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Introduction: McKittrick-Wheelock syndrome is a rare entity characterized by chronic diarrhea, acute kidney injury, and hydroelectrolytic imbalance associated with a large rectal tumor, frequently a villous adenoma. Case report: A 69-year-old male with chronic diarrhea with mucus. He underwent a colonoscopy with biopsies, reporting adenocarcinoma of the rectum in situ, and underwent a robot assisted intersphincteric resection with colo-anal anastomosis and a protecitive ileostomy. Discussion: Described in 1954, this syndrome is manifested by electrolyte imbalance and acute renal injury secondary to diarrhea associated with a rectal villous adenoma, often with long lasting symptoms. The most frequent symptom being watery diarrhea with mucus. The definitive treatment consists of surgical resection. Conclusion: Although this is a rare pathology, it should be considered as a differential diagnosis in cases of chronic diarrhea associated with water and electrolyte disorders. (AU)

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The objective of the present study was to evaluate the effects of increasing doses of protease on broilers from 1 to 42 days of age. A total of 1290 Ross AP broilers were used, distributed among five treatments: positive control diet, negative control diet (NC), NC + 50 ppm of protease, NC + 100 ppm of protease, and NC + 200 ppm of protease. Each treatment contained six replicates of 43 animals each. The inclusion of proteases in the diet had effects (P < 0.05) on body weight, feed intake, weight gain, and feed conversion in the 12 to 21 day period; body weight, weight gain, and feed intake in the 29 to 42 day period; nutrient digestibility (energy metabolizability coefficient and crude protein at 28 days); and intestinal parameters (crypt and muscle width of jejunum and ileum at 28 days and villus length, crypt length, and jejunum thickness muscle layer at 42 days). These results indicate that the inclusion of protease in broiler feed can improve production parameters when the amount of crude protein in the diet is reduced.

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Villous adenoma is a benign neoplasm with an exceptional presentation in the renal pelvis, hence very few cases have been reported. Herein we present the case of a patient who presented with left flank pain clinically suggestive of complicated pyelonephritis, culminating in simple nephrectomy with a villous adenoma in the renal pelvis as histopathological finding associated to the presence of a microscopic focus of intestinal-type adenocarcinoma.

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Villous adenoma is uncommonly seen in the urogenital tract and is even more rarely seen in the upper urinary tract and renal pelvis. Like colorectal adenomas, these neoplasms can transform into adenocarcinoma. The preoperative diagnosis is challenging due to their frequent association with hydronephrosis. Herein, we present the case of a villous adenoma of the renal pelvis in a 62-year-old man presenting with recurrent urinary tract infection. The computed tomography scan showed marked hydronephrosis but no suspicious mass in the right kidney. A laparoscopic right nephrectomy was performed. Gross examination revealed a dilated renal pelvis with an irregular exophytic lesion in the renal pelvis's upper surface. The histopathological examination showed slender, elongated villi with thin fibrovascular cores, consistent with villous adenoma morphology. Isolated villous adenomas have a favorable prognosis. However, the pathologist should undertake a search for an invasive component.

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Heme oxygenase-1 (HO-1) enzyme exerts beneficial effects at the maternal-fetal interface, especially in trophoblasts, being involved in survival and maturation of these cell phenotypes. Trophoblast cells play essential roles throughout pregnancy, being the gateway for pathogens vertically transmitted, such as Toxoplasma gondii. It was previously shown that HO-1 activity was involved in the control of T. gondii infection in vivo; however, its contribution in trophoblast cells during T. gondii infection, remain undefined. Thus, this study aimed to investigate the influence of HO-1 in T. gondii-infected BeWo and HTR-8/SVneo human trophoblast cells. For this purpose, trophoblast cells were infected and the HO-1 expression was evaluated. T. gondii-infected BeWo cells were treated with hemin or CoPPIX, as inducers of HO-1, or with bilirubin, an end-product of HO-1, and the parasitism was quantified. The involvement of p38 MAPK, a regulator of HO-1, and the cytokine production, were also evaluated. It was found that T. gondii decreased the HO-1 expression in BeWo but not in HTR-8/SVneo cells. When treated with the HO-1 inducers or bilirubin, BeWo cells reduced the parasite proliferation. T. gondii also decreased the p38 MAPK phosphorylation in BeWo cells; on the other hand, HO-1 induction sustained its activation. Finally, the IL-6 production was upregulated by HO-1 induction in T. gondii-infected cells, which was associated with the control of infection.

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Resumen Introducción: Los adenomas vellosos son lesiones del tubo digestivo con tendencia alta a la malignidad. Su ubicación en parches de mucosa gástrica ectópica en el esófago cervical determina una presentación atípica de interés tanto clínico como patológico. Objetivo: Presentar un caso de adenoma velloso en la mucosa gástrica ectópica del esófago cervical. Métodos: Describir el caso de un paciente con diagnóstico de adenoma velloso y realizar una revisión de la literatura disponible hasta el momento. Resultados: Se identificó mediante un estudio histopatológico un adenoma tubulovelloso con displasia de bajo grado, cuya ubicación endoscópica era un parche de mucosa ectópica gástrica en el esófago cervical. Conclusiones: La ubicación de los adenomas vellosos en el esófago cervical puede predisponer al desarrollo de lesiones neoplásicas. La evaluación detallada de este segmento, con técnicas como la cromoendoscopia digital de alta definición, permiten la detección temprana de estas lesiones y su oportuna intervención.

Abstract Introduction: Villous adenomas are lesions of the digestive tract with a high tendency to malignancy. Its location in ectopic gastric mucosa patches in the cervical esophagus is an atypical presentation of clinical and pathological interest. Objective: To present a case of villous adenoma in ectopic gastric mucosa of the cervical esophagus. Methods: A case study of a patient with a diagnosis of villous adenoma is presented, as well as a review of the current literature. Results: A tubulovillous adenoma with low-grade dysplasia was identified by histopathological study. Its endoscopic location was a gastric ectopic mucosa patch in the cervical esophagus. Conclusions: The location of villous adenomas in the cervical esophagus may predispose to the development of neoplastic lesions. Detailed evaluation of this segment using techniques, such as high-definition digital chromoendoscopy, would allow for early detection and treatment of these lesions.

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Villous adenoma is uncommonly seen in the urogenital tract and is even more rarely seen in the upper urinary tract and renal pelvis. Like colorectal adenomas, these neoplasms can transform into adenocarcinoma. The preoperative diagnosis is challenging due to their frequent association with hydronephrosis. Herein, we present the case of a villous adenoma of the renal pelvis in a 62-year-old man presenting with recurrent urinary tract infection. The computed tomography scan showed marked hydronephrosis but no suspicious mass in the right kidney. A laparoscopic right nephrectomy was performed. Gross examination revealed a dilated renal pelvis with an irregular exophytic lesion in the renal pelvis's upper surface. The histopathological examination showed slender, elongated villi with thin fibrovascular cores, consistent with villous adenoma morphology. Isolated villous adenomas have a favorable prognosis. However, the pathologist should undertake a search for an invasive component.

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The safety and bioactive potential of crude carotenoid extract from Cantaloupe melon nanoencapsulated in porcine gelatin (EPG) were evaluated in a chronic inflammatory experimental model. Animals were fed a high glycemic index and high glycemic load (HGLI) diet for 17 weeks and treated for ten days with 1) HGLI diet, 2) standard diet, 3) HGLI diet + crude carotenoid extract (CE) (12.5 mg/kg), and 4) HGLI diet + EPG (50 mg/kg). General toxicity signals were investigated, considering body weight, food intake, hematological, biochemical parameters, relative weight, morphology, and histopathology of organs. The biochemical parameters indicated the low toxicity of EPG. Acute hepatitis was observed in animals' livers, but CE and EPG groups presented improved tissue appearance. Chronic enteritis was observed in animals, with villi and intestinal glands preservation in the EPG group. The results suggest the safety and the bioactive effect of EPG, possibly related to its anti-inflammatory potential.

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SUMMARY Tubulovillous adenomas of the duodenal ampulla are rare neoplasms. The present report describes a case with radiological-endoscopic and pathological correlation in which the patient underwent duodenal pancreatectomy with good postoperative progression. With advanced imaging methods, especially magnetic resonance and endoscopic ultrasound, locoregional aspects and extraluminal, lymphovascular, and metastatic invasion have been increasingly discussed as contributors to therapeutic decision making. This progression improves lesion staging and is especially useful in selecting eligible candidates for endoscopic treatment.

RESUMO Os adenomas túbulo-vilosos da ampola duodenal são neoplasias raras. Neste trabalho apresentamos um caso com correlação radiológico-endoscópica e patológica, tendo a paciente sido submetida à duodenopancreatectomia com boa evolução pós-operatória. Com os avanços dos métodos de imagem, em especial da ressonância magnética e ultrassonografia endoscópica, aspectos locorregionais, além da invasão extraluminal, linfovascular e metastática, têm sido discutidos de maneira crescente como contribuintes na decisão terapêutica. Essa evolução contribui para o melhor estadiamento destas lesões e é especialmente útil para selecionar candidatos elegíveis ao tratamento endoscópico.

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La Lipomatosis Sinovial es una entidad poco frecuente de la membrana sinovial, afecta con mayor frecuencia a la articulación de la rodilla, pudiendo presentarse en otras articulaciones. Ocurre en varones de la 5° o 6° década de la vida, de presentación monoarticular habitual. Su etiología es desconocida, pero se apoya un proceso reactivo más que neoplásico. Esta enfermedad tiene una morfología radiológica, macroscópica y microscópica característicamente arborescente, por infiltración adiposa del tejido subsinovial, que es clave para su diagnóstico. Presentamos el caso de un varón de 63 años, realizándose revisión de los hallazgos radiológicos y patológicos, así como su diagnóstico diferencial con otras entidades y su tratamiento.

Synovial Lipomatosis is a rare entity of the synovial membrane, most often affects the knee joint, and can occur in other joints. It occurs in 5th or 6th decade of life, men of usual monoarticular presentation. Its etiology is unknown and there is more a reactive process rather than neoplastic. This disease has a characteristically arborescent radiological, macroscopic and microscopic morphology, due to adipose infiltration of the subsinovial tissue, which is key for its diagnosis. We present the case of a 63-year-old male, reviewing the radiological and pathological findings, as well as its differential diagnosis with other entities and their treatment.

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Los adenomas vellosos pueden manifestarse con sangrado, diarrea, alteraciones hidroelectrolíticas (síndrome Mackittrick-Weelock), obstrucción intestinal, y, muy infrecuentemente, condicionar un prolapso rectal. El prolapso rectal es la protrusión de la pared completa del recto a través del canal anal, su presentación como prolapso rectal incarcerado es poco habitual. Cuando la reducción manual no es posible, la rectosigmoidectomía vía perineal o procedimiento de Altemeier es una buena opción quirúrgica; como alternativa puede realizarse una resección transanal del pólipo y la posterior reducción manual del prolapso rectal. Referiremos el caso de una mujer que acude al Servicio de urgencias presentando un prolapso rectal incarcerado con una masa ulcerada, friable, de 10 × 8 × 5 cm compatible con un pólipo velloso en la cara posterior del recto. Ante la imposibilidad de reducirlo se decide una resección transanal del pólipo con posterior reducción manual del prolapso rectal. Este caso es de interés por la infrecuente asociación entre un prolapso rectal incarcerado y un pólipo velloso gigante, con solo 4 casos comunicados en la literatura.

Villous adenomas may present with bleeding, diarrhea, electrolyte imbalance (Mackittrick-Weelock syndrome), obstruction, being a very rare cause of rectal prolapse. Rectal prolapse is a full thickness protrusion of the rectum through the anal canal and its presentation as an incarcerated rectal prolapse is very infrequent. If manual reduction is deemed impossible, perineal recto-sigmoidectomy, or Altemeier's procedure, is one of the best surgical options, as an alternative transanal excision of the polyp could be performed with subsequent manual reduction of the rectal prolapse. We report the case of a female patient, admitted to the emergency room presenting an incarcerated rectal prolapse with a friable ulcerated mass of 10 × 8 × 5 cm, compatible with a villous polyp in the back side of the rectum. Since manual reduction was considered not feasible, surgery was decided and a transanal excision of the polyp was performed, following a successful manual reduction of the rectal prolapse. This case is of particular interest for its unusual association of incarcerated rectal prolapse due to a giant villous adenoma, having only 4 cases been reported in the literature.

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Congenital toxoplasmosis is a serious health problem that can lead to miscarriage. HTR-8/SVneo is a first trimester extravillous trophoblast, while BeWo is a choriocarcinoma with properties of villous trophoblast cells. In the placenta, iron is taken up from Fe-transferrin through the transferrin receptor being the ion an important nutrient during pregnancy and also for Toxoplasma gondii proliferation. The aim of this study was to evaluate the role of iron in T. gondii proliferation in BeWo and HTR-8/SVneo cells and in human chorionic villous explants. The cells were infected with T. gondii, iron supplemented or deprived by holo-transferrin or deferoxamine, respectively, and parasite proliferation and genes related to iron balance were analyzed. It was verified that the addition of holo-transferrin increased, and DFO decreased the parasite multiplication in both trophoblastic cells, however, in a more expressive manner in HTR-8/SVneo, indicating that the parasite depends on iron storage in trophoblastic cells for its growth. Also, tachyzoites pretread with DFO proliferate normally in trophoblastic cells demonstrating that DFO itself does not interfere with parasite proliferation. Additionally, T. gondii infection induced enhancement in transferrin receptor mRNA expression levels in trophoblastic cells, and the expression was higher in HTR-8/SVneo compared with BeWo. Finally, DFO-treatment was able to reduce the parasite replication in villous explants. Thus, the iron supplementation can be a double-edged sword; in one hand, it could improve the supplement of an essential ion to embryo/fetus development, and on the other hand, could improve the parasite proliferation enhancing the risk of congenital infection.

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BACKGROUND: Cardiac myxomas are the most frequent cardiac tumors. Although histologically benign, in some cases myxomas may be lethal, due to impairment of cardiac dynamics and their thromboembolic potential. The study aimed to assess the clinical presentation of cardiac myxomas and their correlation with echocardiographic features and to describe the perioperative results and long-term outcome of surgically treated patients. METHODS: A prospective study of 53 patients with cardiac myxomas who were operated the Hospital Argerich, followed clinically and with echocardiography from 1993 until 2013. All patients underwent echocardiographic studies. RESULTS: The patient's mean age was 53 ± 16 years (62.3% were women). The most common findings were dyspnea followed by embolic events. Most tumors were localized in the left atrium (77.4%), mainly in the fossa ovalis (63%). Mean size of the tumors was 4.76 x 3.50 cm. Tumors were generally mobile (88%) and went beyond the valve plane, causing mild mitral or tricuspid valve obstruction (58%) and dilation of the respective atrial chamber. Patients whose tumors were obstructive had higher pulmonary artery systolic pressures (50 vs 33 mmHg p < 0.01). According to the echocardiographic appearance 67% of tumors had a smooth surface and the remaining 32% had a villous surface. All patients with embolic manifestations had tumors with a villous surface. CONCLUSIONS: Clinical presentation relates to the ultrasound characteristics of myxomas. Smooth tumors are larger, occur with obstructive symptoms, and benefit from an elective surgery, whereas villous myxomas entailed a high embolic risk and require prompt surgical treatment.

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BACKGROUND: Toxoplasma gondii is a protozoan parasite that causes congenital toxoplasmosis by transplacental transmission. Parasite strains are genetically diverse and disease severity is related to the genotype. In Uberlândia city, Brazil, two virulent strains were isolated: TgChBrUD1 and TgChBrUD2. Congenital toxoplasmosis is more prevalent in South America compared to Europe, and more often associated with severe symptoms, usually as a result of infection with atypical strains. METHODS: Considering that T. gondii has shown high genetic diversity in Brazil, the effectiveness of traditional treatment may not be the same, as more virulent strains of atypical genotypes may predominate. Thus, the aim of this study were to evaluate the Brazilian strain infection rate in human villous explants and the azithromycin efficacy with regard to the control of these strains compared to traditional therapy. Villi were infected with RH, ME49, TgChBrUD1 or TgChBrUD2 strains and treated with azithromycin, spiramycin or a combination of pyrimethamine plus sulfadiazine. The villous viability was analyzed by LDH assay and morphological analysis. Parasite proliferation, as well as production of cytokines was analyzed by qPCR and ELISA, respectively. Statistical analysis was performed using the GraphPad Prism 5.0. RESULTS: The treatments were not toxic and TgChBrUD1 infected villi showed a higher parasite burden compared with others strains. Treatments significantly reduced the intracellular proliferation of T. gondii, regardless of the strain. TgChBrUD1-infected villi produced a larger amount of MIF, IL-6 and TGF-ß1 compared with other infected villi. Azithromycin treatment increased MIF production by RH- or TgChBrUD2-infected villi, but in ME49- or TgChBrUD1-infected villi, the MIF production was not altered by treatment. On the other hand, azithromycin treatment induced lower IL-6 production by ME49- or TgChBrUD1-infected villi. CONCLUSIONS: Azithromycin treatment was effective against T. gondii Brazilian strains compared with conventional treatment. Also, the TgChBrUD1 strain replicated more in villi and modulated important cytokines involved in parasite control, showing that different strains use different strategies to evade the host immune response and ensure their survival.

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Accumulated evidence suggests that an abnormal placentation and an altered expression of a variety of trophoblast transporters are associated to preeclampsia. In this regard, an abnormal expression of AQP3 and AQP9 was reported in these placentas. Recent data suggests that placental AQPs are not only water channel proteins and that may participate in relevant processes required for a normal placental development, such as cell migration and apoptosis. Recently we reported that a normal expression of AQP3 is required for the migration of extravillous trophoblast (EVT) cells. Thus, alterations in this protein might lead to an insufficient transformation of the maternal spiral arteries resulting in fluctuations of oxygen tension, a potent stimulus for oxidative damage and trophoblast apoptosis. In this context, the increase of oxygen and nitrogen reactive species could nitrate AQP9, producing the accumulation of a non-functional protein affecting the survival of the villous trophoblast (VT). This may trigger the exacerbated release of apoptotic VT fragments into maternal circulation producing the systemic endothelial dysfunction underlying the maternal syndrome. Therefore, our hypothesis is that the alteration in the expression of placental AQPs observed at the end of gestation may take place during the trophoblast stem cell differentiation, disturbing both EVT and VT cells development, or during the VT differentiation and turnover. In both situations, VT is affected and at last the maternal vascular system is activated leading to the clinical manifestations of preeclampsia.

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Resumen: Desde que inició la toma de biopsias a través de métodos endoscópicos para el diagnóstico de enfermedad celíaca (EC), se ha intentado describir distintos marcadores macroscópicamente visibles que sugirieran o confirmaran la presencia de atrofia vellositaria en la zona estudiada. Algunos de estos signos son altamente específicos pero su sensibilidad es baja por lo que, por si solos, tienen escaso valor en el algoritmo diagnóstico. El objetivo de esta revisión es analizar la evidencia científica existente sobre la utilidad de las nuevas tecnologías y técnicas endoscópicas en la identificación de marcadores de atrofia vellositaria en el diagnóstico y seguimiento de la enfermedad celíaca Método. Se llevó a cabo una revisión descriptiva de bibliografía donde se buscaron artículos originales en las bases de datos Pubmed y LILACS en el periodo 2006-2016. Resultados. El valor de la cromoendoscopía digital para la búsqueda de marcadores endoscópicos de atrofia vellositaria ha sido escasamente estudiado La sensibilidad de NBI con magnificación se estima entre 83 y 95%. Los únicos trabajos con OBI e I-Scan evidenciaron especificidad y sensibilidad perfectas, pero únicamente en pacientes con alta probabilidad de ser celiacos o portadores de atrofia severa. Con respecto a la microscopía endoscópica, la endocitoscopía no parece mejorar el desempeño de la endoscopía de manera significativa, sin embargo, con solo dos trabajos con bajo número de pacientes, la endomicroscopía laser confocal ha mostrado mayor sensibilidad en la detección de marcadores de atrofia. La VCE tiene alta especificidad (95-100%) pero menor sensibilidad (89%) y su mayor utilidad se encuentra en objetivar alteraciones que están más allá del alcance de la endoscopía tradicional y valorar su extensión. No existen trabajos que evalúen específicamente su presencia con enteroscopía doble balón, balón único o espiral. Conclusiones. Algunas de las nuevas técnicas y tecnologías parecen ser altamente específicas pero poco sensibles en la detección de marcadores endoscópicos de atrofia vellositaria. Son necesarios más estudios para determinar el valor de técnicas de microscopía endoscópica como herramienta diagnóstica a futuro.

Abstract: Since endoscopic methods are used for biopsying the duodenum at diagnosis or follow-up in celiac disease, attempts have been made to find macroscopically visible markers that suggest or confirm the presence of villous atrophy in the studied area. Some of these signs are highly specific but their sensitivity is low so that, if alone, they have little value in the diagnostic algorithm. The objective of this review is to analyze the existing scientific evidence on the usefulness of new technologies and endoscopic techniques in the identification of markers of villous atrophy in the diagnosis and follow-up of celiac disease. Method. A descriptive review of literature was conducted, where original articles were sought in Pubmed and LILACS databases in the period 2006-2016. Results. The value of digital chromoendoscopy for the search of endoscopic markers of villous atrophy has barely been studied. Sensitivity of NBI with magnification is estimated between 83 and 95%. The only studies with OBI and I-Scan showed perfect specificity and sensitivity, but only in patients with high probability of being celiac or with severe atrophy. Regarding endoscopic microscopy, endocytoscopy does not seem to improve performance in a significant way, however, with only two studies with a small number of patients, confocal laser endomicroscopy has shown greater sensitivity in the detection of atrophy markers. The VCE has high specificity (100%) but low sensitivity and its greatest utility is finding alterations that are beyond the scope of traditional endoscopy and assess its extent. There are no studies that specifically evaluate the presence of the same signs with double balloon enteroscopy, single balloon or spiral. Conclusions. Some of the new techniques and technologies appear to be highly specific but less sensitive in the detection of endoscopic markers of villous atrophy. More studies are needed to determine the value of endoscopic microscopy techniques as a diagnostic tool in the future.

Resumo: Desde o início das biópsias através de métodos endoscópicos para o diagnóstico de CD, uma tentativa foi feita para descrever diferentes marcadores macroscopicamente visíveis que sugerem ou confirmam a presença de atrofia vilosa na área estudada. Alguns desses sinais são altamente específicos, mas sua sensibilidade é baixa, por si só, eles têm pouco valor no algoritmo de diagnóstico. O objetivo desta revisão é analisar a evidência científica existente sobre a utilidade de novas tecnologias e técnicas endoscópicas na identificação de marcadores de atrofia vilosa no diagnóstico e monitoramento da doença celíaca. Método. Foi realizada uma revisão descritiva da literatura onde os artigos originais foram pesquisados ​​nas bases de dados Pubmed e LILACS no período 2006-2016. Resultados. O valor da cromoendoscopia digital para a busca de marcadores endoscópicos de atrofia vilosa foi mal estudado. A sensibilidade do NBI com ampliação é estimada entre 83 e 95%. O único trabalho com OBI e I-Scan mostrou especificidade e sensibilidade perfeita, mas apenas em pacientes com alta probabilidade de serem celíacos ou portadores de atrofia grave. Em relação à microscopia endoscópica, a endocitoscopia não parece melhorar o desempenho da endoscopia de forma significativa, no entanto, com apenas dois estudos com um número reduzido de pacientes, a endomicroscopia confocal laser mostrou maior sensibilidade na detecção de marcadores de atrofia. O VCE tem alta especificidade (95-100%), mas menor sensibilidade (89%) e sua maior utilidade é objetivar alterações que estão além do alcance da endoscopia tradicional e avaliam sua extensão. Não há estudos que avaliem especificamente sua presença com balão duplo, bola única ou enteroscopia espiral. Conclusões. Algumas das novas técnicas e tecnologias parecem ser altamente específicas, mas não muito sensíveis na detecção de marcadores endoscópicos de atrofia vilosa. Mais estudos são necessários para determinar o valor das técnicas de microscopia endoscópica como ferramenta de diagnóstico no futuro.

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McKittrick-Wheelock syndrome is caused by chronic water and electrolyte hypersecretion from an intestinal tumor, usually a villous adenoma, located in the rectum or sigmoid. Patients often have dehydration, hypovolemic shock and kidney failure associated with hypokalemia, hyponatremia, hypochloremia and metabolic acidosis. We report a 62-year-old male, suffering chronic diarrhea for eight years who was admitted after a syncope. He had severe hypokalemia, hyponatremia, metabolic acidosis, hypovolemia and acute renal failure. After his metabolic disorders were corrected, a colonoscopy showed a large rectosigmoid tumor with the characteristics of a villous adenoma. During the follow up after the complete tumor resection, the patient has remained asymptomatic.

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OBJECTIVE: To assess whether children at risk for celiac disease should be screened systematically by comparing their baseline and follow-up characteristics to patients detected because of clinical suspicion. STUDY DESIGN: Five hundred four children with celiac disease were divided into screen-detected (n = 145) and clinically detected cohorts (n = 359). The groups were compared for clinical, serologic, and histologic characteristics and laboratory values. Follow-up data regarding adherence and response to gluten-free diet were compared. Subgroup analyses were made between asymptomatic and symptomatic screen-detected patients. RESULTS: Of screen-detected patients, 51.8% had symptoms at diagnosis, although these were milder than in clinically detected children (P < .001). Anemia (7.1% vs 22.9%, P < .001) and poor growth (15.7% vs 36.9%, P < .001) were more common, and hemoglobin (126 g/l vs 124 g/l, P = .008) and albumin (41.0 g/l vs 38.0 g/l, P = .016) were lower in clinically detected patients. There were no differences in serology or histology between the groups. Screen-detected children had better dietary adherence (91.2% vs 83.2%, P = .047). The groups showed equal clinical response (97.5% vs 96.2%, P = .766) to the gluten-free diet. In subgroup analysis among screen-detected children, asymptomatic patients were older than symptomatic (9.0 vs 5.8 years of age, P = .007), but the groups were comparable in other variables. CONCLUSIONS: More than one-half of the screen-detected patients with celiac disease had symptoms unrecognized at diagnosis. The severity of histologic damage, antibody levels, dietary adherence, and response to treatment in screen-detected cases is comparable with those detected on a clinical basis. The results support active screening for celiac disease among at-risk children.

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La diarrea es un efecto secundario habitual a la toma de fármacos, y en algunas ocasiones la enteropatía perdedora de proteínas tipo "sprue like" puede estar detrás de esta patología. El estudio de esta enfermedad puede suponer un desafío importante para el clínico, sobre todo en los casos que cursan con serología negativa para enfermedad celiaca. La atrofia vellositaria duodenal secundaria a la ingesta de micofenolato-mofetil y metotrexate es bien conocida y descrita desde hace tiempo, pero desde la inclusión en la posológica habitual de olmesartán como antihipertensivo de primera elección hemos objetivado un repunte importante de esta entidad. Debido al amplio uso de esta medicación, queremos poner de manifiesto esta enteropatía iatrogénica a través de dos casos clínicos ocurridos en nuestro hospital en 2014.(AU()

Diarrhea is a common side effect of medical treatment. "Sprue like" enteropathy may be behind this pathology. The study of this disease can be an important clinical challenge, especially in those cases with negative serology for celiac disease. Duodenal villous atrophy secondary to the intake of mycophenolate mofetil and methotrexate have been well known and described but since the inclusion of olmesartán as a first-line antihypertensive, we have seen an important rebound of this entity. Due to the wide use of this medication we want to report this iatrogenic effect through two clinical cases that occurred in our hospital in 2014.(AU)

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A enteropatia induzida por olmesartana é uma entidade reconhecida recentemente como diagnóstico diferencial de atrofia vilosa. A apresentação clínica é semelhante à doença celíaca, porém a não resposta à retirada do glúten e sorologia antitransglutaminase negativa são chaves para o diagnóstico diferencial. A fisiopatologia é incerta, havendo especulações quanto à predisposição genética e mecanismo de ação da própria droga. A melhora clínica e histológica após a suspensão da medicação é a principal característica. Aqui reportamos um caso de enteropatia induzida por olmesartana de apresentação clínica aguda.(AU)

The olmesartan induced enteropathy is a recently recognized entity in the differential diagnosis of villous atrophy. The clinical presentation is similar to celiac disease, but transglutaminase negative sorology and noimprovement after gluten removal are key to the differential diagnosis. The pathophysiology is uncertain, withspeculations about genetic predisposition and the medication's mechanism of action itself. The clinical and histological improvement after drug discontinuation is the main feature. Here we report a case of Olmesartaninduced enteropathy with acute clinical presentation.(AU)

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