Le spectrum des entéropathies

Le spectrum des entéropathies 14:30

Enteropathies Celiac disease GI manifestations of food allergy Eosinophilic gastro-enteropathies Inflammatory Bowel Disease (IBD) Crohn s disease, Ulcerative colitis, Non specific colitis Link between Food allergy and IBD

Allergic disorders

IgE Non IgE 8e Congrès Francophone d'allergologie Milk Egg Wheat Soy Peanut Tree nuts Kiwi fruit Sesame Fish Shellfish Milk Egg Wheat Soy - - - - -

IgE mediated 8e Congrès Francophone d'allergologie Quicker onset SKIN G.I. TRACT RESPIRATORY Erythema Urticaria Angioedema / Swelling Abdominal pain Vomiting Diarrhoea Rhinitis Conjunctivitis Laryngeal oedema and/or Asthma

Non IgE mediated 8e Congrès Francophone d'allergologie Slower onset SKIN Eczema G.I. TRACT RESPIRATORY Reflux or vomiting Diarrhoea Constipation Faltering Growth Rhinitis Catarrhal symptoms Asthma

Non-IgE mediated: GIT food protein induced syndromes (typically milk and soy induced) Enterocolitis (FPIES) Proctocolitis Enteropathy Age Onset: Infant Infant/Toddler Newborn Duration: 12-24 mo? 12-24 mo < 12mo Characteristics: Failure to thrive Malabsorption Bloody stools Shock Villous atrophy No systemic sx Lethargy Diarrhea Eosinophil Vomiting # Solid foods implicated: Diarrhea fish, corn, chicken, turkey, vegetables Nowak-Wegrzyn et al Pediatrics 2003 Zapatero Remon L et al. Allergol Immunopathol 2005

Non IgE mediated: 8e Congrès Francophone d'allergologie Food protein-induced enterocolitis syndrome Infants < 8-12 months, delayed in breast-fed babies (milk or soy protein-based formulas mainly) Symptoms : irritability, protracted vomiting 1-3 hours after feeding, bloody diarrhoea (leading to dehydration), anaemia, abdominal distension, failure to thrive Resolves: 50% at 18 months, 90% at 36 months (Adults and older children: fish, shellfish and cereals hypersensitivity may provoke a similar syndrome with delayed onset of severe nausea, abdominal cramps and protracted vomiting) Adapted from J Allergy Clin Immunol. 2004; 113:808-809

Non-IgE Mediated 8e Congrès Francophone d'allergologie Food protein-induced enteropathy (excluding celiac disease) 0-24 months Diarrhea (mild to moderate steatorrhea in about 80% of cases) Food : milk, cereals, egg, fish Poor weight gain Diagnosis: - Biopsy : patchy villous atrophy with prominent mononuclear round cell infiltrate, few eosinophils, - Response to elimination diet - Challenge test Resolves at 2-3 years old Adapted from J Allergy Clin Immunol. 2004; 113:808-809

Food protein-induced protocolitis Usually presents in the first few months of life and is thought to be due to food proteins passed to the infant in maternal breast milk, or to milk or soy-based formulas Rectal bleeding is common Diagnosis: endoscopy and colonic biopsy (eosinophils in epithelium and lamina propia) Good response to extensively hydrolyzed formulas. Diet without dairy product in mother if lactating Good prognosis with resolution at 12 months of life Adapted from J Allergy Clin Immunol. 2004; 113:808-809

Vomiting during CMA IgE-mediated Anaphylaxis Vomiting, almost immediately after feeding Shock Treament with epinephrin Positive for skin prick tests and specific IgE non IgE-mediated FPIES Vomiting, 2-3 hrs following consumption Dehydration and shock Treatment with fluids and steroids Most of the time confused with anaphylactic shock But negative for skin prick tests and specific IgE

Irritable bowel syndrome Kokkonen et al (JPGN 2001) 56 children, 10 years of age CMA in infancy 45% digestive problems with milk, vs 10% (controls) 14% lactose intolerance vs 3% (controls) Spontaneous reduction in daily dairies Saps N et al. JPGN, 2011 52 subjects, 8.1 years (mean age,) CMA in infancy 44.2% GI symptoms (including abdominal pain, constipation, or diarrhea) vs 20.75% in controls (odds ratio 3.03, P = 0.01)

Allergic disorders

Eosinophilic esphagitis

EE: physiopathology

EoE From birth Spergel et al, JPGN, 2009

How not to miss EoE Pédiatre Persistent reflux Abdominal pain Difficulties in swallowing Failure to thrive Allergologue Digestive symptoms associated with eczema Difficulties in increasing doses during OIT High total IgE

Inflammatory bowel disease Auto-immune disease

Epidemiology 8e Congrès Francophone d'allergologie Crohn s disease (CD) chronic relapsing inflammatory condition, flare-ups alternating with periods of remission, increasing disease severity and incidence of complications as time goes on. Can affect any part of the gastrointestinal tract from the mouth to the anus. Extensive Small Bowel 5% Terminal Ileum only 20% Ileocaecal 45% Colon only 25% Other: anorectal, gastroduodenual, oral only 5%

Epidemiology 8e Congrès Francophone d'allergologie World wide distribution but more common in the West. Females are affected more than males 1.2:1 Epidemiology Incidence: 7/100 000 pop/yr The incidence is lower in non-white races. Jews are more affected than non-jews Bimodal age distribution: 20-40 yrs/60-80 yrs The incidence is rising Prevalence: 100/100 000 pop/yr

Pathology Patchy transmural inflammation. 8e Congrès Francophone d'allergologie Chronic inflammation leads to thickening of bowel wall and narrows lumen. Prominent lymphoid follicles followed by aphthoid ulceration. Later, larger deep fissuring ulcers separated by normal looking mucosa (cobble-stoning), fibrosis, stricturing and fistulation. Changes are often segmentally distributed.

Aetiology & Pathogenesis 8e Congrès Francophone d'allergologie The aetiology of Crohn s disease is unknown. CARD15 gene Chrom 16 3 mutations 20-30% of CD. Putative loci Chrom 12 (IBD2) Chrom 6 (IBD3) Chrom (IBD4). Genetic susceptibility Host Immune Response Crohn s Disease Environmental factors As there is no one cause, it is likely that Crohn s disease is an outcome of interactions between genetic predisposition, environmental factors and the subsequent reaction of the host immune system.

Decreased abundance of Faecalibacterium prausnitzii in the gut microbiota of Crohn s disease, J Gastroenterol Hepatol, 2013

Crohn s disease and allergy

Cow's Milk Allergy, Asthma and Pediatric Inflammatory Bowel Disease, JPGN, 2013

Conclusion IgE et non IgE médiés Attention à l enterocolite Ne pas oublier l éosinophile Un enfant qui ne grandit pas et qui ne tolère pas le blé: Cœliaque? Allergique non IgE? EoE?