Global Prevalence of Celiac Disease: Systematic Review and Meta-analysis

Are gluten-free food staples accessible to all patients with coeliac disease?

INTRODUCTION

Within England the removal of prescribed gluten-free (GF) foods from many Clinical Commissioning Groups has resulted in a greater reliance on commercially available GF food by adults and children with coeliac disease (CD). High cost and limited availability of GF foods are associated with poorer dietary adherence in people with CD.

AIM

To assess if the rise in popularity of GF diets globally has improved the cost or availability of cereal-based GF foods over the past 6 years.

DESIGN

Observational study where data were collected on cereal-based GF foods from 50 stores and 10 internet retailers. The number of GF foods within each food category and the cost per 100 g of GF and gluten-containing (GC) foods were compared by store type.

RESULTS

GF food availability has increased in premium stores and online. The majority (82%) of GF food categories were significantly more expensive online compared with regular supermarkets. On average, GF breads were 400% more expensive compared with GC breads (p<0.001); no narrowing in cost difference over time observed. Convenience stores did not stock any GF bread nor GF pasta and only one of the budget supermarkets stocked them, similar to data reported 6 years ago.

CONCLUSIONS

GF food availability has increased, predominately in premium markets. The GF food desert within convenience and budget stores will continue to disproportionately impact poor socioeconomic cohorts, the elderly and physically disabled. A lack of accessibility to GF foods impacts GF dietary adherence, increasing related comorbidities and healthcare costs.

Automatic classification of IgA endomysial antibody test for celiac disease: a new method deploying machine learning

Widespread use of endomysial autoantibody (EmA) test in diagnostics of celiac disease is limited due to its subjectivity and its requirement of an expert evaluator. The study aimed to determine whether machine learning can be applied to create a new observer-independent method of automatic assessment and classification of the EmA test for celiac disease. The study material comprised of 2597 high-quality IgA-class EmA images collected in 2017–2018. According to standard procedure, highly-experienced professional classified samples into the following four classes: I - positive, II - negative, III - IgA deficient, and IV - equivocal. Machine learning was deployed to create a classification model. The sensitivity and specificity of the model were 82.84% and 99.40%, respectively. The accuracy was 96.80%. The classification error was 3.20%. The area under the curve was 99.67%, 99.61%, 100%, and 99.89%, for I, II, III, and IV class, respectively. The mean assessment time per image was 16.11 seconds. This is the first study deploying machine learning for the automatic classification of IgA-class EmA test for celiac disease. The results indicate that using machine learning enables quick and precise EmA test analysis that can be further developed to simplify EmA analysis.

Non-Invasive Biomarkers for Celiac Disease

Once thought to be uncommon, celiac disease has now become a common disease globally. While avoidance of the gluten-containing diet is the only effective treatment so far, many new targets are being explored for the development of new drugs for its treatment. The endpoints of therapy include not only reversal of symptoms, normalization of immunological abnormalities and healing of mucosa, but also maintenance of remission of the disease by strict adherence of the gluten-free diet (GFD). There is no single gold standard test for the diagnosis of celiac disease and the diagnosis is based on the presence of a combination of characteristics including the presence of a celiac-specific antibody (anti-tissue transglutaminase antibody, anti-endomysial antibody or anti-deamidated gliadin peptide antibody) and demonstration of villous abnormalities. While the demonstration of enteropathy is an important criterion for a definite diagnosis of celiac disease, it requires endoscopic examination which is perceived as an invasive procedure. The capability of prediction of enteropathy by the presence of the high titer of anti-tissue transglutaminase antibody led to an option of making a diagnosis even without obtaining mucosal biopsies. While present day diagnostic tests are great, they, however, have certain limitations. Therefore, there is a need for biomarkers for screening of patients, prediction of enteropathy, and monitoring of patients for adherence of the gluten-free diet. Efforts are now being made to explore various biomarkers which reflect different changes that occur in the intestinal mucosa using modern day tools including transcriptomics, proteomics, and metabolomics. In the present review, we have discussed comprehensively the pros and cons of available biomarkers and also summarized the current status of emerging biomarkers for the screening, diagnosis, and monitoring of celiac disease.

HLA-DQB1*02 allele in children with celiac disease: Potential usefulness for screening strategies

Through a retrospective analysis of a real-life cohort of children with celiac disease (CD), who underwent HLA-DQ genotyping, we supported our previous findings indicating the presence of HLA-DQB1*02 allele in at least 90%-95% of pediatric patients. In the present study, reporting the HLA-DQ analysis from 184 children (age range: 1-16 years) diagnosed with CD in a single centre, we found that 97.29% of all these CD children (n = 179 out of 184 genotyped patients) resulted to be carriers of at least one copy of HLA-DQB1*02 allele. If a widened screening for CD should result to be appropriate in the pediatric population after further clinical research, this observation might be potentially exploited to consider a two-step screening strategy, starting with the HLA-DQB1*02 targeted analysis followed by the specific serology for CD in these predisposed patients only. However, additional and larger studies are needed to support our findings.

Prospective longitudinal study: use of faecal gluten immunogenic peptides to monitor children diagnosed with coeliac disease during transition to a gluten-free diet

BACKGROUND

Treatment for coeliac disease is a lifelong strict gluten-free diet. Although guidelines recommend regular follow-up with dietary interviews and coeliac serology, these methods may be inaccurate.

AIM

To evaluate the usefulness of faecal gluten immunogenic peptides to support the diagnosis and to determine the adherence to the gluten-free diet in coeliac children.

METHODS

Multicentre prospective observational study including 64 coeliac children. Faecal gluten peptides, and tissue transglutaminase and deamidated gliadin peptide antibodies were analyzed at diagnosis, and 6, 12 and 24 months thereafter. Gluten consumption was estimated from gluten peptide levels.

RESULTS

Most children (97%) had detectable gluten peptides at diagnosis. On a gluten-free diet, the rate of gluten peptides increased from 13% at 6 months to 25% at 24 months. Mean estimated gluten exposure dropped from 5543 mg/d at diagnosis to 144 mg/d at 6 months, then increased to 606 mg/d by 24 months. In contrast, deamidated gliadin peptide antibodies normalised and only 20% had elevated tissue transglutaminase antibody by 24 months. The elevation of tissue transglutaminase antibody was more prolonged in patients with detectable gluten peptides (P < 0.05). Nevertheless, absolute levels of tissue transglutaminase antibody had low sensitivity to identify patients with detectable gluten peptides (P > 0.1). Dietitian assessment was only moderately correlated with gluten peptide detection (κ = 0.5).

CONCLUSIONS

Faecal gluten peptides testing may guide treatment of coeliac disease prior to diagnosis and during the assessment diet adherence. Further studies could determine if early identification of gluten exposure reduces the need for expensive/invasive investigations for non-responsive coeliac disease. ClinicalTrials.gov Number: NCT02711397.

Lactobacilli Degrade Wheat Amylase Trypsin Inhibitors to Reduce Intestinal Dysfunction Induced by Immunogenic Wheat Proteins

BACKGROUND & AIMS

Wheat-related disorders, a spectrum of conditions induced by the ingestion of gluten-containing cereals, have been increasing in prevalence. Patients with celiac disease have gluten-specific immune responses, but the contribution of non-gluten proteins to symptoms in patients with celiac disease or other wheat-related disorders is controversial.

METHODS

C57BL/6 (control), Myd88^-/-, Ticam1^-/-, and Il15^-/- mice were placed on diets that lacked wheat or gluten, with or without wheat amylase trypsin inhibitors (ATIs), for 1 week. Small intestine tissues were collected and intestinal intraepithelial lymphocytes (IELs) were measured; we also investigated gut permeability and intestinal transit. Control mice fed ATIs for 1 week were gavaged daily with Lactobacillus strains that had high or low ATI-degrading capacity. Nonobese diabetic/DQ8 mice were sensitized to gluten and fed an ATI diet, a gluten-containing diet or a diet with ATIs and gluten for 2 weeks. Mice were also treated with Lactobacillus strains that had high or low ATI-degrading capacity. Intestinal tissues were collected and IELs, gene expression, gut permeability and intestinal microbiota profiles were measured.

RESULTS

In intestinal tissues from control mice, ATIs induced an innate immune response by activation of Toll-like receptor 4 signaling to MD2 and CD14, and caused barrier dysfunction in the absence of mucosal damage. Administration of ATIs to gluten-sensitized mice expressing HLA-DQ8 increased intestinal inflammation in response to gluten in the diet. We found ATIs to be degraded by Lactobacillus, which reduced the inflammatory effects of ATIs.

CONCLUSIONS

ATIs mediate wheat-induced intestinal dysfunction in wild-type mice and exacerbate inflammation to gluten in susceptible mice. Microbiome-modulating strategies, such as administration of bacteria with ATI-degrading capacity, may be effective in patients with wheat-sensitive disorders.

Non-Celiac Gluten Sensitivity: A Review

Background and objectives: Grain food consumption is a trigger of gluten related disorders: celiac disease, non-celiac gluten sensitivity (NCGS) and wheat allergy. They demonstrate with non-specific symptoms: bloating, abdominal discomfort, diarrhea and flatulence. Aim: The aim of the review is to summarize data about pathogenesis, symptoms and criteria of NCGS, which can be helpful for physicians. Materials and Methods: The PubMed and Google Scholar databases were searched in January 2019 with phrases: 'non-celiac gluten sensitivity', non-celiac gluten sensitivity', non-celiac wheat gluten sensitivity', non-celiac wheat gluten sensitivity', and gluten sensitivity'. More than 1000 results were found. A total of 67 clinical trials published between 1989 and 2019 was scanned. After skimming abstracts, 66 articles were chosen for this review; including 26 clinical trials. Results: In 2015, Salerno Experts' Criteria of NCGS were published. The Salerno first step is assessing the clinical response to gluten free diet (GFD) and second is measuring the effect of reintroducing gluten after a period of treatment with GFD. Several clinical trials were based on the criteria. Conclusions: Symptoms of NCGS are similar to other gluten-related diseases, irritable bowel syndrome and Crohn's disease. With Salerno Experts' Criteria of NCGS, it is possible to diagnose patients properly and give them advice about nutritional treatment.

Novel Nondietary Therapies for Celiac Disease

Celiac Disease (CeD) is defined as a chronic small intestinal immune-mediated enteropathy that is precipitated by exposure to dietary gluten in genetically predisposed individuals. CeD is one of the most common autoimmune disorders affecting around 1% of the population worldwide. Currently, the only acceptable treatment for CeD is strict, lifelong adherence to a gluten-free diet (GFD) which can often present a challenging task. A GFD alone is not sufficient to control symptoms and prevent mucosal damage that can result from unintentional gluten exposure. Moreover, long-term complications can occur in many patients. Consequently, there is an unmet need for non-dietary therapies for the management of CeD. Such therapies could serve as an adjunct to the GFD but eventually may replace it. This review will focus on and discuss non-dietary therapies currently in clinical development for the management of CeD. METHODOLOGY: We searched clinicaltrials.gov and PubMed to extract articles about celiac disease. We used keywords including, but not limited to, "celiac disease," "non-dietary," "therapeutics," "pathophysiology," "Endopeptidases," "tight junction modulators," "vaccine," and "Nexvax2". We focused mainly on articles that conducted pathophysiologic and therapeutic research in human trials.

Faecal Scent as a Novel Non-Invasive Biomarker to Discriminate between Coeliac Disease and Refractory Coeliac Disease: A Proof of Principle Study

Currently, the gold standard for diagnosis of coeliac disease (CD) is based on serology and gastroduodenoscopy with histology of duodenal mucosal biopsies. The aim of this study was to evaluate the potential of faecal volatile organic compounds (VOCs) analysis as a novel, non-invasive tool to discriminate between CD in remission in patients on a gluten-free diet (GFD), refractory coeliac disease (RCD) and controls without CD. Patients with an established diagnosis of CD on a GFD, RCD and healthy controls (HC) were instructed to collect a faecal sample. All subjects completed questionnaires on clinical symptoms, lifestyle and dietary information. Faecal VOCs were measured using gas chromatography-ion mobility spectrometry. A total of 13 CD, 7 RCD and 10 HC were included. A significant difference in VOC profiles between CD and RCD patients (area under the curve (AUC) ± 95% CI: 0.91 (0.79–1) p = 0.000) and between CD and HC (AUC ± 95% CI: 0.71 (0.51–0.91) p = 0.0254) was observed. We found no significant differences between faecal VOC patterns of HC and RCD. Based on faecal VOCs, CD could be discriminated from RCD and HC. This implies that faecal VOC analysis may hold potential as a novel non-invasive biomarker for RCD. Future studies should encompass a larger cohort to further investigate and validate this prior to application in clinical practice.

Relevance of HLA-DQB1*02 Allele in the Genetic Predisposition of Children with Celiac Disease: Additional Cues from a Meta-Analysis

Background and Objectives: Celiac disease (CD) is a multifactorial immune-mediated disorder, triggered by the ingestion of gluten in genetically-predisposed subjects carrying MHC-DQ2 and -DQ8 heterodimers, which are encoded by four HLA-DQ allelic variants, overall. This meta-analysis aims at providing further epidemiological support to the predominant relevance of one specific allele, namely HLA-DQB1*02, in the predisposition and genetic risk of CD. Materials and Methods: We performed a search of MEDLINE/PubMed, Embase, Web of Science, and Scopus, retrieving all publications (case-control study, cross-sectional, and retrospective cohort study) on the association between HLA class II polymorphisms and first-degree relatives (FDRs) of children with CD. After a critical reading of the articles, two investigators independently performed data extraction according to the following inclusion criteria: HLA class II genes, any DQ and DR molecules, and CD diagnosed following the current clinical guidelines. A third participant was consulted for discussion to reach an agreement concerning discrepancies. Results: Our search strategy selected 14 studies as being eligible for inclusion, and those were submitted for data extraction and analysis. These studies were published between 1999 and 2016 and, collectively, enrolled 3063 FDRs. Positive and negative likelihood ratios (LR+ and LR-, respectively) for CD diagnosis, according to the presence of the HLA-DQ genotype coding a complete MHC-DQ2 and/or MHC-DQ8 molecules, were 1.449 (CI 1.279-1.642) and 0.187 (CI 0.096-0.362), respectively. If only the isolated presence of HLA-DQB1*02 allele is considered, the pooled estimation of LR+ was 1.659 (CI 1.302-2.155) and, importantly, the LR- still showed a very good discriminatory power of 0.195 (CI 0.068-0.558). Conclusions: Through our differential meta-analysis, comparing the presence of the genotype coding the full MHC-DQ2 and/or DQ8 molecules with the isolated presence of HLA-DQB1*02 allelic variant, we found that the LR- of the latter analysis maintained the same value. This observation, along with previous evidences, might be useful to consider potential cost-effective widened screening strategies for CD in children.

Recent practical researches in the development of gluten-free breads

Wheat bread is consumed globally and has played a critical role in the story of civilization since the development of agriculture. While the aroma and flavor of this staple food continue to delight and satisfy most people, some individuals have a specific allergy to wheat or a genetic disposition to celiac disease. To improve the quality of life of these patients from a dietary standpoint, food-processing researchers have been seeking to develop high-quality gluten-free bread. As the quality of wheat breads depends largely on the viscoelastic properties of gluten, various ingredients have been employed to simulate its effects, such as hydrocolloids, transglutaminase, and proteases. Recent attempts have included the use of redox regulation as well as particle-stabilized foam. In this short review, we introduce the ongoing advancements in the development of gluten-free bread, by our laboratory as well as others, focusing mainly on rice-based breads. The social and scientific contexts of these efforts are also mentioned.

Discordance Between Serology and Histology for Celiac Disease in a Cohort with Coexisting Liver Disorders

Background

The liver and celiac disease (CeD) share a complex relationship. While in some patients, isolated hypertransaminasemia is the only manifestation of CeD, liver diseases (LD) may also be associated with the presence of isolated tissue transglutaminase antibodies IgA (tTG IgA) without histologic evidence of CeD.

Aims

To examine the yield of tTG IgA testing (a) in the workup for chronic liver disease (CLD) or cytolysis and (b) to identify biopsy-confirmed CeD (BxCeD) among patients with concomitant LD.

Methods

Retrospective study including two cohorts. Cohort 1 represented 444 consecutive individuals without known CeD for which liver specialists requested tTG IgA. Incidence of positive tTG and BxCeD was evaluated. Cohort 2 included 212 consecutive individuals with positive tTG IgA and subsequent duodenal biopsies. The frequency and clinical characteristics of individuals without BxCeD were examined, with and without concurrent LD.

Results

The rate of first time positive tTG IgA among the tests requested by a liver specialist (cohort 1) was 2.0% (n = 9). However, 33.0% (n = 3) of these patients did not have BxCeD. Cohort 2 included 33 individuals with coexisting LD, of which 42.4% did not have BxCeD, compared with 16.2% of the patients without LD (P < 0.001). The majority of the patients without BxCeD (65.1%) showed an increase < 3 times upper limit of normal of tTG IgA.

Conclusions

Although there is clinical value in testing for CeD in the context of LD, there could be a high rate of positive CeD serology unaccompanied by histologic signs in patients with coexisting LD.

RNA sequencing of intestinal mucosa reveals novel pathways functionally linked to celiac disease pathogenesis

BACKGROUND & AIMS

The early steps in the pathophysiology of celiac disease (CD) leading to loss of tolerance to gluten are poorly described. Our aim was to use RNA sequencing of duodenal biopsies in patients with active CD, CD in remission, and non-CD controls to gain insight into CD pathophysiology, identify additional genetic signatures linked to CD, and possibly uncover targets for future therapeutic agents.

METHODS

We performed whole transcriptome shotgun sequencing of intestinal biopsies in subjects with active and remission CD and non-CD controls. We also performed functional pathway analysis of differentially expressed genes to identify statistically significant pathways that are up or down regulated in subjects with active CD compared to remission CD.

RESULTS

We identified the upregulation of novel genes including IL12R, ITGAM and IGSF4 involved in the immune response machinery and cell adhesion process in the mucosa of subjects with active CD compared to those in remission. We identified a unique signature of genes, related to innate immunity, perturbed exclusively in CD irrespective of disease status. Finally, we highlight novel pathways of interest that may contribute to the early steps of CD pathogenesis and its comorbidities such as the spliceosome, pathways related to the innate immune response, and pathways related to autoimmunity.

CONCLUSIONS

Our study confirmed previous findings based on GWAS and immunological studies pertinent to CD pathogenesis and describes novel genes and pathways that with further validation may be found to contribute to the early steps in the pathogenesis of CD, ongoing inflammation, and comorbidities associated with CD.

Role of Dietary Gluten in Development of Celiac Disease and Type I Diabetes: Management Beyond Gluten-Free Diet

Gluten triggers Celiac Disease (CD) and type I diabetes in genetically predisposed population of human leukocyte antigen DQ2/DQ8+ and associates with disorders such as schizophrenia and autism. Application of a strict gluten-free diet is the only well-established treatment for patients with CD, whereas the treatment for patients with celiac type I diabetes may be depend on the timing and frequency of the diet. The application of a gluten-free diet in patients with CD may contribute to the development of metabolic syndrome and nonalcoholic fatty liver disease and may also lead to a high glycemic index, low fiber diet and micronutrient deficiencies. The alteration of copper bioavailability (deficient, excess or aberrant coordination) may contribute to the onset and progress of related pathologies. Therefore, nutrient intake of patients on a gluten-free diet should be the focus of future researches. Other gluten-based therapies have been rising with interest such as enzymatic pretreatment of gluten, oral enzyme supplements to digest dietary gluten, gluten removal by breeding wheat varieties with reduced or deleted gluten toxicity, the development of polymeric binders to suppress gluten induced pathology.

Overview in the clinical management of patients with seronegative villous atrophy

Differential diagnosis and management of enteropathies found in the context of seronegative villous atrophy (VA) are still a clinical challenge. Although seronegative coeliac disease may be the most frequent cause of serology-negative VA, other conditions must be taken into account in the differential diagnosis of seronegative VA. The rarity of these enteropathies with frequent overlapping of histological features may result in misclassification of such patients as affected by a seronegative or a refractory form of coeliac disease with consequent inappropriate treatments and long-term morbidity. The aim of this review is to summarize the current knowledge and to provide an evidence base and practical algorithmic approach for the investigation and management of seronegative VA.

Coeliac disease detection with an IgA/IgG-deamidated gliadin peptide based point of care test in community pharmacies

Background Coeliac disease affects 1% of the population, but 75% remain undiagnosed. Objective To conduct a case finding feasibility and efficacy study for the detection of coeliac disease in community pharmacies. Setting Six community pharmacies across Sheffield, UK. Method A prospective study was performed using a point of care test, Simtomax^® (IgA/IgG-deamidated gliadin peptide) (C-test) in pharmacies. Pharmacy customers with symptoms suggestive of or risk factors for coeliac disease were tested with the C-test. Positive individuals were referred for a gastroscopy with duodenal biopsies alongside conventional serology. People with known coeliac disease, those on a gluten free diet or those who were investigated for coeliac disease were excluded. Main outcome measure The case detection rate and the uptake rate of the C-test and gastroscopies. Results Five-hundred participants fulfilled the inclusion criteria and were tested with the C-test (369 females, 73.8%; age range 18–87, median 49). The C-test uptake rate was 63%, and the positive rate was 7.2% (36/500). Twenty-seven positive participants (75%) underwent further investigations, confirming three new cases of coeliac disease (0.6%). Conclusion It was feasible to use the C-test as a case finding tool in pharmacies. There was good uptake for the C-test, although the case detection rate and the test specificity were low. Based on this, the C-test has a limited role in case finding in a community pharmacy setting.

Coeliac disease and obstetric and gynaecological disorders: where are we now?

Coeliac disease (CD) is a chronic gluten-dependent enteropathy very common in the general population and characterized by an extremely heterogeneous clinical picture. Although its prevalence is growing worldwide, case-finding strategy remains the mainstay to diagnosis. Thus, correct identification of high-risk categories of patients who need to be tested for CD is an essential part of medical knowledge to a large number of specialists and primary care providers. In this regard, although CD might have a serious effect on women's reproductive health, a widespread consensus is lacking on which categories of obstetric and gynaecological disorders should be tested for CD. The aim of this review is to critically summarize the current literature relevant to CD and obstetric and gynaecological disorders and to provide practical proposals that may be helpful to clinicians involved in the management of these patients.

Duodenal bacterial proteolytic activity determines sensitivity to dietary antigen through protease-activated receptor-2

Microbe-host interactions are generally homeostatic, but when dysfunctional, they can incite food sensitivities and chronic diseases. Celiac disease (CeD) is a food sensitivity characterized by a breakdown of oral tolerance to gluten proteins in genetically predisposed individuals, although the underlying mechanisms are incompletely understood. Here we show that duodenal biopsies from patients with active CeD have increased proteolytic activity against gluten substrates that correlates with increased Proteobacteria abundance, including Pseudomonas. Using Pseudomonas aeruginosa producing elastase as a model, we show gluten-independent, PAR-2 mediated upregulation of inflammatory pathways in C57BL/6 mice without villus blunting. In mice expressing CeD risk genes, P. aeruginosa elastase synergizes with gluten to induce more severe inflammation that is associated with moderate villus blunting. These results demonstrate that proteases expressed by opportunistic pathogens impact host immune responses that are relevant to the development of food sensitivities, independently of the trigger antigen.

Gluten triggers celiac disease in genetically predisposed individuals, but additional unknown mechanisms are required. Here, the authors show that proteases from Pseudomonas aeruginosa can modulate inflammatory pathways that are relevant to the development of food sensitivities, independently of the trigger antigen.

(Outcome) Measure for (Intervention) Measures: A Guide to Choosing the Appropriate Noninvasive Clinical Outcome Measure for Intervention Studies in Celiac Disease

There is an unmet need for diagnostic and treatment interventions for celiac disease. Both clinical trials and real-world studies require careful selection of clinical outcome measures. Often, neither serology nor histology is an appropriate primary outcome. This article reviews various measures of intestinal function and nutrition, patient-reported outcome measures for symptoms and for health-related quality of life, and measures of sickness burden as they apply to intervention studies for celiac disease. A series of case studies is presented to illustrate key considerations in selecting outcome measures for dietary interventions, pharmacologic interventions, and real-world studies.

AGA Clinical Practice Update on Diagnosis and Monitoring of Celiac Disease-Changing Utility of Serology and Histologic Measures: Expert Review

PURPOSE

The purpose of this clinical practice update is to define key modalities in the diagnosis and monitoring of celiac disease (CD) in adults as well as in children and adolescents.

METHODS

The recommendations outlined in this expert review are based on available published evidence, including cohort and case-control studies of the diagnostic process as well as controlled and descriptive studies of disease management. Best Practice Advice 1: Serology is a crucial component of the detection and diagnosis of CD, particularly tissue transglutaminase-immunoglobulin A (TG2-IgA), IgA testing, and less frequently, endomysial IgA testing. Best Practice Advice 2: Thorough histological analysis of duodenal biopsies with Marsh classification, counting of lymphocytes per high-power field, and morphometry is important for diagnosis as well as for differential diagnosis. Best Practice Advice 2a: TG2-IgA, at high levels (> ×10 upper normal limit) is a reliable and accurate test for diagnosing active CD. When such a strongly positive TG2-IgA is combined with a positive endomysial antibody in a second blood sample, the positive predictive value for CD is virtually 100%. In adults, esophagogastroduodenoscopy (EGD) and duodenal biopsies may then be performed for purposes of differential diagnosis. Best Practice Advice 3: IgA deficiency is an infrequent but important explanation for why patients with CD may be negative on IgA isotype testing despite strong suspicion. Measuring total IgA levels, IgG deamidated gliadin antibody tests, and TG2-IgG testing in that circumstance is recommended. Best Practice Advice 4: IgG isotype testing for TG2 antibody is not specific in the absence of IgA deficiency. Best Practice Advice 5: In patients found to have CD first by intestinal biopsies, celiac-specific serology should be undertaken as a confirmatory test before initiation of a gluten-free diet (GFD). Best Practice Advice 6: In patients in whom CD is strongly suspected in the face of negative biopsies, TG2-IgA should still be performed and, if positive, repeat biopsies might be considered either at that time or sometime in the future. Best Practice Advice 7: Reduction or avoidance of gluten before diagnostic testing is discouraged, as it may reduce the sensitivity of both serology and biopsy testing. Best Practice Advice 8: When patients have already started on a GFD before diagnosis, we suggest that the patient go back on a normal diet with 3 slices of wheat bread daily preferably for 1 to 3 months before repeat determination of TG2-IgA. Best Practice Advice 9: Determination of HLA-DQ2/DQ8 has a limited role in the diagnosis of CD. Its value is largely related to its negative predictive value to rule out CD in patients who are seronegative in the face of histologic changes, in patients who did not have serologic confirmation at the time of diagnosis, and in those patients with a historic diagnosis of CD; especially as very young children before the introduction of celiac-specific serology.

MANAGEMENT

Best Practice Advice 10: Celiac serology has a guarded role in the detection of continued intestinal injury, in particular as to sensitivity, as negative serology in a treated patient does not guarantee that the intestinal mucosa has healed. Persistently positive serology usually indicates ongoing intestinal damage and gluten exposure. Follow-up serology should be performed 6 and 12 months after diagnosis, and yearly thereafter. Best Practice Advice 11: Patients with persistent or relapsing symptoms, without other obvious explanations for those symptoms, should undergo endoscopic biopsies to determine healing even in the presence of negative TG2-IgA.

Helicobacter pylori prevalence and risk factors among children with celiac disease

BACKGROUND/AIMS

The relationship between Helicobacter pylori and celiac disease (CD) remains controversial. The aim of this study was to assess the prevalence and risk factors for H. pylori infection among children diagnosed with CD.

MATERIALS AND METHODS

This study included 70 patients diagnosed with CD at a tertiary referral center in Romania. Age, gender, and indicators of environmental conditions were evaluated via interviews with the children's caretakers. A multivariable logistic regression analysis was performed to identify the independent predictors for H. pylori infection.

RESULTS

Of the 70 patients, 37 (52.9%) were females, and the mean age was 4.04±3.26 years. H. pylori infection was diagnosed in 23 (32.8%) patients, of whom 12 (52.1%) were females, and the mean age was 6.2±4.5 years. Of the total number of children with CD and H. pylori infection, 18 (78.2%) had milder forms of enteropathy (Marsh I-II), whereas the remaining 5 (21.7%) had villous atrophy compared to the other 47 (67.2%) patients who were negative for H. pylori-infection and showed more severe intestinal damage. The development of H. pylori infection was independently related to children with one parent only [odd ratio (OR), 9.04; 95% confidence interval (CI), 1.29-62.89; p<0.001], living in houses without sanitary facilities (OR, 3.88; 95% CI, 1.27-14.22; p=0.016), belonging to low-income families (OR, 8.52; 95% CI, 2.52-71.39; p=0.002), and of parents with a prior history of gastritis (OR, 2.68; 95% CI, 1.49-14.50; p=0.004).

CONCLUSION

Children with CD and H. pylori infection had milder forms of enteropathy compared to children who are negative for H. pylori, suggesting that H. pylori infection may confer some protection against the development of severe degrees of villous atrophy.

Effects of the Gluten-free Diet on Body Mass Indexes in Pediatric Celiac Patients

OBJECTIVE

The aim of the study was to determine the effects of the gluten-free diet (GFD) on body mass indexes (BMIs) in children with celiac disease at University of Chicago before and after 2011, when processed gluten-free foods became readily available on the market.

METHODS

We conducted a retrospective chart review of children seen at University of Chicago Celiac Center from January 2002 to May 2016. BMI was recorded upon GFD initiation in addition to at least 1 other timepoint: 6 months, 1 year, 2 years, 3 years, and 4+ years. We compared the rate of BMI increase in children who were diagnosed before versus after 2011.

RESULTS

A total of 147 children (66% girls) with biopsy-confirmed celiac disease were included in the study. The mean BMI at diagnosis was 17.8 (standard deviation 3.9) for those diagnosed before 2011 and 17.1 (standard deviation 2.7) for those diagnosed after 2011. Based on a mixed-effects random-intercept random-slope regression model, there was no evidence for significant difference in BMI change over time between the 2 groups (P value = 0.36). BMI values overall were noted to increase after starting the GFD, even at the first appointment. Serologies were monitored after patients started the GFD and approached normal values, allowing us to conclude that patients were adherent to the GFD.

CONCLUSIONS

Although overall we observed no significant changes in BMI before and after 2011, we did notice that in adolescent celiac patients there was a trend toward a higher postdiagnosis BMI in the years after 2011. We speculate that teenagers may be especially vulnerable to choosing quick and easy processed gluten-free options over more healthy, natural alternatives leading to a rise in their BMIs after the 2011 surge in production of processed gluten-free foods on the market. Therefore, special attention must be paid to this population to insure ongoing healthy food choices even after many years on the GFD.

Health related quality of life among Saudi children and adolescents with celiac disease

BACKGROUND/AIMS

Celiac disease (CD) is an immune-mediated enteropathy triggered by gluten ingestion in genetically susceptible individuals. This study reports on the quality of life (QOL) of Saudi children and adolescents with CD.

PATIENTS AND METHODS

This is a case control study that included Saudi patients with CD, aged 9-18 years, who attended CD Clinic at KAU between February 2017 and July 2018. The study was conducted using the Short-Form (SF-36) questionnaire for all candidates, CD-specific QOL questionnaire for the CD patients group, and CD screen questionnaire for the control group.

RESULTS

Overall, 354 subjects were studied (111 CD patients and 243 control). Female subjects constituted 56.8% of both patient and control groups. In the generic SF-36 questionnaire, QOL was comparable between patients and controls in all domains except for the general health domain, which showed difference in favor of the controls (55.01 ± 26.41 and 62.96 ± 18.16, P = 0.005). We also found that males have lower QOL scores in the domains comprising health change (P = 0.02), physical functioning (P = 0.04, role functioning/emotional and emotional well-being (P = 0.049). The CD-specific QOL showed excellent and good scores for 79.3% of patients overall in the tested domains. Patients with poor adherence showed poor QOL in all generic (SF-36) domains but not in CD-specific domains.

CONCLUSION

The HRQOL for Saudi CD children on GFD is generally comparable to the healthy control with exception of the general health domain. Adherence to the GFD improves the generic (SF-36) QOL domains.

Comparison of Small Gut and Whole Gut Microbiota of First-Degree Relatives With Adult Celiac Disease Patients and Controls

Recent studies on celiac disease (CeD) have reported alterations in the gut microbiome. Whether this alteration in the microbial community is the cause or effect of the disease is not well understood, especially in adult onset of disease. The first-degree relatives (FDRs) of CeD patients may provide an opportunity to study gut microbiome in pre-disease state as FDRs are genetically susceptible to CeD. By using 16S rRNA gene sequencing, we observed that ecosystem level diversity measures were not significantly different between the disease condition (CeD), pre-disease (FDR) and control subjects. However, differences were observed at the level of amplicon sequence variant (ASV), suggesting alterations in specific ASVs between pre-disease and diseased condition. Duodenal biopsies showed higher differences in ASVs compared to fecal samples indicating larger disruption of the microbiota at the disease site. The duodenal microbiota of FDR was characterized by significant abundance of ASVs belonging to Parvimonas, Granulicatella, Gemella, Bifidobacterium, Anaerostipes, and Actinomyces genera. The duodenal microbiota of CeD was characterized by higher abundance of ASVs from genera Megasphaera and Helicobacter compared to the FDR microbiota. The CeD and FDR fecal microbiota had reduced abundance of ASVs classified as Akkermansia and Dorea when compared to control group microbiota. In addition, predicted functional metagenome showed reduced ability of gluten degradation by CeD fecal microbiota in comparison to FDRs and controls. The findings of the present study demonstrate differences in ASVs and predicts reduced ability of CeD fecal microbiota to degrade gluten compared to the FDR fecal microbiota. Further research is required to investigate the strain level and active functional profiles of FDR and CeD microbiota to better understand the role of gut microbiome in pathophysiology of CeD.

Endocrine complications of celiac disease: a case report and review of the literature

PURPOSE

The purpose of this article is to review recent literature regarding endocrine disorders related to celiac disease (CD).

METHODS

We describe a case report and review existing literature on the endocrine manifestations of CD.

RESULTS

CD is an autoimmune disorder characterized by intestinal inflammation in response to gluten. CD can cause a wide range of extra-intestinal complications, including endocrine manifestations. Metabolic bone disease including osteoporosis and osteopenia, vitamin D deficiency, secondary hyperparathyroidism and less frequently osteomalacia can be seen. In CD, fracture risk is increased by 30-40%, while risk for hip fracture is approximately doubled. The risk for other endocrine disorders, particularly autoimmune endocrinopathies, is also increased in those with CD compared to the general population. Epidemiologic data indicate the risk for hypothyroidism is 3-4 times higher among those with CD, while risk of type 1 diabetes is greater than double. Risk for primary adrenal insufficiency is a striking 11-fold higher in those with versus without CD, though the absolute risk is low. Fertility is reduced in women with CD before diagnosis by 37% while male fertility in the absence of hypogonadism does not appear to be affected. Other endocrine conditions including hyperthyroidism, ovarian failure, androgen insensitivity, impaired growth and growth hormone deficiency and autoimmune polyendocrine syndromes have also been associated with CD.

CONCLUSIONS

CD is associated with a wide range of endocrine manifestations.

Coeliac disease

Coeliac disease (CD) develops in genetically susceptible individuals who, in response to unclear environmental triggers, develop an immune response triggered by gluten ingestion. It is now recognised as a global disease affecting about 0.7% of the world's population. The clinical presentation ranges from malabsorption to asymptomatic individuals diagnosed by screening high-risk groups. Diagnosis requires the demonstration of small intestinal villous atrophy in the presence of circulating coeliac auto-antibodies and/or an unequivocal response to a gluten-free diet (GFD). Recent guidelines suggest that, in a subset of children, duodenal biopsies can be avoided in the presence of strict symptomatic and serological criteria. While the majority of patients respond to a GFD, up to 20% of patients with CD have persistent or recurrent symptoms. There are several aetiologies for residual or new symptoms in a patient with CD on a GFD, with inadvertent exposure to gluten being the most common. Following a GFD can be challenging for patients with CD and understanding the barriers/challenges faced by patients in maintaining a GFD is crucial for compliance. Abbreviations: AGA: anti-gliadin antibodies; Anti-DGP-ab: anti-deamidated gliadin peptide antibodies; Anti-tTG-ab: anti-tissue transglutaminase antibodies; ATD: auto-immune thyroid disorders; BMD: bone mineral density; CD: coeliac disease; DH: dermatitis herpetiformis; EMA: anti-endomysial antibodies; FDR: first-degree relatives; GFD: gluten-free diet; HbA1c: haemoglobin A1c; HLA: human leucocyte antigen; IBS: irritable bowel syndrome; LMIC: low- and middle-income countries; NPV: negative predictive value; NRCD: non-responsive coeliac disease; POCT: point-of-care tests; SDR: second-degree relatives; SIBO: small intestinal bacterial overgrowth; T1DM: type 1 diabetes mellitus; ULN: upper limit of normal.

Pediatric Celiac Disease in Central and East Asia: Current Knowledge and Prevalence

The current prevalence of pediatric Celiac Disease (CD) is estimated to be around 1% in the general population, worldwide. However, according to the geographic area, a great variability of CD prevalence has been described. Whereas a number of studies are available from Europe, North and South America, Australia, South-West Asia, and North Africa, the knowledge and awareness of CD in large parts of the remaining world areas is definitively poor. In several countries of Central and East Asia, the consumption of wheat is consistent and/or has significantly increased in recent decades, and CD is supposed to be underdiagnosed in children. In this mini-review, we aimed to summarize the current knowledge about the prevalence of pediatric CD in Central and East Asia, paying attention to the HLA-DQ immunogenetic background as well. Indeed, CD is likely not to be as uncommon as previously or currently thought in countries like Russia, Kazakhstan, and China, in addition to India, where pediatric CD has been clearly showed to be quite prevalent. Therefore, there is an urgent need for population-based studies on the prevalence of CD in those countries, especially in children, in order to increase the awareness of this disease and to improve the diagnostic strategy in these areas.

Identifying and improving adherence to the gluten-free diet in people with coeliac disease

Coeliac disease (CD) is an autoimmune gastrointestinal disorder whereby the ingestion of gluten, a storage protein found in wheat, barley and rye, causes damage to intestinal mucosa with resultant malabsorption, increased risk of anaemia and osteoporosis. Worldwide estimates suggest 1% of the population have CD. With no cure, the only treatment is a gluten-free diet (GFD). Adhering to a GFD can be very challenging; it requires knowledge, motivation and modified behaviours. Assessing adherence to a GFD is methodologically challenging. This review aims to provide an overview of the literature reporting adherence to a GFD in people with CD and the methodological challenges encountered. From six studies it has been reported that rates of adherence to a GFD range between 45 and 90% in patients of different ethnicities with CD. GF dietary adherence can be influenced by age at diagnosis, coexisting depression, symptoms on ingestion of gluten, nutrition counselling, knowledge of GF foods, understanding of food labels, cost and availability of GF foods, receiving GF foods on prescription and membership of a coeliac society. To date only five intervention studies in adults with CD have been undertaken to improve GF dietary adherence. These have included dietary and psychological counselling, and the use of online training programmes, apps, text messages and telephonic clinics. Future interventions should include people of all ethnicities, consider patient convenience and the cost-effectiveness for the healthcare environment.

Coeliac disease

Coeliac disease is an immune-mediated enteropathy against dietary gluten present in wheat, rye and barley and is one of the most common lifelong food-related disorders worldwide. Coeliac disease is also considered to be a systemic disorder characterized by a variable combination of gluten-related signs and symptoms and disease-specific antibodies in addition to enteropathy. The ingestion of gluten leads to the generation of harmful gluten peptides, which, in predisposed individuals, can induce adaptive and innate immune responses. The clinical presentation is extremely variable; patients may have severe gastrointestinal symptoms and malabsorption, extraintestinal symptoms or have no symptoms at all. Owing to the multifaceted clinical presentation, diagnosis remains a challenge and coeliac disease is heavily underdiagnosed. The diagnosis of coeliac disease is achieved by combining coeliac disease serology and small intestinal mucosal histology during a gluten-containing diet. Currently, the only effective treatment for coeliac disease is a lifelong strict gluten-free diet; however, the diet is restrictive and gluten is difficult to avoid. Optimizing diagnosis and care in coeliac disease requires continuous research and education of both patients and health-care professionals.

Evolving Therapy for Celiac Disease

Gluten is known to be the main triggering factor for celiac disease (CeD), an immune-mediated disorder. CeD is therefore managed using a strict and lifelong gluten-free diet (GFD), the only effective treatment available currently. However, the GFD is restrictive. Hence, efforts are being made to explore alternative therapies. Based on their mechanisms of action on various molecular targets involved in the pathogenesis of CeD, these therapies may be classified into one of the following five broad approaches. The first approach focuses on decreasing the immunogenic content of gluten, using strategies like genetically modified wheat, intra-intestinal gluten digestion using glutenases, microwave thermal treatment of hydrated wheat kernels, and gluten pretreatment with either bacterial/ fungal derived endopeptidases or microbial transglutaminase. The second approach involves sequestering gluten in the gut lumen before it is digested into immunogenic peptides and absorbed, using binder drugs like polymer p(HEMA-co-SS), single chain fragment variable (scFv), and anti- gluten antibody AGY. The third approach aims to prevent uptake of digested gluten through intestinal epithelial tight junctions, using a zonulin antagonist. The fourth approach involves tissue transglutaminase (tTG) inhibitors to prevent the enhancement of immunogenicity of digested gluten by the intestinal tTG enzyme. The fifth approach seeks to prevent downstream immune activation after uptake of gluten immunogenic peptides through the intestinal mucosal epithelial layer. Examples include HLA-DQ2 blockers that prevent presentation of gluten derived- antigens by dendritic cells to T cells, immune- tolerizing therapies like the vaccine Nexvax2 and TIMP-Glia, cathepsin inhibitors, immunosuppressants like corticosteroids, azathioprine etc., and anti-cytokine agents targeting TNF-α and interleukin-15. Apart from these approaches, research is being done to evaluate the effectiveness of probiotics/prebiotics, helminth therapy using Necator americanus, low FODMAP diet, and pancreatic enzyme supplementation in CeD symptom control; however, the mechanisms by which they play a beneficial role in CeD are yet to be clearly established. Overall, although many therapies being explored are still in the pre-clinical phase, some like the zonulin antagonist, immune tolerizing therapies and glutenases have reached phase II/III clinical trials. While these potential options appear exciting, currently they may at best be used to supplement rather than supplant the GFD.

Clinical, endoscopic, and histological differentiation between celiac disease and tropical sprue: A systematic review

BACKGROUND AND AIM

While the prevalence of celiac disease (CD) is increasing globally, the prevalence of tropical sprue (TS) is declining. Still, there are certain regions in the world where both patients with CD and TS exist and differentiation between them is a challenging task. We conducted a systematic review of the literature to find out differentiating clinical, endoscopic, and histological characteristics between CD and TS.

METHODS

Medline, PubMed, and EMBASE databases were searched for keywords: celiac disease, coeliac, celiac, tropical sprue, sprue, clinical presentation, endoscopy, and histology. Studies published between August 1960 and January 2018 were reviewed. Out of 1063 articles available, 12 articles were included in the final analysis.

RESULTS

Between the patients with CD and TS, there was no difference in the prevalence and duration of chronic diarrhea, abdominal distension, weight loss, extent of abnormal fecal fat content, and density of intestinal inflammation. The following features were more common in CD: short stature, vomiting/dyspepsia, endoscopic scalloping/attenuation of duodenal folds, histological high modified Marsh changes, crescendo type of IELosis, surface epithelial denudation, surface mucosal flattening, thickening of subepithelial basement membrane and celiac seropositivity; while those in TS include anemia, abnormal urinary D-xylose test, endoscopic either normal duodenal folds or mild attenuation, histologically decrescendo type of IELosis, low modified Marsh changes, patchy mucosal changes, and mucosal eosinophilia.

CONCLUSIONS

Both patients with CD and TS have overlapping clinical, endoscopic, and histological characteristics, and there is no single diagnostic feature for differentiating CD from TS except for celiac specific serological tests.

Mechanisms by which gut microorganisms influence food sensitivities

Finely tuned mechanisms enable the gastrointestinal tract to break down dietary components into nutrients without mounting, in the majority of cases, a dysregulated immune or functional host response. However, adverse reactions to food have been steadily increasing, and evidence suggests that this process is environmental. Adverse food reactions can be divided according to their underlying pathophysiology into food intolerances, when, for instance, there is deficiency of a host enzyme required to digest the food component, and food sensitivities, when immune mechanisms are involved. In this Review, we discuss the clinical and experimental evidence for enteric infections and/or alterations in the gut microbiota in inciting food sensitivity. We focus on mechanisms by which microorganisms might provide direct pro-inflammatory signals to the host promoting breakdown of oral tolerance to food antigens or indirect pathways that involve the metabolism of protein antigens and other dietary components by gut microorganisms. Better understanding of these mechanisms will help in the development of preventive and therapeutic strategies for food sensitivities.

Pigment Epithelium-Derived Factor Affects Angiogenesis in Celiac Disease

OBJECTIVE

Recent studies have demonstrated that angiogenesis is impaired in patients with celiac disease (CD). In this study, we evaluated the levels of the novel antiangiogenic factor pigment epithelium-derived factor (PEDF) in CD patients.

METHODS

Eighty-four patients were included in the study; 71 patients with CD and 13 healthy controls. In the CD patient cohort, there were 21 newly diagnosed patients, 19 with adherence to a gluten-free diet and 31 practicing no adherence to this diet. The PEDF levels were measured using enzyme-linked immunosorbent assays.

RESULTS

The data revealed that celiac patients had higher levels of PEDF than did healthy controls. PEDF levels were not significantly different among the three CD groups. Additionally, the PEDF levels were not correlated with tissue transglutaminase IgA or IgG.

CONCLUSIONS

Our data indicate that PEDF levels are significantly higher in CD patients than those in the healthy controls. This result suggests that PEDF negatively affects angiogenesis in CD. Although we did not observe any differences of PEDF levels among celiac patients, additional studies including more patients could clarify this issue.

Impact of Cereal Seed Sprouting on Its Nutritional and Technological Properties: A Critical Review

Sprouting induces activation and de novo synthesis of hydrolytic enzymes that make nutrients available for plant growth and development. Consumption of sprouted grains is suggested to be beneficial for human health. Positive consumer perceptions about sprouted cereals have resulted in new food and beverage product launches. However, because there is no generally accepted definition of "sprouting," it is unclear when grains are to be called sprouted. Moreover, guidelines about how much sprouted grain material food products should contain to exert health benefits are currently lacking. Accordingly, there is no regulatory base to develop appropriate food labeling for "sprouted foods." This review describes the nutritional and technological properties of sprouted grains in relation to processing conditions and provides guidelines to optimize sprouting practices in order to maximize nutritive value. Relatively long sprouting times (3 to 5 days) and/or high processing temperatures (25 to 35 °C) are needed to maximize the de novo synthesis and/or release of plant bioactive compounds. Nutrient compositional changes resulting from sprouting are often associated with health benefits. However, supportive data from clinical studies are very scarce, and at present it is impossible to draw any conclusion on health benefits of sprouted cereals. Finally, grains sprouted under the above-mentioned conditions are generally unfit for use in traditional food processing and it is challenging to use sprouted grains as ingredients without compromising their nutrient content. The present review provides a basis for better defining what "sprouting" is, and to help further research and development efforts in this field as well as future food regulations development.

Rising prevalence of celiac disease is not universal and repeated testing is needed for population screening

Background

Recent studies suggest that the prevalence of celiac disease is rising. We previously established the prevalence of celiac disease in healthy blood donors in 2002.

Objective

The purpose of this study was to examine whether the prevalence of celiac disease and celiac disease autoimmunity has changed over time by performing a similar prospective study.

Methods

Healthy blood donors (n = 1908) were tested for tissue transglutaminase antibodies and for anti-endomysial antibodies when positive. Further evaluation followed accepted criteria for diagnosis.

Results

Overall, 32 donors had abnormal tissue transglutaminase antibodies (1.68%). Eight donors had tissue transglutaminase antibodies >3 × upper limit of normal (0.42%), two of them with tissue transglutaminase antibodies >10 × upper limit of normal, while 24 donors had tissue transglutaminase antibodies <3 × upper limit of normal (1.26%). Most of the donors with positive tissue transglutaminase antibodies <3 × upper limit of normal had negative tissue transglutaminase antibodies levels on repeated testing (18/19). Celiac disease was diagnosed in four donors with positive tissue transglutaminase antibodies, establishing a prevalence of 1.68% (95% confidence interval 1.15-2.3) for celiac disease autoimmunity and 0.21% for celiac disease (95% confidence interval 0.07-0.5%).

Conclusion

The prevalence of celiac disease in blood donors in Israel did not rise in the last 15 years, suggesting that the increased prevalence of diagnosed celiac disease is mainly due to increased awareness. As most of the donors with elevated tissue transglutaminase antibodies <3 × upper limit of normal were endomysial antibody negative and had a negative tissue transglutaminase antibodies result upon re-testing, repeated tissue transglutaminase antibodies testing is required when screening asymptomatic populations for celiac disease.

The association of celiac disease and allergic disease in a general adult population

Background

The relationship between allergy and celiac disease (CD) is not clear.

Objective

The objective of this article is to investigate the association of CD and CD antibody positivity with hay fever, asthma and immunoglobulin (Ig)E sensitization in a general adult population.

Methods

A total of 2297 individuals were screened for CD antibodies and underwent allergy testing. CD antibody-positive participants were invited to undergo clinical evaluation including biopsies. Additionally, biobank blood samples from four population-based studies (6423, 973, 1718 and 1101 participants) with data on IgE sensitization to inhalant allergens were screened for CD antibodies. CD antibody-positive participants were screened for serum IgE against food allergens in three biobank studies. CD-antibody positivity was defined as IgA or IgG tissue transglutaminase ≥7 U/ml and/or IgG deamidated gliadin peptide ≥10 U/ml.

Results

The nine participants (0.4%) diagnosed with CD had significantly higher prevalence of IgE sensitization to wheat and dust mites. The prevalence of CD antibody positivity was 0.8% (18/2297), and these participants had a significantly higher prevalence of IgE sensitization to food allergens (Fx5), egg, dust mites and mugwort. In the biobank studies, the prevalence of CD antibody positivity was 0.8% to 1.2%. One study showed a positive association between CD antibody positivity and IgE sensitization for dog, horse and food allergens.

Conclusion

We found a possible association of CD and IgE sensitization to some food and inhalant allergens in the Health2006 study. In further studies, however, we could not consistently replicate these associations.

Validation of a novel single-drop rapid human leukocyte antigen-DQ2/-DQ8 typing method to identify subjects susceptible to celiac disease

Background and Aim

Human leukocyte antigen (HLA)‐DQ2 and/or ‐DQ8 is an essential risk factor for celiac disease (CD). About 90–95% of patients with CD carry HLA‐DQ2/‐DQ8 alleles, and HLA‐DQ typing is considered an additional diagnostic test. Conventional polymerase chain reaction (PCR)‐based HLA‐DQ typing methods are expensive, complex, and a time‐consuming process. We assessed the efficacy of a novel HLA‐DQ typing method, “Celiac Gene Screen,” for the detection of CD‐associated HLA haplotypes.

Methods

To assess the diagnostic performance of the Celiac Gene Screen test, 100 ethylenediaminetetraacetic acid (EDTA) blood samples, already characterized by the conventional HLA‐DQ typing method, that is, PCR sequence‐specific oligonucleotide probes (PCR‐SSOP), a concordance between both the methods were explored. For validity, a further 300 EDTA blood samples with unknown HLA‐DQ status were genotyped using the Celiac Gene Screen test, including 141 samples from CD, 56 first‐degree relatives (FDRs) of CD and 103 samples from controls.

Results

Of the 100 samples with known status of HLA‐DQ alleles, 79 samples were HLA‐DQ2 and/or ‐DQ8 positive, and 21 samples were HLA‐DQ2 and/or ‐DQ8 negative by conventional PCR. These 100 samples were re‐typed using the Celiac Gene screen kit; all 79 positives were typed positive, and 21 negatives were typed negative for HLA‐DQ alleles. Among 300 samples with unknown HLA‐DQ status, 118 of 141 (84%) patients with CD, 48 of 56 (86%) FDRs of CD, and 52 of 103 (50%) controls typed positive for HLA‐DQ alleles.

Conclusions

The Celiac Gene Screen HLA‐DQ typing method showed excellent concordance with the conventional HLA‐DQ typing method and could be a cost‐reducing and effective method for CD‐associated HLA screening.

The Effect of Gluten-Free Diet on Health and the Gut Microbiota Cannot Be Extrapolated from One Population to Others

Gluten-related disorders (GRD) affect millions of people worldwide and have been related to the composition and metabolism of the gut microbiota. These disorders present differently in each patient and the only treatment available is a strict life-long gluten-free diet (GFD). Several studies have investigated the effect of a GFD on the gut microbiota of patients afflicted with GRD as well as healthy people. The purpose of this review is to persuade the biomedical community to think that, while useful, the results from the effect of GFD on health and the gut microbiota cannot be extrapolated from one population to others. This argument is primarily based on the highly individualized pattern of gut microbial composition and metabolic activity in each person, the variability of the gut microbiota over time and the plethora of factors associated with this variation. In addition, there is wide variation in the composition, economic viability, and possible deleterious effects to health among different GFD, both within and among countries. Overall, this paper encourages the conception of more collaborative efforts to study local populations in an effort to reach biologically and medically useful conclusions that truly contribute to improve health in patients afflicted with GRD.

A Review on the Gluten-Free Diet: Technological and Nutritional Challenges

Consumers, food manufacturers and health professionals are uniquely influenced by the growing popularity of the gluten-free diet. Consumer expectations have urged the food industry to continuously adjust and improve the formulations and processing techniques used in gluten-free product manufacturing. Health experts have been interested in the nutritional adequacy of the diet, as well as its effectiveness in managing gluten-related disorders and other conditions. In this review, we aim to provide a clear picture of the current motivations behind the use of gluten-free diets, as well as the technological and nutritional challenges of the diet as a whole. Alternative starches and flours, hydrocolloids, and fiber sources were found to play a complex role in mimicking the functional and sensory effects of gluten in gluten-free products. However, the quality of gluten-free alternatives is often still inferior to the gluten-containing products. Furthermore, the gluten-free diet has demonstrated benefits in managing some gluten-related disorders, though nutritional imbalances have been reported. As there is limited evidence supporting the use of the gluten-free diet beyond its role in managing gluten-related disorders, consumers are urged to be mindful of the sensorial limitations and nutritional inadequacies of the diet despite ongoing strategies to improve them.

An in-depth characterization of a large cohort of adult patients with eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic, allergic, immune-mediated disease associated with increased risk of comorbid atopic conditions.

OBJECTIVE

To perform an in-depth characterization of a large cohort of manually verified adult patients with EoE, including evaluation of less studied associations, such as pollen food allergy syndrome, anaphylaxis, autoimmunity, and psychiatric comorbidities.

METHODS

We performed a manual retrospective electronic medical record review of 1,218 patients with EoE identified by International Classification of Diseases, Ninth Revision and International Classification of Disease, 10th Revision codes from the University of Pennsylvania Health Systems. Through manual medical record review, we evaluated patient demographics, family and smoking history, laboratory and endoscopic findings, treatment, and comorbid atopic, autoimmune, and psychiatric conditions.

RESULTS

A total of 950 of the 1,218 patients had biopsy-proven EoE. This cohort was predominantly male, white, and never-smokers who presented most commonly with dysphagia, with an initial biopsy results showing 49 eosinophils per high-powered field, a serum absolute eosinophilic count of 446,000/µL, and mean total IgE level of 243 IU/mL. Of the patients, 55% had impaction (of which 38% required endoscopic removal), and 56% had strictures or fibrosis (of which 56% underwent dilatation). Therapy used was predominantly (77%) medical only. Comorbid atopy, pollen food allergy syndrome, drug allergy, anaphylaxis, autoimmunity, and psychiatric illnesses were higher in the EoE cohort compared with the general University of Pennsylvania Health Systems population.

CONCLUSION

Our adult cohort of manually verified, biopsy-proven EoE had an increased risk of pollen food allergy syndrome, anaphylaxis, and comorbid autoimmune and psychiatric conditions compared with the University of Pennsylvania Health Systems population. There was also an increased prevalence of impaction and stricture or fibrosis requiring endoscopic intervention compared with the pediatric population.

Burden of gastrointestinal and liver diseases in India, 1990-2016

There is no comprehensive report on the burden of gastrointestinal (GI) and liver diseases in India. In this study, we estimated the age-standardized prevalence, mortality, and disability adjusted life years (DALY) rates of GI and liver diseases in India from 1990 to 2016 using data from the Global Burden of Disease (GBD) Study, which systematically reviews literature and reports for international disease burden trends. Despite a decrease in the overall burden from GI infectious disorders since 1990, they still accounted for the majority of DALYs in 2016. Among noncommunicable disorders (NCDs), there were increases in the prevalence and mortality rates for pancreatitis, liver cancer, paralytic ileus and intestinal obstruction, gallbladder and biliary tract cancer, vascular intestinal disorders, colorectal cancer, and inflammatory bowel disease. Prevalence and mortality rates decreased for peptic ulcer disease, hernias, appendicitis, and stomach and esophageal cancer. For gastritis and duodenitis, cirrhosis and other chronic liver diseases, and gallbladder and biliary tract diseases, there was an increase in prevalence but a decrease in mortality while the opposite was true for pancreatic cancer (decreased prevalence, increased mortality). Indian gastroenterologists and hepatologists must continue to attend to the large majority of patients with infectious diseases while also managing the increasing number of GI and liver diseases, noncommunicable nonmalignant and malignant.

There Is No Association between Coeliac Disease and Autoimmune Pancreatitis

Autoimmune pancreatitis (AIP) is a rare disorder whose association with coeliac disease (CD) has never been investigated, although CD patients display a high prevalence of both endocrine and exocrine pancreatic affections. Therefore, we sought to evaluate the frequency of CD in patients with AIP and in further medical pancreatic disorders. The screening for CD was carried out through the detection of tissue transglutaminase (tTG) autoantibodies in sera of patients retrospectively enrolled and divided in four groups: AIP, chronic pancreatitis, chronic asymptomatic pancreatic hyperenzymemia (CAPH), and control subjects with functional dyspepsia. The search for anti-endomysium autoantibodies was performed in those cases with borderline or positive anti-tTG values. Duodenal biopsy was offered to all cases showing positive results. One patient out of 72 (1.4%) with AIP had already been diagnosed with CD and was following a gluten-free diet, while one case out of 71 (1.4%) with chronic pancreatitis and one out of 92 (1.1%) control subjects were diagnosed with de novo CD. No cases of CD were detected in the CAPH group. By contrast, a high prevalence of cases with ulcerative colitis was found in the AIP group (13.8%). Despite a mutual association between CD and several autoimmune disorders, our data do not support the serologic screening for CD in AIP. Further studies will clarify the usefulness of CD serologic screening in other pancreatic disorders.

Development and Validation of the Coeliac Disease Food Attitudes and Behaviours Scale

Objectives

Previous studies on coeliac disease suggest that attitudes towards the gluten-free diet may contribute to the development of disordered eating. This study describes the development and validation of the Coeliac Disease Food Attitudes and Behaviours scale (CD-FAB) to measure these behaviours in coeliac disease.

Research Methods and Procedures

Focus groups were used to develop 33 potential questionnaire items. These items were reviewed by service users and then distributed online to 157 adults with coeliac disease. Items were removed based on ceiling/floor effects, high interitem correlations (>0.7) and factor analysis. 11 items were retained. Exploratory factor analysis was then conducted. The psychometric properties of the final version of the CD-FAB were assessed via using an online platform.

Results

The CD-FAB had 11 items distributed across one factor assessing attitudes and behaviours towards food. These factors explained 44.1% of the variance in responding. The CD-FAB and its subscales had high internal consistency (Cronbach's alpha > 0.7) and psychometric validation indicated good convergent and discriminant validity. High scores on the CD-FAB are associated with psychological distress and an impaired quality of life.

Conclusions

The CD-FAB is a reliable and valid measure of food attitudes and behaviours in coeliac disease. As a new disease-specific instrument, it may be a useful tool for evaluating food concerns in individuals with coeliac disease in a clinical setting and for further exploring the development of disordered eating patterns in coeliac disease. Further research is required to assess the full potential of the CD-FAB.

Extraintestinal Manifestations of Celiac Disease: Early Detection for Better Long-Term Outcomes

Population-based screening studies have shown celiac disease to be one of the most common chronic gastrointestinal diseases. Nevertheless, because of the diverse clinical presentation, the great majority of patients remain unrecognized. Particularly difficult to identify are the multifaceted extraintestinal symptoms that may appear at variable ages. Although the pathogenesis and long-term outcome of these manifestations are still poorly established, there is some evidence that unrecognized celiac disease predisposes to severe complications if not diagnosed and prevented with an early-initiated gluten-free diet. Therefore, it is of utmost importance that physicians of different disciplines learn to recognize celiac disease in individuals with non-gastrointestinal symptoms. In the future, more studies are needed to clarify the factors affecting development and prognosis of the extraintestinal manifestations.