Diagnosis of coeliac disease

The Prevalence and Rate of Undiagnosed Celiac Disease in an Adult General Population, the Trøndelag Health Study, Norway

BACKGROUND & AIMS

This study aimed to determine the total prevalence of celiac disease (CeD), including undiagnosed cases, in a population-based study of adults screened for CeD.

METHODS

The study used the fourth Trøndelag Health Study (HUNT4), conducted in 2017-2019, where 56,042 adult (aged >20 years) residents of Nord-Trøndelag County, Norway, participated. Serum samples from 54,505 participants were analyzed for anti-transglutaminase 2 IgA and IgG. Seropositive individuals were invited for a clinical assessment, including upper endoscopy with duodenal biopsies. Previously diagnosed and seronegative CeD cases were identified through linkage to hospital records and the Norwegian Patient Registry.

RESULTS

The rate of CeD seropositivity was 2.0% (1107/54,505). Out of these, 724 individuals attended the clinical assessment. Additionally, the hospital records and registry identified individuals with a known CeD diagnosis, that were seronegative or without serology in HUNT4 or seropositive in HUNT4 but did not participate in the clinical assessment. In total, the study confirmed a new CeD diagnosis after participation in HUNT4 in 470 individuals and a known CeD diagnosis before participation in HUNT4 in 383 individuals. The total biopsy-confirmed prevalence of CeD was 1.5% (853/56,042), and the ratio of new, previously undiagnosed CeD cases (after HUNT4) to known, previously diagnosed CeD cases (before HUNT4) was 1.2:1 (470/383).

CONCLUSIONS

The total prevalence of CeD in this population-based study of adults in Norway was high and many individuals were previously undiagnosed. Detection of CeD should be improved, because early diagnosis is crucial for effective management and prevention of complications.

Updates in the diagnosis and management of coeliac disease

Coeliac disease is a common autoimmune disorder induced by ingesting gluten, the protein component of wheat, barley, and rye. It is estimated that one-in-hundred people worldwide have coeliac disease, of whom the majority remain undiagnosed. Coeliac disease is characterized by a wide range of gastrointestinal and extraintestinal symptoms but can also present asymptomatically. Diagnosing coeliac disease depends on the concordance of clinical, serological and histopathological data. However, the diagnosis can be challenging and frequently overlooked. Undiagnosed coeliac disease is associated with an increased risk of complications and detrimental effects on quality of life. Early diagnosis and treatment of coeliac disease are necessary to reduce the risk of long-term complications.

Correlation of Celiac Diseases with Candida Spp. Based on Anti-gliadin Antibodies

A variety of Candida spp. can be found as a natural commensal fungus in various parts of the human body. This fungus may be associated with various diseases such as celiac disease (CD). Gliadin, a component of the gluten protein complex that is mostly found in wheat, is the main inducer of CD. A number of studies have demonstrated that patients infected with Candida can develop CD, and vice versa. C. albicansis presumed to induce CD because it has a protein homologous to gliadin in its cell wall called Hwp1. Despite the non-specificity of the anti-gliadin test, the detection of antibodies against anti-gliadin (AGA) and anti-tissue transglutaminase (anti-tTG) are important in the diagnosis of CD. Some evidence is now available to support the hypothetical correlation between Candida spp. and CD, as high levels of AGA have been found in patients infected with candidiasis without CD. Further study is needed to confirm this relationship.

Guidelines of the Italian societies of gastroenterology on the diagnosis and management of coeliac disease and dermatitis herpetiformis

INTRODUCTION

Coeliac disease and dermatitis herpetiformis are immune-mediated diseases triggered by the consumption of gluten in genetically predisposed individuals. These guidelines were developed to provide general practitioners, paediatricians, gastroenterologists, and other clinicians with an overview on the diagnosis, management and follow-up of coeliac patients and those with dermatitis herpetiformis.

METHODS

Guidelines were developed by the Italian Societies of Gastroenterology. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists and a paediatrician with expertise in this field.

RESULTS

These guidelines provide a practical guidance for the diagnosis, management and follow-up of coeliac patients and dermatitis herpetiformis in children and adults, both in primary care and in specialist settings. We developed four sections on diagnosis, gluten-free diet, follow-up and risk of complications in adults, one section focused on diagnosis and follow-up in children and one on the diagnosis and management of dermatitis herpetiformis.

CONCLUSIONS

These guidelines may support clinicians to improve the diagnosis and management of patients with coeliac disease.

Cerebral hemodynamic changes to transcranial Doppler sonography in celiac disease: A pilot study

Background

Sonographic mesenteric pattern in celiac disease (CD) suggests a hyperdynamic circulation. Despite the well-known CD-related neurological involvement, no study has systematically explored the cerebral hemodynamics to transcranial Doppler sonography.

Materials and methods

Montreal Cognitive Assessment (MoCA) and 17-item Hamilton Depression Rating Scale (HDRS) were assessed in 15 newly diagnosed subjects with CD and 15 age-, sex-, and education-matched healthy controls. Cerebral blood flow (CBF) velocities and indices of resistivity (RI) and pulsatility (PI) from the middle cerebral artery (MCA), bilaterally, and the basilar artery (BA) were recorded. We also assessed cerebral vasomotor reactivity (CVR) through the breath-holding test (BHT).

Results

Worse scores of MoCA and HDRS were found in patients compared to controls. Although patients showed higher values of CBF velocity from MCA bilaterally compared to controls, both at rest and after BHT, no comparison reached a statistical significance, whereas after BHT both RI and PI from BA were significantly higher in patients. A significant negative correlation between both indices from BA and MoCA score were also noted.

Conclusion

These treatment-naïve CD patients may show some subtle CVR changes in posterior circulation, thus possibly expanding the spectrum of pathomechanisms underlying neuroceliac disease and in particular gluten ataxia. Subclinical identification of cerebrovascular pathology in CD may help adequate prevention and early management of neurological involvement.

Preserved central cholinergic functioning to transcranial magnetic stimulation in de novo patients with celiac disease

BACKGROUND

Celiac disease (CD) is now viewed as a systemic disease with multifaceted clinical manifestations. Among the extra-intestinal features, neurological and neuropsychiatric symptoms are still a diagnostic challenge, since they can precede or follow the diagnosis of CD. In particular, it is well known that some adults with CD may complain of cognitive symptoms, that improve when the gluten-free diet (GFD) is started, although they may re-appear after incidental gluten intake. Among the neurophysiological techniques, motor evoked potentials (MEPs) to transcranial magnetic stimulation (TMS) can non-invasively probe in vivo the excitation state of cortical areas and cortico-spinal conductivity, being also able to unveil preclinical impairment in several neurological and psychiatric disorders, as well as in some systemic diseases affecting the central nervous system (CNS), such as CD. We previously demonstrated an intracortical disinhibition and hyperfacilitation of MEP responses to TMS in newly diagnosed patients. However, no data are available on the central cholinergic functioning indexed by specific TMS measures, such as the short-latency afferent inhibition (SAI), which might represent the neurophysiological correlate of cognitive changes in CD patients, also at the preclinical level.

METHODS

Cognitive and depressive symptoms were screened by means of the Montreal Cognitive Assessment (MoCA) and the 17-item Hamilton Depression Rating Scale (HDRS), respectively, in 15 consecutive de novo CD patients and 15 healthy controls. All patients were on normal diet at the time of the enrolment. Brain computed tomography (CT) was performed in all patients. SAI, recorded at two interstimulus intervals (2 and 8 ms), was assessed as the percentage amplitude ratio between the conditioned and the unconditioned MEP response. Resting motor threshold, MEP amplitude and latency, and central motor conduction time were also measured.

RESULTS

The two groups were comparable for age, sex, anthropometric features, and educational level. Brain CT ruled out intracranial calcifications and clear radiological abnormalities in all patients. Scores at MoCA and HDRS were significantly worse in patients than in controls. The comparison of TMS data between the two groups revealed no statistically significant difference for all measures, including SAI at both interstimulus intervals.

CONCLUSIONS

Central cholinergic functioning explored by the SAI of the motor cortex resulted to be not affected in these de novo CD patients compared to age-matched healthy controls. Although the statistically significant difference in MoCA, an overt cognitive impairment was not clinically evident in CD patients. Coherently, to date, no study based on TMS or other diagnostic techniques has shown any involvement of the central acetylcholine or the cholinergic fibers within the CNS in CD. This finding might add support to the vascular inflammation hypothesis underlying the so-called "gluten encephalopathy", which seems to be due to an aetiology different from that of the cholinergic dysfunction. Longitudinal studies correlating clinical, TMS, and neuroimaging data, both before and after GFD, are needed.

Enfermedad celíaca: un reto diagnóstico en Colombia

Introducción: la enfermedad celíaca (EC) es una patología sistémica inmunomediada por el gluten en la dieta en personas genéticamente susceptibles con un amplio rango de manifestaciones clínicas, respuesta serológica específica y daño variable de la mucosa intestinal. Objetivo: revisar la fisiopatología, manifestaciones clínicas, diagnóstico, tratamiento, seguimiento y pronóstico de la EC, resaltando la importancia de reconocerla y proponer un algoritmo diagnóstico para la población colombiana. Materiales y métodos: revisión crítica de la literatura científica en las bases de datos Medline y buscadores específicos PUBMED, SCIENCE DIRECT, SCIELO, filtrando resultados a revisiones sistemáticas, metaanálisis, ensayos controlados aleatorios, ensayos clínicos y guías, con un total de 1209 artículos, de los cuales se priorizaron 53. Resultados y discusión: la prevalencia de la EC viene en aumento en países en vía de desarrollo. El diagnóstico tiene tres pilares fundamentales: identificación de casos de alto riesgo o sospecha por manifestaciones clínicas, perfil serológico de anticuerpos específicos y hallazgos histológicos característicos. El tratamiento se basa en dieta sin gluten, detección temprana de complicaciones y manejo de las alteraciones nutricionales. Conclusión: en Colombia no existen protocolos de diagnóstico y tratamiento de la EC, como tampoco una legislación clara con respecto al etiquetado de productos libres de gluten. Hay que establecer estrategias para impactar el curso natural de la enfermedad, las morbilidades asociadas y la calidad de vida de los pacientes.

Perineal cutaneous basal cell carcinomas in patients with familial seronegative celiac disease: Report of three cases

The etiopathogenesis of basal cell carcinoma (BCC) arising in the perineum is unclear. We report BCC arising in the perineum of three longstanding untreated celiac disease (CD) patients. CD is an autoimmune enteropathy due to hypersensitivity to consumed gluten. Patients can present with gastrointestinal symptoms including diarrhea and weight loss, as well as fatigue, iron-deficiency anemia, vitamin D deficiency, depression, and unexplained hypocalcemia. As a result, CD often goes undiagnosed for many years before a diagnosis is made.

Resolution-based distillation for efficient histology image classification

Developing deep learning models to analyze histology images has been computationally challenging, as the massive size of the images causes excessive strain on all parts of the computing pipeline. This paper proposes a novel deep learning-based methodology for improving the computational efficiency of histology image classification. The proposed approach is robust when used with images that have reduced input resolution, and it can be trained effectively with limited labeled data. Moreover, our approach operates at either the tissue- or slide-level, removing the need for laborious patch-level labeling. Our method uses knowledge distillation to transfer knowledge from a teacher model pre-trained at high resolution to a student model trained on the same images at a considerably lower resolution. Also, to address the lack of large-scale labeled histology image datasets, we perform the knowledge distillation in a self-supervised fashion. We evaluate our approach on three distinct histology image datasets associated with celiac disease, lung adenocarcinoma, and renal cell carcinoma. Our results on these datasets demonstrate that a combination of knowledge distillation and self-supervision allows the student model to approach and, in some cases, surpass the teacher model's classification accuracy while being much more computationally efficient. Additionally, we observe an increase in student classification performance as the size of the unlabeled dataset increases, indicating that there is potential for this method to scale further with additional unlabeled data. Our model outperforms the high-resolution teacher model for celiac disease in accuracy, F1-score, precision, and recall while requiring 4 times fewer computations. For lung adenocarcinoma, our results at 1.25× magnification are within 1.5% of the results for the teacher model at 10× magnification, with a reduction in computational cost by a factor of 64. Our model on renal cell carcinoma at 1.25× magnification performs within 1% of the teacher model at 5× magnification while requiring 16 times fewer computations. Furthermore, our celiac disease outcomes benefit from additional performance scaling with the use of more unlabeled data. In the case of 0.625× magnification, using unlabeled data improves accuracy by 4% over the tissue-level baseline. Therefore, our approach can improve the feasibility of deep learning solutions for digital pathology on standard computational hardware and infrastructures.

Intracortical and Intercortical Motor Disinhibition to Transcranial Magnetic Stimulation in Newly Diagnosed Celiac Disease Patients

BACKGROUND

Celiac disease (CD) may present or be complicated by neurological and neuropsychiatric manifestations. Transcranial magnetic stimulation (TMS) probes brain excitability non-invasively, also preclinically. We previously demonstrated an intracortical motor disinhibition and hyperfacilitation in de novo CD patients, which revert back after a long-term gluten-free diet (GFD). In this cross-sectional study, we explored the interhemispheric excitability by transcallosal inhibition, which has never been investigated in CD.

METHODS

A total of 15 right-handed de novo, neurologically asymptomatic, CD patients and 15 age-matched healthy controls were screened for cognitive and depressive symptoms to the Montreal Cognitive Assessment (MoCA) and the 17-item Hamilton Depression Rating Scale (HDRS), respectively. TMS consisted of resting motor threshold, amplitude, latency, and duration of the motor evoked potentials, duration and latency of the contralateral silent period (cSP). Transcallosal inhibition was evaluated as duration and latency of the ipsilateral silent period (iSP).

RESULTS

MoCA and HDRS scored significantly worse in patients. The iSP and cSP were significantly shorter in duration in patients, with a positive correlation between the MoCA and iSP.

CONCLUSIONS

An intracortical and interhemispheric motor disinhibition was observed in CD, suggesting the involvement of GABA-mediated cortical and callosal circuitries. Further studies correlating clinical, TMS, and neuroimaging data are needed.

Intracortical and Intercortical Motor Disinhibition to Transcranial Magnetic Stimulation in Newly Diagnosed Celiac Disease Patients

BACKGROUND

Celiac disease (CD) may present or be complicated by neurological and neuropsychiatric manifestations. Transcranial magnetic stimulation (TMS) probes brain excitability non-invasively, also preclinically. We previously demonstrated an intracortical motor disinhibition and hyperfacilitation in de novo CD patients, which revert back after a long-term gluten-free diet (GFD). In this cross-sectional study, we explored the interhemispheric excitability by transcallosal inhibition, which has never been investigated in CD.

METHODS

A total of 15 right-handed de novo, neurologically asymptomatic, CD patients and 15 age-matched healthy controls were screened for cognitive and depressive symptoms to the Montreal Cognitive Assessment (MoCA) and the 17-item Hamilton Depression Rating Scale (HDRS), respectively. TMS consisted of resting motor threshold, amplitude, latency, and duration of the motor evoked potentials, duration and latency of the contralateral silent period (cSP). Transcallosal inhibition was evaluated as duration and latency of the ipsilateral silent period (iSP).

RESULTS

MoCA and HDRS scored significantly worse in patients. The iSP and cSP were significantly shorter in duration in patients, with a positive correlation between the MoCA and iSP.

CONCLUSIONS

An intracortical and interhemispheric motor disinhibition was observed in CD, suggesting the involvement of GABA-mediated cortical and callosal circuitries. Further studies correlating clinical, TMS, and neuroimaging data are needed.

Preserved central cholinergic functioning to transcranial magnetic stimulation in de novo patients with celiac disease

BACKGROUND

Celiac disease (CD) is now viewed as a systemic disease with multifaceted clinical manifestations. Among the extra-intestinal features, neurological and neuropsychiatric symptoms are still a diagnostic challenge, since they can precede or follow the diagnosis of CD. In particular, it is well known that some adults with CD may complain of cognitive symptoms, that improve when the gluten-free diet (GFD) is started, although they may re-appear after incidental gluten intake. Among the neurophysiological techniques, motor evoked potentials (MEPs) to transcranial magnetic stimulation (TMS) can non-invasively probe in vivo the excitation state of cortical areas and cortico-spinal conductivity, being also able to unveil preclinical impairment in several neurological and psychiatric disorders, as well as in some systemic diseases affecting the central nervous system (CNS), such as CD. We previously demonstrated an intracortical disinhibition and hyperfacilitation of MEP responses to TMS in newly diagnosed patients. However, no data are available on the central cholinergic functioning indexed by specific TMS measures, such as the short-latency afferent inhibition (SAI), which might represent the neurophysiological correlate of cognitive changes in CD patients, also at the preclinical level.

METHODS

Cognitive and depressive symptoms were screened by means of the Montreal Cognitive Assessment (MoCA) and the 17-item Hamilton Depression Rating Scale (HDRS), respectively, in 15 consecutive de novo CD patients and 15 healthy controls. All patients were on normal diet at the time of the enrolment. Brain computed tomography (CT) was performed in all patients. SAI, recorded at two interstimulus intervals (2 and 8 ms), was assessed as the percentage amplitude ratio between the conditioned and the unconditioned MEP response. Resting motor threshold, MEP amplitude and latency, and central motor conduction time were also measured.

RESULTS

The two groups were comparable for age, sex, anthropometric features, and educational level. Brain CT ruled out intracranial calcifications and clear radiological abnormalities in all patients. Scores at MoCA and HDRS were significantly worse in patients than in controls. The comparison of TMS data between the two groups revealed no statistically significant difference for all measures, including SAI at both interstimulus intervals.

CONCLUSIONS

Central cholinergic functioning explored by the SAI of the motor cortex resulted to be not affected in these de novo CD patients compared to age-matched healthy controls. Although the statistically significant difference in MoCA, an overt cognitive impairment was not clinically evident in CD patients. Coherently, to date, no study based on TMS or other diagnostic techniques has shown any involvement of the central acetylcholine or the cholinergic fibers within the CNS in CD. This finding might add support to the vascular inflammation hypothesis underlying the so-called "gluten encephalopathy", which seems to be due to an aetiology different from that of the cholinergic dysfunction. Longitudinal studies correlating clinical, TMS, and neuroimaging data, both before and after GFD, are needed.

Measurement of Inter-Individual Variability in Assessing the Quality of Life in Respondents with Celiac Disease

Quality of life of Celiac Disease (CD) patients is affected by constraints in their physical, social and emotional behaviour. Our objective is to assess differences in two relevant dimensions of the Celiac Quality of Life (CQoL) scale, Limitations due to the disease and Dysphoria (i.e., feelings of depression and discomfort), in relation to the perceived social support and some individual and disease-related characteristics. The paper exploits suitable unidimensional Item Response Theory (IRT) models to individually analyse the two mentioned dimensions of the CQoL and Multidimensional Latent Class IRT models for ordinal polytomous items in order to detect sub-populations of CD patients that are homogenous with respect to the perceived CQoL. The latter methods allow to address patients with similar characteristics to the same treatment, performing at the same time a more tailored overture to health promotion programmes. The analysis extracts the relevant patterns and relations among CD patients, disentangling respondents receiving CD diagnosis in adolescence or adult age rather than in childhood (the first perceive high levels of Limitations and Dysphoria), patients with high perceived social support, a factor influencing in a positive way motivation to engage in management of CD-related distress and psychological well-being, and participants who are married or cohabiting. The latter report higher latent trait levels.

Pathogenesis of Celiac Disease and Other Gluten Related Disorders in Wheat and Strategies for Mitigating Them

Wheat is a major cereal crop providing energy and nutrients to the billions of people around the world. Gluten is a structural protein in wheat, that is necessary for its dough making properties, but it is responsible for imparting certain intolerances among some individuals, which are part of this review. Most important among these intolerances is celiac disease, that is gluten triggered T-cell mediated autoimmune enteropathy and results in villous atrophy, inflammation and damage to intestinal lining in genetically liable individuals containing human leukocyte antigen DQ2/DQ8 molecules on antigen presenting cells. Celiac disease occurs due to presence of celiac disease eliciting epitopes in gluten, particularly highly immunogenic alpha-gliadins. Another gluten related disorder is non-celiac gluten-sensitivity in which innate immune-response occurs in patients along with gastrointestinal and non-gastrointestinal symptoms, that disappear upon removal of gluten from the diet. In wheat allergy, either IgE or non-IgE mediated immune response occurs in individuals after inhalation or ingestion of wheat. Following a life-long gluten-free diet by celiac disease and non-celiac gluten-sensitivity patients is very challenging as none of wheat cultivar or related species stands safe for consumption. Hence, different molecular biology, genetic engineering, breeding, microbial, enzymatic, and chemical strategies have been worked upon to reduce the celiac disease epitopes and the gluten content in wheat. Currently, only 8.4% of total population is affected by wheat-related issues, while rest of population remains safe and should not remove wheat from the diet, based on false media coverage.

Diagnosing coeliac disease: Out with the old and in with the new?

Coeliac disease (CD) is a complex condition resulting from an interplay between genetic and environmental factors. When diagnosing the condition, serological testing and genotyping are useful in excluding CD, although the gold standard of testing is currently histopathological examination of the small intestine. There are drawbacks associated with this form of testing however and because of this, novel forms of testing are currently under investigation. Before we develop completely novel tests though, it is important to ask whether or not we can simply use the data we gather from coeliac patients more effectively and build a more accurate snapshot of CD through statistical analysis of combined metrics. It is clear that not one single test can accurately diagnose CD and it is also clear that CD patients can no longer be defined by discrete classifications, the continuum of patient presentation needs to be recognised and correctly captured to improve diagnostic accuracy. This review will discuss the current diagnostics for CD and then outline novel diagnostics under investigation for the condition. Finally, improvements to current protocols will be discussed with the need for a holistic "snapshot" of CD using a number of metrics simultaneously.

Association between HLA alleles and risk of celiac disease in Iranian patients

Celiac disease (CD) is a common autoimmune disease that is manifested by inflammation of the small intestine and varying extra intestinal symptoms, also considered to be associated with human HLA-DQ genes. In this study, 40 patients of CD and 40 healthy control samples were genotyped for HLA-DQB1 and 14 patients of CD and 14 healthy control samples were genotyped for HLA-DQA1genes using the SSP-PCR technique and a commercial kit.The DQA1*05 allele had the highest frequency among the patient group (42.86%). The frequency of this allele was 28.57% in healthy controls, and there was no statistically significant difference in this case (p= 0.771).The DQB1*02 allele was the most common in patients (33.75%) followed by the DQB1*03 allele (31.25%).The difference in frequency of the HLA-DQB1*02 allele in the patient and control groups was statistically significant (P= 0.0002, OR = 4.72). The remarkable differences in the distribution of HLA-DQ2 in Iranian patients compared to controls and relative risks signified the role of these alleles in the development of CD in Iranian patients and confirmed the likelihood of using HLA-DQ typing in the substantiation of the disease.

Recurrent Fever and Failure to Thrive in an 11-Year-Old Boy

Recurrent fever is frequent among children and mostly associated with viral infections inoculated via social contacts with others of the same age. Rarely, severe conditions such as hematological malignancies, pediatric rheumatoid diseases, chronic infections, or inherited recurrent fever syndromes are causative. Herein, we present the case of an 11-year-old boy with frequently recurring high-fever episodes since early childhood, failure to thrive, and iron deficiency who was found to have classical celiac disease (CD) with highly elevated tissue transglutaminase and anti-gliadin antibodies and marked duodenal villous atrophy. Upon implementation of a gluten-free diet, the boy ceased to have fevers, antibodies decreased markedly, his iron status improved, and he significantly gained weight. Although infrequent, recurrent fever should be included into the polymorphic clinical picture of CD, and the threshold of testing for diagnostic antibodies should be low in such patients.

Celiac-Related Autoantibodies and IL-17A in Bulgarian Patients with Dermatitis Herpetiformis: A Cross-Sectional Study

Background and objectives: Dermatitis herpetiformis (DH) is a blistering dermatosis, which shares common immunologic features with celiac disease (CD). The aim of the present study was to explore the performance of a panel of CD-related antibodies and IL-17A in Bulgarian patients with DH. Materials and Methods: Serum samples from 26 DH patients at mean age 53 ± 15 years and 20 healthy controls were assessed for anti-tissue transglutaminase (anti-tTG), anti-deamidated gliadin peptides (anti-DGP), anti-actin antibodies (AAA), and IL-17A by enzyme linked immuno-sorbent assay (ELISA), as well as anti-tTG, anti-gliadin (AGA), and anti-Saccharomyces cerevisiae antibodies (ASCA) using immunoblot. Results: The average serum levels of anti-tTG, anti-DGP, AGA, AAA, and the cytokine IL-17A were at significantly higher levels in patients with DH compared to the average levels in healthy persons which stayed below the cut-off value (p < 0.05). Anti-DGP and anti-tTG antibodies showed the highest diagnostic sensitivity and specificity, as well as acceptable positive and negative predictive value. None of the healthy individuals was found positive for the tested antibodies, as well as for ASCA within the DH group. All tests showed good to excellent correlations (r = 0.5 ÷ 0.9, p < 0.01). Conclusions: Although the diagnosis of DH relies on skin biopsy for histology and DIF, serologic testing of a panel of celiac-related antibodies could be employed with advantages in the diagnosing process of DH patients. Furthermore, DH patients who are positive for the investigated serologic parameters could have routine monitoring for gastrointestinal complications typical for the gluten-sensitive enteropathy.

Automated Detection of Celiac Disease on Duodenal Biopsy Slides: A Deep Learning Approach

CONTEXT

Celiac disease (CD) prevalence and diagnosis have increased substantially in recent years. The current gold standard for CD confirmation is visual examination of duodenal mucosal biopsies. An accurate computer-aided biopsy analysis system using deep learning can help pathologists diagnose CD more efficiently.

SUBJECTS AND METHODS

In this study, we trained a deep learning model to detect CD on duodenal biopsy images. Our model uses a state-of-the-art residual convolutional neural network to evaluate patches of duodenal tissue and then aggregates those predictions for whole-slide classification. We tested the model on an independent set of 212 images and evaluated its classification results against reference standards established by pathologists.

RESULTS

Our model identified CD, normal tissue, and nonspecific duodenitis with accuracies of 95.3%, 91.0%, and 89.2%, respectively. The area under the receiver operating characteristic curve was >0.95 for all classes.

CONCLUSIONS

We have developed an automated biopsy analysis system that achieves high performance in detecting CD on biopsy slides. Our system can highlight areas of interest and provide preliminary classification of duodenal biopsies before review by pathologists. This technology has great potential for improving the accuracy and efficiency of CD diagnosis.

Determinants of Follow-up Care for Patients With Celiac Disease

GOALS

This study aimed to investigate follow-up patterns among celiac disease (CD) patients.

BACKGROUND

Gender factors are important in CD with women diagnosed more frequently than men despite equal seropositivity in screening studies. To determine if gender influences postdiagnosis care, we performed a retrospective cohort study investigating the impact of gender and mode of presentation on follow-up patterns after diagnosis.

STUDY

The study included adults with biopsy-proven CD presenting to a single tertiary care center between 2005 and 2014. The primary exposure was at least 1 visit with a CD specialist. The primary outcome was ≥2 follow-up visits, including office visits and endoscopic procedures. Data extracted included whether patients had tissue transglutaminase antibodies performed by our laboratory.

RESULTS

We analyzed 708 patients of which 70.5% were female. Follow-up was good with a majority of patients (69%) having at least 1 follow-up visit. On bivariate analysis, patients least likely to follow-up were ages 18 to 29 (P=0.03) and women with atypical presentations (P=0.003). After adjusting for potential confounders, individuals over age 65 were significantly more likely to attend at least 2 follow-up visits (odds ratio, 2.07; 95% confidence interval, 1.21-3.55; P=0.0079). Individuals with an abnormal baseline tissue transglutaminase antibody value in our laboratory were significantly more likely to follow-up (odds ratio, 1.99; 95% confidence interval, 1.39-2.85; P=0.0002).

CONCLUSIONS

Gender had no impact on follow-up patterns despite prior studies demonstrating an impact on diagnosis rates. Future attention should focus on retaining young patients and those with atypical modes of presentation.

Development of gluten-free cereal bar for gluten intolerant population by using quinoa as major ingredient

The present study was carried out to develop gluten free cereal bars for gluten intolerant population. The cereal bar was formulated using dry raw materials (quinoa, brown rice, flaxseed and dry fruits) and binding agents (honey). Honey was added as a sweetener and binding agent. The raw materials were assessed for physico-chemical parameters such as moisture, ash, crude protein and fat content and the functional parameters such as antioxidant activity, total phenolic content and β-carotene. Dry heat treatment (80-100 °C for 8-12 min) was given to grains (quinoa, brown rice and flaxseed) prior to use in preparation of cereal bar. Significant variation was found after treatment of grains among all the physico-chemical and functional parameters of grains except ash content which showed a non-significant variation. Four formulations (F1, F2, F3 and F4) were developed using different combination of grains at different honey levels (40, 50 and 60%). On the basis of sensory evaluation, formulation- 4 at 50% honey level was found to be best. Selected cereal bar was assessed for physico-chemical and functional parameters. Selected cereal bar had 8.53% moisture content, 1.34% ash content, 10.50% protein content, 2.89% fat content, 0.51 mg GAE/g total phenolic content, 33.87% antioxidant activity and 0.384 µg/g β-carotene.

Oxidative and Antioxidative Status of Children with Celiac Disease Treated with a Gluten Free-Diet

Aims

Oxidative stress is a factor involved in the pathogenesis of celiac disease (CD), possibly affecting the course of the disease and celiac-related complications. We assessed the intensity of oxidative processes and the efficiency of antioxidant defense in children with celiac disease. Methods. Group I (n = 32) consisted of children with CD treated with a gluten-free diet, and group II (n = 24) consisted of healthy children on a traditional diet. Antioxidative and oxidative status was assessed by measurement of serum total antioxidant capacity (TAC), total oxidant capacity (TOC), and oxidized low-density lipoprotein (ox-LDL) and on the basis of oxidative stress index (OSI).

Results

There were no significant differences in serum TAC, TOC, ox-LDL, and OSI between children with CD and healthy children. Cluster analysis showed that the group of children with CD is not homogeneous in terms of serum TAC and TOC levels. About 50% of these children had TAC levels < 1.3 mmol/L and TOC levels > 0.35 mmol/L.

Conclusions

Strict adherence to a gluten-free diet by children with CD seems to be important for maintaining oxidative-antioxidant balance. However, further research is needed to identify factors potentially responsible for increased oxidative stress in some children with celiac disease despite adherence to a gluten-free diet.

Coeliac disease and the liver: spectrum of liver histology, serology and treatment response at a tertiary referral centre

BACKGROUND

Coeliac disease (CD) is a gluten-sensitive enteropathy diagnosed on the basis of ESPGHAN criteria and clinical response to gluten-free diet (GFD). Histological abnormalities on liver biopsy have been noted in CD but have seldom been described.

AIMS

To assess the histological spectrum of 'coeliac hepatitis' and possibility of reversal of such features after a GFD.

METHODS

Twenty-five patients with concomitant CD and hepatic derangement were analysed for clinical profile, laboratory investigations and duodenal and liver biopsy. A histological comparison of pre- and post-GFD duodenal and liver biopsies was carried out, wherever possible.

RESULTS

Fifteen patients presenting with CD subsequently developed abnormal liver function tests; 10 patients presenting with liver disease were found to have tissue positive transglutaminase in 70% and antigliadin antibodies in 60%. Serological markers for autoimmune liver disease (AILD) were positive in eight patients. Liver histology ranged from mild reactive hepatitis, chronic hepatitis, steatosis to cirrhosis. Liver biopsies after a GFD were available in six cases, of which five showed a decrease in steatosis, portal and lobular inflammation and fibrosis score.

CONCLUSION

Coeliac hepatitis could be a distinct entity and the patients may present with either CD or secondary hepatic derangement. Evaluation for the presence of CD is recommended for patients presenting with AILD, unexplained transaminasaemia or anaemia. This is one of the very few studies demonstrating the continuum of liver histological changes in 'coeliac hepatitis'. Trial of a GFD may result in clinicopathological improvement of 'coeliac hepatitis'.

Administration of Inulin-Supplemented Gluten-Free Diet Modified Calcium Absorption and Caecal Microbiota in Rats in a Calcium-Dependent Manner

In coeliac disease (CD), the risk of adverse calcium balance and reduced bone density is induced mainly by the disease, but also by a gluten-free diet (GFD), the only accepted CD therapy. Prebiotics through the beneficial impact on intestinal microbiota may stimulate calcium (Ca) absorption. In the present study, we hypothesised that the dietary inulin in GFD would influence positively the intestinal microbiota, and by that will stimulate the absorption of calcium (Ca), especially in the conditions of Ca malnutrition. In a six-weeks nutritional experiment on growing a significant (p < 0.05) luminal acidification, decrease in ammonia concentration and stimulation of short chain fatty acids formation indicated inulin-mediated beneficial effects on the caecal microbiota. However, the effect of inulin on characteristics of intestinal microbiota and mineral utilization depended on the dietary Ca intake from GFDs. Inulin stimulated bifidobacteria, in particular B. animalis species, only if a recommended amount of Ca was provided. Most benefits to mineral utilization from inulin consumption were seen in rats fed Ca-restricted GFD where it increased the relative Ca absorption. Administration of inulin to a GFDs could be a promising dietary strategy for beneficial modulation of intestinal ecosystem and by that for the improvement the Ca absorption.

Subacute copper-deficiency myelopathy in a patient with occult celiac disease

CONTEXT

Acquired copper deficiency represents a rare cause of progressive myelopathy presenting with sensory ataxia and spastic gait. The time interval from neurological symptoms onset to diagnosis of myelopathy ranges from 2 months to several years in almost all cases, mimicking the clinical course of subacute combined degeneration due to vitamin B12 deficiency.

FINDINGS

A 60-year-old man, without any gastrointestinal symptoms, developed over the course of one week rapidly progressive gait imbalance, tingling and numbness in his feet and ascending lower limb weakness. Spine magnetic resonance imaging revealed hyperintensity involving cervical and dorsal posterior columns of spinal cord. Blood analysis revealed undetectable serum copper levels, low serum ceruloplasmin and positive serum Immunoglobulin A anti-tissue transglutaminase. Upper gastrointestinal endoscopy was performed revealing duodenal villous atrophy consistent with a malabsorption pattern. A gluten-free diet in association with intravenous then oral copper supplementation prompted sustained normalization of serum copper levels and progressive clinical improvement.

CONCLUSION/CLINICAL RELEVANCE

We report a rare case of myelopathy induced by copper deficiency secondary to undiagnosed celiac disease, peculiarly presenting with a subacute onset. This case expands the neurological presentation and clinical course of myelopathy due to acquired copper deficiency. We suggest investigation of copper deficiency in patients presenting with subacute or even acute sensory ataxia and spastic gait. Detection of hypocupremia in patients without a previous history of gastric surgery should lead to diagnostic testing for celiac disease even in the absence of any obvious gastrointestinal symptoms.

Coeliac disease and the videocapsule: what have we learned till now

Celiac disease is diagnosed in part by finding areas of pathology in the small bowel (SB) mucosa. This can often be difficult because the pathologic alterations, including atrophy of the small intestinal villi, can often be sparse and subtle. Some of the quantitative methods for detecting and measuring the presence of villous atrophy from videocapsule endoscopy (VCE) images are presented and discussed. These methods consist of static features of measurement including texture, gray level, and presence and abundance of fissures contained within each acquired image. The methods also consist of dynamic measurements including spectral analysis, and determining motion from a sequence of endoscopic images as obtained from a VCE clip. Thus far, several methods have been found useful to characterize the SB mucosa of untreated celiac disease patients versus control patients lacking villous atrophy, which have revealed significant differences in texture, frequency, and motion on analysis of VCE. In untreated celiac patients undergoing endoscopy, there tends to be greater magnitude of changes and spatial differences in textural descriptors, longer periodic components, indicating slower periodic activity, and differences in feature location, suggesting alterations in motility at areas of pathology as compared to patients without villous atrophy. Improvements in the quantitative analysis of VCE imaging in celiac patients is important to detect pathology in suspected patients, so that biopsies can be obtained from pertinent regions of the small intestinal mucosa. Improvements are also necessary so that patients with celiac disease can be monitored to evaluate the progress of mucosal healing after onset of treatment.

Classification chaos in coeliac disease: Does it really matter?

The spectrum of mucosal pathology in coeliac disease (CD), initially defined by Marsh in 1992 has been subjected to several modifications in the following years by Oberhuber, then by Corazza and Villanaci, and finally by Ensari. The present study, aimed to end the ongoing confusion regarding the classification of mucosal pathology in CD by applying all the classifications proposed so far on a large series of cases. A total of 270 duodenal biopsies taken from the distal duodenum of patients with a diagnosis of CD were included in the study. All biopsies were classified according to Marsh, Oberhuber, Corazza Villanaci, and Ensari classification schemes. For statistical analyses cases were divided into three groups: Group 1 included type 1 lesions in Marsh, Ensari, and Oberhuber and grade A in Corazza Villanaci classifications. Group 2 comprised of type 2 lesions in Marsh and Ensari classifications together with type2, type 3a and 3b lesions in Oberhuber classification and grade B1 lesions in Corazza Villanaci classification. Group 3 included type 3 lesions in Marsh and Ensari classifications, and type 3c lesions in Oberhuber, and grade B2 lesions in Corazza Villanaci classifications. The kappa value was 1.00 (excellent) for group 1, 0.53 (fair) for group 2 and 0.78 (excellent) for group 3 (p<0.0001). These results suggest that any of the above classification system would serve similar purposes in the diagnosis of CD. Therefore, it is advisable that the pathologist should use the simplest reliable scheme.

Evaluation of the Correlation Between tTG-IgA Titer and Duodenal Biopsy Findings in Children With Suspected Celiac Disease

Background:

Celiac disease is an immune-mediated inflammation of the small intestine caused by sensitivity to dietary gluten in genetically sensitive individuals.

Objectives:

In this study, we aimed to evaluate the predictive value of tissue transglutaminase (tTG) antibodies for the diagnosis of celiac disease in a pediatric population in order to determine if duodenal biopsy can be avoided.

Patients and Methods:

The subjects were selected among individuals with probable celiac disease, referring to a gastrointestinal clinic. After physical examinations and performing tissue transglutaminase-immunoglobulin A (tTG-IgA) tests, upper endoscopy was performed if serological titer was higher than 18 IU/mL. Therapy started according to pathologic results.

Results:

The sample size was calculated to be 121 subjects (69 female and 52 male subjects); the average age of subjects was 8.4 years. A significant association was found between serological titer and pathologic results; in other words, subjects with high serological titer had more positive pathologic results for celiac disease, compared to others (P < 0.001). Maximum sensitivity (65%) and specificity (65.4%) were achieved at a serological titer of 81.95 IU/ml; the calculated accuracy was lower in comparison with other studies. As the results indicated, lower antibody titer was observed in patients with failure to gain weight and higher antibody titer was reported in diabetic patients.

Conclusions:

As the results indicated, a single serological test (tTg-IgA test) was not sufficient for avoiding intestinal biopsy.

Application of Deamidated Gliadin Antibodies in the Follow-Up of Treated Celiac Disease

Introduction

The role of serological tests such as IgA anti-transglutaminase autoantibodies has become increasingly important in celiac disease (CD) diagnosis. However, the efficiency of these tests for patient follow-up is controversial. We investigated the correlation of 12 different serological tests, including recent deamidated gliadin and actin IgA tests, with villous atrophy (VA) in a retrospective cohort of treated celiac patients.

Materials and Methods

Serum samples were collected from 100 treated CD patients who had intestinal biopsy in the course of their follow-up. Antibodies against transglutaminase, deamidated gliadin peptides, and native gliadin were measured, along with IgA anti-actin. The biopsy slides were all blind-reviewed and scored according to Marsh classification.

Results

For all deamidated gliadin and transglutaminase tests, we found that a positive result was significantly associated with persistence of intestinal VA, with a diagnostic efficacy up to 80%. Furthermore, antibodies titers directly correlated with the degree of VA, indicating a strong link between disease activity and presence of antibodies in the serum. Interestingly, the tests with the highest association with persistent VA were those for deamidated gliadin IgG. Using a test positivity pattern analysis, we were also able to identify several groups of patients with distinct antibody profiles that showed significant differences in intestinal damage and diet compliance.

Conclusions

Altogether, these results show that deamidated gliadin antibodies are strongly correlated with VA and should be considered valuable tools in CD follow-up and that multiplex serologic analysis for treated CD represents a promising tool for personalized patient management.

Quantitative image analysis of celiac disease

We outline the use of quantitative techniques that are currently used for analysis of celiac disease. Image processing techniques can be useful to statistically analyze the pixular data of endoscopic images that is acquired with standard or videocapsule endoscopy. It is shown how current techniques have evolved to become more useful for gastroenterologists who seek to understand celiac disease and to screen for it in suspected patients. New directions for focus in the development of methodology for diagnosis and treatment of this disease are suggested. It is evident that there are yet broad areas where there is potential to expand the use of quantitative techniques for improved analysis in suspected or known celiac disease patients.

Celiac Disease: Diagnosis

Historically the diagnosis of celiac disease has relied upon clinical, serological, and histological evidence. In recent years the use of sensitive serological methods has meant an increase in the diagnosis of celiac disease. The heterogeneous nature of the disorder presents a challenge in the study and diagnosis of the disease with patients varying from subclinical or latent disease to patients with overt symptoms. Furthermore the related gluten-sensitive disease dermatitis herpetiformis, while distinct in some respects, shares clinical and serological features with celiac disease. Here we summarize current best practice for the diagnosis of celiac disease and briefly discuss newer approaches. The advent of next-generation assays for diagnosis and newer clinical protocols may result in more sensitive screening and ultimately the possible replacement of the intestinal biopsy as the gold standard for celiac disease diagnosis.

Seroprevalence of celiac disease among United Arab Emirates healthy adult nationals: A gender disparity

AIM: To determine celiac disease (CD) prevalence and associated manifestations or risk factors in healthy adult Emiratis.

METHODS: It is a cross-sectional prospective study, recruiting 1197 (573 women and 624 men) healthy Emiratis between September 2007 and April 2008 among those who went to Al Ain Hospital to undertake the prenuptial examination. Test for anti-tissue transglutaminase (tTG) IgA antibodies was used for CD diagnosis. Subjects with positive results in the anti tTG antibodies assay were also tested for anti-endomysial (EMA) IgA antibodies. A structured interview was used to collect basic demographic and clinical recall data including: information on name, contact address, age, gender, education status, previous diagnosis of CD, diagnosis of CD in 1^st degree relatives and history of “chronic diarrhea, anemia, headache, hepatitis, diabetes, tumor, and thyroid disorder”.

RESULTS: Fourteen blood samples (1.17%; 14/1197) were seropositive for CD. The latent CD seropositive patients were 13 women and 1 man and therefore the seroprevalence of CD was 1:86 (14/1197) for adult Emiratis: 1:44 (13/573) for women and 1:624 for men. Binary logistic regression revealed that history of chronic anemia (crude OR = 7.09; 95%CI: 2.32-21.61; P = 0.003) and being a woman (OR = 14.46; 95%CI: 1.89-110.91; P = 0.001) were associated with CD seropositivity. Whereas, the thyroid disorder showed a positive association with CD seropositivity that approach statistical significance (OR = 11.30; 95%CI: 1.32-96.95; P = 0.09) and therefore was included in the multiple logistic regression analysis, which showed that CD seropositivity is independently associated only with history of chronic anemia (OR = 4.58; 95%CI: 1.45-14.48; P = 0.01) and being a woman person (OR = 10.47; 95%CI: 1.33-82.14; P = 0.026).

CONCLUSION: Compared to men the CD seroprevalence among women was remarkably higher. The CD association with women and chronic anemia is of importance from a public health perspective.

Teff (Eragrostis tef) as a raw material for malting, brewing and manufacturing of gluten-free foods and beverages: a review

The demand for gluten-free foods is certainly increasing. Interest in teff has increased noticeably due to its very attractive nutritional profile and gluten-free nature of the grain, making it a suitable substitute for wheat and other cereals in their food applications as well as foods for people with celiac disease. The main objective of this article is to review researches on teff, evaluate its suitability for different food applications, and give direction for further research on its applications for health food market. Teff is a tropical low risk cereal that grows in a wider ecology and can tolerate harsh environmental conditions where most other cereals are less viable. It has an excellent balance of amino acid composition (including all 8 essential amino acids for humans) making it an excellent material for malting and brewing. Because of its small size, teff is made into whole-grain flour (bran and germ included), resulting in a very high fiber content and high nutrient content in general. Teff is useful to improve the haemoglobin level in human body and helps to prevent malaria, incidence of anaemia and diabetes. The nutrient composition of teff grain indicates that it has a good potential to be used in foods and beverages worldwide. The high levels of simple sugars and α-amino acids as a result of breakdown of starch and protein, respectively, are essential for fermentation and beer making.

Pathologic bone alterations in celiac disease: etiology, epidemiology, and treatment

Low bone mineral density (BMD), osteopenia, and osteoporosis are frequent complications of celiac disease (CD). The etiology of pathologic bone alterations in CD is multifactorial; however, two main mechanisms are involved: intestinal malabsorption and chronic inflammation. A strict gluten-free diet (GFD) is thought to be the only effective treatment for CD; but treating bone complications related to CD remains complex. The objective of this review is to elucidate the bones problems related to CD and to increase awareness of osteoporosis development, considered as a sign of atypical CD presentation. Currently, a question of whether GFD alone is an effective treatment to correct the bone alterations in patients with CD is under debate. This review presents factors contributing to pathologic bone derangement, recent research on the epidemiology of low BMD, osteoporosis, and fractures, and the treatment of bone problems in patients with CD. The roles of calcium and transport mechanisms are additionally presented.

High-titre circulating tissue transglutaminase-2 antibodies predict small bowel villous atrophy, but decision cut-off limits must be locally validated

Numerous studies suggest that high levels of circulating immunoglobulin (Ig)A tissue transglutaminase (TTG2) antibodies predict coeliac disease with high specificity. Accordingly, it has been suggested that duodenal biopsy may not be required routinely for diagnostic confirmation where quantitative serology identifies the presence of high antibody titres. However, defining a cut-off TTG2 threshold is problematic, as the multiple available assay methods are not harmonized and most studies have been focused on the paediatric population. Recent paediatric guidelines proposed a TTG2 antibody diagnostic cut-off at 10 × the upper limit of normal (ULN) for the method; however, concerns remain about errors of generalization, between both methods and laboratories. In this study, we used retrospective laboratory data to investigate the relationship between TTG2 antibody levels and Marsh 3 histology in the seropositive population of adults and children at a single centre. Among 202 seropositive patients with corresponding biopsies, it was possible to define a TTG2 antibody cut-off with 100% specificity for Marsh 3 histology, at just over 10 × ULN for the method. However, UK National External Quality Assurance Scheme returns during the study period showed a wide dispersion of results and poor consensus, both between methods and between laboratories using the same method. Our results support the view that high-titre TTG2 antibody levels have strong predictive value for villous atrophy in adults and children, but suggest that decision cut-offs to guide biopsy requirement will require local validation. TTG2 antibody assay harmonization is a priority, in order to meet the evolving requirements of laboratory users in this field.

Assessment of the response to gluten-free diet in an Iraqi population with coeliac disease. A histological and serological follow-up study

INTRODUCTION

Coeliac disease (CD) is a common diagnosis among children and adults in Iraq; however, removal of gluten from the diet is essential for patients with CD. The aim of this study, the first such study in Iraq, was to assess the serological and histological recovery profiles of coeliac patients, in both children and adults groups after commencing a gluten-free diet (GFD) for at least 1 year ± 1 month.

MATERIAL AND METHODS

The study group comprised 78 proved coeliac patients (46 children and 32 adults, median age: 15 years, range: 1-66 years) who all agreed to undergo endoscopy in addition to serological assessment before and after treatment. The duodenal biopsies were interpreted histologically according to modified Marsh criteria and the sera were tested for anti-gliadin antibody (AGA), endomysium antibody (EMA) and anti-tissue transglutaminase antibody (tTG).

RESULTS

Complete histological remission was seen in 29 (63.1%) of 46 treated children CD patients, while only 5 (10.9%) showed Marsh IIIa changes compared with 11 (24%) before GFD. Similarly none of the 32 adults after GFD showed Marsh IIIb and Marsh IIIc compared with 46.9% and 28.1% before treatment respectively (p = 001). Meanwhile, there was strongly significant reduction in AGA, EMA, and tTG antibodies levels (p = 0.00001) following GFD.

CONCLUSIONS

Repeating the duodenal biopsy 1 year ±1 month after diagnosis and starting a GFD supports the routine measurement of using histological findings as a gold standard test to confirm recovery of Iraqi CD patients along with using known coeliac serology antibodies.

PREVALENCE OF CELIAC DISEASE IN CHILDREN WITH EPILEPSY

ContextNeurological symptoms have been well-documented in patients with celiac disease, nevertheless, the presumption of a greater prevalence of epilepsy in celiac patients remains controversial.ObjectivesTo determine the frequency of celiac disease in children and adolescents with idiopathic or cryptogenic epilepsy.MethodsA cross-sectional study. One hundred pediatric patients with non-symptomatic epilepsy were followed-up at two public pediatric neurology clinics in Salvador, Bahia, Brazil. Screening for celiac disease was performed by serial measurements of IgA anti-transglutaminase and IgA anti-endomysium antibodies, followed by bowel biopsy in positive cases. HLA DQ02 and DQ08 were investigated in seropositive individuals, assessing the type of seizures, the number of antiepileptic drugs used and the presence gastrointestinal symptoms.ResultsThree (3.0%) patients tested anti-tTG-positive, two with normal duodenal mucosa (Marsh 0) and one with intraepithelial infiltrate (Marsh I). No villous atrophy of the duodenal mucosa (Marsh III) celiac disease was found. Two patients tested positive for HLA DQ02; none were DQ08 positive.ConclusionThe present study failed to prove the association between celiac disease and epilepsy.

Immunohistochemical stains for CD3 and CD8 do not improve detection of gluten-sensitive enteropathy in duodenal biopsies

Patients with gluten-sensitive enteropathy usually have increased numbers of duodenal intraepithelial lymphocytes even if the villous architecture is normal. Some authors advocate the use of CD8 and CD3 immunohistochemical stains to improve detection of intraepithelial lymphocytosis, yet the added value of immunohistochemistry when biopsies appear normal remains unproven. The purpose of this study was to evaluate the utility of CD3 and CD8 immunostains in detecting intraepithelial lymphocytosis among duodenal biopsies originally interpreted to be normal based on routine evaluation. We identified 200 duodenal biopsies from 172 patients, all of which were accompanied by a clinical question of gluten-sensitive enteropathy. Five well-oriented villi from each biopsy were assessed. Intraepithelial lymphocytes present in hematoxylin and eosin (H&E)-stained slides were counted and compared with the number of CD3 and CD8 immunopositive cells present in the villous epithelium. Results were expressed as the mean number of intraepithelial lymphocytes or immunopositive cells present per 20 villous tip enterocytes. Review of H&E-stained slides revealed a mean of 2.1 ± 0.1 intraepithelial lymphocytes, compared with 3.2 ± 0.1 CD3-positive and 2.1 ± 0.1 CD8-positive intraepithelial cells (P=<0.001 and 1, respectively), although none of the cases displayed sufficient numbers of intraepithelial lymphocytes to be considered abnormal (ie, ≥ 12/20 enterocytes) by any method. The number of intraepithelial lymphocytes detected by H&E evaluation or immunohistochemistry did not correlate with results of serologic studies for markers of gluten sensitivity. We conclude that immunostains for T cell markers do not improve detection of gluten-sensitive enteropathy when H&E-stained sections are normal.

Intestinal biopsy is not always required to diagnose celiac disease: a retrospective analysis of combined antibody tests

Background

The objective of this study was to compare celiac disease (CD)– specific antibody tests to determine if they could replace jejunal biopsy in patients with a high pretest probability of CD.

Methods

This retrospective study included sera from 149 CD patients and 119 controls, all with intestinal biopsy. All samples were analyzed for IgA and IgG antibodies against native gliadin (ngli) and deamidated gliadin peptides (dpgli), as well as for IgA antibodies against tissue transglutaminase and endomysium.

Results

Tests for dpgli were superior to ngli for IgG antibody determination: 68% vs. 92% specificity and 79% vs. 85% sensitivity for ngli and dpgli, respectively. Positive (76% vs. 93%) and negative (72% vs. 83%) predictive values were also higher for dpgli than for ngli. Regarding IgA gliadin antibody determination, sensitivity improved from 61% to 78% with dpgli, while specificity and positive predictive value remained at 97% (P < 0.00001). A combination of four tests (IgA anti-dpgli, IgG anti-dpgli, IgA anti- tissue transglutaminase, and IgA anti-endomysium) yielded positive and negative predictive values of 99% and 100%, respectively and a likelihood ratio positive of 86 with a likelihood ratio negative of 0.00. Omitting the endomysium antibody determination still yielded positive and negative predictive values of 99% and 98%, respectively and a likelihood ratio positive of 87 with a likelihood ratio negative of 0.01.

Conclusion

Antibody tests for dpgli yielded superior results compared with ngli. A combination of three or four antibody tests including IgA anti-tissue transglutaminase and/or IgA anti- endomysium permitted diagnosis or exclusion of CD without intestinal biopsy in a high proportion of patients (78%). Jejunal biopsy would be necessary in patients with discordant antibody results (22%). With this two-step procedure, only patients with no CD-specific antibodies would be missed.

Histopathology of celiac disease

Small bowel biopsy remains the gold standard for diagnosing celiac disease (CD). Intraepithelial lymphocytosis in the context of villous atrophy is considered a characteristic histologic finding of CD. However, studies have also indicated that the detection of intraepithelial lymphocytosis in the absence of villous atrophy is not specific for CD, having been documented in other small intestinal disorders. This review summarizes key aspects regarding the histopathologic assessment, impact of the site and number of small bowel biopsy samples on diagnosis, old and emerging classifications, and benefit of standardized pathology report in the diagnostic workup of CD.

Celiac disease in the developing world

The prevalence of celiac disease (CD) in many developing countries is similar to that of developed areas, in both low- and high-risk groups. The disorder is underestimated because of lack of disease awareness. CD is strongly associated with HLA-DQ2 in developing countries. Clinical presentation may be characterized by chronic diarrhea, anemia, stunting and increased mortality. Few studies have addressed atypical or silent CD. Diagnosis is initially made by serologic tests and is confirmed by small intestinal biopsies. In developing countries the adherence to the treatment is still difficult because of poor availability of dedicated gluten-free food.

Celiac disease and giardiasis: a case report

When investigating a patient with suspected celiac disease (CD), several other conditions must be considered, including potential infection with Giardia lamblia. Although giardiasis is rare, its histopathological and serological picture may resemble that of CD. We report the case of a young man with diabetes mellitus and a family history of CD referred to our hospital because of diarrhoea and weight loss. Investigation showed, among other factors, partial villous atrophy in duodenal biopsies and elevated immunoglobulin A antitissue transglutaminase antibodies. The patient was diagnosed with CD and recommended a gluten-free diet. At the same time, faecal tests were conducted, indicating the presence of G. lamblia. The patient was treated and improved, even after discontinuing the gluten-free diet. Subsequent follow-up after 6 months showed total regression of mucosal histopathology and a normal antitissue transglutaminase antibodies level.

Gastrointestinal pathology in celiac disease: a case series of 150 consecutive newly diagnosed patients

The main histologic feature of celiac disease is increased intraepithelial lymphocytes (IELs) with or without villous atrophy of the duodenal mucosa. The aim of this study was to document a broad range of additional morphologic changes in intestinal mucosa biopsy specimens from patients with celiac disease. Our cohort comprised 150 patients with positive tissue transglutaminase serologic findings; 7 were at Corazza stage A1, 58 at stage B1, and 85 at stage B2. IEL counts per 100 epithelial cells ranged from 34 to 156 (mean, 88.6); a significant neutrophilic infiltrate was present in 85 cases (56.7%); eosinophil count ranged from 3 to 50 per high-power field (mean, 14.6). Additional findings included morphologic changes in enterocytes in 68.7%, subepithelial collagen thickening in 45.3%, and associated lymphocytic gastritis in 30.4% of patients. We demonstrated that these underrecognized features, which can be misleading, are not uncommon in celiac disease and were positively associated with more advanced stages of the disease (P < .0001).

IgA antibodies against deamidated gliadin peptides in patients with chronic liver diseases

BACKGROUND/AIMS

IgA antibodies against tissue-transglutaminase (anti-tTG-IgA) and IgA and IgG antibodies against deamidated gliadin peptides (anti-DGP-IgA and anti-DGP-IgG) are considered specific for celiac disease (CD) whereas, patients with chronic liver disorders have an increased risk of latent CD development. We investigated the prevalence and clinical significance of anti-DGP-IgA, anti-DGP-IgG and anti-tTG-IgA in a large cohort of patients with chronic liver diseases.

METHODS

668 patients without gastrointestinal symptoms (426 viral hepatitis, 94 autoimmune liver diseases, 61 alcoholic disease, 46 non-alcoholic fatty liver disease, 41 with other liver disorders) were investigated by ELISAs (INOVA Diagnostics). Patients positive for at least one autoantibody invited for a small-intestinal biopsy and HLA-DQ typing.

RESULTS

Anti-DGP-IgA were detected in 8.5%, anti-DGP-IgG in only one (0.15%, P<0.001) and anti-tTG-IgA in 5.8% of patients (P=0.05). Fifty-two were anti-DGP-IgA(+)/anti-tTG-IgA(-), 34 anti-DGP-IgA(-)/anti-tTG-IgA(+), and 5 anti-DGP-IgA(+)/anti-tTG-IgA(+). Anti-DGP-IgA positivity was associated with older age (P<0.05), cirrhosis (P<0.05) and increased IgA (P<0.05) whereas, anti-tTG-IgA only with cirrhosis (P<0.05). Histology and HLA-typing compatible with CD was revealed in 4/14 anti-DGP-IgA(+)/anti-tTG-IgA(-), 0/13 anti-DGP-IgA(-)/anti-tTG-IgA(+) and 2/2 anti-DGP-IgA(+)/anti-tTG-IgA(+). All 6 patients diagnosed with CD were anti-DGP-IgA(+) and only 2 anti-tTG-IgA(+).

CONCLUSIONS

Although a significant number of patients had detectable CD-related autoantibodies, anti-DGP-IgA test seems better than anti-tTG-IgA for unmasking occult forms of CD in patients with chronic liver disorders. The known good performance for CD diagnosis of anti-DGP-IgG test was not confirmed in this specific group of patients.

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.

Lipid peroxidation and paraoxonase-1 activity in celiac disease

Paraoxonase-1 (PON1) plays an antioxidant and anti-inflammatory role. Aim of the study was to investigate the alteration of paraoxonase-1 activity in celiac disease (CD), an intestinal disorder characterized by toxic injury exerted by gluten peptides. Activities of PON1, levels of biochemical markers of lipid peroxidation and total antioxidant capacity were evaluated in serum obtained from 27 celiac patients (11 at diagnosis, 16 treated with gluten free diet) and 25 healthy subjects. Moreover, the serum susceptibility of Cu²⁺-induced lipid peroxidation was investigated in controls and patients. The results showed a lower PON1 activity in serum of both groups of celiac patients with respect to control subjects. PON1 activity in CD was related with markers of disease severity and was negatively correlated with the levels of lipid hydroperoxide and with the susceptibility of serum to lipid peroxidation induced in vitro by metal ions. The alteration of PON1 activity and markers of lipid peroxidation realized at lower extent in patients who were on a gluten-free diet.

Atypical celiac disease as cause of increased need for thyroxine: a systematic study

OBJECTIVE

Replacement T4 dose in hypothyroid patients bearing both chronic autoimmune thyroiditis and atypical celiac disease (CD) has been analyzed.

DESIGN

Replacement T4 dose has been analyzed in 35 hypothyroid patients with Hashimoto's thyroiditis (HT) and atypical CD, as defined by the American Gastroenterological Association. We have evaluated the ability of the same dose of T4 to reach target TSH in 21 patients before and during gluten-free diet (GFD). In the remaining 14 patients, noncompliant with GFD, we analyzed replacement T4 dose and compared it with that in a similar group consisting of 68 patients with hypothyroid HT but no evidence of celiac sprue or other conditions interfering with T4 absorption.

RESULTS

In patients with isolated HT, the desired serum TSH (median=1.02 mU/liter) was reached in all patients after 5±2 months of treatment at a median T4 dose of 1.31 μg/kg·d. After a similar period and dose of T4, higher levels of TSH (median=4.20 mU/liter) were observed in patients with HT and CD. In 21 CD patients, target TSH (median TSH=1.25 mU/liter) has been attained after 11±3 months of GFD without increasing T4 dose (1.32 μg/kg·d). In the remaining 14 patients, who were noncompliant with GFD, target TSH has also been achieved but at a higher T4 dose (median=1.96 μg/kg·d; +49%; P=0.0002) than in hypothyroid patients without CD.

CONCLUSIONS

Atypical CD increases the need for T4. The effect was reversed by GFD or by increasing T4 dose. Malabsorption of T4 may provide the opportunity to detect CD that was overlooked until the patients were put under T4 therapy.

Design of a peptide for immunodetection of IgA antigliadin antibody for the purpose of screening of celiac disease

Celiac disease (CD) is gluten induced enteropathy which requires jejunal biopsy for diagnosis. To select the patients for endoscopoic procedure some serologic tests are popular in clinical practice for screening of CD. Although gliadin is one of the key immuno activator of the disease; serological screening by immuno-detection of gliadin is not recommended. In this context we have designed a peptide using tools of computational biology keeping molecular pathogenesis of the disease into consideration such that antigliadin antibody detection based sensitive and specific cost effective tool for screening of celiac disease can be developed. The designed peptide QPFPEP interacts in a stable manner with dimeric immunoglobin A1 molecule and its parent peptide QPFPQP are sequentially present in maximum number of gliadin epitopes. This hexapeptide is predicted to interact with dimeric IgA1, which increases in the biofluids of the CD patients.

ABBREVIATIONS

CD - Celiac disease, TT - Tissue transglutamase, IgA - Immunoglobulin A, AGA - antigliadin antibody, Immunoglobulin G - IgG.