Advertisement

Diarrhea pp 357-378 | Cite as

Diarrhea Related to Non-neoplastic Endocrine Diseases

  • Ashwani K. Singal
  • Nischita K. Reddy
  • Don W. Powell
Chapter
Part of the Clinical Gastroenterology book series (CG)

Summary

Diarrhea may result from either neoplastic (e.g., gastrinoma, VIPoma, medullary carcinoma of the thyroid) or non-neoplastic dysfunction of the endocrine glands. This chapter deals with diarrhea due to hyper- or hypofunction of the endocrine pancreas, thyroid, adrenal gland, or congenital immune-related disease affecting several endocrine glands. The epidemiology, clinical features, diagnosis, and treatment of the diarrhea of these non-neoplastic endocrine diseases are covered here. Although some of these diarrheal syndromes are rare, some (e.g., diabetic diarrhea and the diarrhea of hyperthyroidism) are common because of the prevalence of the underlying disease.

Key Words

Non-neoplastic endocrinal diarrhea Diabetic diarrhea Celiac disease Diabetes mellitus Sorbitol Bile acid malabsorption Lymphocytic colitis Pancreatic insufficiency Diabetic microangiopathy Autonomic neuropathy Intestinal fluid and electrolyte transport Intestinal motility Bacterial overgrowth Anorectal dysfunction Fecal incontinence Loperamide Clonidine Somatostatin Thyrotoxicosis Steatorrhea Coefficient of fat absorption Ulcerative colitis Propylthiouracil Beta blockers Addison’s disease Autoimmune polyglandular syndrome APS type I APS type II John F Kennedy IPEX Polyendocrinopathy FOXP3 Cyclosporine Tacrolimus Bone marrow transplantation 

Notes

Acknowledgments

No financial or assistance in any other form was received.

References

  1. 1.
    Powell DW. Approach to the patient with diarrhea. In: Yamada T, Alpers DH, Kalloo AN, Kaplowitz N, Owyang C, Powell DW, eds. Principles of clinical gastroenterology, 5th edn. Oxford: Wiley-Blackwell, 2008, pp. 304–360.CrossRefGoogle Scholar
  2. 2.
    Feldman M, Schiller LR. Disorders of gastrointestinal motility associated with diabetes mellitus. Ann Intern Med 1983; 98:378–384.PubMedGoogle Scholar
  3. 3.
    Bytzer P, Talley NJ, Leemon M, Young LJ, Jones MP, Horowitz M. Prevalence of gastrointestinal symptoms associated with diabetes mellitus: a population-based survey of 15,000 adults. Arch Intern Med 2001; 161:1989–1996.PubMedCrossRefGoogle Scholar
  4. 4.
    Bytzer P, Talley NJ, Hammer J, Young LJ, Jones MP, Horowitz M. GI symptoms in diabetes mellitus are associated with both poor glycemic control and diabetic complications. Am J Gastroenterol 2002; 97:604–611.PubMedCrossRefGoogle Scholar
  5. 5.
    Lysy J, Israeli E, Goldin E. The prevalence of chronic diarrhea among diabetic patients. Am J Gastroenterol 1999; 94:2165–2170.PubMedCrossRefGoogle Scholar
  6. 6.
    de Boer SY MA, lam WF, Schipper J, Jansen JB, Lamers CB. Hyperglycemia modulates gallbladder motility and small intestinal transit time in man. Dig Dis Sci 1997; 38:2228–2235.CrossRefGoogle Scholar
  7. 7.
    Bragen JA, Bollman JL, Kepler EJ. The ‘diarrhea of diabetes’ and steatorrhea of pancreatic insufficiency. Mayo Clin Proc 1936; 11:737–742.Google Scholar
  8. 8.
    Whalen GE, Soergel KH, Geenen JE. Diabetic diarrhea. A clinical and pathophysiological study. Gastroenterology 1969; 56:1021–1032.PubMedGoogle Scholar
  9. 9.
    Malins JM, Mayne N. Diabetic diarrhea. A study of thirteen patients with jejunal biopsy. Diabetes 1969; 18:858–866.PubMedGoogle Scholar
  10. 10.
    Sjoberg K, Eriksson KF, Bredberg A, Wassmuth R, Eriksson S. Screening for coeliac disease in adult insulin-dependent diabetes mellitus. J Intern Med 1998; 243:133–140.PubMedCrossRefGoogle Scholar
  11. 11.
    Cronin CC, Feighery A, Ferriss JB, Liddy C, Shanahan F, Feighery C. High prevalence of celiac disease among patients with insulin-dependent (type I) diabetes mellitus. Am J Gastroenterol 1997; 92:2210–2212.PubMedGoogle Scholar
  12. 12.
    Talal AH, Murray JA, Goeken JA, Sivitz WI. Celiac disease in an adult population with insulin-dependent diabetes mellitus: use of endomysial antibody testing. Am J Gastroenterol 1997; 92:1280–1284.PubMedGoogle Scholar
  13. 13.
    Maki M, Hallstrom O, Huupponen T, Vesikari T, Visakorpi JK. Increased prevalence of coeliac disease in diabetes. Arch Dis Child 1984; 59:739–742.PubMedCrossRefGoogle Scholar
  14. 14.
    Sategna-Guidetti C, Grosso S, Pulitano R, Benaduce E, Dani F, Carta Q. Celiac disease and insulin-dependent diabetes mellitus. Screening in an adult population. Dig Dis Sci 1994; 39:1633–1637.PubMedCrossRefGoogle Scholar
  15. 15.
    Collin P, Salmi J, Hallstrom O, et al. High frequency of coeliac disease in adult patients with type-I diabetes. Scand J Gastroenterol. 1989; 24:81–84.PubMedCrossRefGoogle Scholar
  16. 16.
    Koletzko S, Burgin-Wolff A, Koletzko B, et al. Prevalence of coeliac disease in diabetic children and adolescents. A multicentre study. Eur J Pediatr 1988; 148:113–117.PubMedCrossRefGoogle Scholar
  17. 17.
    Page SR, Lloyd CA, Hill PG, Peacock I, Holmes GK. The prevalence of coeliac disease in adult diabetes mellitus. Q J Med 1994; 87:631–637.Google Scholar
  18. 18.
    Savilahti E, Simell O, Koskimies S, Rilva A, Akerblom HK. Celiac disease in insulin-dependent diabetes mellitus. J Pediatr 1986; 108:690–693.PubMedCrossRefGoogle Scholar
  19. 19.
    Sigurs N, Johansson C, Elfstrand PO, Viander M, Lanner A. Prevalence of coeliac disease in diabetic children and adolescents in Sweden. Acta Paediatr 1993; 82:748–751.PubMedCrossRefGoogle Scholar
  20. 20.
    Cacciari E, Salardi S, Volta U, et al. Prevalence and characteristics of coeliac disease in type 1 diabetes mellitus. Acta Paediatr Scand 1987; 76:671–672.PubMedCrossRefGoogle Scholar
  21. 21.
    Barera G, Bianchi C, Calisti L, et al. Screening of diabetic children for coeliac disease with antigliadin antibodies and HLA typing. Arch Dis Child 1991; 66:491–494.PubMedCrossRefGoogle Scholar
  22. 22.
    Gadd S, Kamath KR, Silink M, Skerritt JH. Co-existence of coeliac disease and insulin-dependent diabetes mellitus in children: screening sera using an ELISA test for gliadin antibody. Aust N Z J Med 1992; 22:256–260.PubMedCrossRefGoogle Scholar
  23. 23.
    Rossi TM, Albini CH, Kumar V. Incidence of celiac disease identified by the presence of serum endomysial antibodies in children with chronic diarrhea, short stature, or insulin-dependent diabetes mellitus. J Pediatr 1993; 123: 262–264.PubMedCrossRefGoogle Scholar
  24. 24.
    Verge CF, Howard NJ, Rowley MJ, et al. Anti-glutamate decarboxylase and other antibodies at the onset of childhood IDDM: a population-based study. Diabetologia 1994; 37:1113–1120.PubMedCrossRefGoogle Scholar
  25. 25.
    Rensch MJ, Merenich JA, Lieberman M, Long BD, Davis DR, McNally PR. Gluten-sensitive enteropathy in patients with insulin-dependent diabetes mellitus. Ann Intern Med 1996; 124:564–567.PubMedGoogle Scholar
  26. 26.
    Saukkonen T, Savilahti E, Reijonen H, Ilonen J, Tuomilehto-Wolf E, Akerblom HK. Coeliac disease: frequent occurrence after clinical onset of insulin-dependent diabetes mellitus. Childhood Diabetes in Finland Study Group. Diabet Med 1996; 13:464–470.PubMedCrossRefGoogle Scholar
  27. 27.
    De Vitis I, Ghirlanda G, Gasbarrini G. Prevalence of coeliac disease in type I diabetes: a multicentre study. Acta Paediatr Suppl 1996; 412:56–57.PubMedCrossRefGoogle Scholar
  28. 28.
    Larsson K, Carlsson A, Cederwall E, et al. Annual screening detects celiac disease in children with type 1 diabetes. Pediatr Diabetes 2008; 9:354–359.PubMedCrossRefGoogle Scholar
  29. 29.
    Frohlich-Reiterer EE, Hofer S, Kaspers S, et al. Screening frequency for celiac disease and autoimmune thyroiditis in children and adolescents with type 1 diabetes mellitus – data from a German/Austrian multicentre survey. Pediatr Diabetes 2008; 9:546–553.PubMedCrossRefGoogle Scholar
  30. 30.
    Smyth DJ, Plagnol V, Walker NM, et al. Shared and distinct genetic variants in type 1 diabetes and celiac disease. N Engl J Med 2008; 359:2767–2777.PubMedCrossRefGoogle Scholar
  31. 31.
    Holmes GK. Screening for coeliac disease in type 1 diabetes. Arch Dis Child 2002; 87:495–498.PubMedCrossRefGoogle Scholar
  32. 32.
    Scarpello JH, Hague RV, Cullen DR, Sladen GE. The 14C-glycocholate test in diabetic diarrhoea. Br Med J 1976; 2:673–675.PubMedCrossRefGoogle Scholar
  33. 33.
    Merrick MV. Bile acid malabsorption. Clinical presentations and diagnosis. Dig Dis 1988; 6:159–169.PubMedCrossRefGoogle Scholar
  34. 34.
    Olesen M, Eriksson S, Bohr J, Jarnerot G, Tysk C. Lymphocytic colitis: a retrospective clinical study of 199 Swedish patients. Gut 2004; 53: 536–541.PubMedCrossRefGoogle Scholar
  35. 35.
    Blumenthal HT, Probstein JG, Berns AW. Interrelationship of Diabetes Mellitus and Pancreatitis. Arch Surg. 1963; 87:844–850.PubMedCrossRefGoogle Scholar
  36. 36.
    De Las Casas LE, Finley JL. Diabetic microangiopathy in the small bowel. Histopathology 1999; 35:267–270.PubMedCrossRefGoogle Scholar
  37. 37.
    Bennett WA, Berge KG, Sprague RG. The intestinal tract in diabetic diarrhea; a pathologic study. Diabetes 1956; 5:289–294.PubMedGoogle Scholar
  38. 38.
    Green PA, Berge KG, Sprague RG. Control of diabetic diarrhea with antibiotic therapy. Diabetes 1968; 17:385–387.PubMedGoogle Scholar
  39. 39.
    Dudl RJ, Anderson DS, Forsythe AB, Ziegler MG, O’Dorisio TM. Treatment of diabetic diarrhea and orthostatic hypotension with somatostatin analogue SMS 201-995. Am J Med 1987; 83:584–588.PubMedCrossRefGoogle Scholar
  40. 40.
    French JM, Hall G, Parish DJ, Smith WT. Peripheral and autonomic nerve involvement in primary amyloidosis associated with uncontrollable diarrhoea and steatorrhoea. Am J Med 1965; 39:277–284.PubMedCrossRefGoogle Scholar
  41. 41.
    Hensley GT, Soergel KH. Neuropathologic findings in diabetic diarrhea. Arch Pathol 1968; 85:587–597.PubMedGoogle Scholar
  42. 42.
    Chang EB, Bergenstal RM, Field M. Diarrhea in streptozocin-treated rats. Loss of adrenergic regulation of intestinal fluid and electrolyte transport. J Clin Invest 1985; 75:1666–1670.PubMedCrossRefGoogle Scholar
  43. 43.
    Chang EB, Fedorak RN, Field M. Experimental diabetic diarrhea in rats. Intestinal mucosal denervation hypersensitivity and treatment with clonidine. Gastroenterology 1986; 91:564–569.PubMedGoogle Scholar
  44. 44.
    Michaels PE, Cameron RB. Octreotide is cost-effective therapy in diabetic diarrhea. Arch Intern Med. 1991; 151:2469–2473.PubMedCrossRefGoogle Scholar
  45. 45.
    Camilleri M, Malagelada JR. Abnormal intestinal motility in diabetics with the gastroparesis syndrome. Eur J Clin Invest 1984; 14:420–427.PubMedCrossRefGoogle Scholar
  46. 46.
    Dooley CP, el Newihi HM, Zeidler A, Valenzuela JE. Abnormalities of the migrating motor complex in diabetics with autonomic neuropathy and diarrhea. Scand J Gastroenterol. 1988; 23:217–223.PubMedCrossRefGoogle Scholar
  47. 47.
    Keshavarzian A, Iber FL. Intestinal transit in insulin-requiring diabetics. Am J Gastroenterol 1986; 81:257–260.PubMedGoogle Scholar
  48. 48.
    Spengler U, Stellaard F, Ruckdeschel G, Scheurlen C, Kruis W. Small intestinal transit, bacterial growth, and bowel habits in diabetes mellitus. Pancreas 1989; 4:65–70.PubMedCrossRefGoogle Scholar
  49. 49.
    Wegener M, Borsch G, Schaffstein J, Luerweg C, Leverkus F. Gastrointestinal transit disorders in patients with insulin-treated diabetes mellitus. Dig Dis 1990; 8:23–36.PubMedCrossRefGoogle Scholar
  50. 50.
    Vantrappen G, Janssens J, Hellemans J, Ghoos Y. The interdigestive motor complex of normal subjects and patients with bacterial overgrowth of the small intestine. J Clin Invest. 1977; 59:1158–1166.PubMedCrossRefGoogle Scholar
  51. 51.
    Schiller LR, Santa Ana CA, Schmulen AC, Hendler RS, Harford WV, Fordtran JS. Pathogenesis of fecal incontinence in diabetes mellitus: evidence for internal-anal-sphincter dysfunction. N Engl J Med 1982; 307:1666–1671.PubMedCrossRefGoogle Scholar
  52. 52.
    Valdovinos MA, Camilleri M, Zimmerman BR. Chronic diarrhea in diabetes mellitus: mechanisms and an approach to diagnosis and treatment. Mayo Clin Proc 1993; 68:691–702.PubMedCrossRefGoogle Scholar
  53. 53.
    Schiller LR, Sellin J. Diarrhea. In: Feldman M, Friedman LS, Brandt LJ, eds. Textbook of gastroenterology, 8th edn. Philadelphia, PA: Saunders, 2008, pp. 159–186.Google Scholar
  54. 54.
    Fine KD, Fordtran JS. The effect of diarrhea on fecal fat excretion. Gastroenterology 1992; 102:1936–1939.PubMedGoogle Scholar
  55. 55.
    Talley NJ, Young L, Bytzer P, et al. Impact of chronic gastrointestinal symptoms in diabetes mellitus on health-related quality of life. Am J Gastroenterol 2001; 96:71–76.PubMedCrossRefGoogle Scholar
  56. 56.
    Jonas MM, Bell MD, Eidson MS, Koutouby R, Hensley GT. Congenital diabetes mellitus and fatal secretory diarrhea in two infants. J Pediatr Gastroenterol Nutr 1991; 13:415–425.PubMedCrossRefGoogle Scholar
  57. 57.
    Powell DW. Muscle or mucosa: the site of action of antidiarrheal opiates. Gastroenterology 1981; 80:406–408.PubMedGoogle Scholar
  58. 58.
    Powell DW, Field M. Pharmacological approaches to treatment of secretory diarrhea. In: Field M, Fordtran JS, Schultz S, eds. Secretory diarrhea. Bethesda, MD: American Physiology Society, 1980, p. 187.Google Scholar
  59. 59.
    Fedorak RN, Field M, Chang EB. Treatment of diabetic diarrhea with clonidine. Ann Intern Med 1985; 102:197–199.PubMedGoogle Scholar
  60. 60.
    Sacerdote A. Topical clonidine for diabetic diarrhea. Ann Intern Med 1986; 105(1):139.PubMedGoogle Scholar
  61. 61.
    Gaginella TS, O’Dorisio TM, Fassler JE, Mekhjian HS. Treatment of endocrine and nonendocrine secretory diarrheal states with Sandostatin. Metabolism 1990; 39:172–175.PubMedCrossRefGoogle Scholar
  62. 62.
    Walker JJ, Kaplan DS. Efficacy of the somatostatin analog octreotide in the treatment of two patients with refractory diabetic diarrhea. Am J Gastroenterol 1993; 88:765–767.PubMedGoogle Scholar
  63. 63.
    Meyer C, O’Neal DN, Connell W, Alford F, Ward G, Jenkins AJ. Octreotide treatment of severe diabetic diarrhoea. Intern Med J 2003; 33:617–618.PubMedCrossRefGoogle Scholar
  64. 64.
    Middleton WR. Thyroid hormones and the gut. Gut 1971; 12:172–177.PubMedCrossRefGoogle Scholar
  65. 65.
    Scarf M. Gastrointestinal manifestations of hyperthyroidism. J Lab Clin Med 1936; 21:1253–1258.Google Scholar
  66. 66.
    Chapman EM, Maloof F. Bizarre clinical manifestations of hyperthyroidism. N Engl J Med. 1956; 254:1–5.PubMedCrossRefGoogle Scholar
  67. 67.
    Kim SK. Small intestine transit time in the normal small bowel study. Am J Roentgenol Radium Ther Nucl Med 1968; 104:522–524.PubMedGoogle Scholar
  68. 68.
    Bond JH Jr, Levitt MD, Prentiss R. Investigation of small bowel transit time in man utilizing pulmonary hydrogen (H2) measurements. J Lab Clin Med 1975; 85:546–555.PubMedGoogle Scholar
  69. 69.
    Shirer JW. Hypermotility of the gastrointestinal tract in hyperthyroidism. Am J Med Sci 1933; 186:73–78.CrossRefGoogle Scholar
  70. 70.
    Tobin MV, Fisken RA, Diggory RT, Morris AI, Gilmore IT. Orocaecal transit time in health and in thyroid disease. Gut 1989; 30:26–29.PubMedCrossRefGoogle Scholar
  71. 71.
    Goswami R, Tandon RK, Dudha A, Kochupillai N. Prevalence and significance of steatorrhea in patients with active Graves’ disease. Am J Gastroenterol 1998; 93:1122–1125.PubMedCrossRefGoogle Scholar
  72. 72.
    Thomas FB, Caldwell JH, Greenberger NJ. Steatorrhea in thyrotoxicosis. Relation to hypermotility and excessive dietary fat. Ann Intern Med 1973; 78:669–675.PubMedGoogle Scholar
  73. 73.
    Raju GS, Dawson B, Bardhan KD. Bile acid malabsorption associated with Graves’ disease. J Clin Gastroenterol 1994; 19:54–56.PubMedCrossRefGoogle Scholar
  74. 74.
    Szilagyi A, Lerman S, Barr RG, Stern J, Colacone A, McMullan S. Reversible lactose malabsorption and intolerance in Graves’ disease. Clin Invest Med 1991; 14:188–197.PubMedGoogle Scholar
  75. 75.
    Culp KS, Piziak VK. Thyrotoxicosis presenting with secretory diarrhea. Ann Intern Med 1986; 105:216–217.PubMedGoogle Scholar
  76. 76.
    Snook JA, de Silva HJ, Jewell DP. The association of autoimmune disorders with inflammatory bowel disease. Q J Med 1989; 72:835–840.PubMedGoogle Scholar
  77. 77.
    Jarnerot G. The thyroid in ulcerative colitis and Crohn’s disease. I. Thyroid radioiodide uptake and urinary iodine excretion. Acta Med Scand 1975; 197: 77–81.PubMedCrossRefGoogle Scholar
  78. 78.
    Powell JR, Shapiro HA, Carbone JV. Therapeutic problems of ulcerative colitis with hyperthyroidism. Am J Gastroenterol 1968; 50:116–124.PubMedGoogle Scholar
  79. 79.
    Counsell CE, Taha A, Ruddell WS. Coeliac disease and autoimmune thyroid disease. Gut. 1994; 35:844–846.PubMedCrossRefGoogle Scholar
  80. 80.
    Goldin E WD. Diarrhea in hypothyroidism: bacterial overgrowth as a possible etiology. J Clin Gastroenterol 1990; 12:98–99.PubMedCrossRefGoogle Scholar
  81. 81.
    Papa A, Cammarota G, Tursi A, et al. Effects of propylthiouracil on intestinal transit time and symptoms in hyperthyroid patients. Hepatogastroenterology 1997; 44:426–429.PubMedGoogle Scholar
  82. 82.
    Bricker LA, Such F, Loehrke ME, Kavanaugh K. Intractable diarrhea in hyperthyroidism: management with beta-adrenergic blockade. Endocr Pract 2001; 7:28–31.PubMedGoogle Scholar
  83. 83.
    Addison T. On the constitutional and local effects of diseases of Supra-renal capsules. London Med Gaz 1855; 43:517 (abstract).Google Scholar
  84. 84.
    Nerup J. Addison’s disease – clinical studies. A report for 108 cases. Acta Endocrinol (Copenh). 1974; 76:127–141.Google Scholar
  85. 85.
    Tobin MV, Aldridge SA, Morris AI, Belchetz PE, Gilmore IT. Gastrointestinal manifestations of Addison’s disease. Am J Gastroenterol 1989; 84:1302–1305.PubMedGoogle Scholar
  86. 86.
    Dunlop D. Eighty-six cases of Addison’s disease. Br Med J 1963; 2:887–891.PubMedCrossRefGoogle Scholar
  87. 87.
    Ross EJ. Symptomatology in adrenal disease. In: Milo KW, Fowler PBS, eds. Clinical endocrinology. London: William Heinman Medical Books, 1984, pp. 425–433.Google Scholar
  88. 88.
    Oelkers W. Adrenal insufficiency. N Engl J Med 1996; 335:1206–1212.PubMedCrossRefGoogle Scholar
  89. 89.
    Guarini G, Macaluso M. Steatorrhoea in Addison’s disease. Lancet 1963; 1: 955–956.PubMedCrossRefGoogle Scholar
  90. 90.
    A case of adult coeliac disease with Addison’s disease. Presented at the Royal Postgraduate Medical School. Br Med J 1970; 2:711–716.CrossRefGoogle Scholar
  91. 91.
    Myhre AG, Aarsetoy H, Undlien DE, Hovdenak N, Aksnes L, Husebye ES. High frequency of coeliac disease among patients with autoimmune adrenocortical failure. Scand J Gastroenterol 2003; 38:511–515.PubMedCrossRefGoogle Scholar
  92. 92.
    O’Mahony D, O’Leary P, Quigley EM. Aging and intestinal motility: a review of factors that affect intestinal motility in the aged. Drugs Aging 2002; 19:515–527.PubMedCrossRefGoogle Scholar
  93. 93.
    Biagi F, Campanella J, Soriani A, Vailati A, Corazza GR. Prevalence of coeliac disease in Italian patients affected by Addison’s disease. Scand J Gastroenterol 2006; 41:302–305.PubMedCrossRefGoogle Scholar
  94. 94.
    Collin P, Kaukinen K, Valimaki M, Salmi J. Endocrinological disorders and celiac disease. Endocr Rev 2002; 23:464–483.PubMedCrossRefGoogle Scholar
  95. 95.
    Barker JM, Gottelib PA, Eisenbarth GS. The immunoendocrinopathy syndromes. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams textbook of endocrinology, 11th edn. Philadelphia, PA: Saunders Elsevier, 2008, pp. 1748–1758.Google Scholar
  96. 96.
    Hogenauer C, Meyer RL, Netto GJ, et al. Malabsorption due to cholecystokinin deficiency in a patient with autoimmune polyglandular syndrome type I. N Engl J Med 2001; 344:270–274.PubMedCrossRefGoogle Scholar
  97. 97.
    Mandel LR. Endocrine and autoimmune aspects of the health history of John F. Kennedy. Ann Intern Med 2009; 151:350–354.PubMedGoogle Scholar
  98. 98.
    Powell BR, Buist NR, Stenzel P. An X-linked syndrome of diarrhea, polyendocrinopathy, and fatal infection in infancy. J Pediatr 1982; 100:731–737.PubMedCrossRefGoogle Scholar
  99. 99.
    Hori S, Nomura T, Sakaguchi S. Control of regulatory T cell development by the transcription factor Foxp3. Science 2003; 299:1057–1061.PubMedCrossRefGoogle Scholar
  100. 100.
    Baud O, Goulet O, Canioni D, et al. Treatment of immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) by allogenic bone marrow transplantation. N Eng J Med 2001; 344:1758–1762.CrossRefGoogle Scholar
  101. 101.
    Bindl L, Togerson T, Perroni L, et al. Successful use of the new immune-suppressor sirolimus in IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome). J Pediatr 2005; 147:256–259.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Ashwani K. Singal
    • 1
  • Nischita K. Reddy
    • 1
  • Don W. Powell
    • 2
  1. 1.Division of Gastroenterology and Hepatology, Department of Internal MedicineUniv. of Texas Medical BranchGalvestonUSA
  2. 2.Division of Gastroenterology and Hepatology, Department of Internal MedicineThe University of Texas Medical BranchGalvestonUSA

Personalised recommendations