Seronegative Intestinal Villous Atrophy: A Diagnostic Challenge

Abstract

Celiac disease is the most important cause of intestinal villous atrophy. Seronegative intestinal villous atrophy, including those that are nonresponsive to a gluten-free diet, is a diagnostic challenge. In these cases, before establishing the diagnosis of seronegative celiac disease, alternative etiologies of atrophic enteropathy should be considered. Recently, a new clinical entity responsible for seronegative villous atrophy was described—olmesartan-induced sprue-like enteropathy. Herein, we report two uncommon cases of atrophic enteropathy in patients with arterial hypertension under olmesartan, who presented with severe chronic diarrhea and significant involuntary weight loss. Further investigation revealed intestinal villous atrophy and intraepithelial lymphocytosis. Celiac disease and other causes of villous atrophy were ruled out. Drug-induced enteropathy was suspected and clinical improvement and histologic recovery were verified after olmesartan withdrawal. These cases highlight the importance for clinicians to maintain a high index of suspicion for olmesartan as a precipitant of sprue-like enteropathy.

Significant Weight Loss in a Patient Taking Olmesartan: An Unusual Case Report

“…Symptoms of this syndrome include severe chronic diarrhea, weight loss, fatigue, nausea and vomiting, abdominal pain, bloating, and, less commonly, reflux symptoms and loss of appetite [23]. This disorder seems to affect the whole gastrointestinal tract [2].…”

“…Angiotensin II promotes enterocyte apoptosis, suggesting that olmesartan-associated enteropathy results from excess apoptosis of enterocytes. The high affinity of olmesartan for AT1 receptors may explain the greater incidence of enteropathy with this ARB [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29].…”

Diarrea crónica de fácil solución, a propósito de 3 casos

“…La enteropatía por olmesartán tiene como síntoma principal la diarrea crónica1, 2. En 2013, la Food and Drug Administration incluyó este efecto adverso en su ficha técnica, por la publicación de Rubio-Tapia et al, quienes presentaron 22 pacientes tratados con dicho fármaco que desarrollaron diarrea crónica, pérdida de peso y atrofia vellositaria en las biopsias duodenales1, 2, 3, 4, 5.…”

“…La enteritis por olmesartán se presenta como diarrea, pérdida de peso, náuseas, vómitos y malabsorción2, 4, 5. Se ha descrito un caso de perforación colónica 3 .…”

“…El tiempo de exposición está relacionado con el riesgo de hospitalización, y la clínica aparece meses/años después de su inicio1, 5. Al suspenderlo, tanto los síntomas como las alteraciones histológicas remiten en unas semanas1, 3, 5.…”