Friday, December 28, 2007

Mastocytic Enterocolitis Associated Food Intolerance Missed Due to Lack of Special Stains of Intestinal Biopsies and Celiac Gene Testing?

Increased mast cells have been reported in association with eosinophils in the gut in patients with celiac disease and inflammatory bowel diseases like ulcerative colitis and Crohn’s disease condition. Mastocytic enterocolitis (entero=small bowel, colitis- colon + -itis= inflammation) is a newly recognized disorder defined specifically by the microscopic presence of increased mast cells (>20 mast cells/high power field) in the gut, typically associated with abdominal pain and diarrhea diagnosed as IBS-D.

Mast cells are a type of white blood cell important in immune defense. These “covert” cells are hard to see in the lining of the gut without special stains. Therefore, they have been not recognized as being increased in the gut until recently when this association was found with IBS.

Mast cells have granules that contain chemical mediators such as histamine. These mediators are released resulting in pain due to irritation of nerves. Diarrhea is most commonly noted but impairment of nerves can result in opposite effects on gut movement.

Since routinely looking for mast cells in small bowel and colon biopsies about a year ago I have diagnosed more 35 patients with mastocytic enterocolitis. Interestingly, there appears to be a very strong correlation of this condition with HLA DQ2 and DQ8, white blood cell protein pattern types genetically determined and inherited that are highly associated with celiac disease and gluten intolerance. In my experience, those with this condition have a high risk of gluten and other food protein sensitivity or intolerance. A combination of food elimination based on food allergy and sensitivity testing (Signet Diagnostic Corporation, MRT or Alcat food intolerance testing) with use of histamine blockers, oral steroids including budesonide (Entocort EC), or the mast cell stabilizer sodium Cromalyn (Gastrocrom).

Unfortunately, most patients undergoing evaluation for abdominal pain, diarrhea, gas-bloat or nausea either do not have biopsies of normal appearing intestinal tissue or that tissue is not stained with special stains to look for mast cells. As a result I believe many with this treatable condition are being missed despite undergoing invasive diagnostic endoscopy (scope) exams. Further studies are needed to look into the association of HLA DQ genetic patterns and the helpfulness of food intolerance tests combined with specific elimination diet based on these results.

I am attempting to get a research protocol designed, approved and funded to look into this link. There continues to accumulate mounting evidence of the role of food proteins, dietary yeast and gut bacteria and yeast in the development of a wide variety of symptoms and diseases, especially inflammatory bowel disorders including celiac disease, Crohn’s disease, ulcerative colitis, microscopic colitis, eosinophilic gastrointestinal disorders, and now irritable bowel syndrome. Our goal is a “healthy gut, healthy life” and to provide useful information to those who follow the Food Doc blog to achieve this goal.

Jakate S, Demeo M, John R, Tobin M, Keshavarzian A. “Mastocytic enterocolitis: increased mucosal mast cells in chronic intractable diarrhea.” Arch Pathol Lab Med. 2006 Mar;130(3):362-7.

Barbara G, Wang B, Stanghellini V, de Giorgio R, Cremon C, Di Nardo G, Trevisani M, Campi B, Geppetti P, Tonini M, Bunnett NW, Grundy D, Corinaldesi R. “Mast cell-dependent excitation of visceral-nociceptive sensory neurons in irritable bowel syndrome.” Gastroenterology. 2007 Jan;132(1):26-37.

Park JH, Rhee PL, Kim HS, Lee JH, Kim YH, Kim JJ, Rhee JC. “Mucosal mast cell counts correlate with visceral hypersensitivity in patients with diarrhea predominant irritable bowel syndrome.”
J Gastroenterol Hepatol. 2006 Jan;21(1 Pt 1):71-8.

Barbara G, Stanghellini V, De Giorgio R, Cremon C, Cottrell GS, Santini D, Pasquinelli G, Morselli-Labate AM, Grady EF, Bunnett NW, Collins SM, Corinaldesi R. “Activated mast cells in proximity to colonic nerves correlate with abdominal pain in irritable bowel syndrome.” Gastroenterology. 2004 Mar; 126(3):693-702.

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