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

High prevalence of celiac disease in Mexican Mestizo adults with type 1 diabetes mellitus

BACKGROUND AND AIMS

Recent studies have shown that celiac disease (CD) could affect 0.5% to 3% of the general population, including Mexican Mestizos, which represents a complex mixture of genetics, and constitutes the core of Mexican and Latin American populations. However, the association between CD and other conditions, specifically type-1 diabetes mellitus, in this population remains unknown. Thus, our aim was to determine the prevalence of both serologic and biopsy proven CD in Mexican Mestizo adults with type-1 diabetes.

METHODS

Over a 6-month period, serum samples obtained from consecutive Mexican Mestizo adult patients (age >or=18 y) with type-1 diabetes were tested with a new generation human recombinant protein based IgA tissue transglutaminase enzyme-linked immunosorbent assay commercial kit. All patients with positive serologic test results underwent upper gastrointestinal endoscopy and small intestinal biopsies to confirm CD.

RESULTS

Eighty-four type-1 diabetic patients were included (62 women, mean age 28.9+/-9 y). Overall, 9 patients (9/84) were positive for IgA tissue transglutaminase with a point prevalence of 10.7% (95% CI, 4%-17%). Seven patients agreed to undergo endoscopy. Five subjects had biopsy-proven CD (5.9%, 95% CI, 1.9%-13.3%). One patient had chronic diarrhea and other abdominal bloating; whereas the remaining 3 were asymptomatic. CD associated type-1 diabetic patients tended to have higher hemoglobin A1c levels (P=0.07), reflecting poor glycemic control.

CONCLUSIONS

As in other populations, we demonstrated a high prevalence of biopsy-proven CD (5.9%) among Mexican Mestizo patients with type-1 diabetes. Clinicians should be aware of this common association in this ethnic group.

Adult celiac disease followed by onset of systemic lupus erythematosus

BACKGROUND

Celiac disease has been associated with autoimmune disease (eg, autoimmune thyroiditis) and the appearance of different autoantibodies (eg, antidouble-stranded DNA). Conversely, tissue transglutaminase antibodies have been detected in autoimmune disorders, including systemic lupus erythematosus (SLE), but cases of celiac disease with SLE have been only rarely recorded.

METHODS

In this study, 246 patients with biopsy-defined celiac disease were evaluated for a prior diagnosis of SLE on the basis of American Rheumatological Association-defined clinical and serologic parameters.

RESULTS

There were 6 patients with celiac disease and SLE, or 2.4%, including 4 females and 2 males. Their mean age at diagnosis of celiac disease was 44.7 years and SLE 50 years. In all patients, the diagnosis of SLE was established from 2 years to more than 10 years after the diagnosis of celiac disease, with a mean of 5.3 years. The celiac disease in all 6 patients responded to a gluten-free diet with histologic normalization of the small intestinal biopsies. Despite this small bowel biopsy response, SLE appeared later in the clinical course of the celiac disease.

CONCLUSIONS

This study suggests that SLE occurs far more frequently in biopsy-defined celiac disease than is currently appreciated, and detection may be more likely if the period of clinical follow-up of the celiac disease is prolonged.

Low prevalence of neurologic and psychiatric manifestations in children with gluten sensitivity

OBJECTIVE

To determine the frequency of neurologic manifestations in children with gluten sensitivity (GS) and the frequency of GS in children with neurologic disease.

STUDY DESIGN

A total of 835 children with GS (based on positive titers for serum anti-gliadin antibody [AGA], anti-endomysial antibody [EMA], and anti-tissue transglutamine [tTG] antibody and a positive gut biopsy), representing the local childhood GS population in the town of Catania, Italy, were recruited, prospectively followed up, and screened for neurologic and psychiatric disturbances between 1991 and 2004. Serum AGA, EMA, and anti-tTG antibody titers were estimated in a prevalence sample of 630 consecutive children with neurologic disorders of unknown cause despite full investigation, 300 children with known neurologic syndromes, and 300 healthy children who served as controls. Statistical significance was assessed by the chi(2) test and Yates' chi(2) test.

RESULTS

Neurologic or psychiatric problems were noted in 15 of 835 children with GS (1.79%) with previously diagnosed GS enteropathy (GSE). In 7 of 630 children (1.1%) with a cryptogenic neurologic disorder, GS was identified based on GS autoantibody screening. These 22 children had febrile seizures, epilepsy, headache, mental retardation, neuropathy, and bipolar disorder; no children had ataxia or cerebellar disturbances. The HLAs were DQ2 (n = 16), DQ8 (n = 4), and DQ2/DQ8 (n = 2). Two of the 300 healthy controls (0.66%) had GS.

CONCLUSIONS

Based on our findings, the prevalence of neurologic/psychiatric manifestations in this group of children with GS was low but slightly higher than that in the controls (P = .041). Children with known (P = .772) and cryptogenic (P = 1.0) neurologic disorders did not exhibit a higher prevalence of GS.

Chronic hepatitis C virus and celiac disease, is there an association?

Celiac disease (CD) has been epidemiologically associated with chronic hepatitis C (HCV), and CD activation after the initiation of interferon (IFN-alpha) in patients with HCV is documented. However, clear association of CD and HCV is lacking. A prospectively maintained database of 878 CD patients showed a prevalence of 0.68% (six patients). Symptoms of diarrhea, weight loss, and depression prompted the diagnosis of CD during or after IFN-alpha therapy in four cases. Also, 294 subjects with liver disease (195 with HCV, 80 normal controls and 19 disease controls) were prospectively screened for CD. The mean age of the subjects was 50.1 years (SD 12.3), 58% males:42% females. A total of 30% received IFN-alpha therapy (16% at the time of testing for CD). Two HCV patients (1%) had positive tTG-IgA but these had negative endomysial antibody (EMA) and normal duodenal biopsies. CD prevalence is not increased in patients with HCV. Routine screening of CD in HCV patients is not warranted, however, the presence of CD should be considered in the setting of clinical deterioration during or after IFN-alpha therapy.

Long-term follow-up of individuals with celiac disease: an evaluation of current practice guidelines

INTRODUCTION

Celiac disease can be treated by following a strict gluten-free diet for life. If properly followed, the diet resolves symptoms and nutritional deficiencies. It is generally recommended that individuals with celiac disease have careful long-term follow-up. However, it is not clear which elements of disease status evaluation, laboratory investigations and self-management support should be included in follow-up.

OBJECTIVES

To examine the current practice guidelines and recommendations regarding follow-up of individuals with celiac disease.

METHODS

Guidelines issued by gastroenterological societies and associations, and recommendations by experts were retrieved using Medline and other Internet search engines.

RESULTS

Practice guidelines were available from the American Gastroenterological Association; the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition; the National Institutes of Health Consensus Development Conference 2004; the World Gastroenterology Organization; the British Society for Gastroenterology and the United Kingdom-based Primary Care Society for Gastroenterology. Most guidelines recommended a scheduled annual review and regular measurements of body mass index. The British Society for Gastroenterology recommended dietary review only at times of stress, while others recommended dietary review with a nutritionist. All associations recommended serial tissue transglutaminase antibody testing. The American Gastroenterological Association and the Primary Care Society for Gastroenterology recommended annual hemoglobin, ferritin and folate checks. One guideline recommended annual hemoglobin, electrolyte, calcium, albumin, ferritin, folate, fat-soluble vitamin, liver function test, parathyroid hormone and bone density measurements (approximately $400 per patient).

CONCLUSIONS

The current practice guidelines regarding the follow-up of patients with celiac disease varied greatly in their recommendations and many were not evidence-based. Prospective studies are required to develop rational, cost-effective and risk-stratified guidelines for long-term follow-up of these patients.

Clinical presentation and incidence of complications in patients with coeliac disease diagnosed by relative screening

BACKGROUND

There is an increased prevalence of coeliac disease (CD) among relatives of those with the disease.

AIMS

To compare the clinical features in patients with CD detected via family screening with those in patients diagnosed routinely.

METHODS

Information on screening was provided to relatives of patients. Those who wished to be screened were tested for endomysial and/or tissue transglutaminase antibodies. Duodenal biopsy was performed in those with positive antibodies. The clinical details of the relative screening group were compared with those of 105 patients diagnosed routinely.

RESULTS

183 relatives underwent screening, of whom 32 had positive serology, 24 had histology diagnostic of CD, six had normal biopsies and two declined duodenal biopsy. Patients in the relative screening group were younger with a median age of 33 years (range 17-72 years) compared to the routine group which had a median age of 54 years (range 25-88 years). In the relative screening group, there was a male preponderance (M:F ratio 16:8), anaemia at presentation was significantly less common (13% v 58%; p<0.001) and osteoporosis was less frequent (9% v 22%; p<0.244) compared with the routine group. 65% of the relative screening group had gastrointestinal symptoms or anaemia at diagnosis.

CONCLUSIONS

Patients detected by family screening are younger with a male preponderance, but fewer had anaemia and osteoporosis.

Unexplained polyarthralgia and celiac disease

Celiac disease is an immunological disorder whose best-known manifestations are gastrointestinal symptoms. However, early joint manifestations are common and frequently overlooked features of celiac disease. We report a case in which unexplained inflammatory polyarthralgia and iron-deficiency anemia led to the diagnosis of celiac disease. Autoimmune thyroiditis was also a feature. Early diagnosis and treatment of celiac disease protect patients against complications such as digestive neoplasis. A simple and rapid tool for achieving the early diagnosis is the measurement of the serum of anti-gliadin, anti-endomysial and anti-tissue transglutaminase antibodies. However, a duodenal biopsy remains the only means of making the definitive diagnosis of celiac disease.

Intramural Fat in the Duodenum and Proximal Small Intestine in Patients with Celiac Disease

OBJECTIVE

The purpose of this article is to describe and illustrate intramural fat in the duodenum and jejunum, to our knowledge a previously undescribed finding in celiac disease.

CONCLUSION

Celiac disease is known to produce inflammation of the duodenum and jejunum. We propose that postinflammatory intramural fat deposition occurs in a distribution likely unique for celiac disease. CT scans of the chest and abdomen obtained for many indications include these portions of the bowel. Celiac disease is now recognized as a common disease, and the recognition of intramural fat in the duodenum and jejunum on CT may allow earlier diagnosis.

Video capsule enteroscopy in the diagnosis of celiac disease: a multicenter study

OBJECTIVES

Duodenal biopsy is the current gold standard for diagnosis of celiac disease. Videocapsule endoscopy examines the entire small bowel and allows visualization of mucosal villi. We evaluated the potential of videocapsule endoscopy in assessing the severity and extent of mucosal changes in patients with suspected celiac disease.

METHODS

Consecutive patients with signs/symptoms suggesting celiac disease and positive anti-gliadin and/or anti-endomysial and/or anti-tissue transglutaminase antibodies underwent upper gastrointestinal endoscopy and videocapsule endoscopy. Duodenal biopsies were classified according to modified Marsh's criteria. Capsule findings were evaluated for the presence of lesions compatible with celiac disease (scalloping of duodenal folds, fissures, flat mucosa, and mosaic appearance).

RESULTS

Forty-three patients were studied. Duodenal histology was normal in 11 and compatible with celiac disease in 32. Using duodenal histology as the gold standard, the performance characteristics of capsule endoscopy for the diagnosis of celiac disease were: sensitivity 87.5% (95% CI 76.1-98.9%), specificity 90.9% (95% CI 81.0-100%), positive predictive value 96.5% (95% CI 90.1-100%), negative predictive value 71.4% (95% CI 55.8-87%), positive and negative likelihood ratios 9.6 and 0.14, respectively. Eighteen patients had mucosal changes extending beyond the duodenum, involving the entire small bowel in three. These patients tended to have more severe symptoms, but the difference was not statistically significant. Interobserver agreement for the diagnosis of celiac disease by capsule endoscopy ranged between 79.2 and 94.4%; kappa values ranged between 0.56 and 0.87.

CONCLUSIONS

Videocapsule endoscopy shows good sensitivity and excellent specificity for the detection of villous atrophy in patients with suspected celiac disease.

Predictors of clinical response to gluten-free diet in patients diagnosed with diarrhea-predominant irritable bowel syndrome

BACKGROUND & AIMS

Gluten sensitivity might cause abdominal symptoms in the absence of villous atrophy. We examined the prevalence of celiac disease-associated serum antibodies in diarrhea-dominant irritable bowel syndrome (d-IBS) patients and their efficacy in combination with HLA-DQ2 expression to predict the response to gluten-free diet.

METHODS

HLA-DQA1*0501/DQB1*0201 expression and celiac disease-associated IgA and IgG serum antibodies against gliadin and tissue-transglutaminase were measured in 145 patients with d-IBS, 74 patients with untreated and treated celiac disease, and 57 patients with active IBD. Follow-up antibody levels, stool frequency, and gastrointestinal symptom scores were determined in 41 d-IBS patients (26 women, 15 men; median age, 46 years, range, 30-67 years) who participated in a nonrandomized evaluation of 6 months of gluten-free diet.

RESULTS

Increased celiac disease-associated serum IgG, but not IgA, was found in the majority of patients with treated (55%) as in most patients with untreated celiac disease (97%). In d-IBS patients, celiac disease-associated serum IgG antibodies (37%) and HLA-DQ2 expression (39%) were more frequent than in IBD patients (18% and 23%, respectively). After 6 months of gluten-free diet, stool frequency and gastrointestinal symptom score returned to normal values in 60% of d-IBS patients who were positive and in 12% who were negative for HLA-DQ2 and celiac disease-associated serum IgG; both parameters combined yielded positive and negative predictive values of 56% (95% confidence interval, 30%-80%) and 88% (69%-97%), respectively.

CONCLUSIONS

Celiac disease-associated serum IgG and HLA-DQ2 expression can identify likely responders to gluten-free diet in d-IBS patients.

Where are all those patients with Celiac disease?

Celiac disease is considered to occur in approximately 1% of the U.S. population. It is, however, markedly underdiagnosed. In this issue, Fasano and his colleagues have continued their work in demonstrating just where all these patients are. Their current study explores a case finding policy in the primary practice setting. They identified patients who exhibited either symptoms that could be attributed to celiac disease, or had an associated condition. In this population, 2.25% had celiac disease. The study emphasizes the need for physician education in both the prevalence of celiac disease and the wide availability of the serological tests that can facilitate the diagnosis of celiac disease.

Celiac disease: pathogenesis of a model immunogenetic disease

Celiac disease is characterized by small-intestinal mucosal injury and nutrient malabsorption in genetically susceptible individuals in response to the dietary ingestion of wheat gluten and similar proteins in barley and rye. Disease pathogenesis involves interactions among environmental, genetic, and immunological factors. Although celiac disease is predicted by screening studies to affect approximately 1% of the population of the United States and is seen both in children and in adults, 10%-15% or fewer of these individuals have been diagnosed and treated. This article focuses on the role of adaptive and innate immune mechanisms in the pathogenesis of celiac disease and how current concepts of immunopathogenesis might provide alternative approaches for treating celiac disease.

Prevalence of silent celiac disease in patients with dyspepsia

Celiac disease (CD) has become more common than in the past, although it frequently remains undetected for long periods of time. One reason for this is failure by health care professionals to recognize the variable clinical manifestations of CD and to perform the appropriate tests to make the diagnosis. Although dyspepsia may be part of a clinical spectrum in CD patients, there are scarce data about its prevalence in silent CD. We aimed to determine the prevalence of CD in otherwise healthy dyspeptic patients by means of serologic screening followed by endoscopic biopsies if appropriate. Anti-endomysium antibody assay was positive in 3 of 196 patients. All 3 were female, ages ranged from 19-52 years (mean +/- SD age, 36 +/- 16 years). Duodenal biopsies were compatible with CD in all, whereas abnormal endoscopic findings were noted in 2. Therefore, a 1.5% prevalence of CD was observed in this study group. The odds ratio for CD was 2.57 (95% confidence interval) in comparison with the general population. CD should be kept in mind as a cause of dyspepsia during clinical activities. The association between these 2 conditions is, at most, weak, but a gluten-free diet may still bring symptomatic relief for dyspeptic symptoms in CD. During endoscopic examination for dyspepsia, if indicated, endoscopists should carefully inspect the duodenum for CD findings. Although routine serologic screening can not be recommended, it may be appropriate for the patients with refractory dyspepsia, especially females.

Advances in celiac disease

PURPOSE OF REVIEW

Increasing numbers of atypical or asymptomatic cases of celiac disease are being diagnosed. This review aims to summarize recent critical research in celiac disease.

RECENT FINDINGS

Alternative candidate genes outside of the human leukocyte antigen complex continue to be identified, whilst innate and adaptive immune responses to key gliadin epitopes are now both recognized to be important in celiac disease pathogenesis.

SUMMARY

Serological tests and small bowel biopsy remain the cornerstones of diagnosis. Treatment options other than the restrictive gluten-free diet remain limited.

The pathology of malabsorption: current concepts

Intestinal malabsorption results from a wide variety of causes, which can most easily be organized into three groups. Maldigestion arises from problems with mixing or with digestive mediators, and includes post-gastrectomy patients and those with deficiencies of pancreatic or intestinal enzymes, or of bile salts. Mucosal and mural causes of malabsorption are abundant, and include gluten-sensitive enteropathy, tropical sprue, autoimmune enteropathy, and HIV/AIDS-related enteropathy, as well as mural conditions such as systemic sclerosis. Finally, microbial causes of malabsorption include bacterial overgrowth, Whipple's disease, and numerous infections or infestations that are most frequently seen in immunocompromised patients. An overview of the most common and interesting entities in each of these categories follows, along with a discussion of current concepts. Mucosal conditions and microbial causes of malabsorption are given special attention.

Is exocrine pancreatic insufficiency in adult coeliac disease a cause of persisting symptoms?

BACKGROUND

Patients with coeliac disease may have diarrhoea despite being on a gluten-free diet.

AIM

To assess whether exocrine pancreatic insufficiency causes persisting symptoms compared with controls, we determined whether pancreatic enzyme supplementation provided symptomatic benefit in coeliac patients with chronic diarrhoea.

METHODS

Patients (n = 259) were subdivided into four groups: (a) new coeliac disease (n = 57), (b) coeliac disease patients on a gluten-free diet without gastrointestinal symptoms (n = 86), (c) coeliac disease patients on a gluten-free diet with chronic diarrhoea (n = 66) and (d) patients with chronic diarrhoea without coeliac disease (n = 50). Stool frequency and weight, before and after treatment with pancreatic enzyme supplementation were recorded.

RESULTS

The prevalence of a low faecal elastase-1 within the groups was: group (A) six of 57 (11%), group (B) five of 86 (6%), group (C) 20 of 66 (30%) and group (D) two of 50 (4%). Low faecal elastase-1 was more frequent in coeliac disease patients with chronic diarrhoea vs. other subgroups of coeliac disease (P < or = 0.0001) and controls (P < or = 0.0003). In 18 of 20 stool frequency reduced following pancreatic enzyme supplementation from four per day to one (P < or = 0.001). No weight increase (P = 0.3) was observed.

CONCLUSIONS

Low faecal elastase is common in patients with coeliac disease and chronic diarrhoea, suggesting exocrine pancreatic insufficiency. In this group of patients, pancreatic enzyme supplementation may provide symptomatic benefit.

Gluten intolerance: sex and age-related features

OBJECTIVE

Gluten intolerance is an immune-mediated enteropathy associated with gluten-containing foods in genetically susceptible patients. The typical form mainly affecting children shows failure to thrive and/or gastrointestinal symptoms. The adult form is less typical, presenting vague gastrointestinal symptoms, iron deficiency (with or without anemia) or nonspecific serum chemistry abnormalities. The present study aims to analyze clinical and biochemical differences of celiac disease (CD) according to sex and age.

PATIENTS AND METHODS

The present study reviewed clinical and biochemical features of patients with suspected CD admitted to the Hospital General of Móstoles (Madrid, Spain) between July 2001 and June 2005. Two hundred fifty-two patients were analyzed, in whom intestinal biopsy was performed due to clinical and/or biochemical abnormalities suggestive of CD. One hundred seventy-eight asymptomatic relatives of the affected patients were also included. Overall, 125 patients showed diagnostic features of CD in the intestinal biopsy.

RESULTS

The results confirmed higher prevalence of typical forms of CD in children (67% in children compared with only 14.3% in adults). CD seemed to be more frequent in adult women than in men (ratio of women to men 4:1), but it is worth noting that men diagnosed were most often referred with a typical clinical picture, so atypical forms of the disease in men may have been underdiagnosed.

CONCLUSIONS

CD shows atypical features in adults, and physicians must include this disorder in the differential diagnosis of adults with iron deficiency or slight hypertransaminasemia. Increased awareness of the disease and extensive availability of accurate sero-logical tests will lead to improved diagnosis of this disorder, both in children and adults.

Undiagnosed coeliac disease and nutritional deficiencies in adults screened in primary health care

OBJECTIVE

To compare the nutritional parameters of individuals with a previous diagnosis of coeliac disease (CD) with those of screen-detected patients in a large cohort of adults in primary care.

MATERIAL AND METHODS

A cohort of 1900 adults (aged 18-64 years) was screened for tissue transglutaminase antibodies (TG2A) in primary care in the capital region of Finland. IgA-endomysium antibodies (EmA), HLADQ2/8 associated with CD were determined in positive individuals. Folate, iron, and transferrin receptor in sera were assessed in patients reporting a previous diagnosis of CD and patients positive for the above tests.

RESULTS

Twenty-two out of 1900 (1%) patients reported a previous diagnosis of CD (biopsy-based 16/22 cases; 6/22 cases diagnostic criteria unknown). Among the screen-detected cases with TG2A> or = the cut-off value, 14/32 cases were considered to have CD based on high levels of both TG2A and EmA, DQ2/8 genotype and/or biopsy results. The prevalence of CD was as high as 1:53 in the total study population (36/1900), and in women even 1:46 (2.2%). Nutritional deficiencies were rare among CD patients diagnosed earlier (low iron = 1; low folate n=1) but common among those who had an undiagnosed CD (low folate n=6; p<0.005; concomitant iron deficiency n=2). One-third of the screen-detected CD patients were obese. Screen-detected patients did not present more abdominal symptoms than those with no CD.

CONCLUSIONS

CD is common, the proportion among women possibly being as high as 2.2%. Although the great majority of screen-detected patients do not present any gastrointestinal symptoms at primary care, nutritional deficiencies such as low folate levels and iron deficiency are common.

Population screening for coeliac disease in a low prevalence area in Italy

OBJECTIVE

A screening program was proposed for the village of Carcare (population 5700), located in a region of Italy with an apparently low prevalence of coeliac disease (CD): only 1 patient diagnosed out of 2557 inhabitants. The study group comprised 1002 individuals (568 F, 434 M, age range 13-90 years) recruited from blood donors, secondary school pupils and people referred to the local outpatient facilities for routine blood chemistry.

MATERIAL AND METHODS

Total IgA, IgA anti-tissue transglutaminase (tTG) (ELISA, recombinant human antigen) and IgA antiendomysium (EMA) (IFI, umbilical cord substrate) antibodies were measured in the serum of all participants. All patients with IgA deficiency were investigated for IgG tTG antibodies, and in the case of disagreement between tTG and EMA, they were typed for HLA DQ2-DQ8 haplotypes.

RESULTS

Thirteen subjects were positive and 988 negative for autoantibodies (3/988 had IgA deficiency). One serum sample was positive for tTG antibodies but negative for EMA. Ten out of 13 positive subjects consented to undergo duodenal biopsy, which invariably produced evidence of CD despite the absence of clinical signs/symptoms. A post-diagnostic clinical investigation provided evidence showing mild iron deficiency (4 subjects) and osteoporosis (2 subjects). After counselling, all subjects accepted a gluten-free diet.

CONCLUSIONS

The prevalence of CD in the study group was 1:100 (1.0%; 95% CI: 0.5-1.8%): this indicates that CD is largely underdiagnosed in Carcare. Our results suggest that the low prevalence of CD observed in some regions is likely to be due to underdiagnosis.

Consumption of gluten-free products: should the threshold value for trace amounts of gluten be at 20, 100 or 200 p.p.m.?

OBJECTIVE

The threshold of gluten contamination in gluten-free products of both dietary and normal consumption is under debate. The objective of this study was to gather information on consumption of gluten-free products intended for dietary use of people under a gluten-free diet. This information is essential to ascertain the exposure of coeliac patients to gluten through their diet and deduce the maximum gluten content that these products should contain to guarantee a safe diet.

METHODS

A diet diary of consumption of gluten-free products intended for dietary use was distributed to the coeliac societies of two typical Mediterranean countries (Italy and Spain) and two Northern countries (Norway and Germany). The diet diary included a self-weigh table of the selected food items and a 10-day consumption table. Results were reported in percentiles as distributions were clearly right skewed.

RESULTS

The respondents included in the study accounted for 1359 in Italy, 273 in Spain, 226 in Norway and 56 in Germany. Gluten-free products intended for dietary use contributed significantly to the diet of coeliac patients in Italy, Germany and Norway and to a lesser degree in Spain. The most consumed gluten-free product in all countries was bread, and it was double consumed in the Northern countries (P<0.001). Mediterranean countries showed consumption of a wider variety of gluten-free foods and pasta was eaten to a large degree in Italy.

CONCLUSIONS

The differences between Northern and Mediterranean countries were not in the total amount of gluten-free products but in the type of products consumed. The observed daily consumption of gluten-free products results in the exposure to rather large amounts of gluten, thus the limit of 200 p.p.m. should be revised. A limit of 20 p.p.m. for products naturally gluten-free and of 100 p.p.m. for products rendered gluten-free is proposed to guarantee a safe diet and to enable coeliac patients to make an informed choice. These limits should be revised as new data become available.

Overweight in celiac disease: prevalence, clinical characteristics, and effect of a gluten-free diet

BACKGROUND

It is well established that a minority of celiac patients present with "classic" symptoms due to malabsorption. However, few studies have focussed on the distribution of body mass index (BMI) in celiac populations and its relationship to clinical characteristics, or on its response to treatment.

METHODS

We reviewed BMI measurements and other clinical and pathological characteristics from a database of 371 celiac patients diagnosed over a 10-yr period and seen by a single gastroenterologist. To assess response to gluten exclusion, we compared BMI at diagnosis and after 2 yr treatment in patients with serological support for dietary compliance.

RESULTS

Mean BMI was 24.6 kg/m2 (range 16.3-43.5). Seventeen patients (5%) were underweight (BMI < 18.5), 211 (57%) were normal, and 143 (39%) were overweight (BMI > or = 25), including 48 (13% of all patients) in the obese range (BMI > or = 30.0). There was a significant association between low BMI and female gender, history of diarrhea, reduced hemoglobin concentration, reduced bone mineral density (BMD), osteoporosis, and higher grades (subtotal/total) of villous atrophy. Of patients compliant with a gluten-free diet, 81% had gained weight after 2 yr, including 82% of initially overweight patients.

CONCLUSIONS

Few celiac patients are underweight at diagnosis and a large minority is overweight; these are less likely to present with classical features of diarrhea and reduced hemoglobin. Failed or delayed diagnosis of celiac disease may reflect lack of awareness of this large subgroup. The increase in weight of already overweight patients after dietary gluten exclusion is a potential cause of morbidity, and the gluten-free diet as conventionally prescribed needs to be modified accordingly.

[Clinical features and diagnosis of celiac disease]

Celiac disease is a life-long enteropathy caused by an intolerance to gluten. The pathologic lesion of the small intestinal mucosa is characterized by the loss of absorptive villi, crypt cell hyperplasia, and infiltration of the lamina propria with inflammatory cells. The clinical presentation of celiac disease varies greatly depending on patient's age, duration and extent of the disease, and the presence of extraintestinal manifestations. The classical symptoms like diarrhea, weight loss and abdominal pain are seen less common. Unfortunately, most patients with celiac disease have either silent or atypical presentations, thus escaping diagnosis for several years. The pathologic changes and symptoms resolve when gluten is excluded from the diet for a sustained period. Untreated celiac disease is associated with significant risk of the development of enteropathy-associated intestinal lymphoma.

Celiac disease

Celiac disease is an autoimmune disease that occurs in genetically predisposed individuals as the result of an immune response to gluten. This immune response occurs in both the lamina propria and the epithelium of the small intestine. There is a close link to HLA DQ2 and DQ8, although these HLA genes account for only 40% of the genetic influence. Environmental factors, such as the amount and timing of gluten administration in infancy, as well as breastfeeding, influence the disease. Serologic screening studies that use sensitive and specific antibody tests have revealed the disease to be common, occurring in approximately 1% of the population. Clinical presentations are diverse and atypical; the majority of patients lack diarrhea. Therapy is a gluten-free diet that requires avoidance of wheat, rye, and barley, although there is potential for other therapies based on our understanding of the pathophysiology of the disease.

Capsule endoscopy in celiac disease: diagnosis and management

Celiac disease occurs in about 1% of the population. Although diarrhea is the classical presentation, the diagnosis of celiac disease is frequently not considered as part of the differential diagnosis of a variety of different symptoms. It is,therefore, imperative that physicians who perform capsule endoscopy, and those who review the images, are aware of the variety of mucosa appearances inpatients who have celiac disease. In addition, studies are needed to determine the role of capsule endoscopy in the diagnosis and management of celiac disease.

Myosin IXB variant increases the risk of celiac disease and points toward a primary intestinal barrier defect

Celiac disease is probably the best-understood immune-related disorder. The disease presents in the small intestine and results from the interplay between multiple genes and gluten, the triggering environmental factor. Although HLA class II genes explain 40% of the heritable risk, non-HLA genes accounting for most of the familial clustering have not yet been identified. Here we report significant and replicable association (P = 2.1 x 10(-6)) to a common variant located in intron 28 of the gene myosin IXB (MYO9B), which encodes an unconventional myosin molecule that has a role in actin remodeling of epithelial enterocytes. Individuals homozygous with respect to the at-risk allele have a 2.3-times higher risk of celiac disease (P = 1.55 x 10(-5)). This result is suggestive of a primary impairment of the intestinal barrier in the etiology of celiac disease, which may explain why immunogenic gluten peptides are able to pass through the epithelial barrier.