow in skin.

What Is Melanoma?

M elanoma is a cutaneous malignancy with rapid invasion and metastasis to other parts of the body.

Melanoma is characterized by growth from melanocytes appearing as a new mole or enlarging from an exisiting mole, changing shape, size or color.

Melanocytes are cells found in the lower epidermis layer that produce melanin, or pigment, that colors the skin.

What Is Melanoma In Celiac Disease and/or Gluten Sensitivity?

Glycogenic Acanthosis (Esophageal Plaques)

What Is Intraepithelial Lymphocytosis In Normal Small Bowel Samples? I ntraepithelial lymphocytosis is characterized by an abnormal increase in the numbers of intraepithelial lymphocytes (IELs) that are present in the small intestinal mucosa. Q: What… 

Bleeding: Fecal Occult Blood In Children 

Muscle fiber anatomy. Courtesy NIH.
Muscle Fiber Anatomy. Courtesy NIH.

What Is Muscle Weakness?

M uscle weakness is the impaired status of muscle function characterized by decreased or low muscle strength and inability to perform normal work such as lifting a pot off the stove.

Q: How do muscles work?

A: Muscles do their work by contracting or shortening. For example, to move the foot up and down at the ankle, muscles attached to the foot by tendons must contract to shorten or relax to return to their resting length. Calf muscles contract to point the foot down (flexion) while the shin muscles relax (extension).  For the foot to point up, calf muscles relax while the opposing shin muscles contract.

Each muscle is made up of individual muscle fibers. A muscle fiber is a long cylindrical cell that contains many nuclei, mitochondria, and sarcomeres. Each muscle fiber is surrounded by a thin layer of connective tissue called the endomysium.

Approximately 20–80 of these muscle fibers are grouped together in a parallel arrangement called a muscle fascicle or fiber bundle that is encapsulated by a perimysium. A distinct muscle is formed by enveloping a large number of muscle fascicles in a thick collagenous external sheath extending from the tendons called the epimysium.1

Muscles fall into three types:

  • Voluntary muscles.  These muscles, also called skeletal, we can control by will. Voluntary muscles function by contracting their fibers to draw one part of the body toward another in flexion while opposing muscles that extend or pull a body part away from another. They move our bones to perform activities such as walking to get somewhere, chewing to eat food, lifting to do work, and moving the eyeball to look at something.
  • Involuntary muscles. These muscles work independently of our conscious control. They are needed for internal organs, sphincters, and other parts to do their work, such as peristalsis in the gut that must function at all times to digest and move food, the squirting of bile juice into the duodenum by the Sphincter of Odi in the presence of fat eaten, and action of the pupil to see.
  • Cardiac muscles. These muscles are specialized to keep the heart functioning at all times.

  Muscle weakness can involve all types of muscles.

What Is Muscle Weakness In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. http://www.ncbi.nlm.nih.gov/books/NBK57140/ [↩]

Constipation Alternating with Diarrhea

Bristol Stool Chart Showing Normal and Abnormal Stool.
Bristol Stool Chart Showing Normal and Abnormal Stool.

What Is Chronic Constipation Alternating With Diarrhea?

Chronic constipation alternating with diarrhea is an intestinal motility disorder, or irregularity, characterized by alteration in stool formation, consistency, and evacuation which results in a bowel movement that consists of some hard or balled stool along with some loose stool that can cause leakage.

Q: How do irregular movement patterns develop in the colon?

A: The colon produces irregular movements as a result of problems that originate in  the colon (large intestine) itself and/or the small intestine which then affects function of the colon.

Here are listed the many types of problems or diseases that cause these abnormal bowel movements:

  • Disorders that adversely affect the colon, an organ which must propel stool, remove excess water, absorb electrolytes, ferment undigested food material that passes into it, and produce nutrients from the fermentation process:
  • Poor diet that does not contain adequate nutrition, fiber, probiotics, prebiotics, and water to form normal stool.
  • Diet that contains irritating, toxic or allergenic food that cause spasms.
  • Diseases that inflame the mucosa lining such as collagenous colitis, altering the proper absorption of water and electrolytes.
  • Diseases that damage and swell the colon walls, such as Crohn’s disease, ulcerative colitis, and diverticulitis.
  • Diseases that obstruct the lumen or passageway so that stool passes with difficulty.
  • Diseases that hamper normal peristalsis (muscle action), such as irritable bowel syndrome (IBS), diabetes and thyroid disease.
  • Disorders that adversely affect the small intestine, an organ which must digest and absorb nutrients needed by the body while passing unabsorbed food material to the colon:  
  • Diet that conatins too much fat, sugar or artifical sweeteners, causing diarrhea.
  • Disorders that result in malabsorption, such as gluten enteropathy, milk enteropathy, steatorrhea (fat malabsorption), lactose intolerance, sucrose intolerance, maltose intolerance, and bacterial overgrowth, passing abnormal amounts of undigested food material to the colon where it is fermented producing excessive gas, diarrhea and spasm.
  • Disorders that impair peristalsis, such as active celiac disease, diabetes, scleroderma, and thyroid disease.
  • Tumors like cancer and lymphoma impair regular passage of material to colon.
  • Drugs that impair peristalsis, such as iron supplements, aluminum containing antacids, narcotics, some anti-depressants, some anti-seizure, and some diuretics.

What Is Chronic Constipation Alternating With Diarrhea In Celiac Disease and/or Gluten Sensitivity?

Bleeding, Occult Gastrointestinal

Erosions Of The Esophagus Can Be A Cause Of Gastrointestinal Bleeding.
Erosions Resulting From Esophagitis Can Be A Cause Of Gastrointestinal Bleeding.

What Is Occult Gastrointestinal Bleeding?

Occult gastrointestinal bleeding is characterized by unseen or minute quantities of blood in stool. The origin of bleeding is from mucosa that lines the inside of the digestive tract at a site that must be found by medical testing and procedures to look at the lining.

Q: What tests and procedures are performed to locate the bleeding?

A: The simplest test to discover blood that cannot be seen is the stool test. This consists of a card with 3 spaces for 3 separate  stool collection over 3 separate days. A tiny smear of stool is placed on a test card space on each of three days. Then the card is examined for a reaction that indicates the existence of blood in the stool.

If the stool test is positive, the origin of bleeding must be located. This search requires certain procedures that look at the mucosal lining directly by a gastroenterologist, usually under light sedation.

  • Gastroscopy procedure can visualize the upper gastrointestinal tract, which includes the esophagus and stomach.
  • Endoscopy procedure can also visualize the upper small intestine. However, endoscopy procedure is limited in that it cannot visualize the middle small intestine (jejunum).
  • Colonoscopy can visualize the end of the small intestine and colon all the way to the rectum.
  • Capsule endoscopy procedure.  If  gastroendoscopy and colonoscopy fail to discover the source of bleeding, the physician may administer a capsule endoscopy which visualizes the entire gastrointestinal tract. In this procedure, the patient swallows a capsule size camera (encased) which takes constant pictures over the course of a day until expelled through the rectum.  Of course, the patient must be able to swallow the large size capsule.

What Is Occult Gastrointestinal Bleeding In Celiac Disease and/or Gluten Sensitivity?

Celiac Disease, Refractory

Anatomy of Upper Airway and Throat. Courtesy Wikipedia.org
Anatomy of Upper Airway and Throat. Courtesy Wikipedia.org

What Is Post-Cricoid Carcinoma?

P ost-cricoid carcinoma is a rare malignancy arising in the hypopharynx.

Q: What is the hypopharynx?

A: The hypopharynx is the lower portion of the pharynx that opens into the larynx. It is comprised of the postcricoid region, pyriform sinus, and posterior hypopharyngeal wall.

Tumors rarely appear in the posterior pharyngeal wall or postcricoid region without also involving the pyriform sinus. The lack of anatomic barriers between these sites and a propensity for these tumors to develop in the pyriform sinus and spread outward account for this phenomenon.

Overall prognosis for these tumors is poor. Because of the rich organic lymphatic and vascular networks, aggressive growth and early cervical metastases (compared with cancers at other head and neck sites) characterize these cancers.

A study investigating the clinical course of 21 patients with post-cricoid carcinoma found the 5-year cause-specific survival rate was 52%. All the patients who eventually died did so within 3 years of the treatment. Seven patients had distant metastases, representing a higher frequency as compared with that of patients with recurrence of the primary focus and cervical lymph node metastasis. All of these patients who had been treated by surgery died of the cancer.1

Unfortunately, hypopharyngeal cancers are discovered at a later stage than other head and neck cancers. The delay in diagnosis from symptom onset averages 10 months.2

What Is Post-Cricoid Carcinoma In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Asakage T, Nakao K, Ebihara Y, Fujishiro Y, Watanabe K. A clinical study of post-cricoid carcinoma. Acta Otolaryngol Suppl. 2007 Dec;(559):118-22. doi: 10.1080/03655230701599354. [↩]
  2. http://emedicine.medscape.com/article/848359-overview [↩]

Cheilosis (Cracks in corners of mouth)

cheilosisWhat Is Cheilosis?

Cheilosis is a painful feature of nutritional deficiencies, especially riboflavin and/or pyridoxine deficiency, and less frequently, from vitamin B12, folic acid, and iron. It is characterized by redness of the lips with cracking and weeping in the corner of the mouth.

Q: What is the consequence of weeping at the corners of the mouth?

A: The open sores that develop at the corners of the mouth invite infection by candida albicans, a yeast organism, and less commonly by bacteria normally present on the skin such as staphylococcus aureus.

These sores make opening the mouth very painful and so restrict eating, talking, socializing, and dental care.

What Is Cheilosis In Celiac Disease and/or Gluten Sensitivity?