Celiac disease: is the atypical really typical? Summary of the recent National Institutes of Health Consensus Conference and latest advances

Celiac disease and risk of sarcoidosis: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Several epidemiologic studies have suggested that patients with celiac disease may be at an increased risk of sarcoidosis but the results were inconsistent. This systematic review and meta-analysis was conducted with the aim to better characterize this risk by summarizing all available data.

METHODS

A literature review was performed using MEDLINE and EMBASE database from inception to February 2019. Studies that compared the risk of sarcoidosis among patients with celiac disease versus individuals without celiac disease were included. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Of 426 retrieved studies, four studies with 693 639 participants met the eligibility criteria and were included in meta-analysis. The risk of sarcoidosis among patients with celiac disease was higher than individuals without celiac disease with the pooled OR of 7.16 (95% CI, 1.48-34.56). The statistical heterogeneity of this study was high (I²  = 95%).

CONCLUSIONS

This systematic review and meta-analysis found a significantly higher risk of sarcoidosis among patients with celiac disease.

Implementation and adherence to osteoporosis screening guidelines among coeliac disease patients

BACKGROUND

There are no studies evaluating the implementation of American Gastroenterological Association (AGA) guidelines on osteoporosis screening in coeliac disease.

AIMS

To investigate implementation of osteoporosis screening guidelines in coeliac disease patients and determine how often bone mineral density (BMD) assessment leads to therapeutic intervention.

METHODS

We screened all patients with biopsy-proven coeliac disease at our center from 2003 to 2013 and collected data on indication and results of dual energy X-ray absorptiometry scanning (DXA) and therapeutic interventions.

RESULTS

Of 222 adults with coeliac, only 80 (36%) underwent DXA after their diagnosis. Of those, 43 had DXA for osteoporosis screening specifically related to their coeliac diagnosis. Of these 43 patients, 28 (65.1%) had low BMD. A therapeutic intervention was made in the majority of these patients (21/28, 75%). Of 330 pediatric coeliac cases, 52 (15.8%) had DXA specifically in the context of the coeliac disease diagnosis with only 5 being complicated coeliac disease. Of these, 3 (5.8%) had low BMD and only 2 underwent therapeutic intervention.

CONCLUSIONS

Osteoporosis screening guidelines are not followed in the majority of patients with coeliac disease but, when followed, frequently lead to therapeutic intervention. Osteoporosis screening guidelines in coeliac disease need to be updated, strengthened and publicized.

Patients with celiac disease may have normal weight or may even be overweight

BACKGROUND

It is believed that patients with celiac disease (CeD) are likely to be underweight. Data from west suggest that 8% to 40% of them can be overweight or obese. We reviewed data on body mass index (BMI) of our patients with CeD and derived the correlations between BMI and other disease characteristics.

METHODS

We retrospectively studied case records of 210 adolescent and adult patients with CeD at the Celiac Disease Clinic. We classified BMI as underweight, normal weight, overweight, and obese based on the Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians for those with age >18 years and revised Indian Association of Pediatrics BMI-for-age charts for those between 12 and 18 years.

RESULTS

Of 210 patients, 76 (36.2%) were underweight, 115 (54.8%) were normal weight, 13 (6.2%) were overweight, and 6 (2.9%) were obese. There was no difference in the proportion of underweight between male and female patients with CeD. The mean age of underweight patients was similar to those having normal or overweight. There was no difference in the mean duration of symptoms; frequencies of diarrhea, anorexia, and weakness; anemia; titer of anti-tissue transglutaminase antibody; and severity of villous atrophy in those with underweight or normal weight or overweight.

CONCLUSIONS

In our practice, only one third of patients with CeD had low BMI. A diagnosis of CeD should not be excluded if patient has normal or high BMI.

Sarcoidosis in patients with celiac disease

PURPOSE

Several case reports and European studies have suggested an association between sarcoidosis and celiac disease; however, they have been inconsistent. We therefore analyzed a large cohort of celiac-disease patients to assess this association.

METHODS

An anonymized database of patients with celiac disease was reviewed to determine the number of patients with sarcoidosis. Age- and gender-adjusted standardized morbidity ratios with corresponding 95% confidence intervals (CI) were calculated by comparing results to US-population-derived prevalence data.

RESULTS

Ten patients were found to have a comorbid diagnosis of sarcoidosis, representing an age- and gender-adjusted standardized morbidity ratio of 36.8 (95% CI 26.7-50.9).

CONCLUSIONS

In this cohort of patients with celiac disease, there was a significantly increased risk of sarcoidosis when compared with the American white population. This further strengthens prior associations that have been made suggesting a shared mechanism behind the etiologies of celiac disease and sarcoidosis.

Detection of Celiac disease in primary care: a multicenter case-finding study in North America

BACKGROUND

Celiac disease (CD) is one of the most common lifelong disorders in western countries. However, most cases remain currently undiagnosed in North America, mostly due to poor awareness of CD by primary care physicians.

OBJECTIVES

The aims of this study were (a) to determine whether an active case-finding strategy in primary care could increase the frequency of CD diagnosis and (b) to determine the most common clinical presentations of the condition.

METHODS

This was a multicenter, prospective study involving adult subjects during the years 2002-2004, attending one of the participating practices. All individuals with symptoms or conditions known to be associated with CD were tested for immunoglobulin A anti-transglutaminase (tTG) antibodies, and those with elevated anti-tTG were subsequently tested for IgA antiendomysial antibodies (EMA). All subjects who were positive for EMA were advised to undergo an intestinal biopsy and HLA typing.

RESULTS

The study group included 737 women and 239 men, with a median age of 54.3 yr. A positive anti-tTG test was found in 30 out of 976 investigated subjects (3.07%, 95% CI 1.98-4.16). CD was diagnosed in 22 patients (18 women, 4 men). The most frequent reasons for CD screening in these 22 cases were bloating (12/22), thyroid disease (11/22), irritable bowel syndrome (7/22), unexplained chronic diarrhea (6/22), chronic fatigue (5/22), and constipation (4/22). The prevalence of CD in the serologically screened sample was 2.25% (95% CI 1.32-3.18). The diagnostic rate was low at baseline (0.27 cases per thousand visits, 95% CI 0.13-0.41) and significantly increased to 11.6 per thousand visits (95% CI 6.8-16.4, P < 0.001) following active screening implementation.

CONCLUSIONS

This study demonstrates that an active case-finding strategy in the primary care setting is an effective means to improve the diagnostic rate of CD in North America.