Wednesday, January 18, 2017

Mast cell, leaky gut and body inflammation: A short primer.

Mast cells are cells that are fairly ubiquitous in the body. They contain a myriad of chemical mediators of inflammation including a large amount of histamine. Upon stimulus particularly real or perceived threat to the body mast cells undergo degranulation the releases these inflammatory mediators to defend the body against attack. There a times when the body is tricked by foreign proteins and/or ineffective barrier defense allows proteins to reach cells especially mast cells within the body triggering mast cell activation. An example of the latter is when the gut permeability is increased, i.e. a leaky gut condition exists. Proteins from foods, medications and/or microbes can get past the gut barrier and come in contact with cells, including mast cells triggering an inflammatory response. Mediators released by cells can act locally to cause pain and diarrhea or the mediators can circulate in the blood causing symptoms distant to the gut, such as in the brain, musculoskeletal system or skin. Intolerance to certain foods may manifest as symptoms as result of mediators released by intestinal infection fighting cells especially mast cells. An increase in the normal number of mast cells in intestinal lining can result in ongoing symptoms in the digestive system and the body systemically. Normally there are somewhere between 4-8 mast cells per high power field in the intestine. When the cells number greater than 20 per high power field as determined by special stains symptoms can arise that may respond to mast cell stabilizing medications ketotifen and sodium cromolyn. Blocking of histamine by type 1 (e.g. cetirizine/zyrtec) and type 2 antihistamines (e.g. ranitidine/zantac) can reduce symptoms as mast cells have abundant histamine. Leukotriene blockers (e.g. montelukast/singulair) also may help as mast cells secreted that inflammatory mediator as well. Ursodiol (Actigall) a hydrophilic bile acid also appears to reduce inflammation associated with mast cells. Mastocytic enterocolitis (MCE) is an increasingly recognized variant of irritable bowel syndrome (IBS) defined by increased mast cells in the intestine that may respond to such treatment regimen as outlined as well as elimination of foods that trigger reactions of food intolerance. I prefer to refer his condition in a broader term Mastocytic Inflammatory Bowel Disease (MIBD) to emphasize its inflammatory nature and response to mast cell specific anti-inflammatory medications. Interestingly mast cells have receptors for corticotrophin releasing hormone (CRH) also known as corticotrophin releasing factor (CRF) secreted by the pituitary gland in response to stress to simulate the adrenal glands for the “fight or flight” response. Therefore stress is also a potent trigger of intestinal mast cell activation supporting the brain gut connection to stress and gastrointestinal symptoms.

Thursday, January 12, 2017

Online Consutations Available Through HealthTap

Through a revolutionary app called HealthTap I will be able to offer online consultations. These are secure. You may access consultations from other specialists through HealthTap as well. My consults will be limited to the specialty of gastroenterology, diseases of the digestive tract. This technology will allow me to reach more people to help them achieve a healthy gut, healthy life. Appointments will be limited initially as my schedule is limited but depending on the demand and success of online visits versus in person visits as well as my ability to open up my schedule I hope to offer this service with more time slots. Check out for free advice & medical information from a huge network of physicians who are embracing the trend of digital/online medical care.

Tuesday, January 10, 2017

Celiac patients may have some reduced response to immunizations. The data is limited but anecdotal reports are common. Hepatitis B vaccination rates to immunization and/or loss of protective antibody as well as reduced response to booster have been reported. More research is needed and I am looking into question that has been posed to me on this issue. Below are two studies I have found. J. Pediatr. Gastroenterol. Nutr. 2015 Oct; 61(4):400-3. OBJECTIVE Previous studies have suggested that hepatitis B virus (HBV) vaccines may be less immunogenic in individuals with celiac disease (CD). A pre-S vaccine (Sci-B-Vac) has demonstrated superior immunogenicity compared with standard HBV vaccines in several diseases. We compared the short-term immunogenicity of a pre-S vaccine with a HBV vaccine (Engerix B) for repeat vaccination of seronegative, previously immunized patients with CD. METHODS Participants were 1 to 18-year-old children with CD who despite standard HBV vaccines in infancy had nonprotective hepatitis B surface antibody (HBs-Ab) concentrations (≤10 mIU/mL). Patients were randomized to receive either Engerix B or pre-S vaccine. HBs-Ab concentrations were measured 1 month after the first dose. For those who had not responded after 1 dose, measurement was repeated after the third dose. RESULTS Children (n = 82) were analyzed (42 pre-S vaccine and 40 Engerix B). Baseline characteristics were similar for both groups, including gluten-free diet status. Both arms showed high response rates following the first injection: 41 (98%) versus 35 (87%) for pre-S vaccine and Engerix B recipients, respectively (P = 0.08). All other patients responded when measured after dose 3. HBs-Ab concentrations (mIU/mL) were higher in the pre-S vaccine group (median 925, interquartile range [IQR] 424-1000) than the Engerix B group (median 363, IQR 106-996, P = 0.005). Twenty (48%) of the pre-S vaccine recipients were "high responders" (>1000 mIU/mL) versus 10 (25%) in Engerix B recipients (P = 0.008). CONCLUSIONS Both vaccines elicited adequate booster responses in most previously vaccinated patients with CD with nonprotective HBs-Ab concentrations. Pre-S vaccine administration resulted in higher Hbs-Ab concentrations. Our data suggest that a single dose of either vaccine is sufficient to raise titers to protective levels in most patients with CD. Long-term antibody persistence and immune memory to hepatitis B virus in adult celiac patients vaccinated as adolescents. Vaccine 2011 Jan 29; 29(5):1005-8. Aim of this study was to investigate the anti-HBs antibody persistence and immune memory to hepatitis B virus in adult celiacs vaccinated as adolescents and the effect of a booster administration in non-protected individuals. Eleven years after primary vaccination, the proportion of vaccinees with titres ≥ 10 mIU/ml and antibody geometric mean concentrations (GMCs) were lower among celiac patients than among controls (68.6% vs 91.7%, p<0.01; GMCs 29.38 mIU/ml vs 250.6 mIU/ml, p<0.001). Participants with anti-HBs below 10 mIU/ml received a booster dose and were retested 2 weeks later to assess the anamnestic response. Post-booster anti-HBs levels were still <10 mIU/ml in 71.4% celiacs and 25% controls (p<0.01). Our findings indicate that the prevalence of seroprotective levels of anti-HBs detected eleven years after primary immunization as well as the frequency of response to a booster dose of vaccine are lower in celiac patients compared to healthy controls.
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