Autoimmunity and approach to patients with complaints of bowel complaints

With lifestyle which we follow, irregular diet habits, smoking,alcohol and lack of sleep leads to major health problems.

Inflammatory bowel disease (IBD) represents a group of intestinal disorders that cause prolonged inflammation of the digestive tract.IBD can be debilitating and sometimes leads to life-threatening complications.Bowel disorder is one amongst the largest burning issues.

Two types are Crohn’s disease and Ulcerative colitis.

Crohn’s disease: Crohn’s disease seems to be an imbalance of the body’s own immune system (called an autoimmune reaction). The digestive system may be exposed to a virus or bacteria, triggering the body’s immune system to attack the invader, leading to an inflammatory response in the digestive system. It is thought that the immune system continues this inflammatory reaction after the virus or bacteria has been eliminated, resulting in persistent inflammation.

People with Crohn’s disease also seem to have other problems with their immune systems, such as food and environmental allergies, so that allergic reactions may also play a role in this disease.

ULCERATIVE COLITIS

Ulcerative colitis is caused by inflammation of the inner lining of an area of the digestive tract. The main difference between ulcerative colitis and Crohn’s disease is where in the digestive system the inflammation occurs. Unlike Crohn’s disease, which can affect any part of the digestive tract from mouth to anus, the inflammation of ulcerative colitis is limited to the colon and/or the rectum.

The Cause

Like Crohn’s disease, it is thought that the body’s own immune system reacts to an invading bacteria or virus, causing inflammation, and that this inflammatory reaction cannot stop itself, leading to the development of ulcerative colitis.

What is to be done?

The commonest diagnostic step apart from a complete blood count, CRP, Stool for occult blood may be wait , but the first step would be endoscopy to look at the intestines and biopsy.

But with access to self medication and multiple factors lead to delay in approaching the GI specialist, thus the picture of the endoscopy and the biopsy also changes. The ideal book picture of Crohn’s or UC is not seen in cases.

There are two blood investigations which are non-invasive and can assist the clinicians in ruling our or in for the case of IBD.

The first and foremost is Fecal Calprotectin

Calprotectin is highly specific for IBD. If positive titre then we are definitively looking at IBD , if negative we rule out IBD. These are the cases were we can think of Irritable Bowel Syndrome-IBS.

What is differentiating factor…

Fecal Calprotectin- is a biochemical measurement of the protein calprotectin in the stool.

Elevated faecal calprotectin indicates the migration of neutrophils to the intestinal mucosa, which occurs during intestinal inflammation, including inflammation caused by inflammatory bowel disease.

Why to use Calprotectin?

Calprotectin assay in stool offers significant advantages in the evaluation of intestinal

inflammation.

It has been observed that Calprotectin is extremely stable in faeces, even for

more than 7 days, at room temperature.

The second is a Autoimmune panel which are now available as Indirect Immunofluroscent biochips ( IIFT test ) with combinations of :

P- ANCA

Antibodies against Pancreatic Acini

Antibodies against Intestinal Goblet cells

Most confusing result is when the fecal calprotectin is borderline and one of the parameters in IIFT are positive , then ruling out intestinal tuberculosis is a must in our country.

Third option if all above parameters are not contributing then think about Celiac disease , because the clinical symtoms may overlap .One of the most definative tests are Endomysial antibodies and Anti-TTG antibodies .

Lastly , allergy is on rise and is gaining lot of significance. Again these cases present with vague symtoms. A simple test -Serum IGE is the frist line , if elevated then must be followed by allergens testing for food .

I have seen our patients suggesting if adviced for food allergy panel, they insist on vegetarian panel,quoting that they are strictly vegetarians. But doing the incomplete panel may misguide the patient and the clincian, because patient may be allergic to say for example prawns, but the similar protein may be cross reacting with some vegetarian proteins like Soya .

Finally ,proper clinical history, dietary habits, understanding the lifestyle of the patient is very helpful and critical.