of cases , while complete villous atrophy was present in 74 % of cases . Intraepithelial lymphocytes ( IELs ) were noted in only 60 % of cases while the remaining reports had no comment on IELs and either mentioned inflammatory cells in the lamina propria or changes consistent with CD . When the IELs were noted , the reports typically did not specify the IEL number . Furthermore , 93 % of reports did not mention the crypt architecture . Hence , detailed Marsh classification is not reported . Only five patients had genetic testing for HLA DQ2 / DQ8 with positive results in four patients .
All patients received serology testing at the time of diagnosis ( Table 4 ), with all patients having one or more positive serology levels . tTG IgA levels were positive in 88 % of patients , while tTG IgG was positive in 63 % of patients . DGP IgA was positive in 62 % of cases and DGP IgG in 88 % of patients . EMA antibodies were positive in only 70 % of cases and total IgA levels were normal in 98 % of cases .
Follow-up serology testing was ordered for all patients . A total of 49 patients ( 83 %) received testing within the health system , occurring six to 12 months in 31 patients and greater than 12 months in 18 patients . In the 10 patients without follow-up serology , patients may have received lab testing at outside facilities or did not complete ordered serology testing . Upon follow-up testing , tTG IgA antibodies remained positive in 45 % of tested patients ; however , tTG IgA antibody levels improved from presentation values in all patients ( Table 4 ). Patients showed improvement in the additional tested serological markers . Out of the examined 59 patients , 37 patients ( 63 %) were recorded as returning for follow-up visits to pediatric gastroenterology between six months to one-year post-diagnosis . All 37 patients reported symptom improvement following GFD introduction .
DISCUSSION
In our study , we ascertained the characteristics of pediatric CD in southern WV . Examined children presented with a wide variety of symptoms at the time of CD diagnosis . Abdominal pain was found to be the most common symptom followed by constipation and nausea / vomiting at presen -
TABLE 2 : Documented Symptoms at Presentation Symptoms Present n % Asymptomatic 19 32 % Symptomatic 40 68 % Classical Symptoms Abdominal distention 4 10 % Diarrhea 9 23 % Failure to thrive / unexplained weight loss 9 23 %
Nonclassical Gastrointestinal Symptoms Abdominal pain 31 78 % Constipation 12 30 % Nausea / Vomiting 10 25 %
Extraintestinal Symptoms Amenorrhea 0 0 % Anemia 3 8 % Aphthous ulcers 1 3 % Arthritis 0 0 % Dermatitis herpetiformis 1 3 % Easy fractures 0 0 % Elevated liver enzymes 0 0 % Elevated sedimentation rate 2 5 % Fatigue 2 5 % Hypoproteinemia 1 3 % Neurological symptoms 1 3 % Osteoporosis 0 0 % Poor appetite 2 5 % Pubertal delay 0 0 % Short stature 2 5 % Tooth enamel defects 0 0 %
tation , supporting other studies reporting delayed onset and vague presentation . 6 , 7 , 11 These symptoms are not exclusive to CD and can be seen in various other gastrointestinal tract diseases , leading to diagnostic challenges . Classic CD , characterized by the presence of malabsorptive symptoms ( diarrhea , failure to thrive , or abdominal distention ), was present in only a small fraction of patients in our study ( 10-23 %). A review of literature corroborates that the classic form of CD has become less predominant . 6 , 11 With greater clinical awareness and screening availability , an increased number of asymptomatic CD cases are being identified . In our study , one-third of patients were asymptomatic and were diagnosed as a part of the normal screening process for type 1 diabetes or autoimmune thyroiditis . The prevalence of CD in other disorders often in the absence of symptoms has prompted the recommendation to screen at-risk patients at frequent intervals . 12
The study population included in this retrospective chart review presented with a range of clinical features . The mean age at diagnosis was 10 years comparable to the upward trend in age at diagnosis observed
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