[Celiac disease diagnosis in 2008]

Celiac disease: Understandings in diagnostic, nutritional, and medicinal aspects

Celiac disease (CD) is characterized by clinical polymorphism, with classic, asymptomatic or oligosymptomatic, and extra-intestinal forms, which may lead to diagnostic delay and exposure to serious complications. CD is a multidisciplinary health concern involving general medicine, pediatric, and adult gastroenterology, among other disciplines. Immunology and pathology laboratories have a fundamental role in diagnosing and monitoring CD. The diagnosis consists of serological testing based on IgA anti-transglutaminase (TG2) antibodies combined with IgA quantification to rule out IgA deficiency, a potential misleading factor of CD diagnosis. Positive TG2 serology should be corroborated by anti-endomysium antibody testing before considering an intestinal biopsy. Owing to multiple differential diagnoses, celiac disease cannot be confirmed based on serological positivity alone, nor on isolated villous atrophy. In children with classical signs or even when asymptomatic, with high levels of CD-linked markers and positive HLA DQ2 and/or DQ8 molecules, the current trend is to confirm the diagnosis on basis of the non-systematic use of the biopsy, which remains obligatory in adults. The main challenge in managing CD is the implementation and compliance with a gluten-free diet (GFD). This explains the key role of the dietitian and the active participation of patients and their families throughout the disease-management process. The presence of the gluten in several forms of medicine requires the sensitization of physicians when prescribing, and particularly when dispensing gluten-containing formulations by pharmacists. This underlines the importance of the contribution of the pharmacist in the care of patients with CD within the framework of close collaboration with physicians and nutritionists.

Taurine administration prevents the intestine from the damage induced by beta-lactoglobulin sensitization in a murine model of food allergy

BACKGROUND

Allergy to cow's milk proteins has often been associated with dysfunction of the intestinal mucosa caused by chronic inflammation in infants. This study evaluated the protective effect of taurine on intestinal damage induced by beta-lactoglobulin (β-Lg) in Balb/c mice used as an animal model of allergy to cow's milk proteins.

METHODS

Balb/c mice were treated with taurine administered orally by gavage (3mmol/kg/day) or intraperitoneally (100mg/kg/day) for two weeks, then sensitized intraperitoneally with β-Lg. The electrophysiological parameters: active ion transport of chloride (Short-circuit current: Isc) and the passive ion permeability (Conductance: G) were measured ex vivo in Ussing chamber by intestine challenge with β-Lg. Histological study was used to assess gut inflammation. Serum levels of TNF-α and IL-6 were measured. Serum IgG and IgE anti-β-Lg were determined by ELISA.

RESULTS

Compared with sensitized mice, β-Lg challenge of intestinal epithelium of taurine-pre-treated mice in Ussing chamber did not influence the intensity of Isc, nor produce any changes in the G, reflecting a reduction in the secretory response and epithelial permeability. Histological and morphometric analysis showed that taurine reduced the intestinal damage and limited intestine retraction caused by β-Lg sensitization. No statistically significant difference in the serum levels of TNF-α or IL-6 was found after oral or intraperitoneal administration of taurine. Treatment with taurine significantly decreased the IgG (p<0.001) and IgE anti β-Lg levels (p<0.05).

CONCLUSIONS

These results have for the first time provided evidence that pre-treatment with taurine appears to prevent intestinal damage induced by β-Lg.

[Should the whole population be screened for coeliac disease?]

To address the issue of mass screening in coeliac disease strict criteria shall be defined. Principles and practice of screening for disease have been defined 40 years ago by Wilson and Jungner, there are still accurate and applied, specially in France for neonatal screening. Screening the whole population for gluten intolerance is not recommended at this time. Aress with gap in scientific knowledge are identified and further prospective epidemiologic studies are needed. These include the timing of screening, defining the natural history of screening-identified asymptomatic patients, developing tools to predict disease onset and disease remission and the potential risks of screening. At the present time, only identification and testing of high-risks groups is recommended.

Acupuncture and a gluten-free diet relieve urticaria and eczema in a case of undiagnosed dermatitis herpetiformis and atypical or extraintestinal celiac disease: a case report

OBJECTIVE

The purpose of this case report is to describe the use of acupuncture and a gluten-free diet (GFD) for urticaria and severe eczema in a patient with undiagnosed dermatitis herpetiformis and atypical or extraintestinal celiac disease.

CLINICAL FEATURES

A 48-year-old woman presented with intense urticaria, eczema, worsening heartburn, chronic constipation, headaches, and an intense feeling of heat for 4 months. Results of punch biopsies of the skin lesions and laboratory tests were inconclusive. After the acupuncture sessions reported here ended, human leukocyte antigen blood typing revealed celiac disease and dermatitis herpetiformis-associated human leukocyte antigen DQ-8. Results of an endoscopy and colonoscopy were negative.

INTERVENTION AND OUTCOME

The patient received 3 acupuncture treatments a week for 12 weeks. The patient's symptoms began in March 2008. She began using topical and oral steroids and felt that her symptoms were not responding. Acupuncture began in July 2008. At the end of the first 12 treatments, during which she was using topical and oral steroids, the urticaria and constipation resolved completely; and she had temporary relief from the heartburn. It is thought that the urticaria and constipation resolved because of the acupuncture as that was the only change. At the end of the second 12 treatments, during which time she had started Optifast, a GFD, the heartburn, headache, and eczema resolved. At the end of the third 12 treatments, all her symptoms remained resolved. Steroid treatment was discontinued after the first 12 treatments.

CONCLUSION

Acupuncture and diet changes appeared to provide relief from the urticaria and eczema of dermatitis herpetiformis beyond that obtained by traditional treatment of a GFD alone.

[Histopathology of coeliac disease]

Coeliac disease is a common disease, affecting 1% of the population. Clinical manifestations are multiple. The diagnosis requires serologic testing and a duodenal biopsy that shows the characteristic findings of intraepithelial lymphocytosis, crypt hyperplasia and villous atrophy, and a positive response to a gluten-free diet. In most patients, the histological diagnosis is easily established. Pitfalls in the pathological diagnosis include a poorly orientated biopsy specimen, either an inadequate biopsy sampling in patients with patchy villous atrophy and the other causes of villous atrophy. A non-response to the gluten-free diet needs to reassess first, the initial diagnosis, second to be sure of the gluten-free diet adherence, and third, to exclude malignant complications such as refractory celiac disease or enteropathy-associated T-cell lymphoma.