Allergic GI diseases, Allergic rhinitis, Conjunctivits Flashcards
How to test for IgE mediated food allergies
- skin prick test
- specific IgE
How to test for non-IgE mediated food allergies
- atopy patch test
Food allergy classification
IgE mediated
- immediate GI hypersensitivity
- Pollen associated allergy syndrome
non-IgE mediated disorders
- food protin induced enterocolitis syndrome (FPIES)
- food protein induced allergic proctolitis (AP)
- food protein enteropathy
mixed IgE and cell-mediated
- eosinophilic esophagitis
- eosinophilic gastritis
- eosinophilic gastroenteritis
- Eosinophilic colitis
Immediete gastrointestinal hypersensitivity
- igE mediated mast cell degranulation
- nausea, vomiting, diarrhea, colic or abdominal pain within minutes to 2 hours after ingestions
- latent allergen exposure: vomiting may be followed by anorexia, poor weight gain, abdominal pain and colic
Immediete gastrointestinal hypersensitivity
- diagnosis and treatment
- Sensitization to the food
- Oral food challenge
Treatment:
- dietary therapy
Oral allergy syndrome
IgE mediated mast cell degranulation
- itching, burning, erythema or tingling of the lips, tongue, palate or oropharynx wihtin minutes or during raw allergen ingestions
- resolution shortly afterwards
Oral allergy syndrome
- diagnosis and treatmetn
- sensitization to the plant food
- Sensitization to pollen
- Correlation between the plan food(s) in question and pollens to which the patient is sensitizes
+/- oral food challenge
Treatment:
avoidance of raw foods
Eosinophilic esophagitis
- T-cell and IgE mediated mechanisms
- feeding dysfunction, vomiting, abdominal or chest pain, dysphagia, odynophagia, food impaction
Eosinophilic esophagitis
- diagnosis and treatment
- Endoscopic abnormalities
- Histopathological abnormalities
+/- sensitization to food
+/- oral food challenge
Treatment
- Dietary therapy
- PPI
- Local glucocorticoids
Eosinophilic gastritis and Gastroenterocolitis
- T-cell and IgE mediated mechanisms
1. Mucosal: nausea, vomiting, abdominal pain and diarrhea; ot may be associated with occult blood loss, iron deficiency anemia, protein losing enteropathy, failure to thrive
2. Muscular: obstructuve symtpoms, mimicking pyloric stenosis or thickening of the gastric outlet
3. Serosal: asites and abdominal pain
Eosinophilic gastritis and Gastroenterocolitis
- diagnosis and treatment
- Endoscopic abnormalities
- Histopathological abnormalities
+/- sensitization to food
+/- oral food challenge
Treatment:
- Cromolyn
- Systemic glucocorticoids
Eosinophilic esophagitis endoscopic signs
- edema
- rings
- white exudate
- furrows
- strictures
- combination
Eosinophilic gastroenteritis endoscopic signs
nodularity and polypoid mucosa of tha antrum
Eosinophilic esophagitis histologic signs
- over 15 eosinophis/ HPF
- over 20 eosinophils/ HPF
- fibrosis
- eosinophil degranulation
- basal layer hyperplasia
- microabscess
Eosinophilic gastroenteritis histologic signs
- over 30 eosinophils/ HPF
Food protein-induced enterocilitis syndrome (FPIES)
- t-cell mediated mechanisms
ACUTE
- repetitive vomiting and lethargy 1-3 hours, ill appearing, hypotensive, diarrhea within 2 to 10 hours, dehydration, pallor, hypothermia
CHRONIC
- diarrhea, occasional mucus, abdominal distention, intermittent comiting, dehydration and lethary, failure to rhive and poor weight gain, weight loss, enamia, hypoproteinemia and hypoalbuminemia
Food protein-induced enterocilitis syndrome (FPIES)
- diagnosis and treatment
Diagnosis:
- elimination diet
+/- sensitization to the food (SPT, APT)
+/- oral food challenge
treatment
- dietary therapy
- emergency plan
Food protein induced allergic proctolitis (AP)
- t-cell mediated
- multiple daily stools with visible blood, mucous-streaked stools that are hemoccult positive, infrequent stools with occasional bleeding
Food protein induced allergic proctolitis (AP)
- diagnosis and treatment
diagnosis - elimination diet - reintroduction at home \+/- microscopic stool exam \+/- CBC
treatment
- dietary therapy
Foor protein- induced enterophaty (FPE)
- t- cell mediated
- diarrhea, failure to thrive , emesis and abdominal distention, malabsorption with steatorrhea, lack of acute symtpoms
Foor protein- induced enterophaty (FPE)
- diagnosis and treatment
diagnosis:
- laboratory studies to confirm malabsorption
- moderate anemia
- hypoproteinemia
- prolonged coagulation time
- jejunal biopsies with villous atrophy and crypt hyperplasia
treatment:
- dietary therapy
FPIES emergency treatment plan
MILD (1-2 epidoses of emesis and no or mild lethargy)
- oral rehydration and treating with antiemetic if patient is over 6 months old
MODERATE (> 3 episodes of emesis with or without moderate lethargy)
- ondansetron (antiemetic) if patient is > 6 mo
- peripheral iv line with saline
SEVERE (> 3 episodes of emesis, severe lethargy, hypotonia and/or cyanotic appearance)
- peripheral iv line with saline
- methylprednisolone
- epihenphrine i.m.
- correct electrolyte abnormalities
- noninvasive monitoring of BP and HR
Which formula to choose?
AAF: anaphylaxis, FPIES, cow’s milk protein induced enteropathy
eHF: urticaria, eczema, immediate GI allergy, eosinophilic esophagitis, GERD, cow milk protein induced gastroenteritis and proctolitis, colic, constipation/diarrhea
Allergic rhinoconjunctivitis symptoms
two or more symptoms that last > 1 hours
- rhinorrhea
- sneezing (often paroxysmal)
- stuffy nose
- itching of nose
- dennie-morgan lines
- allergic shinners
- conjunctival erythema
- +/- conjunctivitis
- +/- itching og palate/ inner ear
Symtpoms of allergic rhintitis
- nasal crease
- allergic salute
- cobblestoning on the back of the pharynx –> hypertrophied lymphoid tissue
- postnasal drip
- nasal discharge
- edemic/ hypertrophied lower nasan conchae
- serous otitis
- allergic shinners
- recesses lower jaw
Indications for nasal provocation challange
- local allergic rhinitis
- occupational rhinitis
- unclear cases
- to monitor the effectiveness of immunotherapy
Classification of rhinitis (duration)
- intermittent: symptoms < 4 days per week or < 4 consecutive weeks
- persistent: symptoms > 4 days of week and > 4 consecutive weeks
Classification of rhinitis (severity)
MILD (all of the following)
- normal sleep
- no impairment of daily activities
- no impairment of work/ school
- symptoms present but not troublesome
MODERATE/ SEVERE (one or more)
- distrubed sleep
- impairment of daily activitities
- impairment of work/school
- troublesome symptoms
Allergic rhinitis treatment optione
- allergen avoidane
- pharmaceutical treatment - symptomatic treatmnt
- immunotherapy - etiological treatment
Assessment of control in untreated symptomatic patient
VAS < 5 --> initiate treatment (anti H1, INCS, INCS + AZE) VAS > 5 --> intermittent: (like above) --> persistnet (INCS or INCS+ AZA)
reassess VAS daily up to D3
VAS < 5
–> if symtpomatic: continue treatment
–> if no symtpoms: consider step down treatment
VAS > 5
–> step up and re-assess VAS daily up to D7
– > if VAs is then still over 5, consider SIT
Allergen-specific immunotherpay (ASIT)
- only etiological treatment
- desensitization of the immune system by introducing an allergen in very small doses
- main types: sublingual and subcutaneous
- duration of treatment: 3-5 years
- treatment targets: children from 5 years old
ASIT indications
- symptoms strongly suggestive or AR with or without conjunctivitis
- there is evidence of IgE sensitization
- experience moderate-to-severe symptoms which interfere with suual activities
ASIT contraindications
- uncontrolled or severe asthma
- systemic autoimmune disorders
- active malignant neoplasia
- initiation udring pregnancy
Complications of allergic rhinitis
- recurrent sinusitis, nasal polyps, chronic nasal discharge
- persistent or chronic cough
- eustachian tube dysfunction
- secondary serous otitis
- overbite
- sleep disorders and apnea
- reduction in quality of life
Ocular allergy classification
OCULAR NON ALLERGIC HYPERSENSITIVITY
- irritative conjunctivitis
OCLAR ALLERGY
- -> IgE mediated
- seasonal and perennial allergic conjunctivitis
- vernal keratoconjunctivitis
- atopic keratoconjunctivitis
- -> non IgE mediated
- contact blepharoconjunctivitis
- vernal keratoconjunctivitis
- atopic keratoconjunctivitis
Seasonal allergic conjunctivitis symptoms
- intermittent itching
- tearing
- conjunctivan redness
- eyelid swelling
- small papillary hpyertrophy of tarsal conjunctiva
Perennial allergic conjunctivitis symptoms
- all.year rounds similar to seasonal
Vernal keratoconjunctivitis symptoms
- intense itching
- tearing
- photophobia
- corneal involvement may resolve with different leels of scarring
Atopic keratoconjunctivitis symptoms
- eczematous lesions of the eyelids
- conjunctival redness
- limbus and cornea can be involved
Contact Blepharoconjunctivitis symptoms
- itching and burning of the eyelid
- edema
- eyelid skin redness
- eczema or lichenification
- conjunctival redness
- papillae
Ocular allergy classification according to duration
- intermittent (< 4 days pr week or < 4 weeks)
- persistent (> 4 days per week and > 4 weeks)
Ocular allergy classification according to severity
- vision distrubance
- impairment of daily activities
- impairment of school or work
- troublesome symtpoms
mild: 0
Moderade: 1
Severe: 2 and more
IgE mediated ocular allergy treatment
- avoidance
- topical antihistamines, mast cell stabilizers, double-action durgs
- intranasal corticosteroids (should not be used if only ocular symptoms)
- topical vasoconstrictors
- systemic antihistamines in acute forms
- consider SIT
Persistent/ chronic (IgE- and non-IgE-mediated) ocular allergy treatment
- avoidance
- cold compresses, good eyelid hygiene and lubricants
- topical antihistamines, mast cell stabilizers, double-action durgs
- topical corticosteroids in acut4e exacerbations when cornea is involved
- topical cancineurin inhibitors
- systemic immunosuppressive treatment in refractory cases of AKC with visual treat –> cyclosporine
Non-IgE-mediated ocular allergy treatment
- avoidance
- eyelid hygiene
- emollients
- oral antihistamines
- topical antihistamiens
- topical calcineurin inhibitors
