Celiac sprue

Celiac disease

Celiac disease, or gluten-sensitive enteropathy, classically presents as diarrhea and weight loss in childhood, but it may also have protean manifestations and appear well into adult life. The increasing availability of noninvasive blood tests that are highly sensitive and specific for celiac disease enables primary care physicians to recognize the disorder in a wide variety of clinical situations. The authors believe that the disease is more common than supposed and thus offer this diagnostic review to increase awareness.

Wheat starch intolerance in patients with celiac disease

OBJECTIVE

Evaluate in patients with celiac disease the tolerance of prolonged consumption of small amounts of gliadin contained in products containing wheat starch.

DESIGN

Open 1-year trial of the addition of wheat starch to a gluten-free diet in a cohort of adult patients with biopsy-proven celiac disease who had never consumed wheat starch. The control group consisted of patients with celiac disease who tolerated wheat starch.

SUBJECTS

Seventeen patients with celiac disease and 14 control patients, all diagnosed according to criteria of the European Society of Pediatric Gastroenterology and Nutrition, were recruited from the Canadian Celiac Association and the Quebec Celiac Foundation.

SETTING

The study was conducted in the outpatient clinic of the Gastroenterology and Nutrition Service of Ste Justine Hospital, Montreal, Quebec, Canada.

INTERVENTIONS

Patients were asked to consume four to six portions daily of a wheat starch-containing product, mainly bread, for up to 1 year.

MAIN OUTCOME MEASURES

The gliadin content of the wheat starch product used in this trial was quantified by enzyme-linked immunosorbent assay. Patient outcome measures included symptoms, nutritional parameters (anthropometric data, complete blood count, serum folate and iron levels), and immunologic parameters (antigliadin antibody and antiendomysium antibody titers).

RESULTS

A quantifiable amount of immunoreactive gliadin (0.75 mg/100 g) was found in the wheat starch. The majority of the patients with celiac disease (11 of 17) who had never consumed wheat starch previously developed symptoms, which resolved within weeks of discontinuing the product. Relapse of skin lesions was seen in two of three patients with coexisting dermatitis herpetiformis. No weight loss or biochemical changes were observed. Despite the presence of symptoms, antigliadin antibody and antiendomysium antibody determinations were not useful to detect the clinical intolerance.

APPLICATIONS

The innocuousness of the long-term ingestion of "gluten-free" products containing wheat starch is still unproven, and prolonged use of such products by patients with celiac disease cannot be recommended.

Correlation of clinical characteristics and small bowel histopathology in celiac disease

BACKGROUND

Literature information regarding clinical and histological correlates in celiac disease is limited. The present study was designed to assess the value of various clinical parameters in predicting the severity of small bowel histopathology.

METHODS

Small bowel biopsy specimens of 59 children with established celiac disease (ESPGAN criteria) were evaluated blindly. Morphology was evaluated based on a common histopathology score. The following clinical variables were evaluated: age at diagnosis, duration of symptoms, severity score of clinical symptoms, severity score of physical signs, and growth parameters (height and weight Z scores). Multiple regression analysis was performed to evaluate the relative importance of each clinical parameter.

RESULTS

Only three clinical variables revealed a significant correlation with the histopathology score. The symptom severity score (t = 3.883, p = 0.0003) demonstrated a positive correlation. The two others, age at diagnosis (t = 3.076, p = 0.0032) and duration of symptoms (t = -2.987, p = 0.0041), revealed a negative correlation.

CONCLUSIONS

We conclude that more severe clinical symptoms of a shorter duration, presented at a younger age, are better predictors of a more severe form of small bowel histopathology in children with celiac disease.

IgA endomysium antibodies on human umbilical cord: an excellent diagnostic tool for celiac disease in childhood

BACKGROUND

An improvement in screening for celiac disease has recently been described that uses human umbilical cord as a substitute for monkey esophagus to determine IgA endomysium antibodies in adults. As using monkey esophagus is ethically questionable for large-scale screening, we studied whether substitution of umbilical cord would be suitable for pediatric patients as well.

METHODS

Serum from 53 children with untreated celiac disease, 22 in remission and 13 on challenge, were screened for antigliadin IgA, antigliadin IgG, and IgA reticulin antibodies, in addition to IgA endomysium antibodies tested both on monkey esophagus and on human umbilical cord. Controls included 20 patients with cow-milk-sensitive enteropathy, 23 with inflammatory bowel disease, and 23 with diabetes mellitus, and 48 patients who were biopsied to exclude celiac disease either because of positive gliadin antibody test or disturbed growth.

RESULTS

Sensitivity (0.94) and specificity (1.0) were similar for umbilical cord and esophageal determinations in active celiac disease. Both substrates detected identical positive cases and neither gave false-positive results. In celiac patients on a gluten-free diet, endomysium antibodies with either substrate were positive in seven identical cases and negative in 15 of 22 cases. Correlations with reticulin antibodies were comparable with human umbilical cord and monkey esophagus (0.83 and 0.85, respectively; Spearman Correlation Section Pair-Wise deletion).

CONCLUSIONS

Human umbilical cord is an excellent substitute for monkey esophagus to determine endomysium antibodies in celiac diagnosis in children and adolescents.

Serum levels of osteocalcin and type I procollagen in children with celiac disease

BACKGROUND

Bone metabolism may be disturbed in children with celiac disease.

METHODS

Two markers of bone turnover were used: the level of osteocalcin (BGP) and the level of carboxylterminal peptide of type I procollagen (PICP). BGP and PICP were measured by radioimmunoassays in 18 untreated children with celiac disease (mean age: 22.9 +/- 15.6 months) and in 15 control subjects (mean age 28.5 +/- 21 months). All the patients were rechecked after 1 month and again after 3 months from beginning of a gluten-free diet (GFD).

RESULTS

Compared with controls at diagnosis our patients had significantly lower serum levels of BGP and PICP (p = 0.003 and p = 0.018 by Student's t test, respectively). These levels increased markedly during the 1st 3 months of GFD.

CONCLUSIONS

The alteration in calcium phosphate homeostasis caused by celiac disease directly affects the synthesis of both components of the connective matrix of bone. Measurements of BGP and PICP provide a reliable and rapidly obtainable index of normalization of the processes of bone growth which can be achieved with a GFD.

Secretor status and human leucocyte antigens in coeliac disease

BACKGROUND

The ability to secrete blood group antigens into body fluids and secretions is controlled by a single gene on chromosome 19. By means of erythrocyte Lewis (Le) antigen phenotype secretor status can be inferred. An increase prevalence of non-secretors of blood group antigens among coeliac patients has recently been described.

METHODS

Blood was collected from 112 coeliac patients and 103 controls and tested for secretor status. Secretor status was correlated with human leucocyte antigens (HLA) in coeliac patients, thus evaluating a proposed interaction of susceptibility genes--that is, the secretor gene on chromosome 19 and HLA-linked genes on chromosome 6. Case notes for coeliacs were reviewed with regard to clinical outcome.

RESULTS

Of 112 coeliacs who had either Le(a) or Le(b) antigens, 36 (32%) were non-secretors Le(a+, b-), compared with 27% (28) of 103 disease-free controls (P = 0.313). Recessive Lewis phenotype Le(a-, b-) was found in 9% of coeliacs versus 2% of controls. Prevalence of HLA-A1, B8, DR3, and DQ2 was unrelated to secretor status in coeliac versus patients. An increased prevalence of complications and coeliac-associated abnormalities was found in the non-secreting and recessive coeliac groups.

CONCLUSIONS

This study shows no firm relationship between the non-secretor state and coeliac disease, nor any difference in the distribution of HLA markers among secretor and non-secretor coeliacs. It is unlikely, therefore, that the secretor gene is the much sought-after second coeliac gene.

Intestinal T-cell lymphoma: a reassessment of cytomorphological and phenotypic features in relation to patterns of small bowel remodelling

Intestinal T-cell lymphoma (ITCL) is an uncommon entity among primary gastrointestinal lymphomas. In this study we evaluated tumours from 20 patients presenting with (n = 8) or without (n = 12) a history of coeliac disease (CD). Neoplastic lesions were composed of predominantly small (n = 4), small-to-medium (n = 2), medium/mixed-to-large (n = 7) or large and anaplastic (n = 7) cells. Different patterns of tumour growth and remodelling of the small bowel wall were observed. Pattern a (n = 4) was characterized by an intramucosal spread of small tumour cells with a small growth fraction. This pattern resembles mucosal inflammation in CD. In pattern b (n = 2), ulcerated solitary or multiple tumours composed of small to medium-sized cells were observed. The adjacent or distant mucosa showed a nearly normal architecture. In pattern c (n = 7), ulcerated lesions were composed of medium-sized to large cells. Mucosal flattening occurred in all segments infiltrated by lymphoma. In pattern d (n = 7), bowel remodelling was observed along the small intestine even at sites not affected by lymphoma. The main neoplastic lesions were composed of pleomorphic large or anaplastic cells frequently expressing the CD30 molecule. Intramucosal spread of a small epitheliotropic T-cell population was observed in the vicinity or even at distant segments of the small bowel. The demonstration of clonal rearrangements of T-cell receptor genes helped to trace widespread occurrence of this small intraepithelial neoplastic component. We suggest that different features of tumour cells such as the expression of activation antigens may contribute to the remodelling of small bowel mucosa. The addition of immunophenotyping data to macroscopic and microscopic features of specimens provided evidence that this uncommon lymphoma exhibits a spectrum in cytological composition and growth patterns. However, despite the considerable heterogeneity of the cases analysed, most of them shared a characteristic immunohistochemical profile (CD3+, CD8+/-, CD103+), further substantiating the view that ITCL is the neoplastic equivalent of an intraepithelial T-cell subset of the small intestine. This phenotype and the intraepithelial accumulation of lymphoma cells observed in the surviving mucosa are clues to the diagnosis of this clinicopathological lymphoma entity characterized by a broad range of morphological expressions.

Estimating the incidence of coeliac disease with capture-recapture methods within four geographic areas in Italy

STUDY OBJECTIVE

To estimate the incidence rate of newly diagnosed cases of coeliac disease in Italy.

DESIGN

This was a descriptive study of coeliac disease incidence in the period 1990-91.

SETTING

During 1990-91 newly diagnosed cases of coeliac disease were signalled by several sources including diagnostic records of departments of paediatrics, general medicine and gastroenterology, national health service records for the supply of gluten free diets and the archives of the Italian Coeliac Society.

PATIENTS

Altogether 1475 cases were flagged throughout Italy, 478 of whom were selected, corresponding to 270 individual patients from a target population resident in four areas: Provices of Turin and Cuneo (Piedmont Region, northern Italy); Province of Brescia (Lombardia Region, northern Italy); Umbria Region (central Italy) and Sardinia Region (insular Italy). Only for these areas were patients flagged from several sources and the reference population was identifiable.

MAIN RESULTS

The overall crude incidence rates for all ages per 100,000 residents per year were 2.4, 2.7, 1.5, and 1.7 in the four areas, respectively. The childhood cumulative incidence rates (aged < or = 15 years) per 100,000 live births were 143, 141, 72, and 80 respectively. The mean ages at diagnosis were similar for both childhood and adult cases throughout the areas--these were around 4 and 34 years respectively. For each area, the incidence rate was constantly higher in the main city than elsewhere. Using the capture-recapture method, an estimated completeness of case archives of 0.84 was obtained, whereas this figure was only 0.47 for hospital sources.

CONCLUSIONS

This population based study on the incidence of coeliac disease shows that several information sources should be used to avoid underestimation. The incidence rate of coeliac disease in Italy was among the highest in Europe, and was widely variable showing highest figures in Piedmont and Lombardia and the lowest in Umbria and Sardinia. This trend was not due to different age at diagnosis, which suggests variable diagnostic awareness of the disease rather than different environmental patterns affecting the clinical presentation.

In vitro hydrolysis of gliadin and casein peptides: secondary defect in coeliac disease shown by organ culture

BACKGROUND

Small-intestinal organ culture was used as an in vitro model of coeliac disease, studying biopsy specimens from patients with coeliac disease, cow's milk allergy, and controls.

METHODS

Organ culture incubations were done using the pure gliadin peptide B3144 (amino acid sequences 3-56 of alpha-type gliadins) and a control peptide from casein (amino acid sequences 152-193 of alpha s1-casein). The importance of using negative controls was stressed by non-specific tissue damage. By reversed-phase high-performance liquid chromatography of organ culture supernatants, 27 specimens were further investigated.

RESULTS

There was good retrieval of peptide calibration peaks after culture. Qualitative and quantitative evaluation of chromatography runs showed degradation of at least 29% of B3144 and 37% of Cas-P. Normal mucosa (controls and coeliac patients on a gluten-free diet) was able to hydrolyse peptide fractions completely, whereas incubation with damaged mucosa (coeliac disease, cow's milk allergy) left initial peptides.

CONCLUSION

It is concluded, using a pure single gliadin peptide, that deficient peptide hydrolysis in coeliac disease was a secondary event.

Infant feeding history shows distinct differences between Swedish celiac and reference children

Infant feeding history was investigated in 72 celiac and 288 age-matched reference children in a retrospective questionnaire study. The reply rate was 100% in celiac and 91.6% in reference children. The celiac children were breast-fed for a significantly shorter time than reference children, and they were less often breast-fed at the introduction of gluten. The age of the children at gluten introduction was similar, but the celiac children were significantly more often introduced by a gluten-containing follow-up formula, while the reference children more often started on a gluten-containing porridge. The results can be interpreted in two ways. First, it could be argued that breast milk per se protects against symptoms of celiac disease in childhood. It could, however, also be claimed that breast-feeding merely modulates the gluten introduction, causing a less abrupt introduction of gluten in the baby diet and thereby fewer overt symptoms of the disease.

Oesophageal motility in adult coeliac disease

Coeliac sprue is a relatively frequent disease with protean clinical manifestations. Recent studies suggest that gastrointestinal motor abnormalities may explain some symptoms complained of by such patients. We investigated whether coeliac patients have oesophageal motor abnormalities from both a clinical and a physiological point of view. Thirty-six consecutive adult sprue subjects (14 during the florid phase and 22 on gluten-free diet) were studied. A clinical questionnaire on gastrointestinal symptoms (with emphasis on those of oesophageal origin) was administered. Moreover, 18 patients (13 on free and five on gluten-free diet) gave their consent for oesophageal manometry and eight subjects for pH-metry also. Oesophageal clinical symptoms were compared with those of 144 age- and sex-matched controls from a general population sample, and manometry with that of 34 healthy volunteers. Of coeliac patients 50% complained of dysphagia (P < 0.001 vs. controls) and 14% noncardiac chest pain (P = NS vs. controls). Manometric examination showed motor abnormalities in 67% of the subjects examined, consisting of nutcracker oesophagus, hypotonic lower oesophageal sphincter associated with simultaneous contractions, and frequent repetitive (> 3 peaks) contractions. These abnormalities were equally distributed among free and gluten-free diet patients. pH-metry showed only one pathological reflux out of eight subjects studied. We conclude that patients with coeliac sprue may display abnormal oesophageal motility. This confirms previous studies suggesting that gastrointestinal motor abnormalities should probably be added to the clinical spectrum of the disease.

Neuroproliferation in the mucosa is a feature of coeliac disease and Crohn's disease

The pathogenesis of villous damage in coeliac disease is unknown. Change to the delicate neuromuscular core may be significant and this study stained various categories of coeliac disease and controls with neuron-specific enolase (NSE) to examine neurofilaments in the mucosa. The amount of NSE staining was evaluated using computer image analysis. The first part of the study compared coeliac disease with Crohn's disease, carcinoma, and biopsy specimens from normal subjects. There was increased NSE staining in both the coeliac disease and Crohn's disease cases but not in carcinomas or normal controls. This difference was statistically significant. The average value for the coeliac disease patients was 50% higher than that of Crohn's disease patients. The second part of the study compared treated coeliac disease with untreated coeliac disease. Treated coeliac disease cases had normal amounts of NSE staining, which were the same as normal controls. These findings suggest that neuroproliferation is a feature of coeliac disease and Crohn's disease. Both share a common feature--namely chronic inflammation--which has been occasionally associated with neuroproliferation. The fact that neuroproliferation resolves with treatment is further evidence for its association with chronic inflammation. The extra neuroproliferation seen in coeliac disease compared with Crohn's disease may contribute to the architectural abnormalities seen in coeliac disease.

Non-Hodgkin's lymphoma, coeliac disease, and Epstein-Barr virus: a study of 13 cases of enteropathy-associated T- and B-cell lymphoma

A group of 166 patients with coeliac disease was followed for a period of up to 25 years. During this time, 17 patients developed intestinal tumours that were diagnosed as lymphoma, of which 15 cases were available for review. Eleven of the lymphomas were of T-cell type (enteropathy-associated T-cell lymphoma, EATL) and two were of B-cell type. Two cases were reclassified as undifferentiated carcinoma. The interval between the diagnosis of enteropathy and the onset of lymphoma varied from less than 2 months in four patients to more than 5 years in seven. Seven of the T-cell and both B-cell lymphomas were investigated for the presence of Epstein-Barr virus (EBV) by in situ hybridization (ISH) using probes against Epstein-Barr virus-encoded RNAs (EBERs) and by immunohistochemistry with EBV-specific monoclonal antibodies. All EATL cases were negative, suggesting that EBV is not an important factor in these cases. In one of the B-cell cases, EBV was detectable by ISH and immunohistochemistry in most tumour cells in the mesenteric lymph nodes, but not in any of the tumour cells in the primary ileal tumour, indicating that in this case EBV infection was a late event in the neoplastic process. These results show that lymphoma may develop any time after the onset of coeliac disease and that in our cases of EATL, EBV was not an important factor. In some cases of EBV-related neoplasia, virus infection may be a late event.

Detection of low bone mineral density by dual energy x ray absorptiometry in unsuspected suboptimally treated coeliac disease

Patients with coeliac disease may present with calcium malabsorption but it is unclear whether this results in longterm impairment of bone mineralisation. Dual energy x ray absorptiometry (DXA) was used to study bone mineral density in 34 asymptomatic coeliac disease patients, treated with a gluten free diet for at least two years, and also in 10 newly diagnosed or untreated patients. As expected, untreated patients had low bone mineral density in all regions. In the 29 treated female coeliac disease patients, overall mean values for age adjusted bone mineral density expressed as Z scores were normal although there were many patients with low values, particularly of the lumbar spine and total body. Scores in the postmenopausal patients were significantly worse than in the premenopausal patients and low mean Z scores were found in the five treated male patients. The subjects who had reduced bone mineral density could not be predicted clinically but, despite being asymptomatic, were more likely to have subtotal or partial villous atrophy on small intestinal biopsy (p < 0.0275). In conclusion, although many treated coeliac disease patients have normal bone mineral density, suboptimally treated and newly diagnosed or untreated patients have osteopenia. To reduce the risk of osteoporotic fractures, it is recommended that bone mineral density be measured in all treated coeliac disease patients and those with osteopenia have a repeat intestinal biopsy to assess disease activity.

Gliadin-specific T cell responses in peripheral blood of healthy individuals involve T cells restricted by the coeliac disease associated DQ2 heterodimer

Coeliac disease (CD) is probably caused by an abnormal immune response towards wheat gliadin in the small intestine. We found that gliadin-specific T cells from the small intestinal mucosa of HLA-DQ2 positive CD patients were almost exclusively restricted by the disease-associated DQ2 molecule. In the peripheral blood of CD patients, a large proportion of gliadin-specific T cells were found to be restricted by DQ molecules, including DQ2, but many were instead restricted by DR or DP molecules of the patient. We have now investigated gliadin-specific T cell responses in peripheral blood from healthy individuals. Four of 20 persons tested had strong in vitro responses and were used as donors for gliadin-specific T cell clones. We found gliadin-specific T cells restricted by the CD-associated DQ2 molecule in peripheral blood for two of these four individuals. It is the presence of such T cells also in the small intestinal mucosa which seems typical of CD.

Coeliac disease in adults

Coeliac disease is a chronic disease characterized by small bowel villous atrophy which impairs nutrient absorption and improves on withdrawal of wheat gliadins and barley, rye and oat prolamins from the diet. Knowledge of the adult form of coeliac disease has greatly improved in recent years. Although this knowledge is not yet sufficiently widespread among referring clinicians, it has, over the past few years, allowed an increasing number of patients to be diagnosed with subclinical forms characterized by minor, transient or apparently unrelated symptoms. As a consequence, our views on the clinical and epidemiological aspects of this condition, the prevalence of which in the general population is believed to be close to 1 in 300, have changed and are still changing. Since it has been demonstrated that a strict gluten-free diet is protective against the complications of adult coeliac disease, it is important that even subclinical and silent forms are diagnosed and treated as early as possible. Non-invasive screening tests, such as anti-gliadin and anti-endomysium antibody estimation, should therefore be used systematically in groups considered to be at risk of coeliac disease. These include first-degree relatives of coeliac patients and patients with insulin-dependent diabetes mellitus, iron-deficiency anaemia, epilepsy with cerebral calcification, recurrent aphthous stomatitis and dental enamel hypoplasia. Other conditions will probably be identified in the near future.

The major complications of coeliac disease

Neoplasms constitute the major complication of coeliac disease, and high-grade T-cell lymphoma of the small intestine (enteropathy-associated T-cell lymphoma) is the most common neoplasm in this category. HLA genotyping indicates that in patients with enteropathy-associated T-cell lymphoma have the coeliac disease associated DQA1*0501, DQB1*0201 phenotype, although additional HLA-DR/DQ alleles may represent risk factors for lymphoma development. Molecular biological and immunohistochemical studies have shown that the intestinal mucosa distant from the tumour contains clonal populations of small T cells, often of the same clone as the high-grade T-cell lymphoma. These findings suggest that enteropathy-associated T-cell lymphoma arises in the setting of coeliac disease and evolves from reactive intraepithelial lymphocytes through a low-grade lymphocytic neoplasm to a high-grade tumour, which is usually the cause of the presenting symptoms. Most cases of chronic ulcerative enteropathy (ulcerative jejunitis) are probably part of the same disease process. If the ulceration occurs at a time when the neoplastic T-cells are of a low grade, morphological recognition of tumour cells in the ulcers may be impossible. Carcinoma of the pharynx and oesophagus, and adenocarcinoma of the small intestine, are increased in frequency in patients with coeliac disease. The increased risk of carcinoma of the oesophagus may be related to vitamin A deficiency. A number of reports have indicated an increased prevalence of various types of chronic hepatitis in patients with coeliac disease, but no coherent view of the cause of this association has emerged. Similarly, patients with coeliac disease have been reported to have various forms of fibrosing lung disease of uncertain causation. In recent years, there have been several reports, mainly from Italy, of a syndrome of epilepsy and bilateral brain calcification occurring in coeliac patients. The pathogenesis of this condition is not known and its prevalence in other communities is uncertain. Splenic atrophy occurs frequently in patients with coeliac disease and is related to the severity of the disease and degree of dietary control. Splenic atrophy predisposes to infection with capsulated bacteria, although mortality studies indicate that infection with these organisms is not a major cause of death in patients with coeliac disease.

Elevated levels of serum antibodies to the lectin wheat germ agglutinin in celiac children lend support to the gluten-lectin theory of celiac disease

Lectins recognize carbohydrate moities of glycoproteins and glycolipids, and can elicit several biological effects, including cell agglutination, cell activation and mitogenesis. According to the gluten-lectin theory, celiac lesions represent a response to a toxic lectin, putatively wheat germ agglutinin (WGA). In this study we compared the serum antibody levels IgA, IgG and IgM to WGA and to gliadin in children under investigation for celiac disease (CD), as compared to reference children. We found that the levels of IgA and IgG to WGA as well as gliadin were significantly higher in celiac children on a gluten-containing diet, compared to children on gluten-free diet and reference children. These findings lend support to the concept that WGA is a biologically significant component of gluten. Since WGA can mimic the effects of epidermal growth factor (EGF) at the cellular level, we hypothesize that the crypt hyperplasia seen in celiac children could be due to a mitogenic response induced by WGA.

HLA-linked genes acting as additive susceptibility factors in celiac disease

Susceptibility to developing CD is widely accepted to be primarily associated with a particular HLA-DQ alpha beta heterodimer encoded by the DQA1*0501 and DQB1*0201 alleles in cis position on the DR3,DQ2 haplotype or in trans position by DR5,DQ7/DR7,DQ2 heterozygotes. We performed genomic HLA-DR and -DQ typing of 100 unrelated Spanish celiac children and 180 ethnically matched controls. As expected, most (92 out of 100) celiac patients carried the HLA-DQ alpha beta heterodimer, and we selected these individuals for further studies. The results corroborate that although the DQA1*0501 and DQB1*0201 genes in single dosage appear sufficient for conferring disease susceptibility, individuals homozygotes for DQB1*0201 show an increased risk. Furthermore, our data also show that those carrying the genotype DR5,DQ7/DR7,DQ2 have a significantly increased risk of developing CD as compared to those that are non-DR7 positive, also carrying the CD-associated HLA-DQ alpha beta heterodimer. This strongly suggests that there is an MHC linked non-HLA-DQ gene primarily associated with CD present on DR7,DQ2 haplotype, which should either be DR7 or in strong linkage disequilibrium with it. Our data also indicate that, as has already been suggested, another HLA-associated CD susceptibility gene may be present on some DR4-carrying haplotypes.

Wheat deficient in gliadins: promising tool for treatment of coeliac disease

The toxicity of two varieties of bread wheat, one poor in alpha and beta gliadins and the other poor in alpha, beta, gamma, and omega gliadins, has been tested. The peptic-tryptic digest of these wheats was assessed using coeliac mucosa in an in vitro organ culture system. A significantly lower toxicity was found in respect of bread wheat containing all gliadin fractions. These results suggest new opportunities for the treatment of coeliac disease.

Case Report: Increased Levothyroxine Requirement in a Patient with Cryptic Celiac-Sprue Disease

An increased requirement for levothyroxine may be due to poor patient compliance, pregnancy, low potency levothyroxine preparations, interfering drugs and small intestinal disease. Data on thyroid hormone absorption in celiac sprue disease is limited to a single study involving four patients without thyroid disease, in which malabsorption of a single dose of radiolabeled levothyroxine was noted in three of the four subjects. Increased levothyroxine requirements have not been reported in hypothyroid patients with celiac sprue. Furthermore, cryptic celiac sprue has never been described to cause levothyroxine malabsorption. We report such a patient in whom cryptic celiac sprue was an important cause of levothyroxine malabsorption with increased thyroid hormone requirement.

Subclinical coeliac disease is a frequent cause of iron-deficiency anaemia

BACKGROUND

Although it is known that anaemia may be the only presenting symptom in coeliac disease, prevalence figures of unsuspected coeliac disease in anaemic patients are not available. The aim of this study was to assess the clinical usefulness of antigliadin and antiendomysial antibody tests in the diagnostic algorithm of anaemic patients.

METHODS

Two hundred consecutive anaemic patients were tested for antigliadin antibodies, and those positive were also tested for antiendomysial antibodies. All patients positive for antigliadin and antiendomysial antibodies underwent intestinal biopsy.

RESULTS

Sixteen patients were antigliadin antibody-positive, and 10 were also antiendomysial antibody-positive. In all 10 a jejunal biopsy was consistent with coeliac disease (prevalence, 5%). This prevalence rose to 8.5% when patients with macrocytic anaemia or with microcytic anaemia due to previous bleeding or responsive to oral iron therapy were excluded from the calculation.

CONCLUSIONS

Coeliac disease is a frequent cause of iron-deficiency anaemia, and antigliadin and antiendomysial antibody tests should be always performed in the diagnostic algorithm of anaemic patients.

The association between coeliac disease, dermatitis herpetiformis and certain HLA-antigens in Icelanders

Twenty-eight cases of coeliac disease (CD) and seven of dermatitis herpetiformis (DH) have been verified in Iceland. Standard serological techniques were used for HLA typing. Twenty-five individuals with CD were typed, 21 (84%) of whom carried DR3,DQ2. Twelve of these 25 (48%) had DR3,DR7, DQ2, which makes them possibly homozygous for DQ2, and suggests that homozygosity of DQ2 increases the risk for CD. The four DH patients that were typed all had HLA-B8,DR3,DQ2. It is concluded that CD and DH are associated with DR3, DQZ in Icelanders.

Predominance of T cell receptor V delta 3 in small bowel biopsies from coeliac disease patients

Increased numbers of T cells bearing the gamma delta antigen receptor (gamma delta T cells) have been reported in small bowel biopsies of patients with latent, active or treated coeliac disease. We have studied jejunal biopsies from seven children with coeliac disease and 10 children with normal gut histology to characterize gamma delta T cell receptor (TCR) variable region gene subfamily expression in resident gamma delta T cells and compared the results with the findings in peripheral blood mononuclear cells (PBMC) obtained on the same day as the gut biopsy. Molecular analysis of RNA extracted from PBMC and biopsies was performed by reverse transcription and amplification with the polymerase chain reaction using primers specific for six TCR V delta families and four TCR V gamma families. We report, first, that a significantly increased number of gamma delta T cells expressing the TCR V delta 3 subfamily (P = 0.008) was observed in jejunal biopsies from children with coeliac disease, and second, that gamma delta T cell V region subfamily populations in gut differed from those seen in PBMC for both control and coeliac patients. Significantly reduced numbers of TCR V delta 2, V delta 3, V delta 5 (P < 0.01) and V gamma 2, V gamma 4 (P < 0.01) T cells were found in gut compared with PBMC. The difference in gamma delta T cell repertoire observed between gut and blood may reflect differences in the nature of the antigens usually encountered in these two compartments. The over-representation of TCR V delta 3 in patients with coeliac disease suggests a specific role for these cells in the induction or maintenance of the jejunal abnormality associated with this disease.

Increasing incidence of childhood celiac disease in Sicily: results of a multicenter study

By screening the patient list of four Sicilian centers of gastroenterology and those with gluten-free product consumption, 1074 patients (607 females and 467 males) with celiac disease, diagnosed between 1975 and 1989, were identified. A maximum cumulative incidence rate by birth cohort was reached in 1986 (1.65/1000). When the incidence rate was adjusted for the years of follow-up, the actual standardized rate was 3 cases per 1000 live births. Growth failure and chronic diarrhea were the most common symptoms, but a diminishing trend for chronic diarrhea was observed when symptoms were distributed by year of diagnosis. Even though 61.1% of all cases were diagnosed within six months from the onset of symptoms, mean age at diagnosis showed an increasing trend, from less than two years to approximately four years of age. The results of our study showed an increasing incidence of celiac disease due to diagnosis of less typical cases at an older age and also to a steady increase in the rate of diagnosis of cases with a classic clinical picture.

Identification of the triggers of celiac sprue

Three theoretically antigenic synthetic peptide subunits of alpha-gliadin were evaluated in vivo in four patients with celiac disease. A sequence of alpha-gliadin (amino acids 31-49) was toxic in all patients, suggesting that this sequence is one of the triggers of the immune system in celiac sprue.

Abnormal gastrointestinal motility in patients with celiac sprue

No study to date has objectively investigated whether the motor behavior of the small bowel is abnormal in celiac sprue. The purpose of this study was to systematically address this topic by means of intraluminal pressure recordings in a series of such patients. Sixteen subjects (nine adults, seven children, age range 2-69 years) with celiac sprue were recruited and studied while untreated. Manometric examination was carried out for 6 hr during fasting and 3 hr after a meal. Adult celiac patients displayed a significantly (mean +/- SEM) greater frequency of migrating motor complexes in comparison to controls during fasting (4.44 +/- 1.6 vs 2.45 +/- 0.20, P < 0.01), whereas no differences were found in the pediatric group with respect to this variable. Fasting motor abnormalities, chiefly represented by discrete clustered contractions, giant jejunal contractions, and bursts of nonpropagated contractions, were discovered in a high percentage in both groups of celiac subjects (89% in adults and 44% in children, respectively). Similar abnormalities were observed in the postprandial period, especially in adults. In conclusion, patients with celiac sprue frequently display discrete gastrointestinal motor abnormalities, which though perhaps nonspecific may account for several symptoms complained of by such patients.

IgA antibodies to jejunum. Specific immunity directed against target organ of gluten-sensitive enteropathy

Serum IgA antibodies to jejunum (JAB) were found in 78 (96%) of 81 adults and children with untreated celiac disease. Not only did IgA JAB display a significant higher prevalence than IgA antigliadin antibodies (AGA) (72%) in untreated gluten-sensitive enteropathy, but they also allowed us to identify another three celiacs in addition to those detected by IgA antiendomysial antibodies (EmA). Like IgA EmA, IgA JAB persisted at low titer in seven (14%) of 50 celiacs tested after 12 months of gluten-free diet (GFD) despite the regrowth of jejunal villi, whereas IgA AGA disappeared in all these patients consistently with the normalization of intestinal mucosa. IgA JAB and EmA reappearance was close to 100% in the 13 celiacs studied after six months of gluten challenge, while IgA AGA reached the highest prevalence (about 70%) after one month of gluten ingestion without any increase in the following months. All disease and healthy controls were always negative for the three IgA antibodies. Our results prove that IgA JAB and EmA are the best screening tests for active (untreated and on gluten challenge) celiac disease, whereas IgA AGA should be used for monitoring the response to gluten withdrawal. IgA JAB are an expression of a specific immunity directed against the target organ of gluten-sensitive enteropathy, but, before ascribing them a role in the pathogenesis of celiac disease, it should be ascertained whether their production is a primary event leading to jejunal lesions or whether it is a secondary phenomenon due to antigen release from a previously damaged jejunal mucosa.

T cells from the peripheral blood of coeliac disease patients recognize gluten antigens when presented by HLA-DR, -DQ, or -DP molecules

Coeliac disease (CD) is a T-cell mediated immunological disease of the small intestine which is precipitated in susceptible individuals by ingestion of gluten. We recently reported that gliadin-specific T cells can be found in the small intestinal mucosa of CD patients, and that a preponderance of these T cells was restricted by the CD-associated DQ(alpha 1*0501,beta 1*0201) heterodimer. Here we report studies on whether the same is found for gliadin specific T cells in the peripheral blood of CD patients. T-cell responses towards gluten antigens in vitro were found for both most CD patients and healthy controls. Gluten-specific T-cell clones (TCC) were established from four CD patients. Although a large proportion of these TCC were restricted by DQ molecules, including the CD-associated DQ(alpha 1*0501,beta 1*0201) heterodimer, several were restricted instead by DR or DP molecules. Thus, gluten-derived peptides can be presented to T cells by several different HLA class-II molecules, and the preferential DQ(alpha 1*0501,beta 1*0201) restriction of gluten-specific T cells in the small intestinal mucosa of CD patients is less pronounced than for similar T cells in the peripheral blood.

Polymorphism of antigen processing (TAP, LMP) and HLA class II genes in celiac disease

Susceptibility to CD is strongly associated with particular HLA class II molecules. However, additive genetic factors are likely to be required for the development of the disease. The polymorphic TAP and LMP genes, located within the HLA class II region, are involved in the antigen presentation pathway and thus represent candidate susceptibility genes. HLA class II DRB1, DRB3, DQA1, DQB1, and DPB1 as well as TAP1, TAP2, and LMP2 polymorphism was studied in 80 Caucasian CD patients and 213 normal controls by DNA oligotyping. The DQB1*0201 allele was found in 96.3% of CD patients and provided the highest risk (RR = 50), whereas only 89% of CD patients carried the DQ alpha 501/beta 201 heterodimer (RR = 30). The participation of the DRB3 and DPB1 locus was ruled out as it was attributed to a linkage disequilibrium on the DR3 haplotype. TAP1 and LMP2 allelic distribution was not significantly different among CD patients and controls. The TAP2-C allele was completely absent from the CD population, while it was found in 22.5% of controls. Although linkage disequilibrium between TAP2 and class II loci clearly exists in some haplotypes, TAP could act as additional susceptibility genes.

T cells recognize a peptide derived from alpha-gliadin presented by the celiac disease-associated HLA-DQ (alpha 1*0501, beta 1*0201) heterodimer

CD is unique among the HLA-associated diseases since (a) the disease-promoting agent (gliadin) is known and (b) the disease is precipitated mainly in individuals carrying a particular cis- or trans-encoded HLA-DQ heterodimer; i.e., DQ(alpha 1*0501, beta 1*0201). Further, a preponderance of gliadin-specific T cells derived from the small intestinal mucosa of CD patients are restricted by this DQ heterodimer. T-cell recognition of gliadin peptides presented by the DQ(alpha 1*0501, beta 1*0201) heterodimer may thus be of importance in CD. Here we report that a T-cell clone from a patient with CD recognizes a synthetic alpha-gliadin peptide, when presented by the cis- or trans-encoded CD-associated DQ(alpha 1*0501, beta 1*0201) heterodimer. The minimal peptide recognized by the T-cell clone corresponds to residues 31-47 of alpha-gliadin, which is included in the part of alpha-gliadin previously shown to have disease-promoting activity. When testing analogue peptides derived from other alpha-gliadin sequences, one peptide differing by one amino acid was recognized by the T-cell clone, whereas the other peptide differing by two amino acids was not recognized. Our findings demonstrate that the CD-associated DQ(alpha 1*0501, beta 1*0201) heterodimer may serve as an antigen-presenting molecule to T cells for certain gliadin peptides.

Wheat peptide challenge in coeliac disease

The exact nature of the cereal moiety that exacerbates coeliac disease is unknown. In-vitro studies have implicated both the N-terminal and far C-terminal domains of one of the wheat prolamins, A-gliadin. Peptides within these regions may act as epitopes that trigger immune events leading to enteropathy. We synthesized three peptides corresponding to amino-acids 3-21, 31-49, and 202-220 of A-gliadin. Four patients with coeliac disease were challenged by intraduodenal infusion of 1 g of gliadin or 200 mg of the synthetic peptides. Jejunal biopsies were taken before and at hourly intervals for 6 h after the infusion. Morphometric variables were measured and intraepithelial lymphocytes counted. Significant histological changes occurred in the small intestinal mucosa after challenge with a synthetic peptide corresponding to amino acids 31-49 of A-gliadin. The N-terminal peptide, residues 3-21 of A-gliadin, did not cause histological changes in any of the patients. In one of the four patients, minor histological changes following challenge with the peptide corresponding to residues 202-220 of A-gliadin were seen. Our results suggest that the oligopeptide corresponding to aminoacids 31-49 of A-gliadin is toxic in vivo, but there is no evidence of toxicity of the far N-terminal peptide, residues 3-21. The C-terminal peptide 202-220 may contain an epitope to which patients with coeliac disease display variable sensitivity. Since the oligopeptide corresponding to amino-acids 31-49 of A-gliadin is recognised by HLA DQ2-restricted T cells, the observed effects may be due to immune activation within the intestinal mucosa.

Celiac disease: clinical features and pathogenesis

Celiac disease is a fascinating illness, from both a clinical and research perspective. Most clinicians consider a diagnosis of celiac disease when a young patient has classic signs and symptoms of steatorrhea and severe malabsorption. However, the typical gastrointestinal symptoms often are absent. The patient may only have subtle signs of chronic malnutrition or nonspecific gastrointestinal complaints. Celiac disease is not diagnosed commonly in the United States, at least in part because of a low clinical index of suspicion. A diagnosis of celiac disease is confirmed by a small bowel mucosa biopsy. A dramatic clinical response to a gluten-free diet verifies the diagnosis, and provides a cost-effective treatment free of significant side effects. Strict adherence to the prescribed diet usually results in a complete resolution of the symptoms and mucosal histopathologic changes. The serious, long-term complication of intestinal lymphoma also may be prevented. To the clinical investigator, celiac disease is an important model of the HLA-associated immune-mediated illnesses. A specific HLA-DQ heterodimer is found in 95% of patients, representing perhaps the strongest association of any illness with a specific class II HLA molecule. In addition, an important environmental trigger (gluten) has been identified, providing a unique opportunity to study the interaction of gene products and environmental factors in the pathogenesis of an immune-mediated disease.

Prevalence and clinical significance of gliadin antibodies in healthy children and adults

Coeliac disease (CD) is associated with the presence of gliadin antibodies (GA) (IgG and IgA), often used as a screening test for CD. Using a modified micro-enzyme-linked immunosorbent assay for GA, we studied the prevalence of GA in three healthy groups: children (mean age, 12 years), adult blood donors (mean age, 38 years), and healthy women (mean age, 57 years). We also studied the clinical characteristics of the blood donors. On the basis of findings in 27 untreated CD patients, cut-off levels of IgG and IgA antibody titres were chosen to yield a test with relatively low sensitivity (56%) but high specificity (100%). Analysis of IgM antibodies did not improve the sensitivity. Of the 384 12-year-old children, both IgG and IgA GA positivity was found in 15 (3.91%), a rate significantly greater than that in the blood donors (22 of 1537, 1.43%; p < 0.001) or in the middle-aged women (11 of 944, 1.17%; p < 0.0001). Of the 22 GA-positive healthy blood donors, 13 underwent small-bowel biopsy, but only 1 of the specimens manifested histologic changes compatible with CD. The other 12 had normal specimens, including a normal intraepithelial lymphocyte count. The estimated frequency of CD among the blood donors was thus 1 of 1500, a figure consistent with those previously published. We conclude that GA occur frequently in the Swedish population but that their prevalence decreases with increasing age. As a screening test for CD in healthy individuals, the GA titre is of poor predictive value.

Molecular characterization of HLA class II genes in celiac disease patients of Latin American Caucasian origin

In the present study, the polymorphic domain of HLA class II genes present in a pediatric population of Argentinian celiac disease patients was analyzed by hybridization to sequence-specific oligonucleotides and DNA sequencing. Sixteen out of 16 DR5/7 heterozygous patients bore the DQA1*0501 and DQB1*0201 alleles implicated in the DQ2 risk specificity. The second exon of DQA1, DQB1 and DRB1 genes from 2 DR5/7 patients was characterized by DNA sequencing. The following alleles were found in both patients: DRB1*1101 and DRB1*0701; DQB1*0301 and DQB1*0201; DQA1*0501 and DQA1*0201. Previous serological analysis in this population had shown the presence of DQ2 in 95% of the patients (40% in controls) and a negative association with DQ1 haplotypes, suggesting the presence of other "permissive" or neutral alleles. The following HLA-DQB1 alleles, besides DQB1*0201, were identified in 31 CD patients: DQB1*0301, 0302, 0401 and 0402. All these alleles share a common pattern of residues between positions 84 and 90, and distinct from that present in DQ1-related alleles.

Patients with psoriasis often have increased serum levels of IgA antibodies to gliadin

It was recently observed that in six patients with psoriasis and one with palmoplantar pustulosis, with newly discovered gluten intolerance, a gluten-free diet had a remarkable effect on the skin lesions. This prompted us to undertake a screening investigation to discover whether increased levels of serum antibodies to gliadin are more common in patients with psoriasis than in healthy persons. IgA and IgG antibodies to gliadin (IgA AGA and IgG AGA) were quantified by a micro-ELISA method. Out of 302 patients with psoriasis, 16% (18 females, 31 males) showed serum IgA AGA levels above the 90th percentile value (51 u/ml) of the reference group. This tendency was even more marked when the proportion of patients with values > 70 u/ml was compared with the corresponding proportion of 99 reference subjects. Thus, 3% of the reference subjects but 7.9% of the patients had values > 70 u/ml. The corresponding figures for men were 1.6% and 8.9%, respectively. Men with psoriasis had a significantly higher mean IgA AGA than the male reference group. The means based on logarithmic values of the individual IgA AGA values were significantly higher in the psoriatic groups than in the reference groups. Although the mean level of IgG AGA was not increased in the psoriasis group, there was a correlation between the values for IgA AGA and IgG AGA. The serum concentrations of IgG, IgA and IgM were also measured. In the male patients, the mean IgA value was significantly increased. Women in whom IgA AGA was elevated also showed a significantly increased mean IgA.(ABSTRACT TRUNCATED AT 250 WORDS)

Pioneer in the gluten free diet: Willem-Karel Dicke 1905-1962, over 50 years of gluten free diet

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HLA susceptibility genes in celiac disease: genetic mapping and role in pathogenesis

The overrepresentation of particular HLA alleles in patients with celiac disease was first noted two decades ago. Several lines of evidence obtained during the last years strongly suggest that a particular HLA-DQ heterodimer, encoded by the DQA1*0501 and DQB1*0201 genes in cis or trans configuration, confers the primary disease susceptibility. This paper reviews the evidence behind this concept and discusses how this particular DQ molecule may be involved in the pathogenesis.

Gliadin-specific, HLA-DQ(alpha 1*0501,beta 1*0201) restricted T cells isolated from the small intestinal mucosa of celiac disease patients

Celiac disease (CD) is most probably an immunological disease, precipitated in susceptible individuals by ingestion of wheat gliadin and related proteins from other cereals. The disease shows a strong human HLA association predominantly to the cis or trans encoded HLA-DQ(alpha 1*0501,beta 1*0201) (DQ2) heterodimer. T cell recognition of gliadin presented by this DQ heterodimer may thus be of immunopathogenic importance in CD. We therefore challenged small intestinal biopsies from adult CD patients on a gluten-free diet in vitro with gluten (containing both gliadin and other wheat proteins), and isolated activated CD25+ T cells. Polyclonal T cell lines and a panel of T cell clones recognizing gluten were established. They recognized the gliadin moiety of gluten, but not proteins from other cereals. Inhibition studies with anti-HLA antibodies demonstrated predominant antigen presentation by HLA-DQ molecules. The main antigen-presenting molecule was established to be the CD-associated DQ(alpha 1*0501, beta 1*0201) heterodimer. The gluten-reactive T cell clones were CD4+, CD8-, and carried diverse combinations of T cell receptor (TCR) V alpha and V beta chains. The findings suggest preferential mucosal presentation of gluten-derived peptides by HLA-DQ(alpha 1*0501, beta 1*0201) in CD, which may explain the HLA association.

Diet and gastrointestinal disease

Diet therapy in the treatment of gastrointestinal disease has become better defined. Because maldigestion or malabsorption frequently occurs, malnutrition is a common complication. Careful assessment of nutritional status by the health care providers is mandatory. Diet therapy, by eliminating offending foods such as lactose or gluten or by addition of specialized enteral formulas containing MCT, or elemental diets can be instituted with marked relief in symptoms. The role of dietary fiber is now better defined in the treatment and prevention of many diseases. Further refinement and rational uses of diet therapy can be expected in future years.

Studies on the aetiology of coeliac disease: no evidence for lectin-like components in wheat gluten

In an approach to examine the lectin-hypothesis in the pathogenesis of coeliac disease, the presence of lectin-like components in three wheat gluten preparations known to induce coeliac disease, gliadin, Frazer fraction III and an acetic acid/ethanol extract of gluten, was investigated. Lectin-like components in these wheat gluten preparations were traced in binding studies employing a variety of model glycoproteins glycosylated with the different types of N-linked oligosaccharides, i.e., those of the high mannose-, complex- and hybrid-type. Binding affinity of wheat proteins to these glycoproteins was analyzed by affinity dotting and blotting techniques and was compared to that of the well characterized lectins Galanthus nivalis agglutinin, Concanavalin A and wheat germ agglutinin. Though the three wheat gluten preparations exhibited binding reactivity for distinct model glycoproteins, no correlation was found between the type of N-glycosylation of the model glycoproteins and their binding capability to the different wheat gluten preparations. Moreover, binding of the three gluten preparations to the model glycoproteins could not be inhibited by competitive saccharides (methyl-alpha-D-mannopyranoside, N-acetyl-D-glucosamine, mannan). Enzymatic deglycosylation of the ligand glycoproteins with endo-beta-N-acetylglucosaminidase H (Endo H, EC 3.2.1.96) or peptide N-glycosidase F (PNGase F, EC 3.5.1.52) abolished their binding reactivity for the plant lectins, but did not affect binding of the wheat gluten preparations. These results give no evidence for the presence of lectin-like components in wheat gluten preparations and do question the 'lectin hypothesis' of coeliac disease.

Is an intestinal permeability test a valid marker for slight dietary transgressions in adolescents with coeliac disease?

Adolescents with coeliac disease often fail to adhere to a strict gluten free diet. The effectiveness of intestinal permeability to sugars as a marker of slight dietary transgressions by such adolescents was assessed. Severe dietary transgressions were excluded from the study. Subjects were divided into two groups according to whether they committed slight dietary transgressions or adhered to a strict gluten free diet. A reference group of preadolescents with coeliac disease was also included in the study. Intestinal permeability and antigliadin antibody tests were performed on all patients. The diagnostic marker of intestinal permeability was excellent in the reference group. Neither the intestinal permeability test nor antigliadin antibody tests, however, succeeded in discriminating between the two groups of adolescents considered in this study. In conclusion the intestinal permeability test is not a valid marker for slight dietary transgression in such patients.