Coeliac disease in developing countries: Middle East, India and North Africa

Screening for Celiac Disease in Patients with Irritable Bowel Syndrome Fulfilling Rome III Criteria

Background Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder. Celiac disease (CD), a treatable autoimmune enteropathy, with varied presentations, may simulate clinically symptoms of IBS. The aim of the present study is to screen for CD in patients with IBS diagnosed based on the Rome III criteria.

Patients and Methods A cross-sectional study was conducted at a secondary care gastrointestinal unit in Al-Salam General Hospital in Mosul city, Iraq, from November 2015 to October 2016. All patients fulfilling the Rome III criteria for IBS were screened for CD using antitissue transglutaminase IgA antibodies (anti-tTG). Patients who tested positive were subjected to endoscopic duodenal biopsy to confirm the diagnosis of CD.

Results A total of 100 patients were included in the present study (58 female and 42 male), the mean age of the participants was 40.8 years old (standard deviation [SD] ± 11.57). Ten patients (10/100, 10%) tested positive for anti-tTG antibodies. Five of the seropositive patients (5/10, 50%) showed positive biopsy results according to the Marsh classification, 3 of whom having diarrhea, and 2 with constipation.

Conclusion Positive serology and biopsy results suggestive of CD are common among patients with IBS. Screening patients with IBS for CD is justified.

Prevalence of HLA DQ 2, 8 in children with celiac disease

OBJECTIVE

Celiac disease is a chronic disease that affect small bowel by making its villi become atrophic. Various environmental and genetic factors have been identify as inducing factors for celiac disease. Most of the patients has one of the HLA DQ forms. Although the prevalence of these genes are variable in different areas of the world, we do not have a comprehensive information about this issue in our region. Thus the aim of present study is to investigate the prevalence of HLA DQ typing of patients who visited Emam Reza Gastroenterology clinic of Shiraz(IRAN).

METHODS

In this case-control study all under 18 years old children who were diagnosed with celiac disease and have visited Emam Reza gastroenterology clinic were investigated. The diagnosis of celiac disease was made by history, physical exam, serologic test, and histopathology of duodenal biopsy. Blood sample was taken and HLA typing performed using PCR method at Motahari clinic cytology laboratory. Also those people who neither them self nor their first degree relatives were not case of celiac disease and underwent HLA typing for other reason were identified as control group. The statistical analysis was done using SPSS 18 software. The p value < 0.05 was identified as statistically significant.

RESULTS

A total of 139 patients with celiac disease and 146 normal children were studied. The mean age of the patient with celiac disease were 9.1 years old with standard deviation of 3.4 years old. 64% of the celiac patients were girls and 36% were boys. While this proportion was 54.4% for boy and 48.6% for girls in control group. The most common HLA in celiac patients group were HLA DQ2 and 8 but the most common ones in control group were HLA DQ 8 and 5. Failure to Thrive were the most common signs of the celiac patients with a prevalence of 60 children. Total IgA titer were normal in 98.6% of the patients and TTG IgA titer were positive in 93.5% of the patients. The most common co existing disease with the celiac disease were diabetes with a prevalence of 30 children (66.7%).

CONCLUSION

present study reveals that the prevalence of the HLA DQ2 and 8 among patients with celiac disease is 72.6% and 53% in our normal population.

An updated overview of spectrum of gluten-related disorders: clinical and diagnostic aspects

The incidence of gluten-related disorders (GRDs) continues to increase and its global prevalence is estimated at approximately 5% of the population. Celiac disease (CD), dermatitis herpetiformis (DH), gluten ataxia (GA), wheat allergy (WA), and non-celiac gluten sensitivity (NCGS) are the five major GRDs that present with a wide range of clinical manifestations. The diagnosis of GRDs can be challenging because the typical and atypical clinical manifestations of the GRDs overlap. In this review, the current definitions of gluten-related disorders, focusing on their clinical features, diagnostic and therapeutic approaches are presented. We concluded that GRDs are usually diagnosed using a combination of clinical features, serological tests, and histopathological findings. Treatment usually involves dietary modification.

Celiac Disease in Kosovar Albanian Children: Evaluation of Clinical Features and Diagnosis

BACKGROUND

Celiac disease is an immune-mediated disorder characterized by variable clinical manifestations, specific antibodies, HLA-DQ2/DQ8 haplotypes, and enteropathy.

OBJECTIVES

The aim of this study was to present the clinical spectrum and patterns of celiac disease in Kosovar Albanian children.

METHODS

A cross-sectional retrospective study was performed with Albanian children aged 0-18 years, treated for celiac disease in the Pediatric Clinic, University Clinical Center of Kosovo from 2005 to 2016.

RESULTS

During the study period, 63 children were treated for celiac disease. The mean age at diagnosis was 5.5 years (SD ± 3.31). The mean age at celiac disease onset was 3.3 years (SD ± 2.02), while the mean delay from the first symptoms indicative of celiac disease to diagnosis was 2.2 years (SD ± 2.09). More than 70% of the patients were diagnosed in the first 7 years of life, mainly presented with gastrointestinal symptoms, while primary school children and adolescents mostly showed atypical symptoms (p<0.001). The classical form of celiac disease occurred in 78% of the cases. Sixty (95%) patients carried HLA-DQ2.5, DQ2.2 and/or HLA-DQ8 heterodimers, and only three of them tested negative.

CONCLUSION

Kosovo, as the majority of developing countries, is still facing the classical form of celiac disease as the dominant mode of presentation; as a result, most children with other forms of the celiac disease remain undiagnosed. Physicians should be aware of the wide range of clinical presentations and utilize low testing thresholds in order to prevent potential long-term problems associated with untreated celiac disease.

Gluten Detection Methods and Their Critical Role in Assuring Safe Diets for Celiac Patients

Celiac disease, wheat sensitivity, and allergy represent three different reactions, which may occur in genetically predisposed individuals on the ingestion of wheat and derived products with various manifestations. Improvements in the disease diagnostics and understanding of disease etiology unveiled that these disorders are widespread around the globe affecting about 7% of the population. The only known treatment so far is a life-long gluten-free diet, which is almost impossible to follow because of the contamination of allegedly "gluten-free" products. Accidental contamination of inherently gluten-free products could take place at any level from field to shelf because of the ubiquity of these proteins/grains. Gluten contamination of allegedly "gluten-free" products is a constant threat to celiac patients and a major health concern. Several detection procedures have been proposed to determine the level of contamination in products for celiac patients. The present article aims to review the advantages and disadvantages of different gluten detection methods, with emphasis on the recent technology that allows identification of the immunogenic-gluten peptides without the use of antibodies. The possibility to detect gluten contamination by different approaches with similar or better detection efficiency in different raw and processed foods will guarantee the safety of the foods for celiac patients.

Impact of bariatric surgery on outcomes of patients with celiac disease: a nationwide inpatient sample analysis, 2004-2014

Background

While patients with celiac disease have increasingly developed an atypical pattern of weight gain and obesity, the role of bariatric surgery remains unclear. The primary aim of this study was to evaluate the effect of bariatric surgery on clinical outcomes among hospitalized patients with celiac disease.

Methods

The United States Nationwide Inpatient Sample database was queried for discharges with co-diagnoses of morbid obesity and celiac disease between 2004 and 2014. The primary outcome was in-hospital mortality. Secondary outcomes included renal failure, urinary tract infection, malnutrition, sepsis, pneumonia, respiratory failure, thromboembolic events, strictures, micronutrient deficiency, length of stay, and hospitalization costs. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior bariatric surgery compared to those without bariatric surgery.

Results

Among 1499 patients with a discharge diagnosis of celiac disease and morbid obesity, 126 patients (8.4%) underwent bariatric surgery. Despite an increase in morbid obesity over the study period, the proportion of morbidly obese patients with celiac disease who had bariatric surgery declined by 18.5% (P_trend<0.05). On multivariable analysis, bariatric surgery did not influence mortality (P=0.98), but was associated with a lower risk of renal failure, pneumonia, sepsis, urinary tract infection and respiratory failure (all P<0.05). Bariatric surgery increased the risk of vitamin D deficiency (IRR 3.5; 95% confidence interval [CI] 1.6-7.7; P=0.002) and post-operative strictures (IRR 3.3; 95%CI 1.5-7.5; P=0.004).

Conclusion

Despite the underutilization of bariatric surgery in morbidly obese celiac disease patients, the procedure is safe and appears to significantly reduce morbidity.

Efficacy of duodenal bulb biopsy for diagnosis of celiac disease: a systematic review and meta-analysis

Background and study aims  Although duodenal biopsy is considered the "gold standard" for diagnosis of celiac disease, the optimal location of biopsy within the small bowel for diagnosis remains unclear. The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the diagnostic utility of endoscopic duodenal bulb biopsy for celiac disease. Patients and methods  Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed from 2000 through December 2017. Review of titles/abstracts, full review of potentially relevant studies, and data abstraction was performed. Measured outcomes of adult and pediatric patients included location of biopsy, mean number of biopsies performed, and diagnosis of celiac disease as defined by the modified Marsh-Oberhuber classification. Results  A total of 17 studies (n = 4050) were included. Seven studies evaluated adults and 11 studies assessed pediatric populations. Mean age of adults and pediatric patients was 46.70 ± 2.69 and 6.33 ± 1.26 years, respectively. Overall, sampling from the duodenal bulb demonstrated a 5 % (95 % CI 3 - 9; P  < 0.001) increase in the diagnostic yield of celiac disease. When stratified by pediatric and adult populations, duodenal bulb biopsy demonstrated a 4 % (95 % CI: 1 to 9; P  < 0.001) and 8 % (95 % CI: 6 to 10; P  < 0.001) increase in the diagnostic yield of celiac disease. Non-celiac histologic diagnoses including Brunner gland hyperplasia and peptic duodenitis were reported more commonly in the duodenal bulb as compared to the distal duodenum with an increase in diagnostic yield of 4 % (95 % CI 3 - 5; P  < 0.001) and 1 % (95 % CI 1 - 2; P  < 0.001), respectively. Conclusions  Based upon our results, biopsy and histologic examination of duodenal bulb during routine upper endoscopy increases the diagnostic yield of celiac disease.

In Vitro Bioavailability of Calcium, Magnesium, Iron, Zinc, and Copper from Gluten-Free Breads Supplemented with Natural Additives

The aim of this study was to measure the content of calcium, magnesium, iron, zinc, and copper and determine the bioavailability of these ingredients in gluten-free breads fortified with milk and selected seeds. Due to the increasing prevalence of celiac disease and mineral deficiencies, it has become necessary to produce food with higher nutritional values which maintains the appropriate product characteristics. This study was designed for gluten-free breads fortified with milk and seeds such as flax, poppy, sunflower seeds, pumpkin seeds or nuts, and flour with amaranth. Subsequently, digestion was performed in vitro and the potential bioavailability of the minerals was measured. In the case of calcium, magnesium, iron, and copper, higher bioavailability was observed in rice bread, and, in the case of copper and zinc, in buckwheat bread. This demonstrated a clear increase in bioavailability of all the minerals when the bread were enriched. However, satisfactory results are obtained only for the individual micronutrients.

HLA-DQ: Celiac disease vs inflammatory bowel disease

AIM

To determine the genetic predisposition to celiac disease (CeD) in inflammatory bowel disease (IBD) patients by quantifying the frequency of CeD-related human leucocyte antigen (HLA) (HLA-CeD: HLA-DQ2 and -DQ8) in IBD patients globally, by type of IBD and gender, and by calculating the protective/risk contribution of these haplotypes in the development of the IBD disease.

METHODS

We conducted a prospective study with IBD patients from our Unit. Clinical information was gathered and blood was tested for HLA-CeD. The control group was made up of unrelated Valencian organ donors.

RESULTS

1034 subjects were analyzed: 457 IBD [207 ulcerative coliti (UC) and 250 Crohn’s disease (CD)] patients and 577 healthy controls. 39% of the controls and 34% of the patients had HLA-CeD (P = 0.0852). HLA-DQ2 was less frequent in UC patients (P = 0.0287), and HLA-DQ8 in CD (P = 0.0217). In women with UC, the frequency of DQ2.5cis (DQB1*02:01-DQA1*05:01) was reduced ≥ 50% [P = 0.0344; preventive fraction (PF) = 13%]. PFs (7%-14%) were obtained with all HLA-CeD haplotypes. HLA DQB1*02:02-DQA1*02:01 (HLA-DQ2.2) was more frequent in CD patients with respect to controls (P = 0.001) and UC patients (etiological fraction = 15%).

CONCLUSION

HLA-CeD is not more frequent in IBD patients, with an even lower frequency of HLA-DQ2 and -DQ8 in UC and CD respectively. HLA-DQ2.5 confers protection from the development of UC, especially in women, and HLA-DQ8 does so for the appearance of CD. HLA-DQ2.2 is present in 34% of the CD patients and may constitute a genetic risk factor for CD development.

Molecular characterization of gluten hydrolysing Bacillus sp. and their efficacy and biotherapeutic potential as probiotics using Caco-2 cell line

AIM

To isolate and characterize indigenous gluten hydrolysing bacteria from wheat sourdough and curd samples and further evaluation of their probiotic potentiality.

METHODS AND RESULTS

Indigenous gluten hydrolysing isolates GS 33, GS 143, GS 181 and GS 188 were identified as Bacillus sp. by molecular-typing methods and studied extensively for their functional and probiotic attributes. All the tested isolates could survive at pH 2 and toxicity of 0·3% bile and also exhibited cell surface hydrophobicity and autoaggregation phenotype. The isolates were adhered strongly to Caco-2 cells and coaggregated with Escherichia coli MTCC 433 and Listeria monocytogenes MTCC 1143 preventing pathogen invasion into Caco-2 cells in vitro. In addition, the minimum inhibitory concentration of selected antibiotics for all the investigated gluten hydrolysing isolates was within the breakpoint values as recommended by the European Food Safety Authority.

CONCLUSION

The indigenous high intensity gluten hydrolysing bacteria exhibited high resistance to gastric and pancreatic stress and possessed antibacterial, aggregation, adhesion and pathogen exclusion properties, and as a potential probiotics, either alone or in consortium would be useful in the development of gluten-free wheat foods.

SIGNIFICANCE AND IMPACT OF THE STUDY

Exploring new indigenous gluten hydrolysing bacteria from wheat sourdough and curd samples would be beneficial in developing gluten-free wheat foods using potential indigenous probiotics.

Understanding Celiac Disease From Genetics to the Future Diagnostic Strategies

Celiac disease (CD) is an autoimmune disorder characterized by the permanent inflammation of the small bowel, triggered by the ingestion of gluten. It is associated with a number of symptoms, the most common being gastrointestinal. The prevalence of this illness worldwide is 1%. One of the main problems of CD is its difficulty to be diagnosed due to the various presentations of the disease. Besides, in many cases, CD is asymptomatic. Celiac disease is a multifactorial disease, HLA-DQ2 and HLA-DQ8 haplotypes are predisposition factors. Nowadays, molecular markers are being studied as diagnostic tools. In this review, we explore CD from its basic concept, manifestations, types, current and future methods of diagnosis, and associated disorders. Before addressing the therapeutic approaches, we also provide a brief overview of CD genetics and treatment.

Celiac disease: From pathophysiology to treatment

Celiac disease, also known as "celiac sprue", is a chronic inflammatory disorder of the small intestine, produced by the ingestion of dietary gluten products in susceptible people. It is a multifactorial disease, including genetic and environmental factors. Environmental trigger is represented by gluten while the genetic predisposition has been identified in the major histocompatibility complex region. Celiac disease is not a rare disorder like previously thought, with a global prevalence around 1%. The reason of its under-recognition is mainly referable to the fact that about half of affected people do not have the classic gastrointestinal symptoms, but they present nonspecific manifestations of nutritional deficiency or have no symptoms at all. Here we review the most recent data concerning epidemiology, pathogenesis, clinical presentation, available diagnostic tests and therapeutic management of celiac disease.

Screening for celiac disease in 1st degree relatives: a 10-year follow-up study

Background

Although it is known that first degree relatives of celiac patients have an increased risk for celiac disease few studies are available on its incidence. We investigated the incidence of serologic conversion and of new cases of celiac disease among first degree relatives with negative results at a first screening.

Methods

From a total of 634 first degree relatives of 186 biopsy-proven celiac disease patients diagnosed between October 2000 and October 2010, 450 subjects agreed to participate in the study (Group I), and underwent serologic screening. Between January 2010 and October 2012, out of the initial group of 450, 205 previously sero-negative subjects consented to participate in a second stage of the study and undergo new serologic testing (Group II). All serologically positive individuals of both groups (I and II) were genotyped for celiac disease-predisposing alleles (HLA-DQ2/DQ8).

Results

19 subjects (4.2%) out of the 450 subjects of Group I disclosed positive serologic results, presence of DQ2 and/or DQ8 alleles and celiac disease-compatible mucosal abnormalities. The 205 previously negative first degree relatives from Group II that underwent new serologic testing disclosed eight sero-converted subjects. Mucosal abnormalities in five of these patients confirmed the diagnosis of celiac disease. During the 10-year period of the study the incidence of sero-conversion was 8/205 and the incidence of biopsy-proven celiac disease cases was 5/205.

Conclusions

Our data are coincident with other works on this subject and confirm once again that relatives of celiac patients, especially first degree relatives are at high risk of developing celiac disease. In view of the relatively low incidence further studies are needed to try to establish a useful and cost-effective algorithm for follow-up of relatives of celiac patients.

Celiac disease in the Mediterranean area

Background

The World Gastroenterology Organization recommends developing national guidelines for the diagnosis of Celiac Disease (CD): hence a profile of the diagnosis of CD in each country is required. We aim to describe a cross-sectional picture of the clinical features and diagnostic facilities in 16 countries of the Mediterranean basin. Since a new ESPGHAN diagnostic protocol was recently published, our secondary aim is to estimate how many cases in the same area could be identified without a small intestinal biopsy.

Methods

By a stratified cross-sectional retrospective study design, we examined clinical, histological and laboratory data from 749 consecutive unselected CD children diagnosed by national referral centers.

Results

The vast majority of cases were diagnosed before the age of 10 (median: 5 years), affected by diarrhea, weight loss and food refusal, as expected. Only 59 cases (7.8%) did not suffer of major complaints. Tissue transglutaminase (tTG) assay was available, but one-third of centers reported financial constraints in the regular purchase of the assay kits. 252 cases (33.6%) showed tTG values over 10 times the local normal limit. Endomysial antibodies and HLA typing were routinely available in only half of the centers. CD was mainly diagnosed from small intestinal biopsy, available in all centers. Based on these data, only 154/749 cases (20.5%) would have qualified for a diagnosis of CD without a small intestinal biopsy, according to the new ESPGHAN protocol.

Conclusions

This cross-sectional study of CD in the Mediterranean referral centers offers a puzzling picture of the capacities to deal with the emerging epidemic of CD in the area, giving a substantive support to the World Gastroenterology Organization guidelines.

The tip of the "celiac iceberg" in China: a systematic review and meta-analysis

Objective

Until recently, celiac disease was considered to be rare in China. We aimed to estimate its true status.

Methods

By searching the MEDLINE database and four Chinese full-text databases (CNKI, CBM, VIP and WANFANG) (up to August 2012), as well as two HLA allele frequency net databases and the Chinese Statistics Yearbook databases, we systematically reviewed the literature on definite and suspected cases of celiac disease, the predisposing HLA allele frequencies, and on gluten exposure in China. Meta-analysis was performed by analyzing DQ2, DQ8 and DQB1*0201 gene frequencies and heterogeneity in populations from different geographic regions and ethnicities in China.

Results

At present, the number of reported celiac disease cases is extremely low in China. The frequencies of the HLA-DQ2.5 and HLA-DQ8 haplotypes were 3.4% (95% confidence interval 1.3–5.5%) and 2.1% (0.1–4.1%), respectively. HLA-DQ2 and HLA-DQ8 antigen frequencies were 18.4% (15.0–21.7%) and 8.0% (4.5–11.4%), respectively. The frequency of the DQB1*0201 allele was 10.5% (9.3–11.6%) and it was more common in the northern Chinese than in the southern Chinese populations. The chance of being exposed to gluten is rapidly increasing all over China nowadays.

Conclusion

The data on HLA haplotyping, in conjunction with increasing wheat consumption, strongly suggests that the occurrence of celiac disease is more common in China than currently reported. Coordinated measures by the Chinese government, medical and agricultural research institutions, and food industries, would be justified to create more awareness about celiac disease and to prevent it becoming a medical and societal burden.

Prevalence of coeliac disease in patients with non-alcoholic fatty liver disease

BACKGROUND AND STUDY AIMS

Coeliac disease (CD) may be associated with several liver disorders including primary biliary cirrhosis, primary sclerosing cholangitis and autoimmune hepatitis. Furthermore preliminary data suggest a causative role of CD in steatosis and steatohepatitis. The aim of present study was to determine the prevalence of CD in a series of patients with non-alcoholic fatty liver disease (NAFLD).

PATIENTS AND METHODS

In a cross sectional study (2008-2010), 403 consecutive NAFLD patients (127 female and 276 male) referred to GI clinics of the Zahedan University of Medical Sciences were included. IgA anti-tissue transglutaminase (Anti-tTG) was used for screening of coeliac disease. In the patients with a positive serologic test, duodenal biopsies were taken to confirm the diagnosis.

RESULTS

The mean±SD of the age and BMI of patients were 37.4±12.4years and 28.3±4.15kg/m(2) respectively. BMIs lower than 25kg/m(2) were found in 58 subjects (14.5%). Furthermore diabetes mellitus and hyperlipidaemia were diagnosed in 48 (11.9%) and 84 (20.8%) individuals respectively. Positive Anti-tTGs were found in 14/403 (3.4%) and 13/403 (3.2%, 95% CI 1.5-4.9) had coeliac disease according to the modified Marsh classification; 8 had type I, 3 type II, 1 type IIIA and 1 type IIIB lesions.

CONCLUSION

According to our data, prevalence of CD in the subjects with NAFLD is higher than the rates reported in the general population. Therefore screening for CD in selected cases of NAFLD may be appropriate.

Coeliac disease in irritable bowel syndrome (Rome III) in Southeast Iran

BACKGROUND AND STUDY AIMS

Irritable bowel syndrome (IBS) is a common functional gastrointestinal (GI) disorder and coeliac disease (CD) is an auto-immune enteropathy that can mimic almost any functional GI disorder. Both IBS and coeliac disease share common symptoms. The aim of the present study was to estimate the prevalence of CD in patients with IBS and its sub-types.

PATIENTS AND METHODS

In this cross-sectional study (2008-2010), all consecutive patients with IBS who fulfilled the Rome III criteria attending the GI units in Zahedan (Southeast Iran) were included. Patients based on the sub-type of IBS were classified as diarrhoea-predominant irritable bowel syndrome (D-IBS), constipation-predominant irritable bowel syndrome (C-IBS) and alternating symptoms (mixed type). Immunoglobulin A (IgA) tissue transglutaminase (anti-tTG) was used to screen patients for CD. In the case of positive serologic test, duodenal biopsies were taken to confirm the diagnosis.

RESULTS

A total of 364 (221 females and 143 males) patients with IBS were included. The mean ± standard deviation (SD) age of patients was 37.4 ± 12.4 years. Twenty (5.5%) patients were found to have positive IgA anti-tTG. Main symptoms of patients were diarrhoea (11/20), bloating (10/20) and abdominal distension (6/20). Thirteen (10.5%) patients were found to have positive IgA anti-tTG among the D-IBS, two (1.6%) in the C-IBS and five (4.2%) in M-IBS groups.

CONCLUSION

The prevalence of CD in IBS is high. IBS subjects whose main complaint is diarrhoea, bloating or even abdominal distension should be evaluated for CD.

Frequency of celiac disease in adult patients with typical or atypical malabsorption symptoms in isfahan, iran

Aim. Atypical presentations of celiac disease (CD) have now been shown to be much more common than classical (typical) form. We evaluated the frequency of CD among adult patients with typical or atypical symptoms of CD. Materials and Methods. Patients referred to two outpatient gastroenterology clinics in Isfahan (IRAN) were categorized into those with typical or atypical symptoms of CD. IgA antitissue transglutaminase antibody was assessed and followed by duodenal biopsy. In patients for whom endoscopy was indicated (independent of the serology), duodenal biopsy was taken. Histopathological changes were assessed according to the Marsh classification. Results. During the study period, 151 and 173 patients with typical and atypical symptoms were evaluated (mean age = 32.8 ± 12.6 and 35.8 ± 14.8 years, 47.0% and 56.0% female, resp.). Frequency of CD in patients with typical and atypical symptoms was calculated, respectively, as 5.9% (9/151) and 1.25% (3/173) based on positive serology and pathology. The overall frequency was estimated as at least 9.2% (14/151) and 4.0% (7/173) when data of seronegative patients were also considered. Conclusions. CD is more frequent among patients with typical symptoms of malabsorption and these patients should undergo duodenal biopsy, irrespective of the serology. In patients with atypical symptoms, serological tests should be performed followed by endoscopic biopsy, and routine duodenal biopsy is recommended when endoscopic evaluation is indicated because of symptoms.

Histologic findings in biopsies/resection specimens from the small intestine with special emphasis on celiac disease: experience from a developing country in South Asia

Biopsies from the small intestine especially the duodenum are now being performed much more frequently than in the past. The most frequent reason for performing duodenal biopsies is to evaluate for malabsorption. In the last few years, increased awareness has resulted in more biopsies sent for evaluation of malabsorption, especially celiac disease (CD). In the duodenum, features of malabsorption (increased intraepithelial lymphocytes, villous shortening, and atrophy) were the most common histologic finding seen in 63.4% of cases. Serum tTG levels were available for correlation in 52.8% of cases. In patients with confirmed CD, 53.4% were MARSH IIIb, and 29.5% were MARSH IIIc. The most common specific condition diagnosed in the ileum was tuberculosis (35.6%), and 80.8% with ileal tuberculosis were women. Our findings, although preliminary, indicate that CD is not so rare in Pakistan. These are the first findings from Pakistan on this subject, and larger studies are required to determine the true frequency and impact of CD in Pakistan.

Serologic markers of gluten sensitivity in a healthy population from the western region of Saudi Arabia

BACKGROUND/AIM

To identify the prevalence of gluten sensitivity in a healthy adult Saudi population within a low endemic area of celiac disease using IgA tissue transglutaminase antibody. The study was conducted as a prospective pilot study for Saudi attendees of a blood donation centre at King Faisal Specialist Hospital & Research Centre in Jeddah, Saudi Arabia.

PATIENTS AND METHODS

Individuals were invited to participate in the study and screened for gluten sensitivity using immunoglobulin A tissue transglutaminase antibody (IgA TTG) along with serum IgA level. Descriptive data was presented and expressed as mean value; correlation between variables was estimated using Pearson correlation, and nonparametric data using Pearson rho correlation (level of P value <0.05 is considered to be statistically significant).

RESULTS

Two hundred and four individuals (122 males and 82 females, mean age 35 years) attending the blood donation centre were screened. Three individuals tested positive for IgA TTG showing normal IgA level (1 female and 2 males) with a 1.5% prevalence in the cohort.

CONCLUSIONS

Positive celiac screening is present at a low prevalence rate in our adult population, in which the individuals' age and their serum IgA levels are not associated with the positivity level. A study on a larger scale with the application of histologic confirmation of positive cases is needed.

The global burden of childhood coeliac disease: a neglected component of diarrhoeal mortality?

Objectives

Coeliac disease has emerged as an increasingly recognised public health problem over the last half-century, and is now coming to be seen as a global phenomenon, despite a profound lack of globally representative epidemiological data. Since children with coeliac disease commonly present with chronic diarrhoea and malnutrition, diagnosis is often overlooked, particularly in poorer settings where children often fail to thrive and water-borne infectious diarrhoeas are common. This is the first attempt to make global estimates of the burden of coeliac disease in childhood.

Methods

We built a relatively crude model of childhood coeliac disease, incorporating estimates of population prevalence, probability of non-diagnosis, and likelihood of mortality among the undiagnosed across all countries from 1970 to 2010, based around the few available data. All our assumptions are stated in the paper and the model is available as a supplementary file.

Findings

Our model suggests that in 2010 there were around 2.2 million children under 5 years of age living with coeliac disease. Among these children there could be 42,000 deaths related to coeliac disease annually. In 2008, deaths related to coeliac disease probably accounted for approximately 4% of all childhood diarrhoeal mortality.

Conclusions

Although coeliac disease may only account for a small proportion of diarrhoeal mortality, these deaths are not preventable by applying normal diarrhoea treatment guidelines, which may even involve gluten-based food supplements. As other causes of diarrhoeal mortality decline, coeliac disease will become a proportionately increasing problem unless consideration is given to trying gluten-free diets for children with chronic diarrhoea and malnutrition.

Coeliac disease in autoimmune liver disease: a cross-sectional study and a systematic review

BACKGROUND

Several studies have reported an association between coeliac disease and autoimmune liver disease, but there is little information on the prevalence of coeliac disease in certain autoimmune liver diseases, particularly from non-European, non-American countries.

AIMS

To investigate prevalence of coeliac disease in autoimmune liver disease in Iran and to summarize previous literature.

METHODS

We investigated prevalence of coeliac disease among 100 autoimmune liver disease patients and compared it with the prevalence in healthy individuals. We also performed an extensive search of the English literature in PubMed Database.

RESULTS

We found substantially elevated prevalence of coeliac disease in patients with overlap syndrome (10-15%) compared to the general population (0.1-1%). To a lesser extent, the prevalence was high in patients with autoimmune hepatitis (2-4%). In our systematic review, prevalence of coeliac disease in autoimmune hepatitis in the majority of studies was 4% or more; several studies also reported such prevalence in primary biliary cirrhosis.

CONCLUSIONS

Since coeliac disease is common among patients with autoimmune liver disease, screening autoimmune liver disease patients for coeliac disease is indicated. Although the magnitude of benefit from a gluten-free diet in reversing autoimmune liver disease in patients with coeliac disease is controversial, it may reduce the risk of further complications of coeliac disease.

Nonmeat Protein Alternatives as Meat Extenders and Meat Analogs

  The direct consumption of vegetable proteins in food products has been increasing over the years because of animal diseases, global shortage of animal protein, strong demand for wholesome and religious (halal) food, and economic reasons. The increasing importance of legume and oilseed proteins in the manufacturing of various functional food products is due to their high-protein contents. However, the greatest obstacle to utilizing these legumes and oilseeds is the presence of antinutrients; but these antinutrients can be successfully removed or inactivated by employing certain processing methods. In contrast, the potential negative impact of the antinutrients is partially balanced by the fact that they may have a health-promoting role. Legumes and oilseeds provide well-balanced amino acid profiles when consumed with cereals. Soybean proteins, wheat gluten, cottonseed proteins, and other plant proteins have been used for texturization. Texturized vegetable proteins can extend meat products while providing an economical, functional, and high-protein food ingredient or can be consumed directly as a meat analog. Meat analogs are successful because of their healthy image (cholesterol free), meat-like texture, and low cost. Mycoprotein is fungal in origin and is used as a high-protein, low-fat, health-promoting food ingredient. Mycoprotein has a good taste and texture. Texturized vegetable proteins and a number of mycoprotein products are accepted as halal foods. This article summarizes information regarding the molecular, nutritional, and functional properties of alternative protein sources to meat and presents current knowledge to encourage further research to optimize the beneficial effects of alternative protein sources.

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

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

Long term diarrhoea caused by simultaneous Crohn's disease and coeliac disease in the same patient

Coeliac disease and Crohn's disease are among the most well known gastrointestinal disorders, with distinct pathogenic mechanisms. However, because of some overlapping features between these two conditions, there may be some inevitable misdiagnoses. In addition, diarrhoea and changes in bowel habit may lead the physician to misdiagnose more common disorders such as irritable bowel syndrome. There are a few cases reporting both coeliac and Crohn's disease in the same patient. Here we report a case of a 32-year-old woman suffering from long term diarrhoea who was eventually discovered to have coeliac disease and Crohn's disease simultaneously.

Indian task force for celiac disease: Current status

There are limited data on celiac disease (CD) from India. The limited knowledge about CD in India might be attributed to several factors. The first meeting of the Indian Task Force for Celiac Disease was held in the Asian Institute of Gastroenterology, Hyderabad, India in December 2008. The objectives of the meeting were to focus research on prevalence of CD in the wheat-eating Northern vs the rice-eating Southern Indian population, low-budget serological assays to study the underprivileged population, to involve other medical subspecialties in CD, to suggest proper legislation regarding wheat food labeling, and to organize affordable food substitutes for patients with celiac disease.

Prevalence of celiac disease in Iranian children with idiopathic short stature

AIM: To determine the prevalence of celiac disease (CD) in children with idiopathic short stature (ISS) and the diagnostic value of immunoglobulin (Ig) A G antigliadin antibodies (AGA) and transglutaminase (TTG) antibodies for CD.

METHODS: A total of 104 children (49 male, 55 female) with ISS without a specific etiology were studied. Extensive endocrine investigations had shown no abnormalities in any subject. Anthropometric parameters and IgA AGA and IgA TTG antibodies were evaluated in this study group. These antibodies were measured by enzyme-linked immunosorbent assay. All patients were referred for an endoscopic intestinal biopsy. The biopsy samples were classified according to revised Marsh criteria (UEGW 2001).

RESULTS: We detected positive IgA TTG antibodies in 36 and IgA AGA in 35 of these patients. Thirty one IgA TTG antibody positive and 28 IgA AGA positive subjects showed histological abnormalities compatible with celiac disease (33.6%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value for IgA AGA were found to be 80%, 88.4%, 77.8% and 89.7%, respectively. Sensitivity, specificity and PPV for IgA TTG antibodies were 88.6%, 94.2% and 88.6%, respectively.

CONCLUSION: We conclude that the prevalence of celiac disease is high in patients with ISS and it is important to test all children with ISS for celiac disease by measuring serologic markers and performing an intestinal biopsy.

Prevalence of celiac disease in Shiraz, southern Iran

BACKGROUND/AIM

This study was performed to evaluate the prevalence of celiac disease (CD) in Shiraz, southern Iran.

MATERIALS AND METHODS

Serum samples were collected from 1440 persons (age range = 20-83 years, mean age = 45.4 years) in 2004 and screened for endomysial and tissue transglutaminase antibodies. A questionnaire was completed for all subjects in relation to gastrointestinal (GI) symptoms and cases with positive serology were requested to undergo small-bowel biopsy.

RESULTS

Seven cases (0.5%) were positive for IgA anti-tissue transglutaminase (anti-tTG), and only two (0.14%) were positive for IgA anti-endomysial antibody (anti-EMA), both of whom had highly positive anti-tTg levels (40.4 and 48.0 IU/l). The major clinical symptoms of CD, such as recurrent abdominal pain and change in bowel habits were present in all patients with positive anti-tTG assays. Only five subjects with positive serology agreed to undergo upper GI endoscopy and duodenal biopsy. Three of these cases were reported with Marsh I histologic findings, while in the two cases with positive serologic anti-EMA, more advanced forms of CD were present.

CONCLUSION

The prevalence of CD in apparently healthy adults was lower than the reported series from northern parts of the country; therefore, we suggest a more long-term follow-up study in high-risk groups, especially in the apparently healthy subjects in our region.

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.

A tale of two cities: typical celiac sprue presenting symptoms are significantly more common in Turkish than in US Patients

GOAL

Recent studies suggest an increasing prevalence of atypical initial symptoms in patients with celiac disease (CD). The aim of this study was to compare the presenting symptoms of CD at 2 comparable referral institutions in South Florida, and in Ankara, Turkey. We retrospectively reviewed the records of patients with an initial diagnosis of CD by small bowel biopsy during the same (1991 to 2001) 10-year period at Cleveland Clinic Florida and University of Ankara, Turkey. A numerical score was assigned to presenting symptom and signs.

RESULTS

There were 28 patients in the South Florida group (51% men) and 40 patients in the Turkish group (35% men) (P=NS). The Turkish patients were significantly younger at diagnosis (36+/-2 y vs. US patients 66+/-3 y) (P<0.0001). Typical celiac symptom scores were similar (Turkey 1.1+/-0.2 vs. South Florida 1.3+/-0.3) (P=NS). Atypical symptom scores were significantly higher in the US patients (1.9+/-0.2) versus those from Turkey (1.2+/-0.1) (P<0.01). The Turkish patients were significantly more likely (P<0.01) to present with chronic diarrhea, hypoalbuminemia, and mactocytosis at the time of diagnosis.

CONCLUSIONS

Although retrospective, this study points to striking differences in the clinical presentation of CD in individuals in South Florida, United States, and Ankara, Turkey, diagnosed during the same time period at both institutions. Turkish patients were younger, and more likely to present with chronic diarrhea, hypoalbuminemia, and microcytosis-as was more commonly seen in the United States in the 1960s and 70s. These findings raise the question of an interplay of demographics with diet and genetics in the presenting symptoms of CD in these 2 distant geographic areas.

Familial prevalence among first-degree relatives of celiac disease in North India

BACKGROUND AND OBJECTIVES

Prevalence of celiac disease is increased in first-degree relatives with reported prevalence rates in the west between 2.8 and 10%. Paucity of similar data from Asia and the Indian subcontinent prompted us to determine the familial prevalence of celiac disease in first-degree relatives of patients diagnosed with this disorder in Northern India.

METHODS

One hundred sixty-nine first-degree relatives (66 parents, 71 siblings and 32 children) of 53 probands were screened by using anti tissue transglutaminase antibodies. Duodenal biopsy was performed in all seropositive relatives and graded as per Marsh classification. Patients with both positive serology and biopsy suggestive of celiac disease were classified as typical celiac disease whereas those with only positive serology were classified as potential celiacs.

RESULTS

The prevalence of celiac disease among first-degree relatives was 8.2% (14/169). The prevalence of celiac disease among siblings (15.6%) was much higher as compared to that in parents (3.5%) and offspring (3%). More than one family member was affected in 23% (12/53) of families. Of 14 new cases detected by targeted screening, 11 (78%) were overtly symptomatic with either chronic diarrhoea (8) or easy fatiguability (3). Growth retardation was seen in all six newly diagnosed children, three of whom (22%) were otherwise asymptomatic. Eight members detected to be seropositive had minimal changes on duodenal biopsy (Marsh I and II) suggesting that they have potential celiac disease.

CONCLUSION

Familial prevalence of celiac disease in North India is similar to the data from the West. However unlike the situation in the West, the overwhelming majority of first-degree relatives in India are overtly symptomatic with majority having chronic diarrhoea. Since gluten restriction is a highly effective treatment modality, early detection of these patients would result in significant improvement in quality of life as manifested by cessation of diarrhoea and improvement in growth and lab parameters. Our data strongly supports the targeted screening of all first-degree relatives of celiac disease patients in north India.

Speeding up coeliac disease diagnosis in the developing countries

BACKGROUND

Anti-transglutaminase antibodies are highly predictive markers of active coeliac disease. Because limited facilities are available for routine use of anti-transglutaminase antibodies assays in developing countries, a simple, economical immunological test would represent a great step forward in the screening of coeliac disease.

AIM

We determined the prevalence of coeliac disease in two different populations living in an urban area and in a sub-urban impoverished area of Recife (Brazil), using two rapid tests based on detection of anti-transglutaminase antibodies in serum and in one drop of whole blood.

METHODS

Whole-blood and serum samples from 1074 individuals were analysed by the two rapid tests; 580 subjects were university students and 494 subjects were coming from sub-urban impoverished areas, characterized by the endemic presence of filariasis. The positive subjects were evaluated by anti-tranglutaminase enzyme linked immunosorbent assay (ELISA) assay, the coeliac disease-related HLA DQ2/8 and intestinal biopsy.

RESULTS

Both rapid assays were positive in 25/1074 subjects, but only 9/25 (4/4 in urban areas, specificity 100%; 5/21 in poor areas, specificity 76%) were confirmed positive by ELISA assay. The nine subjects testing positive for HLA DQ2 and the intestinal biopsy showed the typical coeliac disease lesions (coeliac disease-prevalence: 0.84%, 9/1074); seven coeliacs were asymptomatic and two presented recurrent abdominal pain.

CONCLUSIONS

The rapid assays were accurate in finding new coeliacs at a remarkably low cost. We are convinced that this new way of testing for coeliac disease can be successfully used by non-specialized personnel in daily practice in developing countries.

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

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

Tropical malabsorption

Malabsorption is an important clinical problem both in visitors to the tropics and in native residents of tropical countries. Infections of the small intestine are the most important cause of tropical malabsorption. Protozoal infections cause malabsorption in immunocompetent hosts, but do so more commonly in the setting of immune deficiency. Helminth infections occasionally cause malabsorption or protein-losing enteropathy. Intestinal tuberculosis, chronic pancreatitis and small-bowel bacterial overgrowth are important causes of tropical malabsorption. In recent years, inflammatory bowel disease and coeliac disease have become major causes of malabsorption in the tropics. Sporadic tropical sprue is still an important cause of malabsorption in adults and in children in South Asia. Investigations to exclude specific infective, immunological or inflammatory causes are important before considering tropical sprue as a diagnosis. This article briefly reviews the management of tropical sprue and presents an algorithm for its investigation and management.

Development of an immunocapture method for measuring IgA antibodies to tissue transglutaminase in the sera of patients with coeliac disease

One of the most reliable sero-diagnostic tests for coeliac disease (CD) is the measurement, by ELISA, of serum IgA antibodies to tissue transglutaminase (tTG) adsorbed to the wells of microtitre plates. In spite of its reliability, however, some discrepancies exist with the results obtained by the antiendomysium histological assay (EMA) and by biopsy the accepted gold standard. Among the reasons for these differences in titres between the ELISA and the last 2 mentioned assays are the conformational changes that proteins undergo on adsorption and the importance of conformational epitopes on tTG for diagnosing CD. To address this problem, a novel procedure was developed using guinea-pig tTG (gptTG) free in solution to interact with IgA antibodies in the sera of CD patients. Any immune complexes so formed are then captured by anti-tTG antibodies preadsorbed to the wells of microtitre plates. This immunocapture method was optimized for the amount of soluble gptTG needed to interact with all the IgA's anti-tTG present in fixed dilutions of serum samples, the amount of rabbit IgG anti-gptTG used to coat the wells of microtitre plates and the order of addition of the reaction components. Comparison of the IgA titres obtained by immunocapture with those by EMA and ELISA (adsorbed tTG) on 9 highly positive and 6 weakly positive sera from clinically characterized CD patients and 5 negative sera from non-CD control subjects revealed that the IgA titres by the immunocapture procedure were well correlated with those obtained by EMA, whereas the titres on ELISA showed discrepancies with both immunocapture and EMA.

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.