CRIZA CELIACA CRDEI EUGEN, LAURA TRANDAFIR

Boala celiac (enteropatia prin sensibilizare la gluten) reprezint o afeciune enteral cronic produs de intolerana la gluten i caracterizat prin: sindrom de malabsorbie asociat cu atrofie vilozitar, rspuns clinic i morfologic la excluderea glutenului din alimentaie i reapariia semnelor clinice i/sau numai histologice dupa reintroducerea glutenului n alimentaie . n prezent boala celiac (BC) este definit ca o enteropatie mediat imun determinat de o sensibilitate permanent la gluten la indivizi susceptibili genetic. Clasic, BC debuteaz n jurul varstei de 18 luni. n cteva sptmni sau luni se contureaz triada clasic reprezentat de diaree cronic, abdomen mrit de volum i malnutriie. Criza celiac, cea mai sever form de manifestare a BC este rar ntlnit n prezent. Clinic se manifest prin diaree acut cu scaune apoase nsoit de sindrom de deshidratare acut cu evoluie spre oc hipovolemic i tulburari hidrolelectrolitice grave. Mecanismul fiziopatologic al crizei celiace este incomplet elucidat n prezent. Criza celiac poate fi o form de debut acut, fulminant a BC sau o evoluie rapid a simptomelor gastrointestinale, caracterizat prin semne i simptome de deshidratare acut sau malnutriie asociate cu hipoproteinemie i edem. Un grup de cercettori au reevaluat cazurile diagnosticate cu criz celiac din dou mari centre de cercetare (Celiac Center of the Beth Israel Deaconess Medical Center - Harvard Medical School, Mayo Clinic) i au ncercat s elucideze mecanismele fiziopatologice ale crizei celiace, criteriile de diagnostic i conduita terapeutic. n lotul studiat doisprezece pacieni erau cunoscui cu BC, iar n unsprezece cazuri criza celiac a fost forma de debut a BC. n 33% din cazuri biopsia duodenala a evideniat atrofie vilozitar total. Toi pacienii au prezentat semne sau simptome de deshidratare sever, insuficien renal i tulburri hidro-electrolitice. Toate cazurile au necesitat spitalizare i reechilibrare intravenoas hidro-electrolitic, ase pacieni au primit corticosteroizi i cinci pacieni nutriie parenteral total. Toi pacienii au rspuns pozitiv la tratamentul cu diet fr gluten pe termen lung. [7]

Pacienii diagnosticai cu criz celiac necesit spitalizare obligatorie cu reechilibrare hidro-electrolitic i acido-bazic (vezi tratamentul sindromului de deshidratare acut), cu corectarea hipocalcemiei, hipomagnezemiei, hipokaliemiei. Hipoproteinemia cu hipoalbuminemie necesit administrarea de albumin. Nutriia parenteral total se utilizeaz n caz de malnutriie i diaree sever. Corticoterapia (sistemic sau Prednison 1-2 mg/kg/zi pe o perioad scurt de timp) este necesar n unele situaii i scurteaz evoluia bolii. Antibioterapia se utilizeaz n caz de suprainfecie bacterian. Dup un interval de 1-3 zile de reechilibrare hidro-electrolitic i nutriie parenteral se reia treptat alimentaia oral. Ulterior, timp de 3-6 saptamani se va folosi un preparat delactozat de lapte (Novalac AD, Aptamil fara lactoza) pana la refacerea arhitecturii vilozitatilor intestinale si restabilirea tolerantei la lactoza. La pacienii cu intoleran tranzitorie la dizaharide se vor exclude din alimentaie dizaharidele (lactoza, zaharoza) timp de 3-6 sptmni. n caz de malabsorbie lipidic important se vor exclude i grsimile cu lan lung. Ulterior se vor trata anemia, rahitismul, se vor administra vitamine liposolubile (A, D, E, K). Bibliografie selectiv 1. Fasano A, Catassi C. Current approaches to diagnosis and treatment of celiac disease: an evolving spectrum. Gastroenterology 2001; 120:636-651. 2. Greco L. From the neolithic revolution to gluten intolerance: benefits and problems associated with the cultivation of wheat. J Pediatr Gastroenterol Nutr 1997; 24:S14-S16. 3. Trandafir Laura Mihaela Aspecte clinico-evolutive ale sindromului de malabsorbie la copil, UMF Gr.T.Popa Iai, 2004. 4. Farrell RJ, Kelly CP. Celiac sprue. N Engl J Med 2002; 346:180-188. 5. Ludvigsson JF, Ansved P, Falth-Magnusson K, et al. Symptoms and signs have changed in Swedish children with coeliac disease. J Pediatr Gastroenterol Nutr 2004; 38:181-186. 6. Steens RF, Csizmadia CG, George EK, et al. A national prospective study on childhood celiac disease in the Netherlands 1993-2000: an increasing recognition and a changing clinical picture. J Pediatr 2005; 147:239-243.

7. Jamma S, Rubio-Tapia A, Kelly C P, Murray J, Najarian R, Sheth S, Schuppan D, Leffler DA Celiac Crisis: A Rare but Serious Complication of Celiac Disease in Adults Clin Gastroenterol Hepatol. 2010;8(7):587-590. 8. Hess JH. Feeding and the Nutritional Disorders in Infancy and Childhood, 6th ed. Philadelphia: FA Davis; 1928. 9. Anderson DH, di Sant-Agnese PA. Idiopathic celiac disease: mode of onset and diagnosis. Pediatrics 1953; 11:207-221. 10. Adlersberg D, Gabriel JB, Himes HW. Previously underdescribed clinical and postmortem observations in non-tropical sprue: possible role of prolonged corticosteroid therapy. Gastroenterology 1957; 32:60-71. 11. Lloyd-Still JD, Grand RJ, Khaw KT, et al. The use of corticosteroids in celiac crisis. J Pediatr 1972; 81:1074-1081. 12. Baranwal AK, Singhi SC, Thapa BR, et al. Celiac crisis. Indian J Pediatr 2003; 70:433-435. 13. Walia A, Thapa BR. Celiac crisis. Indian J Pediatr 2005; 42:1169. 14. Wolf I, Mouallem M, Farfel Z. Adult celiac disease presented with celiac crisis: severe diarrhea, hypokalemia, and acidosis. J Clin Gastroenterol 2000; 30:324-326. 15. Ozaslan E, Kosoglu KB. Coeliac crisis in adults: report of two cases. Eur J Emerg Med 2004; 11:363-365. 16. Sollid LM. Coeliac disease: dissecting a complex inflammatory disorder. Nat Rev 2002; 2:647-655. 17. Green PH, Jones R. Celiac Disease: A Hidden Epidemic. New York: HarperCollins; 2006.