Prevalence of celiac disease among blood donors in Brazil

The spectrum of celiac disease: epidemiology, clinical aspects and treatment

Celiac disease is a gluten-sensitive enteropathy that affects people of all ages worldwide. This disease has emerged as a major health-care problem, as advances in diagnostic and screening methods have revealed its global prevalence. Environmental factors such as gluten introduction at childhood, infectious agents and socioeconomic features, as well as the presence of HLA-DQ2 and/or HLA-DQ8 haplotypes or genetic variations in several non-HLA genes contribute to the development of celiac disease. Growing insight into the variable clinical and histopathological presentation features of this disease has opened new perspectives for future research. A strict life-long gluten-free diet is the only safe and efficient available treatment, yet it results in a social burden. Alternative treatment modalities focus on modification of dietary components, enzymatic degradation of gluten, inhibition of intestinal permeability and modulation of the immune response. A small group of patients with celiac disease (2-5%), however, fail to improve clinically and histologically upon elimination of dietary gluten. This complication is referred to as refractory celiac disease, and imposes a serious risk of developing a virtually lethal enteropathy-associated T-cell lymphoma.

[Seroprevalence of celiac disease at a general pediatric outpatient clinic]

BACKGROUND

Celiac disease is a common problem affecting children and adults, for which early diagnosis and treatment prevent complications and deaths. Seroprevalence studies in our environment are still scarce.

AIMS

To determine the seroprevalence of celiac disease by using human tissue antiendomysial and anti-transglutaminase antibodies, among children and adolescents who were attended at a general pediatric outpatient clinic.

METHODS

This was a seroprevalence study of descriptive cross-sectional design. First, assays for guinea pig tissue anti-transglutaminase antibodies were performed. Subsequently, in the positive cases, assays for human tissue antiendomysial and anti-transglutaminase antibodies were performed.

RESULTS

The seroprevalence of celiac disease by means of anti-guinea pig tissue anti-transglutaminase antibodies was 5% (42/831; 95% CI: 3.76%-6.90%). Considering three positive tests, the seroprevalence was 1.9% (16/831; 95% CI: 1.83%-1.97%). The concordance of human anti-transglutaminase with antiendomysial was 71%.

CONCLUSIONS

The seroprevalence of celiac disease was high. Serological screening for celiac disease among children and adolescents who present signs and/or symptoms compatible with celiac disease should be performed routinely, as well as in groups already known to be at risk, given the high seroprevalence of celiac disease observed in our environment.

Maternal celiac disease: improbable risk factor for neural tube defect

OBJECTIVES

To verify the existence of possible relation between maternal celiac disease (CD) and the appearance of neural tube defects (NTD) in the newborn serological testing in 208 mothers with NTD-affected pregnancy were performed.

METHODS

All sera were tested for total serum immunoglobulin A (IgA) levels and for IgA class endomysial antibody using indirect immunofluorescence technique. Participant age ranged from 19 to 43 years (mean: 33 years). None had been previously investigated for or had a family history of CD.

RESULTS

Immunoglobulin levels were normal and results of the IgA-endomysial antibody tests were negative in all women tested.

CONCLUSION

This study, although nonconclusive, did not corroborate earlier findings described in the literature of increased frequency of CD in mothers with a history of NTD-affected pregnancy. At this moment we feel that a routine screening for CD in pregnant women to avoid a possible pregnancy aggravated by NTD would not be justifiable.

Prevalence of celiac disease among first degree relatives of Brazilian celiac patients

BACKGROUND

Several studies have shown that celiac disease, an autoimmune disorder that occurs in genetically susceptible individuals, is highly prevalent among relatives of celiac patients.

AIM

To determine the prevalence of celiac disease in a group of first degree relatives of Brazilian celiac patients.

METHODS

First degree relatives of celiac patients attending the Brasilia University Hospital Pediatric Gastroenterology Outpatient Clinic or the Celiac Disease Investigation Center, Brasília, DF, Brazil, between March 2001 and November 2004 were invited to undergo serological screening for celiac disease applying the IgA anti-endomysium antibody test (IgA-EMA). All positive IgA-EMA sera underwent a second screening using the IgA anti-tissue transglutaminase antibodies test. Duodenal or small intestinal biopsies were performed in all subjects positive to serological testing. Biopsy samples were classified as type (O) normal, (I) infiltrative, (II) infiltrative hyperplastic, (III) flat destructive, and (IV) atrophic hypoplastic. The final diagnosis was ascertained in subjects showing positive serological tests and a grade I to III small intestinal lesion.

RESULTS

Nine new cases of celiac disease were found among the 188 first degree relatives tested (4.8%).

CONCLUSION

The present study confirms the high prevalence of celiac disease among first degree celiac patients relatives and reinforces the need of extensive diagnostic screening in this specific group.

Celiac disease in children: impact on bone health

Celiac disease is a chronic enteropathy caused by permanent intolerance to gluten and similar proteins found in wheat, barley and rye. The intestinal mucosa of susceptible individuals is crossed by undigested gluten, which leads to a marked inflammatory response. The clinical features may vary from overt intestinal symptoms to silent disease. Bone health has been found to be markedly affected in children and adolescents with untreated celiac disease, regardless of clinical presentation. Bone mass measurements are greatly reduced compared to healthy youth. As indicated by surrogate markers of bone turnover, bone formation rates are depressed and bone resorption rates enhanced in untreated patients. The causes underlying alterations in bone metabolism are still under investigation, but are attributed to non-intestinal factors. Increased production of inflammatory cytokines and presence of specific autoantibodies may together disrupt bone metabolism equilibrium in children and adolescents with celiac disease. Gluten withdrawal is able to restore bone mass quite rapidly, with a normalization of levels of bone formation and bone resorption markers. Good adherence to gluten-free diet is mandatory to maintain optimal bone health. Monitoring of dietary compliance is important to ensure appropriate bone mass accrual through childhood and puberty in these patients, to maximize peak bone mass and reduce fracture risk later in life.

[Clinical profile of Santa Catarina members of Brazilian Celiac Association]

BACKGROUND

Celiac disease is an enteropathy induced by gluten in genetically predisposed individuals.

AIM

To establish the demographic and clinical characteristics of this disease in Santa Catarina State, Brazil.

METHODS

A descriptive transversal study was performed involving members of a regional celiac association, to whom a questionnaire focusing various aspects of the disease was sent.

RESULTS

From a total of 506 members, 145 (28.7%) were enrolled in the study--all of them biopsy-proven celiacs. Their mean age was 30.8 years (range, 3.3-82.5 years). Female to male rate was 2.1:1. The mean age at diagnosis was 16 years for men and 26.7 years for women. Most frequently reported symptoms were: abdominal distention (71.8%), abdominal pain (71%) and diarrhea (65.5%). Anemia, aphthous ulcers and constipation were more related by women, while diarrhea and low weight were more frequent in men. Only 42.1% of the participants had been submitted to biopsies compatible with a correct investigation of the disease (44.2 % had been submitted to biopsy only after gluten exclusion of the diet and 11.7% did not mentioned whether they were in a gluten-free diet when biopsied). Only 61.4% had been submitted to serological tests for diagnostic or dietary control purposes. Associated diseases were related by 65% of the individuals, of which the most common was lactose intolerance (33%). Vitaminic or mineral supplementation was indicated to 45% and only 32.5% have had bone mineral density measured. Of these, 59% had altered results.

CONCLUSIONS

The results suggest a tendency of diagnosis of celiac disease in older ages, specially among women. This may indicate the necessity of improving public and medical knowledge in Santa Catarina concerning the diagnosis and treatment of this disease.

Determining IgA and IgG antigliadin, IgA antitransglutaminase, and antiendomysial antibodies in monkey esophagus and in umbilical cord for diagnosis of celiac disease in developing countries

OBJECTIVES

To assess the efficiency of determining IgA and IgG antigliadin antibodies (IgA- and IgG-AGA, respectively), antitransglutaminase (TgA), and anti-endomysial antibodies (AEA) in human umbilical cord (CO) and monkey esophagus for diagnosis of celiac disease; to determine the correlation between serological markers and celiac disease.

PATIENTS AND METHODS

A total of 400 patients were divided in 3 groups: group 1 with 37 patients with celiac disease, group 2 with 208 patients with no enteropathies, and group 3 with 155 patients with other enteropathies. IgA-AGA, IgG-AGA, and TgA were assessed using enzyme-linked immunosorbent assay, whereas AEA was evaluated by indirect immunofluorescence.

RESULTS

Sensitivity and specificity of IgA-AGA were 81.1% and 95.2%, of IgG-AGA 89.2% and 95.2%, of TgA 83.9% and 96.8%, of AEA-CO 87.9% and 100%, and of AEA of monkey esophagus 88.6% and 100%, respectively. Positive predictive values were 75.0%, 76.7%, 83.9%, and 100%. Negative predictive values were 96.6%, 98.0%, 96.8%, and 97.7% for IgA-AGA, IgG-AGA, TgA, and AEA, respectively. Multivariate analysis showed a strong association between AEA-CO and celiac disease and a good correlation with other markers (TgA, IgA-AGA, and IgG-AGA).

CONCLUSIONS

TgA has been recommended for screening patients with celiac disease. Considering the similar sensitivity and specificity of IgA-AGA and TgA and their correlations in the multivariate analysis, both are applicable for this purpose. However, because TgA tests are highly costly and celiac disease is associated with IgA deficiency, the determination of IgA-AGA and IgG-AGA, followed by AEA-CO, is suitable for screening in developing countries, provided a cutoff point for these examinations is established. The results of antiendomysial antibodies in umbilical cord overlapped those in monkey esophagus. Therefore, umbilical cord should be used as a substrate instead of specimens from endangered species.

Celiac disease in the developing countries: A new and challenging public health problem

In the past, celiac disease was believed to be a chronic enteropathy, almost exclusively affecting people of European origin. The availability of new, simple, very sensitive and specific serological tests (anti-gliadin, anti-endomysium and anti-transglutaminase antibody assays) have shown that celiac disease is common not only in Europe and in people of European ancestry but also in the developing countries where the major staple diet is wheat (Southern Asia, the Middle East, North West and East Africa, South America), both in the general population and in the groups at risk. Gluten intolerance thus appears to be a widespread public health problem and an increased level of awareness and clinical suspicion are needed in the New World where physicians must learn to recognize the variable clinical presentations (classical, atypical and silent forms) of celiac disease. In the developing countries, both serological screening in the general population and serological testing in groups at risk are necessary for an early identification of celiac patients. The gluten-free diet poses a challenging public health problem in the developing countries, especially since commercial gluten-free products are not available.

Recent advances in the understanding of celiac disease: therapeutic implications for the management of pediatric patients

Celiac disease (CD) is an autoimmune condition occurring in genetically susceptible individuals characterized by inflammatory injury to the mucosa of the small intestine after the ingestion of wheat glutens or related barley and rye products. Originally thought to be highly prevalent only in Northern European populations, growing evidence indicates a much higher prevalence in many other regions, including the US as well as South America, North Africa, and Asia. The growing awareness that pediatric patients may present with quite diverse and protean manifestations and the significant impact of CD on childhood development has prompted efforts to increase CD awareness for the early diagnosis and treatment of this disease. The current diagnostic criteria for CD requires characteristic histologic findings in small bowel biopsies and clinical remission when placed on a gluten-free diet. Serologic testing for CD can provide additional support for the diagnosis of CD or a means to assess efficacy and adherence to a gluten-free diet. The mainstay of treatment remains the institution of a gluten-free diet. However, patients with refractory CD may require treatment with immunosuppressant medications. With the increased identification of specific gluten epitopes and understanding of the pathogenesis of CD, future therapies may rely on genetically altering gluten proteins, immunization techniques, or therapies focused on either the development of specific immune tolerance or regulation of mucosal inflammation.

High prevalence of celiac disease in Brazilian blood donor volunteers based on screening by IgA antitissue transglutaminase antibody

OBJECTIVE

To study the prevalence of celiac disease among blood donor volunteers based on screening by IgA antitissue transglutaminase antibody, followed by a confirmatory small intestine biopsy.

METHODS

The transversal study involved 3000 potential blood donors, residing in the city of Sao Paulo, Brazil. The participants were gender divided into 1500 men and 1500 women, with an average age 34.4+/-10.8 years, and included blood donor volunteers who could be turned down owing to anemia. All participants answered a questionnaire concerning the presence of diarrhea, constipation or abdominal pain during the 3 months before the study. Each participant with human recombinant IgA antitissue transglutaminase antibody level above 10 U/ml was invited to undergo a small intestine biopsy by means of an upper gastrointestinal endoscopy. The presence of villous atrophy and a positive antibody test were suggestive of possible celiac disease.

RESULTS

Antitissue transglutaminase antibody was positive in 1.5% (45/3000) of the study population. Among the antibody-positive group, 21 (46.6%) agreed to have a biopsy performed, and within them the histological pattern of villous atrophy was confirmed in 66.7% (14/21). Consequently, the suggestive prevalence of celiac disease was at the minimum, one per 214 of the potential blood donor volunteers. A significant association was found between celiac disease and the symptoms of diarrhea, constipation and abdominal pain.

CONCLUSIONS

The prevalence of celiac disease in Sao Paulo city is high and comparable to that observed in European countries. It is possible that in Brazil the prevalence of this disease had previously been underestimated.

Complications of coeliac disease: are all patients at risk?

Coeliac disease is a common condition that is increasingly being recognised as a result of the development of sensitive and specific serology. The diagnosis of coeliac disease and its subsequent treatment with a gluten-free diet have implications for the patient, not just for symptom control but also for the possible effect on quality of life and risk of complications. Whether the mode of presentation of coeliac disease has an effect on survival or risk of complication is yet unclear. This article reviews the available evidence regarding these issues.

Prevalence of celiac disease in an urban area of Brazil with predominantly European ancestry

AIM: To determine the prevalence of celiac disease in a group of volunteer blood donors at a blood bank in the city of Curitiba, Brazil through detection of the serum marker immunoglobulin A (IgA) antitransglutaminase antibody.

METHODS: Blood samples collected from 2086 healthy subjects at the Paraná State Center for Hematology and Hemotherapy in Curitiba were submitted to ELISA testing for the IgA antitransglutaminase antibody. Positive samples received IgA antiendomysium antibody test through indirect immunofluorescence using human umbilical cord as substrate. Subsequently, patients who were positive on both tests underwent small bowel (distal duodenum) biopsy.

RESULTS: Six subjects, four males and two females, tested positive for the two serum markers. Five of the six were submitted to intestinal biopsy (one declined the procedure). Biopsy results revealed changes in the distal duodenum mucosa (three classified as Marsh IIIb lesions and two as Marsh II lesions). Most donors diagnosed having celiac disease presented multiple symptoms (gastrointestinal tract complaints). One donor reported having a family history of celiac disease (in a niece).

CONCLUSION: Among apparently healthy blood donors, the prevalence of biopsy-confirmed celiac disease was approximately 1:417, similar to that seen in European countries.

Celiac disease could be a frequent disease in Mexico: prevalence of tissue transglutaminase antibody in healthy blood donors

INTRODUCTION/AIM

In North America and Europe, the prevalence of celiac disease (CD) might be much greater than expected in previous estimates. Until recently, the prevalence of CD in Latin America remained largely unknown. So far, information regarding CD in Mexico is limited, and it is still considered a rare disease. Our aim was to determine the prevalence of tTGA in a large group of apparently healthy blood donors.

SUBJECTS AND METHODS

Serum samples from 1009 consecutive blood donors, who attended a third level referral center in Mexico City, were collected between June 2004 and December 2004. Only Mexican Mestizo individuals were included. All sera were tested with a new generation human recombinant protein based tTGA-IgA ELISA commercial kit (Aeskulisa tTG-IgA, Wendelsheim, Germany). The cut-off value provided by the manufacturer was 15 U/mL.

RESULTS

The mean age of the blood donors was 34+/-10 years and 68% (n=683) were men. Six hundred fifty two subjects (65%) were born in Mexico City; and from the remaining 357 subjects, at least one was born in each of the 31 different states in our country. Twenty-seven (2.7%) blood donors were positive for tTGA-IgA; all of them with tTGA-IgA values above 30 U/mL (range 36 to 1639). Overall prevalence was 1:37 [27/1009, 95% confidence interval (CI)=1.6-3.7]. The prevalence among women was 1:33 (10/326, 95% CI=1.04-5.09) and for men 1:40 (17/683, 95% CI=1.24-3.73).

CONCLUSIONS

On the basis of a well-recognized serologic screening method performed to blood donor samples, we demonstrated an unexpectedly high prevalence of tTGA positivity (2.6%) in the adult Mexican Mestizo population. Thus, the prevalence of CD in Mexico could be higher or similar to that observed in other countries. This observation contributes to increase the awareness for this under diagnosed disease in clinical practice and to consider CD as a global health problem.

Celiac disease prevalence in Brazilian dilated cardiomyopathy patients

Celiac disease (CD) is a permanent condition of gluten intolerance and a number of autoimmune diseases have been associated with it. In the past few years, a relation between CD and dilated cardiomyopathy (CM) was described in Europe and United States. The aim of this study was to evaluate the prevalence of CD among south Brazilian precardiac transplant patients with advanced CM. A total of 74 patients on a list for heart transplantation were evaluated for the presence CD. The presence of anti-endomisial antibody (IgA-EmA) was determined by indirect immunofluorescence and for the anti-transglutaminase antibody (IgA anti-h-tTG) by ELISA. Serologically positive patients were submitted to upper endoscopy with intestinal biopsy. Two individuals (2.63%) were positive for IgA-EmA and 5 (6.75%) for IgA anti-h-tTG; 1 (1.35%) had both tests positive. Histologic confirmation of CD occurred only in the IgA-EmA positive patients. In conclusion, data from the present study allows recommend the screening for CD in patients with CM using IgA-EmA test as the method of choice.

Prevalence and demographic characteristics of celiac disease among blood donors in Ribeirão Preto, State of São Paulo, Brazil

Celiac disease (CD) is an underdiagnosed disease occurring in different clinical forms. This study aimed to determine the prevalence of CD among blood donors from Ribeirão Preto, Brazil, and to study some demographic characteristics of celiac patients. Blood samples from 3000 blood donors were tested for the presence of tissue transglutaminase antibody and positive samples were tested for endomysial antibody. Donors positive to both tests were referred for clinical evaluation and for a jejunal biopsy. Twenty-four samples were moderately/strongly positive for transglutaminase, with 9 of them being endomysial negative and 15 positive. Of the 13 biopsies obtained from 12 females and 1 male, 1 was classified as Marsh grade IV, 4 as grade III, 2 as grade II, 4 as grade I, and 2 as grade 0. Estimated prevalence was therefore 1:273 (0.33%; 95% CI, 0.127 to 0.539). The 1:273 estimated prevalence of CD detected indicates that the disease is not rare in Brazil. The frequency was higher among females and among individuals of European descent, with a significantly higher frequency for a family history of digestive tract cancer or epilepsy.

Prevalence of celiac disease in Tunisian blood donors

OBJECTIVES

Prevalence of adult celiac disease is unknown in Tunisia. Symptomatic forms are less frequent than silent forms, which, according to recent serological screening in Europe and the United States, have an estimated prevalence of 1/100 to 1/500. We aimed to determine the prevalence of celiac disease in healthy blood donors in Tunisia.

METHODS

Between November 2002 and March 2004, 1 418 sera from blood donors were tested for IgA anti-endomysium antibodies (EMA) by indirect immuno-fluorescence on monkey esophagus cryosections.

RESULTS

The sample population included 1090 men and 328 women: mean age 29 and 26 years respectively. Three sera from two men and one woman were positive for IgA EMA. ELISA search for anti-tissue tranglutaminase antibodies (ATG) in these three sera was positive in two. Upper gastrointestinal endoscopy with proximal intestinal biopsies was performed in the three patients. Subtotal or total villous atrophy was observed in the two ATG-positive patients, confirming the diagnosis of celiac disease. In the third patient, histologic examination did not show any abnormality.

CONCLUSION

Adult celiac disease is considered relatively rare in Tunisia. In fact, our study revealed a prevalence of about 1/700 among blood donors.

Coeliac disease: a diverse clinical syndrome caused by intolerance of wheat, barley and rye

Coeliac disease is a lifelong intolerance to the gluten found in wheat, barley and rye, and some patients are also sensitive to oats. The disease is genetically determined, with 10% of the first-degree relatives affected and 75% of monozygotic twins being concordant. Of the patients with coeliac disease 95% are human leucocyte antigen (HLA)-DQ2 or HLA-DQ8 positive. Characteristically, the jejunal mucosa becomes damaged by a T-cell-mediated autoimmune response that is thought to be initiated by a 33-mer peptide fragment in A2 gliadin, and patients with this disorder have raised levels of anti-endomysium and tissue transglutaminase antibodies in their blood. Coeliac disease is the major diagnosable food intolerance and, with the advent of a simple blood test for case finding, prevalence rates are thought to be approximately 1:100. Classically, the condition presented with malabsorption and failure to thrive in infancy, but this picture has now been overtaken by the much more common presentation in adults, usually with non-specific symptoms such as tiredness and anaemia, disturbance in bowel habit or following low-impact bone fractures. Small intestinal biopsy is necessary for diagnosis and shows a characteristically flat appearance with crypt hypoplasia and infiltration of the epithelium with lymphocytes. Diet is the key to management and a gluten-free diet effectively cures the condition. However, this commitment is lifelong and many aisles in the supermarket are effectively closed to individuals with coeliac disease. Compliance can be monitored by measuring antibodies in blood, which revert to negative after 6-9 months. Patients with minor symptoms, who are found incidentally to have coeliac disease, often ask whether it is necessary to adhere to the diet. Current advice is that dietary adherence is necessary to avoid the long-term complications, which are, principally, osteoporosis and small bowel lymphoma. However, risk of these complications diminishes very considerably in patients who are on a gluten-free diet.

The gluten connection: the association between schizophrenia and celiac disease

OBJECTIVE

Schizophrenia affects roughly 1% of the population and is considered one of the top 10 causes of disability worldwide. Given the immense cost to society, successful treatment options are imperative. Based on initial findings, gluten withdrawal may serve as a safe and economical alternative for the reduction of symptoms in a subset of patients.

METHOD

A review of the literature relevant to the association between schizophrenia and celiac disease (gluten intolerance) was conducted.

RESULTS

A drastic reduction, if not full remission, of schizophrenic symptoms after initiation of gluten withdrawal has been noted in a variety of studies. However, this occurs only in a subset of schizophrenic patients.

CONCLUSION

Large-scale epidemiological studies and clinical trials are needed to confirm the association between gluten and schizophrenia, and address the underlying mechanisms by which this association occurs.

Prevalence of celiac disease in Brazilian children with type 1 diabetes mellitus

OBJECTIVE

Although the relationship between celiac disease and diabetes mellitus type 1 is well recognized, there are no studies of this association in Brazil. This study aims to identify the prevalence of celiac disease in a group of children with diabetes mellitus type 1 undergoing treatment in the pediatric endocrinology division of a university hospital in Minas Gerais, Brazil.

METHODS

Immunoglobulin (Ig)A and IgG antigliadin antibodies (enzyme-linked immunoadsorbent assay) were measured in blood collected from 236 children and adolescents with diabetes mellitus type 1. Patients with antigliadin antibodies then had jejunal biopsy and determination of antiendomysial antibodies by indirect immunofluorescence.

RESULTS

Twenty-one patients had IgA or IgG antigliadin antibodies. Nineteen underwent jejunal biopsy. Six had mucosal alterations compatible with celiac disease; four had nonspecific histologic changes; nine had normal biopsies. Thirteen antigliadin antibody-positive patients were antiendomysial antibody-negative; one antiendomysial antibody-negative patient had celiac disease. The prevalence of celiac disease was 2.6% among 234 patients.

CONCLUSIONS

Measurement of antigliadin antibodies in patients with diabetes mellitus type 1 helped in the selection of patients to undergo jejunal biopsy. Antiendomysial antibodies were highly specific and moderately sensitive in predicting celiac disease. The prevalence of celiac disease was higher in diabetics than in the general population, suggesting the need for regular screening assessment of diabetic children.

Celiac disease associated with nodular regenerative hyperplasia, pulmonary abnormalities, and IgA anticardiolipin antibodies

The association of nodular regenerative hyperplasia with celiac disease is not as well established as it is with hepatopulmonary syndrome and portopulmonary hypertension. IgA anticardiolipin antibodies were reported recently in celiac patients with nodular regenerative hyperplasia. The subject of this study was the description of pulmonary abnormalities and IgA anticardiolipin antibodies in celiac patients with noncirrhotic portal hypertension. Five patients with portal hypertension were investigated to diagnose its etiology. Celiac disease was diagnosed by means of autoantibody reactivity and duodenal biopsies. Liver histology revealed nodular regenerative hyperplasia in four patients and suggested its presence in 1 case. Two cyanotic patients had severe hypoxemia with a confirmed diagnosis of hepatopulmonary syndrome. Another case exhibited features of hepatopulmonary syndrome with increased levels of arterial pulmonary pressure. The remaining 2 cases had slight abnormalities of arterial oxygenation. Three patients had reactivity to IgA anticardiolipin antibodies. The concomitance of celiac disease and nodular regenerative hyperplasia, two infrequent conditions, raises suspicion of there being a nonfortuitous coincidence. Pulmonary abnormalities, and especially hepatopulmonary syndrome, are described for the first time in association with celiac disease and nodular regenerative hyperplasia.

VSL#3 probiotic preparation has the capacity to hydrolyze gliadin polypeptides responsible for Celiac Sprue

The native structure and distribution of gliadin epitopes responsible for Celiac Sprue (CS) may be influenced by cereal food processing. This work was aimed at showing the capacity of probiotic VSL#3 to decrease the toxicity of wheat flour during long-time fermentation. VSL#3 (10(9) cfu/ml) hydrolyzed completely the alpha2-gliadin-derived epitopes 62-75 and 33-mer (750 ppm). Two-dimensional electrophoresis, immunological (R5 antibody) and mass spectrometry analyses showed an almost complete degradation of gliadins during long-time fermentation of wheat flour by VSL#3. Gliadins non-hydrolyzed during fermentation by VSL#3 were subjected to peptic-tryptic (PT) digestion and analyzed by CapLC-ESI-Q-ToF-MS (Capillary Liquid Chromatography-Electrospray Ionization-Quadrupole-Time of Flight-Mass Spectrometry). Search for several epitopes showed the only presence of alpha2-gliadin-fragment 62-75 at a very low concentration (sub-ppm range). Compared to IEC-6 cells exposed to intact gliadins extracted from the chemically acidified dough (control), VSL#3 pre-digested gliadins caused a less pronounced reorganization of the intracellular F-actin which was mirrored by an attenuated effect on intestinal mucosa permeability. The release of zonulin from intestinal epithelial cells treated with gliadins was considerably lower when digested with VSL#3. Agglutination test on K 562 (S) cells showed that the PT-digest of wheat flour treated with VSL#3 increased the Minimal Agglutinating Activity of ca. 100 times. Wheat proteins were extracted from doughs and subjected to PT digestion. Compared to PT-digest from chemically acidified dough, celiac jejunal biopsies exposed to the PT-digest from the dough fermented by VSL#3 did not show an increase of the infiltration of CD3(+) intraepithelial lymphocytes. Proteolytic activity by probiotic VSL#3 may have an importance during food processing to produce pre-digested and tolerated gliadins for increasing the palatability of gluten-free products.

[Association between serum markers for celiac and thyroid autoimmune diseases]

Celiac disease (CD) is an autoimmune disease of the small bowel characterized by a strong genetic association with HLA - DQ2 and DQ8. Gluten is the etiological factor and the tissue enzyme transglutaminase (TGase) is its autoantigen. CD is associated with several autoimmune diseases such as type 1 diabetes, systemic lupus erythematous, rheumatoid arthritis, Sjögrens syndrome and autoimmune thyroid diseases. The aim of this study was to investigate the occurrence of serum IgA anti-endomysial and anti-human TGase antibodies in individuals with positive anti-thyroid antibody (ATA). The concordance between these two tests was also evaluated. Anti-endomysial antibodies were positive in 10 out of 456 (2.2%) and anti-human TGase were positive in 14 of 454 (3.1%) individuals with positive ATA. In control subjects they were positive in 1 of 197 (0.5%) and 2 of 198 (1%) for anti-endomysial and anti-human tissue TGase antibodies, respectively. The odds ratio (OR) for the anti-endomysial antibodies was 4.42 and for the anti-human TGase 3.12 in individuals with ATA when compared with controls. An elevated concordance index (k= 0.84) was observed between anti-endomisyal antibodies and anti-human TGase. We conclude that the determination of anti-TGase antibodies is a good test for DC screening.

Prevalence of celiac disease in dyspeptic patients

BACKGROUND

Celiac disease is one of the most common dietary-mediated inflammatory enteropathies that occur in genetically predisposed individuals in response to gluten intolerance. This disorder has become more common than in the past, even if it frequently remains undetected for long periods of time. The screening of patients with dyspepsia, a symptom that can be a manifestation of celiac disease, may allow an early identification of affected individuals. Endoscopy and serological tests may have an important role in the management of these patients.

AIMS

Determining the prevalence of celiac disease in dyspeptic patients submitted to routine diagnostic upper gastrointestinal endoscopy.

PATIENTS/METHODS

Endoscopic findings, duodenal biopsy histological specimens and serological test results were assessed and compared in 142 patients consecutively admitted with dyspeptic symptoms between October 2001 and October 2003.

RESULTS

An endoscopic pattern suggestive of celiac disease was observed in four patients. The IgG-AGA assay was positive in 24 patients. Two of the IgG-AGA positive patients also yielded positive results on the IgA-EMA test and concomitantly disclosed endoscopic pattern and histological features in duodenal biopsy compatible with celiac disease. Abnormal endoscopic findings were notably marked in biopsy proven celiac patients. Therefore, a 1.4% prevalence of celiac disease was observed in this study group.

CONCLUSIONS

The high prevalence of celiac among dyspeptic symptomatic individuals indicates that they are a higher risk group for developing celiac disease. Undiagnosed celiac disease may be inferred by endoscopic markers of duodenal villous atrophy. Endoscopic findings, however, may be inadequate to suitably diagnose this disease and consequently the incorporation of diagnostic serologic assays of celiac disease in routine testing for dyspepsia is strongly recommended.

Abdominal CT findings may suggest coeliac disease

BACKGROUND

Coeliac disease is the most common gastrointestinal immunological disorder in the western countries. Many adult patients present non-specific symptoms and signs of malabsorption such as chronic diarrhoea, anaemia, weight loss and abdominal distention. In non-specific and doubtful conditions, computed tomography is often the first medical examination performed. In a clinical practice, a critical review of computed tomography signs is therefore mandatory.

AIMS

To evaluate the abdominal computed tomography findings, which are useful to suggest the presence of coeliac disease in adult patients.

PATIENTS AND METHODS

The computed tomography studies of 28 coeliac patients were reviewed, looking for any intestinal and extraintestinal abnormality. The computed tomography findings evaluated were: abnormalities of intestinal fold pattern, bowel dilatation, fluid and air excess, duodenal abnormalities, intestinal intussusception, bowel wall thickening, lymphadenopathy, ascites, intestinal stenosis, mesenteric vascular changes. The abdominal computed tomography of a group of 30 normal subjects was also analysed.

RESULTS

Intestinal fold pattern abnormalities were seen in 23/28 patients. Intestinal dilatation was seen in 21/28. Fluid excess in 18/28 and lymphadenopathy was seen in 12/28 patients; engorgement of mesenteric vessels in 7/28. Bowel wall thickening was observed in 6/28 patients and transient intussusception was observed in 6/28 patients. Increased air content within the bowel in 4/28 and ascites in 2/28 patients. Bowel dilatation together with fluid excess was observed in 18/28 patients. None of the above mentioned abnormalities abnormalities were seen in normal subjects.

CONCLUSIONS

Data of the present study show that several abdominal computed tomography findings may be seen in coeliac adult patients; these findings should be taken into consideration with a high in level of suspicion by radiologists, to avoid diagnostic delay and unnecessary diagnostic and therapeutic procedures.

Pasta made from durum wheat semolina fermented with selected lactobacilli as a tool for a potential decrease of the gluten intolerance

A pool of selected lactic acid bacteria was used to ferment durum wheat semolina under liquid conditions. After fermentation, the dough was freeze-dried, mixed with buckwheat flour at a ratio of 3:7, and used to produce the "fusilli" type Italian pasta. Pasta without prefermentation was used as the control. Ingredients and pastas were characterized for compositional analysis. As shown by two-dimensional electrophoresis, 92 of the 130 durum wheat gliadin spots were hydrolyzed almost totally during fermentation by lactic acid bacteria. Mass spectrometry matrix-assisted laser desorption/ionization time-of-flight and reversed phase high-performance liquid chromatography analyses confirmed the hydrolysis of gliadins. As shown by immunological analysis by R5-Western blot, the concentration of gluten decreased from 6280 ppm in the control pasta to 1045 ppm in the pasta fermented with lactic acid bacteria. Gliadins were extracted from fermented and nonfermented durum wheat dough semolina and used to produce a peptic-tryptic (PT) digest for in vitro agglutination tests on cells of human origin. The whole PT digests did not cause agglutination. Affinity chromatography on Sepharose-6-B mannan column separated the PT digests in three fractions. Fraction C showed agglutination activity. The minimal agglutinating activity of fraction C from the PT digest of fermented durum wheat semolina was ca. 80 times higher than that of durum wheat semolina. Pasta was subjected to sensory analysis: The scores for stickiness and firmness were slightly lower than those found for the pasta control. Odor and flavor did not differ between the two types of pasta. These results showed that a pasta biotechnology that uses a prefermentation of durum wheat semolina by selected lactic acid bacteria and tolerated buckwheat flour could be considered as a novel tool to potentially decrease gluten intolerance and the risk of gluten contamination in gluten-free products.

Should all children be screened for celiac disease?

To address the issue of screening children for celiac disease, current evidence has been summarized and placed within the context of 8 established criteria for childhood screening. Screening all children for celiac disease is not recommended at this time. Areas with gaps in knowledge are identified as areas in need of further study. These include the timing of screening, defining the natural history of screening-identified celiac disease, developing tools to predict disease onset and disease remission, and the risks of screening.

The many faces of celiac disease: clinical presentation of celiac disease in the adult population

The major modes of presentation of patients with celiac disease are the classic diarrhea-predominant form and silent celiac disease. Those with silent celiac disease lack diarrhea, although they may present with manifestations of celiac disease that include an irritable bowel syndrome, anemia, osteoporosis, neurologic diseases, or malignancy. A significant proportion of patients are diagnosed through screening at-risk groups including relatives of patients and insulin-dependant diabetics. Nondiarrheal presentations now are seen more commonly than those with diarrhea. Patients with celiac disease have a greater burden of disease than the general population because of autoimmune diseases and malignancies. There is a need for screening studies of patients with conditions associated with celiac disease to determine whether the large numbers of people with undiagnosed celiac disease currently are seeking health care.

Celiac disease in the Turkish population

Celiac disease (CD) is characterized by malabsorption of nutrients in the small intestine. The availability of highly specific and sensitive serologic tests has facilitated its diagnosis, increasing the disease prevalence. The aim of this study was to determine the clinical, laboratory, and histopathological features of CD in Turkish adults. Between 1968 and 2002, CD patients presenting to the Gastroenterology Unit were evaluated retrospectively. From 2002, newly diagnosed patients were prospectively followed up. Sixty patients (39 female, 21 male) were included in the study. Mean body mass index was 22.2 +/- 5.4 kg/m2. The most common symptoms were diarrhea, weight loss, and flatulence. Most common comorbidities were anemia, osteoporosis, type 1 diabetes mellitus, and steatohepatitis. Six (10.0%) patients had a family history of diabetes mellitus; one (1.7%) patient had a family history of CD. Plasma glucose and serum gamma-glutamyltransferase levels were significantly higher in females than males. Most common histopathological findings were increased lymphocytes in the lamina propria (76.2%) and villus epithelium (59.5%). Over the years, the cumulative frequency of CD increased more in females than males. This is the first study in the literature showing the characteristics of CD in Turkish adults. In our previous recent study, the prevalence of tissue transglutaminase antibody positivity in Turkish healthy blood donors was 1.3%, indicating a high prevalence of CD in our population. In this study, the cumulative frequency of CD increased more in females than males. With the better understanding and increased suspicion of the disease, more patients are being diagnosed in our population.

Apresentação clínica de doença celíaca em crianças durante dois períodos, em serviço universitário especializado

RACIONAL: Estudos demonstram mudança na forma de apresentação clínica da doença celíaca, com aumento da ocorrência de formas atípicas tanto em crianças, como em adultos. OBJETIVO: Verificar este fato em crianças atendidas em serviço universitário especializado (Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, SP.). MÉTODOS: Foram estudados pacientes celíacos em dois períodos: de janeiro de 1978 a dezembro de 1987 (grupo 1 = G1) e janeiro de 1988 a dezembro de 1997 (grupo 2 = G2). Foram analisados: tempo de doença, idade ao diagnóstico, estado nutricional e formas clínicas. Considerou-se forma típica se o paciente tinha pelo menos dois dos seguintes sinais/sintomas: diarréia, distensão abdominal, perda de peso, associados ou não a outros. A análise estatística foi realizada pelos testes exato de Fisher e de Wilcoxon. RESULTADOS: Mediana de idade ao diagnóstico: 23 meses (G1) e 21 (G2). Intervalo entre início de sintomas e diagnóstico: 13 meses (G1) e 11 (G2). Estado nutricional (%) Gomez: G1:eutrofia = 23,8; DI = 47,61; DII = 23,8 e DIII = 4,76. G2: eutrofia = 20,68, DI = 48,27, DII = 27,58 e DIII = 3,44. Waterloo: G1: eutrofia = 23,8, emaciação = 14,28 baixa estatura = 28,57 e crônico = 33,33. G2: eutrofia = 20,68, emaciação = 13,79, baixa estatura = 34,48 e crônico = 31,03. Formas clínicas (%) - G1: típica 57,14 e atípica 42,85. G2: típica 55,18 e atípica 44,82. Nenhum dado foi estatisticamente diferente nos dois grupos. CONCLUSÕES: No estudo não se encontrou mudança nas formas de apresentação e demais características clínicas da doença celíaca. Cogita-se que essa hipótese poderia ser decorrente de características populacionais, de diferenças na abordagem nos serviços de saúde ou de diferentes períodos de observação, em comparação com os demais estudos.

Epidemiological and clinical features in immigrant children with coeliac disease: an Italian multicentre study

BACKGROUND

There are no available data concerning the incidence and the clinical pattern of coeliac disease in immigrant children coming to Italy from developing countries.

AIMS

To evaluate the epidemiological and clinical features of coeliac immigrant children coming to Italy.

PATIENTS AND METHODS

Hospital records of 1917 children diagnosed in 22 Italian Centres from 1999 to 2001 as having coeliac disease were retrospectively reviewed, comparing immigrant patients versus Italian ones.

RESULTS

36/1917 (1.9%) coeliac children were immigrant. This prevalence was similar to that of the immigrant children among the whole paediatric population living in Italy. Prevalence was influenced by geographical factors, being higher in Northern Italy (1.7%) and in Central Italy (2.5%) than in Southern-Insular Italy (1.5%), as consequence of a higher proportion of immigrants in these regions. The native areas of the immigrant children were East Europe (15/36), Northern Africa (14/36), Southern Asia (4/36), West Africa (1/36), East Africa (1/36) and the Middle East (1/36). The clinical spectrum and dietary habits in immigrant patients were similar to those of the Italian children.

CONCLUSIONS

Coeliac disease among the immigrant children coming from developing countries is an emerging problem, and physicians need to be fully aware of it. An important risk factor for coeliac disease in immigrant children appears to be sharing of the same dietary habits with the Italian population. The finding of coeliac disease in children coming from many countries worldwide suggests that coeliac disease is a global public health problem.

Celiac disease onset after pegylated interferon and ribavirin treatment of chronic hepatitis C

AIM

Report of a case of a woman patient who developed celiac disease after pegylated interferon alpha-2a and ribavirin use for chronic hepatitis C.

PATIENT AND METHOD

A 34-year-old woman with chronic hepatitis C, genotype 3, receiving pegylated interferon alpha-2a and ribavirin for 6 months, developed progressive malaise and anemia 6 months after the end of treatment.

RESULT

Additional investigation revealed duodenal villous atrophy and positivity for anti-endomysium and anti-gliadin antibodies. Celiac disease diagnosis was performed and symptoms and laboratory abnormalities improved after gluten-free diet.

CONCLUSION

Celiac disease must be ruled out in patients with malabsorption complaints in or after interferon (or pegylated interferon) therapy. Screening for celiac disease with detection of anti-endomysium antibodies would be done in susceptible patients.

The global village of celiac disease

In the last years our knowledge on epidemiology of celiac disease has increased: there is a wide spectrum of its clinical presentation (classical, atypical, silent and latent forms of celiac disease), and of its pathological mucosal intestinal features, which range from early and mild pictures to severe villous atrophy (Marsh stages). In addition, a strong genetic component, associated with the susceptibility to the disease (HLA and non HLA genes), has been found. This knowledge, together with the availability of new high sensitive and specific serological tests (antigliadin, antiendomysium and antitransglutaminase antibodies), has led us to the realization that celiac disease is the most common food intolerance in the world, involving genetically predisposed individuals consuming gluten-containing cereals in their diet. So, today it is well known that celiac disease is a common disorder not only in Europe but also in populations of European ancestry (North and South Americas, Australia), in North Africa, in the Middle East and in South Asia, where until a few years ago it was historically considered extremely rare. Therefore, celiac disease is spread worldwide as in a common "Global Village", and greater levels of awareness and attention on gluten intolerance are needed, both in the Old and in the New World.

Prevalence of celiac disease in Brazilian children of short stature

The aim of the present study was to determine the prevalence of celiac disease in children of short stature and to assess whether some of the routine laboratory examinations performed to determine the cause of short stature could suggest the presence of celiac disease. A total of 106 children of short stature and no gastrointestinal symptoms were studied. An extensive endocrine work-up had been negative for all of them and an additional investigation was performed by measuring the concentration of antiendomysial antibody. Patients who were positive for antiendomysial antibody (> or =1:10) or who exhibited IgA deficiency (less than 5 mg/dl) were referred for an endoscopic intestinal biopsy. We detected a pathological titer of antiendomysial IgA in six of these patients. Five of them showed histological abnormalities compatible with celiac disease and one had normal histology and was considered to have potential celiac disease. The prevalence of celiac disease in the population studied was 4.7% (with another 0.9% of the subjects being considered to have potential celiac disease). The children with celiac disease did not differ in any of the parameters tested when compared to those without celiac disease, though they showed an improvement in growth velocity after treatment with a gluten-free diet. We conclude that it is important to test all children with short stature for celiac disease by measuring antiendomysial IgA.

Advances in celiac disease

In recent years, it has become evident that CD is much more common than previously appreciated, with a prevalence of 0.5% to 1% in Western, Arabian, and Indian populations. The disease may be present without symptoms (silent CD) or may present with extraintestinal manifestations only. Increasing awareness of the many faces of CD will increase diagnosis rate. CD patients have a cure for their disease, named the gluten-free diet, but this curative measure is very hard to adhere to. With the new insights into the pathogenesis of CD, clinicians enter an era where new treatment modalities for CD may turn into reality.

Coeliac disease

Coeliac disease is a genetically-determined chronic inflammatory intestinal disease induced by an environmental precipitant, gluten. Patients with the disease might have mainly non-gastrointestinal symptoms, and as a result patients present to various medical practitioners. Epidemiological studies have shown that coeliac disease is very common and affects about one in 250 people. The disease is associated with an increased rate of osteoporosis, infertility, autoimmune diseases, and malignant disease, especially lymphomas. The mechanism of the intestinal immune-mediated response is not completely clear, but involves an HLA-DQ2 or HLA-DQ8 restricted T-cell immune reaction in the lamina propria as well as an immune reaction in the intestinal epithelium. An important component of the disease is the intraepithelial lymphocyte that might become clonally expanded in refractory sprue and enteropathy-associated T-cell lymphoma. Study of the mechanism of the immune response in coeliac disease could provide insight into the mechanism of inflammatory and autoimmune responses and lead to innovations in treatment.

Epidemiological changes in diagnosed coeliac disease in a population of Spanish children

AIM

To investigate the incidence rate of diagnosed coeliac disease among the paediatric population in the province of Cáceres and the changes over the years.

METHODS

The incidence rate of diagnosed coeliac disease between the years 1981 and 1999, age at diagnosis and clinical presentation form were investigated. The study was carried out over two periods: A (1981 to 1990) and B (1991 to 1999).

RESULTS

The incidence rate for period A was 6.87/100,000 (CI 95%: 5.26-8.83) and for period B 16.04/100,000 (CI 95%: 12.99-19.59) (p < 0.0001). The relative risk of receiving a diagnosis of coeliac disease during the first four years of life was 2.31% (CI 95%:1.61-3.31) greater in period B than in period A. The mean age at diagnosis was 37.4 +/- 47.4 mo and 43.9 +/- 43.7 mo in A and B, respectively (p = 0.0058). The typical clinical pattern was the most frequent (83.6% in A and 58.3% in B). The mean age of introduction of gluten to the diet was 4.6 +/- 2.0 mo and 6.9 +/- 1.7 mo, for period A and B, respectively (p < 0.0001).

CONCLUSION

The incidence rate of coeliac disease has increased during the two periods studied. In recent years, the relative risk of receiving a diagnosis of coeliac disease during the first four years of life has increased. The atypical clinical presentation has also increased, although the typical clinical form is still the most frequent in younger children.

The use of a single serological marker underestimates the prevalence of celiac disease in Israel: a study of blood donors

OBJECTIVES

Recent studies suggest that celiac disease was previously underdiagnosed. To find out whether antiendomysial antibodies underestimate the prevalence of celiac disease, we elected to use a strategy combining multiple serological markers to explore the prevalence of celiac disease in Israel and the usefulness of the various antibodies in screening for celiac disease.

METHODS

Serum samples from 1571 healthy blood donors were tested. A small intestinal biopsy was offered to all patients who tested positive for either human tissue transglutaminase antibodies, an ELISA kit based on antiendomysium (EMA-ELISA), immunoglobulin A antigliadin verified by antiendomysial immunofluorescence antibodies, and to patients who were IgA deficient with elevated antigliadin IgG.

RESULTS

A total of 59 subjects (3.8% of study population) were offered an intestinal biopsy based on serological findings, and 30 of 59 patients agreed to undergo intestinal biopsy (1.9% of study population). Celiac disease was diagnosed in 10 patients, establishing a prevalence of at least 1:157 in the general population (0.6%, CI = 0.3-1.1%). Using any serological marker alone would have underestimated the prevalence of celiac disease, as it was diagnosed in only two patients who tested positive for endomysial immunofluorescence antibodies (prevalence of 1:786, 0.1%, CI = 0.02-0.5%), six patients positive for tissue transglutaminase (prevalence of 1:262, 0.4%, CI = 0.1-0.9%), and seven patients positive for ELISA-EMA (prevalence of 1:224, 0.45%, CI = 0.2-0.9%).

CONCLUSIONS

The prevalence of celiac disease in Israel is at least 1:157 in the general population, confirming its underdiagnosis in previous studies. The disparity between the various serological markers suggest that the use of one serological marker is insufficient for establishing the true prevalence of celiac disease.

New developments in childhood celiac disease

Celiac disease (CD) is one of the most common lifelong disorders in Europe and the United States, in both children and adults. It is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. This review addresses new developments in CD with respect to pediatric patients and emphasizes the need for awareness among health-care professionals. The epidemiology, pathophysiology, diagnosis, and clinical spectrum of CD in children are highlighted.

Celiac disease in Brazilian adults

Forty-eight adult patients with celiac disease between 15 and 68 years of age (mean, 41 years) were studied. Sixty-seven percent were female and 33% were male patients. Most of the patients were white (98%). The main clinical features were diarrhea (90%), weight loss (70%), and abdominal pain (56%). On physical examination, the main findings were pallor (40%), aphthous stomatitis (31%), and arthralgia (23%). Associated disorders included diabetes mellitus type I, osteoporosis, and atopy (6% each); dermatitis herpetiformis and depression (4% each); and hypothyroidism, hyperthyroidism, duodenal carcinoma, and Gilbert syndrome (2% each). The histologic results according to Marsh criteria (modified by Rostami) are as follows: type I, 10%; type II, 21%; type IIIa, 19%; type IIIb, 17%; and type IIIc, 33%. The sensitivity and specificity for the antiendomysium antibody-immunoglobulin A test were 92% and 100%, respectively, when considering the whole group of patients; however, the sensitivity (but not the specificity) decreased to 86% when taking into account only the group of patients with mild histologic alterations (Marsh type I, II, and IIIa).

CONCLUSION

In general, the authors' results are similar to those described in developing countries, indicating that celiac disease might have the same spectrum of presentation regardless of the region studied.

The serologic screening for celiac disease in the general population (blood donors) and in some high-risk groups of adults (patients with autoimmune diseases, osteoporosis and infertility) in the Czech republic

The prevalence of celiac disease (CD) was determined in healthy blood donors and in high-risk groups of adults (a total of 1835 adults--randomly selected 1312 healthy blood donors, 102 patients with primary osteoporosis, 58 patients with autoimmune diseases and 365 infertile women). It was calculated on the basis of a two-step serologic screening method--in the first step IgA and IgG antigliadin antibodies (AGA) and IgA anti-gamma-glutamyltransferase ('transglutaminase') antibodies (ATG) were estimated, in the second step sera positive for IgA AGA and/or IgA ATG were examined for antiendomysial IgA (AEA) antibodies. Immunoenzymic assay (ELISA) was used for determining of AGA and ATG antibodies; immunofluorescence method, performed on human umbilical cord tissue, was used for assaying of AEA antibodies. Total serum IgA level in only IgG AGA positive subjects was measured by routine turbidimetric method. 0.45% of healthy blood donors, 0.98% of osteoporotic patients, 2.7% of patients suffering from autoimmune disease and 1.13% of women with infertility considered as immunologically mediated were found to be positive in both steps of serologic screening (AGA and/or ATG and antiendomysium positive). The presumed high prevalence of seropositivity for CD in apparently healthy Czech adult population was confirmed. In the high-risk groups, the prevalence of seropositivity for CD was approximately 2-4 times higher than in healthy blood donors. The real prevalence of CD in the tested groups, however, can be estimated after performing small intestinal biopsy in the seropositive patients.

The changing face of celiac disease

The face of celiac disease has changed significantly over the past 50 years. With the advent of new noninvasive and more sensitive screening tools, it has become increasingly apparent that this disease presents in a heterogeneous fashion, with symptomatic disease only occurring in a small number of patients. Furthermore, great insights have been made into the disease's genetic and immunological components, thus increasing the medical community's understanding of the disease. The current gold standard for diagnosis is histological confirmation, and the cornerstone of therapy is lifelong elimination of gluten. Further advances in immunobiological techniques will most likely aid in earlier detection and commencement of the appropriate diet, thus preventing the development of associated complications.

Prevalence of celiac disease in Argentina: screening of an adult population in the La Plata area

OBJECTIVES

Up to now, the epidemiological characteristic of celiac disease among adults in South America remains unknown. The present prospective screening was designed to determine the prevalence of celiac disease in adults from the general population in an urban area of Argentina.

METHODS

Between January. 1998, and May, 2000, all couples attending a centralized laboratory for an obligatory prenuptial examination in the La Plata area were offered participation in a screening program for celiac disease. The study included 2000 subjects (996 women; median age 29 yr, range 16-79 yr). All individuals completed a clinical questionnaire at the time that serum samples were obtained. A three-step screening protocol was used, as follows: 1) all samples were tested for antigliadin antibodies (AGAs) (type IgA and IgG); 2) samples that were IgA AGA positive were tested for antiendomysial antibody (EmA type IgA); samples that were positive for AGA-G but negative for IgA AGAs were tested for total IgA serum levels and EmA type IgG; and 3) subjects who were EmA-positive were referred for intestinal biopsy.

RESULTS

At the end of the screening we detected 10 subjects who were EmA-A positive and two others who were IgA-deficient (both were EmA-G positive). Up to now, 11 of the 12 subjects (including nine EmA-positive and two IgA-deficient subjects) had endoscopic intestinal biopsies showing the characteristic celiac histology. The remaining EmA-positive individual was considered to be affected by celiac disease. The overall prevalence assessed was 1:167 (6.0 x 1000 subjects; 95% CI = 3.1-10.5). Eight of the 12 (67%) subjects were female (1:124; 8.0 x 1000; 95% CI = 3.5-15.8) and four (33%) were male (1:251; 4.0 x 1000; 95% Cl = 1.1-10.2). Although eight new patients were considered to be asymptomatic, three presented with a subclinical course and one was classically symptomatic. Only one patient had been previously diagnosed with celiac disease.

CONCLUSIONS

Our screening protocol showed a very high prevalence of celiac disease for an urban area of Argentina that is ethnically similar to 90% of the general population of the country. The prevalence among women was double that for men, and the heterogeneous clinical picture of new patients showed predominance of asymptomatic cases.