الفهرس 
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Abstract
Diarrhea is a common symptom worldwide and chronic diarrhea is one of the most common reasons for referral to a gastroenterology clinic. Chronic diarrhea is one of the major presenting features of celiac disease. Celiac disease is an autoimmune gastrointestinal disease caused by intolerance to gluten, dietary proteins which present in wheat, rye, and barley. The disease usually manifests in childhood, and symptoms include diarrhea, abdominal pain, and failure to thrive. Symptoms in adulthood include anemia, fatigue, weight loss, diarrhea, constipation, and neurological symptoms. Apart from that celiac disease is a multiorgan autoimmune disease, celiac disease is associated with a definite increase in the risk of developing cancer, especially enteropathy-associated T-cell lymphoma and other gastrointestinal cancers that are partially responsible for the overall increased mortality reported in celiac disease patients.
The diagnosis of Celiac disease is based up on histological findings in duodenal or jejunal biopsies, which may present in various forms. At one end of the spectrum is a mucosa with normal architecture and an increase in intraepithelial lymphocytes and at the other end, the classic flat mucosa, villous atrophy and crypt hyperplasia.
Among different serological tests for screening of celiac disease , such as anti-gliadin antibodies (AGA) and endomysial IgA antibody (EMA), the tissue transglutaminase antibodies (tTGA) has proved to be a very specific indicator to identify patients with celiac disease. In several studies, the sensitivity and specificity of these tests compared with biopsy-proven disease were 94% - 98%.
A total of 113 consecutive patients with chronic non -bloody diarrhea attending Tropical Medicine & Gastroenterology Department, Assiut university hospital were included in this study.
The patients subjected to full history taking and complete physical examination. Abdominal ultrasonography was done for all patients. Laboratory investigations involving: full blood picture (serum iron for patients with anemia), serum urea and creatinine, blood glucose, liver function tests (HCV Ab & HBsAg in patients with elevated transaminases levels), thyroid function tests ( in suspected patients ), serum electrolytes ( K, Ca and Na ).
All patients subjected to upper gastrointestinal endoscopic examination, and 4 biobsy samples from the second portion of the duodenum were taken, also they subjected to lower endoscopic examination and multiple biopsies were taken. The samples were evaluated by expert pathologist and duodenal biopsies were graded using modified Marsh classification.
Tissue transglutaminase antibody (Celiky tTG-IgA) and deaminated gliadin peptides (GliadinDP) IgA and IgG (Pharmacia Diagnostics, Freiburg, Germany) were done for all patients in Germany
The most frequent causes of chronic non bloody diarrhea in our patients were functional diarrhea where it diagnosed in (32.7%) of patients and irritable bowel syndrome which was diagnosed in (18.6%) of patients. Sixteen patients (14.2%) were diagnosed celiac disease based up on increase of antibody levels to IgA tissue transglutaminase, response to gluten free diet, gluten challenge test and histopathological changes (according to modified marsh classification). Celiky tTG-Ab IgA was positive in 16 patients, GliadinDP IgA and IgG were positive in 8 (50%) of them. Laboratory findings revealed iron deficiency anemia in 6/16 (37.5%), thrombocytosis in 2/16 (12.5%) and elevated serum transaminases levels in 2/16 (12.5%). Twelve of the diagnosed cliac disease patients (75%) had endoscopic findings suggesting of CD (two had absent or reduced duodenal folds, 5 had scalloping of folds and 5 had visible vessels with fishers or cracks). All of them had histopathological changes (one had grade II, 4 had grade IIIa, 9 had grade IIIb and 2 had grade IIIc) (table 4). All of them respond to GFD. Other organic causes of chronic diarrhea in our study were tuberculosis in 12 (10.6%) patients, Giardiasis in 7 (6.2%) patients and capillariasis also in 7 patients.
CONCLUSION
1. The most frequent causes of chronic non bloody diarrhea in our patients were functional diarrhea and irritable bowel syndrome.
2. Celiac disease can be considered as one of the relatively frequent causes of chronic non –bloody diarrhea in Egyptian patients, so, testing for celiac disease may be indicated in all patients being evaluated for chronic diarrhea.
3. Treatment with a gluten free diet is both feasible and effective in our celiac disease patients with chronic diarrhea.
4. Normal endoscopic findings can not exclude celiac disease and histopathological examination of duodenal biopsies is important.
5. Immunological examination is indicated for non invasive diagnosis of celiac disease.
6. Meticulous parasitological examination of the stools in patients with chronic non bloody diarrhea is indicated.