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Shiha MG, Schiepatti A, Maimaris S, Nandi NI, Penny HA, Sanders DS. Clinical outcomes of potential coeliac disease: a systematic review and meta-analysis. Gut 2024:gutjnl-2024-333110. [PMID: 39153845 DOI: 10.1136/gutjnl-2024-333110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 07/29/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVE Potential coeliac disease (PCD) is characterised by positive serological and genetic markers of coeliac disease with architecturally preserved duodenal mucosa. The clinical outcomes and rates of progression to overt coeliac disease in patients with PCD remain uncertain. In this systematic review and meta-analysis, we aimed to evaluate the clinical outcomes of patients with PCD. DESIGN We searched Medline, Embase, Scopus and Cochrane Library from 1991 through May 2024 to identify studies evaluating the clinical outcomes of patients with PCD. The progression rates to villous atrophy, seroconversion and response to a gluten-free diet (GFD) were analysed. A random-effect meta-analysis was performed, and the results were reported as pooled proportions with 95% CIs. RESULTS Seventeen studies comprising 1010 patients with PCD were included in the final analyses. The pooled prevalence of PCD among patients with suspected coeliac disease was 16% (95% CI 10% to 22%). The duration of follow-up in most of the studies was at least 1 year, with follow-up periods within individual studies ranging from 5 months to 13 years. During follow-up, 33% (95% CI 18% to 48%; I2=96.4%) of patients with PCD on a gluten-containing diet developed villous atrophy, and 33% (95% CI 17% to 48%; I2=93.0%) had normalisation of serology. Among those who adhered to a GFD, 88% (95% CI 79% to 97%; I2=93.2%) reported symptomatic improvement. CONCLUSION Almost a third of patients with PCD develop villous atrophy over time, whereas a similar proportion experience normalisation of serology despite a gluten-containing diet. Most symptomatic patients benefit from a GFD. These findings highlight the importance of structured follow-up and individualised management for patients with PCD.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Annalisa Schiepatti
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri SpA SB IRCCS, Pavia, Italy
| | - Stiliano Maimaris
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri SpA SB IRCCS, Pavia, Italy
| | - NIcoletta Nandi
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Pathophysiology and Organ Transplantation, University of Milan, Milano, Italy
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
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Irani MZ, Eslick GD, Burns GL, Potter M, Halland M, Keely S, Walker MM, Talley NJ. Coeliac disease is a strong risk factor for Gastro-oesophageal reflux disease while a gluten free diet is protective: a systematic review and meta-analysis. EClinicalMedicine 2024; 71:102577. [PMID: 38659976 PMCID: PMC11039972 DOI: 10.1016/j.eclinm.2024.102577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 04/26/2024] Open
Abstract
Background Gastro-oesophageal reflux disease (GORD) mechanisms are well described, but the aetiology is uncertain. Coeliac disease (CD), a gluten enteropathy with increased duodenal eosinophils overlaps with GORD. Functional dyspepsia is a condition where duodenal eosinophilia is featured, and a 6-fold increased risk of incident GORD has been observed. Perturbations of the duodenum can alter proximal gastric and oesophageal motor function. We performed a systematic review and meta-analysis assessing the association between CD and GORD. Methods A systematic search of studies reporting the association of GORD and CD was conducted. CD was defined by combined serological and histological parameters. GORD was defined based on classical symptoms, oesophagitis (endoscopic or histologic) or abnormal 24-h pH monitoring; studies reporting oesophageal motility abnormalities linked with GORD were also included. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random-effects model. Findings 31 papers were included. Individuals with CD on a gluten containing diet were 3 times more likely to have GORD than controls (OR: 3.37, 95% CI: 2.09-5.44), and over 10 times more likely when compared to those on a gluten free diet (GFD) (OR: 10.20, 95% CI: 6.49-16.04). Endoscopic oesophagitis was significantly associated with CD (OR: 4.96; 95% CI: 2.22-11.06). One year of a GFD in CD and GORD was more efficacious in preventing GORD symptom relapse than treatment with 8 weeks of PPI in non-CD GORD patients (OR: 0.18, 95% CI: 0.08-0.36). Paediatric CD patients were more likely to develop GORD (OR: 3.29, 95% CI: 1.46-7.43), compared to adult CD patients (OR: 2.55, 95% CI: 1.65-3.93). Interpretation CD is strongly associated with GORD but there was high heterogeneity. More convincingly, a GFD substantially improves GORD symptoms, suggesting a role for duodenal inflammation and dietary antigens in the aetiology of a subset with GORD. Ruling out CD in patients with GORD may be beneficial. Funding The study was supported by an Investigator Grant from the NHMRC to Dr. Talley.
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Affiliation(s)
- Mudar Zand Irani
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
| | - Guy D. Eslick
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
| | - Grace L. Burns
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
| | - Michael Potter
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
| | - Magnus Halland
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
| | - Simon Keely
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
| | - Marjorie M. Walker
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
| | - Nicholas J. Talley
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
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3
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Katunin E, Aitokari L, Kivelä L, Ilus T, Huhtala H, Kaukinen K, Kurppa K. Measured levels of positive transglutaminase 2 antibodies are not associated with presentation or incidental endoscopic findings at celiac disease diagnosis. Scand J Gastroenterol 2024; 59:419-424. [PMID: 38164975 DOI: 10.1080/00365521.2023.2298709] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES It has been suggested that celiac disease could be diagnosed non-invasively in adults with transglutaminase antibody (TGA) levels >10x upper limit of normal (ULN). It is, however, unclear if high values signify more advanced disease and higher risk of co-morbidities. We investigated the association between the TGA levels, clinical characteristics and non-celiac endoscopic findings. METHODS Medical data on 450 celiac disease patients at diagnosis were collected. They were further divided into those with high positive (>10x ULN, n = 164), moderately positive (1-10x ULN, n = 219), and negative (n = 67) TGA. RESULTS Median age of patients was 50 years and 60% were women. Patients with negative TGA were older (median age 58 vs. 51 vs. 46 years respectively, p = 0.002) and had more often weight loss (27% vs. 10% vs. 9%, p < 0.001) and abdominal pain or dyspepsia (40% vs 27% vs. 22%, p = 0.017) than did those with moderately positive/high TGA. The groups did not differ in sex, BMI, or other symptoms. Major endoscopic findings included one esophageal adenocarcinoma presenting with dysphagia, six esophagitis, three gastric ulcers, and 39 H. Pylori or other active gastritis. High, moderately positive or negative TGA levels were not associated with these findings in crude or age-adjusted analyses. CONCLUSIONS Presentation was similar in patients with moderate or high levels of TGA, whereas patients with negative TGA were different. The level of TGA was not associated with incidental endoscopic findings and the only malignancy presented with an alarm symptom atypical to celiac disease.
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Affiliation(s)
- Eneli Katunin
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
- Department of Internal Medicine, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Linnea Aitokari
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
- Tampere Center for Child, Adolescent, and Maternal Health Research, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Laura Kivelä
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
- Tampere Center for Child, Adolescent, and Maternal Health Research, Tampere University and Tampere University Hospital, Tampere, Finland
- University of Helsinki and Helsinki University Hospital, Children's Hospital, and Pediatric Research Center, Helsinki, Finland
- Pediatric Research Institute, University of Oslo, Norway
| | - Tuire Ilus
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Kalle Kurppa
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
- Tampere Center for Child, Adolescent, and Maternal Health Research, Tampere University and Tampere University Hospital, Tampere, Finland
- The University Consortium of Seinäjoki, Seinäjoki, Finland
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Galli G, Carabotti M, Conti L, Scalamonti S, Annibale B, Lahner E. Comparison of Clinical, Biochemical and Histological Features between Adult Celiac Patients with High and Low Anti-Transglutaminase IgA Titer at Diagnosis and Follow-Up. Nutrients 2023; 15:2151. [PMID: 37432272 DOI: 10.3390/nu15092151] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 07/12/2023] Open
Abstract
In adults, celiac disease (CD) diagnosis is based on specific serology (anti-transglutaminase IgA-anti-tTG) and duodenal histology. Evidence is raising the possibility of perform CD diagnosis based only on high anti-tTG titer in children. We aimed to evaluate clinical, histological and biochemical differences between adult patients with high tTG IgA titer (HT) and those with low titer (LT) at CD diagnosis and follow-up. This retrospective study included consecutive adult CD patients divided into two groups: HT (anti-tTG > 10 × ULN) and LT (anti-tTG < 10 × ULN). Clinical, biochemical and histological features were compared between groups at CD diagnosis and at follow-up. A total of 291 patients were included (HT: 47.1%; LT: 52.9%). At CD diagnosis, HT patients showed a non 'classical' presentation (p = 0.04), Marsh 3C (p = 0.005), hypoferritinaemia (p = 0.006) and osteopenia/osteoporosis (p = 0.04) more frequently than LT patients. A total of 216 patients (HT: 48.6%; LT: 51.4%) performed a follow-up after a median Gluten-free diet of 14 months; HT patients had persistent antibodies positivity (p = 0.001) more frequently and GI symptoms (p = 0.04) less frequently than LT patients. In conclusion, HT patients presented severe histological damage more frequently at diagnosis, recovering similarly to LT patients after the start of the Gluten-free diet. At follow-up, anti-tTG persisted positive in HT more frequently compared to LT patients, without differences regarding histological recovery and clinical improvement.
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Affiliation(s)
- Gloria Galli
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Marilia Carabotti
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Laura Conti
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Silvia Scalamonti
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Edith Lahner
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
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5
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Mansour HH, Mohsen NA, El-Shabrawi MHF, Awad SM, Abd El-Kareem D. Serologic, endoscopic and pathologic findings in pediatric celiac disease: A single center experience in a low/middle income country. World J Clin Pediatr 2022; 11:296-307. [DOI: 10.5409/wjcp.v11.i3.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Mansour HH, Mohsen NA, El-Shabrawi MHF, Awad SM, Abd El-Kareem D. Serologic, endoscopic and pathologic findings in pediatric celiac disease: A single center experience in a low/middle income country. World J Clin Pediatr 2022; 11:295-306. [PMID: 35663003 PMCID: PMC9134153 DOI: 10.5409/wjcp.v11.i3.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/25/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of celiac disease (CD).
AIM To describe the serology, endoscopic and histological findings in typical and atypical presentations of pediatric CD at a tertiary referral hospital in an African low/middle income country (LMIC).
METHODS This observational study was conducted on 199 patients with CD from 2010 to 2019. The patients were divided into typical and atypical groups according to the presenting symptoms including 120 and 79 patients respectively. Serology, upper gastrointestinal endoscopy with duodenal biopsy were performed for patients who had symptoms suggestive of CD. The severity of the intestinal damage was graded according to the histo-pathologic Marsh-Oberhuber classification.
RESULTS Chronic diarrhea was the main intestinal presentation in the typical group. Anemia was the most common extraintestinal symptom in both the typical and atypical group. Marsh-Oberhuber type 3b and 3c was significantly higher in the seropositive patients with a P value of 0.007. A significant correlation was observed between the histological grade of the biopsied duodenal mucosa and the clinical presentation (P < 0.001). Age was significantly higher in the atypical group (P value < 0.001).
CONCLUSION Although typical CD was observed in 120 patients in this study, the clinical variability of the condition was frequently observed. Age only was a significant predictor for the appearance of atypical CD. Therefore, CD presentations in LMIC are not different from industrialized countries.
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Affiliation(s)
- Hala H Mansour
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
| | - Nabil A Mohsen
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
| | - Mortada HF El-Shabrawi
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
| | - Somia M Awad
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
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O'Shaughnessy K, Stack W, Hayes T, Kenny E, Jackson L. An Investigation Into What Factors Influence Patterns of Clinical Presentation in Adult-Onset Celiac Disease. Cureus 2022; 14:e21924. [PMID: 35282563 PMCID: PMC8903871 DOI: 10.7759/cureus.21924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Anxiety and depression are common in patients with celiac disease (CD), and many psychosocial explanations have been considered. However, as the gut-brain axis is becoming increasingly understood, biological mechanisms have been proposed, including vitamin or mineral deficiencies and gut inflammation. Aim To investigate associations between anxiety/depression and symptom severity, vitamin status, and gut inflammation in untreated adult patients presenting with a serologic indication of celiac disease. Methods The Hospital Anxiety and Depression Scale (HADS), Celiac Symptom Index (CSI), and Perceived Stress Scale (PSS) questionnaires were administered to 17 patients over a 14-month period. Duodenal biopsies were obtained to determine histological Marsh scores. Iron, B12, folate, vitamin D, and thyroid function tests were reviewed. Results HADS-Anxiety (HADS-A) scores correlated with symptom severity (rs = 0.62, P = 0.008), but not with any hematological investigations or degree of intestinal inflammation. No patients scored highly for depression. Iron deficiency was the most common deficiency observed (n = 6). Greater symptomatology was associated with female sex (females versus males: average CSI scores, 32.1 versus 23.6; t17 = 2.1, P < 0.05), younger age at presentation (rs = -0.55, P = 0.02), and lower Marsh score (Marsh 0 versus Marsh 3C: mean scores, 36 versus 24.5; t5 = 6.2, P = 0.009). Conclusions The anxiety experienced by patients with CD at presentation is likely a reactive form due to gastrointestinal symptoms rather than a biological process specific to CD. Older patients tend to present less symptomatically, highlighting the need for screening of at-risk individuals. The degree of villous atrophy does not correlate well with clinical presentation. Highly symptomatic patients should be screened for anxiety at presentation.
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Abstract
Celiac disease is a chronic, immune-mediated enteropathy driven by dietary gluten found in genetically susceptible hosts. It has a worldwide distribution, is one of the most common autoimmune disorders globally, and is the only autoimmune condition for which the trigger is known. Despite advances in characterizing mechanisms of disease, gaps in understanding of celiac disease pathogenesis remain. A "frontier" concept is considering what moves an HLA-DQ2 or DQ8-positive individual from asymptomatic gluten tolerance to celiac disease manifestation. In this arena, environmental triggers, including age at the time of initial gluten exposure, the occurrence of usual childhood viral infections, and microbiome alterations have emerged as key events in triggering the symptomatic disease. Pathologists play a major role in frontier aspects of celiac disease. This includes the discovery that duodenal mucosal histology in follow-up biopsies does not correlate with ongoing patient symptoms, antitissue transglutaminase antibody titers and diet adherence in celiac disease patients. Further, in light of recent evidence that the detection of monoclonal T-cell populations in formalin-fixed biopsies is not specific for type II refractory celiac disease, pathologists should resist performing such analyses until common causes of "apparent" refractoriness are excluded. The promise of therapies in celiac disease has led to clinical trials targeting many steps in the inflammatory cascade, which depend upon a pathologist's confirmation of the initial diagnosis and evaluation of responses to therapies. As pathologists continue to be active participants in celiac disease research, partnering with other stakeholders, we will continue to impact this important autoimmune disease.
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Affiliation(s)
- Natalie Patel
- El Camino Pathology Medical Group, Mountain View, CA
| | - Marie E Robert
- Department of Pathology and Medicine, Yale University School of Medicine, New Haven, CT
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9
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Möller SP, Apputhurai P, Tye-Din JA, Knowles SR. Quality of life in coeliac disease: relationship between psychosocial processes and quality of life in a sample of 1697 adults living with coeliac disease. J Psychosom Res 2021; 151:110652. [PMID: 34739942 DOI: 10.1016/j.jpsychores.2021.110652] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Coeliac disease is a chronic gastrointestinal condition associated with an increased risk of psychiatric comorbidity, and diminished quality of life. Ongoing gastrointestinal symptomatology is frequently reported post-diagnosis, despite undertaking a gluten-free diet. PURPOSE To examine the role of psychosocial factors in mediating the relationship between gastrointestinal symptoms and quality of life, using a cross-sectional structural equation modelling mediation analysis guided by the Common-Sense Model. METHODS 1697 adults with coeliac disease (83.1% female, mean age = 55.79, SD = 14.98 years) completed an online questionnaire. Measures included gluten-free diet adherence, gastrointestinal symptoms, illness perceptions, coping, gastrointestinal-specific anxiety, pain catastrophising, psychological flexibility, psychological distress, and quality of life. RESULTS A structural equation model was developed explaining 50.6% of the variation in quality of life and demonstrating good fit (χ2 (2) = 8.54, p = .014, χ2/N = 4.27, RMSEA = 0.04, SRMR = 0.01, CFI = 0.999, TLI = 0.98, GFI = 0.999). Gastrointestinal symptoms directly affected quality of life, and indirectly, via negative illness perceptions, maladaptive coping, pain catastrophising, and psychological distress. CONCLUSION Psychosocial processes may affect adjustment in coeliac disease by mediating the relationship between gastrointestinal symptoms and quality of life. Individuals living with coeliac disease may benefit from interventions targeting maladaptive psychosocial factors.
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Affiliation(s)
- Stephan P Möller
- Department of Psychological Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia
| | - Pragalathan Apputhurai
- Department of Statistics Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia
| | - Jason A Tye-Din
- Immunology Division, Walter and Eliza Hall Institute, Melbourne, Australia; Department of Gastroenterology, the Royal Melbourne Hospital, Melbourne, Australia
| | - Simon R Knowles
- Department of Psychological Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia; Department of Gastroenterology, Alfred Health, Melbourne, Australia.
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10
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Dhillon H, Dowling D, Alexander S. A neuroendocrine cause for refractory symptoms in coeliac disease. JGH Open 2021; 5:1314-1315. [PMID: 34816018 PMCID: PMC8593779 DOI: 10.1002/jgh3.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 11/08/2022]
Abstract
Neuroendocrine tumours while rare, need to be considered in patients with chronic diarrhoea. Reported herein is a case of vasoactive intestinal peptideoma in a patient with refractory diarrhoea following a diagnosis of coeliac disease.
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Affiliation(s)
- Hardesh Dhillon
- Department of Gastroenterology University Hospital Geelong, Barwon Health Geelong Victoria Australia
| | - Damian Dowling
- Department of Gastroenterology University Hospital Geelong, Barwon Health Geelong Victoria Australia.,School of Medicine Deakin University Geelong Victoria Australia
| | - Sina Alexander
- Department of Gastroenterology University Hospital Geelong, Barwon Health Geelong Victoria Australia.,School of Medicine Deakin University Geelong Victoria Australia
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11
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Systematic review: Exploration of the impact of psychosocial factors on quality of life in adults living with coeliac disease. J Psychosom Res 2021; 147:110537. [PMID: 34139581 DOI: 10.1016/j.jpsychores.2021.110537] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Individuals living with coeliac disease generally experience a remission of symptoms after adopting the gluten-free diet but often report substantial treatment burden and ongoing quality of life issues. Psychosocial factors have been suggested to play a significant role in post-diagnosis quality of life but have yet to be systematically reviewed. AIM To review the evidence for psychosocial factors associated with quality of life in adult coeliac disease cohorts. METHODS Studies were identified via systematic searches of eight databases (MEDLINE, Embase, Emcare, PsycINFO, Ovid Nursing, CINAHL, Informit Health Collection, Cochrane Library) in May 2019. RESULTS Fourteen studies were included involving 3372 participants (80.2% female, mean age = 46.4 years). Symptoms of depression and anxiety were the most examined psychosocial factors across all studies. Quality of life was differentially associated with psychological distress, illness perceptions, coping, and attitudes/behaviours regarding food and the gluten-free diet. CONCLUSION Several psychosocial factors are associated with quality of life in adults living with coeliac disease. Current evidence suggests these factors are interrelated and may influence quality of life directly, via reduced psychological well-being, and indirectly, via reduced adherence to the gluten-free diet. Future research is needed to examine these processes concurrently, with the aim of elucidating the psychosocial mechanisms underlying post-diagnosis well-being and identifying potential targets for psychosocial intervention.
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12
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Käräjämäki AJ, Taavela J, Nielsen C, Lönnqvist M, Svartbäck M, Kaukinen K, Tertti R. Celiac disease antibody levels reflect duodenal mucosal damage but not clinical symptoms. Scand J Gastroenterol 2021; 56:514-519. [PMID: 33705679 DOI: 10.1080/00365521.2021.1899278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study aimed to investigate, in a real-world population, whether the histological and clinical phenotype differ at baseline and during follow-up in patients with high and low CD (celiac disease) antibody titers. MATERIALS AND METHODS The study cohort consisted of 96 consecutive patients diagnosed to have CD during the years 2010-2018. The clinical parameters, symptoms and laboratory results were registered and histomorphometry was analyzed from the available duodenal biopsies taken during the primary and follow-up esophageal-gastricduodenoscopies. Patients having immunoglobulin A transglutaminase antibody (tTG-ab) levels above 70 U/mL were classified as high titer patients. RESULTS Measured by the villous-crypt ratio, the duodenal mucosa was more severely damaged in the high tTG-ab group than in the low tTG-group at baseline (n = 70, 0.61 ± 0.63 vs. 1.02 ± 0.87, p = .003) and during the follow-up when the patients were on gluten-free diet (n = 27, 1.80 ± 0.72 vs. 2.35 ± 0.64, p = .041). Interestingly, the high tTG-ab group members had fewer gastrointestinal symptoms at baseline than those in the low tTG-ab group (43% vs. 68%, p = .013) but lower vitamin D levels (68 ± 34 nmol/L vs. 88 ± 29 nmol/L, p = .034) and more often microcytosis (28% vs. 10%, p = .040). During the follow-up, these differences were no longer detected. CONCLUSIONS At baseline, CD patients with high tTG-ab have more severe duodenum injury and signs of malabsorption but fewer symptoms. After gluten-free diet has been initiated, the mucosal healing in the high tTG-ab group is prolonged, but symptoms and signs of malabsorption recover equally in both groups.
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Affiliation(s)
- Aki J Käräjämäki
- Department of Internal Medicine, Vaasa Central Hospital, Vaasa, Finland.,Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, and University of Oulu, Oulu, Finland
| | - Juha Taavela
- Central Finland Central Hospital, Jyväskylä, Finland.,Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Christian Nielsen
- Department of Internal Medicine, Vaasa Central Hospital, Vaasa, Finland
| | - Mårten Lönnqvist
- Department of Internal Medicine, Vaasa Central Hospital, Vaasa, Finland
| | | | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Risto Tertti
- Department of Internal Medicine, Vaasa Central Hospital, Vaasa, Finland.,Department of Internal Medicine, University of Turku, Turku, Finland
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13
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Narang V, Jindal A, Singh A, Varun Mehta BG, Sood N, Sood A. Diagnostic utility of multiple site duodenal biopsies in celiac disease. INDIAN J PATHOL MICR 2021; 64:S73-S77. [PMID: 34135142 DOI: 10.4103/ijpm.ijpm_797_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Celiac Disease involves the small intestine patchily affecting more frequently the proximal small bowel but the histological changes have been observed till terminal ileum. Of late in addition to D2, the duodenal bulb (D1 region) biopsies have been found helpful in identifying a small group of patients with CD. Therefore, multiple site biopsies are recommended as histological changes are not uniform throughout small intestine. Methods During this present 1.5 years prospective study, we evaluated 84 cases of suspected celiac disease with respect to the light microscopy (D1, D2, and D3 biopsy) and serology (anti tTg and or EMA). Histological examination was done according to Modified Marsh grading system. Results Out of 84 cases with raised anti tTg, the segmental biopsies significantly increased the diagnostic accuracy from 39/44 cases (88.6%) to 43/44 cases (97.7%) and 44/44 cases (100%) when D2 alone, D1 + D2 and D1 + D2 + D3 biopsies were evaluated, respectively. Of the suspected cases of celiac disease patients (tTg > 10 ULN and associated weight loss, diarrhea), additional D3 biopsy increased the diagnostic yield by 2.1%, compared to D1, D2 region biopsy and 6.38% compared to standard D2 biopsy alone. Of the 28 cases (tTg > 10 times ULN + EMA positive and associated weight loss, diarrhea), the potential celiac disease (histologically Type 1/Normal) cases reduced from 28.5% (standard D2 region alone) to 21.4% and 17.8% when additional biopsies were taken from D1 region and D3 region, respectively, and additional D3 biopsy increased the diagnostic yield by 10.8% (compared to standard D2 biopsy alone) and 3.7% (compared to D1 and D2 biopsy). Conclusion We believe multiple sites duodenal biopsies including D3 region biopsies might increase the diagnostic accuracy of adult celiac disease in addition to sensitive and specific serologic tests.
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Affiliation(s)
- Vikarm Narang
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Akriti Jindal
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Aminder Singh
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | | | - Neena Sood
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Ajit Sood
- Department of Gastroentrology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Abstract
BACKGROUND It is not known if genetic background, characteristics at diagnosis, physical and psychological well-being, and adherence to a gluten-free diet are comparable between patients with familial or sporadic celiac disease. These issues were investigated in a follow-up study. METHODS Altogether 1064 patients were analyzed for celiac disease-associated serology, predisposing HLA-DQ, and non-HLA genotypes. Medical data were collected from patient records and supplementary interviews. Current symptoms and quality of life were further evaluated with the Gastrointestinal Symptom Rating Scale (GSRS), the Psychological General Well-Being questionnaire (PGWB), and Short Form 36 (SF-36) questionnaires. RESULTS Familial and sporadic groups differed (P < 0.001) in the reason for diagnosis and clinical presentation at diagnosis, familial patients being more often screen-detected (26% vs. 2%, P < 0.001) and having less often gastrointestinal (49% vs. 69%) and severe symptoms (47% vs. 65%). The groups were comparable in terms of histological damage, frequency of malabsorption, comorbidities, childhood diagnoses, and short-term treatment response. At the time of the study, familial cases reported fewer symptoms (21% vs. 30%, P = 0.004) and lower prevalence of all (78% vs. 86%, P = 0.007), neurological (10% vs. 15%, P = 0.013), and dermatological (9% vs. 17%, P = 0.001) comorbidities. Dietary adherence and GSRS scores were comparable, but familial cases had better quality of life according to PGWB and SF-36. High-risk genotype HLA-DQ2.5/DQ2.5 was more frequent among familial cases, and four non-HLA SNPs were associated with familial celiac disease. CONCLUSIONS Despite the greater proportion of high-risk genotypes, familial cases had milder symptoms at presentation than did sporadic cases. Worse experience of symptoms and poorer quality of life in sporadic disease indicate a need for intensified support.
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Sukkar G, Alshareef AM, Aljahani M, Alharthi HA, Fakieha A. The Prevalence of Growth Variations Among Pediatric Celiac Disease Patients at the Time of Diagnosis. Cureus 2020; 12:e11706. [PMID: 33391939 PMCID: PMC7769797 DOI: 10.7759/cureus.11706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background and aim Celiac disease is an immune-mediated disorder caused by sensitivity to dietary gluten. Celiac patients typically present with malabsorption and low growth parameters; however, studies have shown that the presentation of celiac disease can have a higher percentage of patients with normal or high growth parameters and no signs of malabsorption. The study aims to estimate the prevalence of the growth variation found in children with biopsy-confirmed celiac disease at the time of diagnosis. Methods We included 31 biopsy-confirmed pediatric celiac patients diagnosed from 2007 to 2018 in King Abdulaziz Medical City, Jeddah, Saudi Arabia. Patients’ height, weight, and BMI at the time of diagnosis were converted to z-scores and growth percentiles according to the Centers for Disease Control and Prevention growth charts. In addition, patients’ comorbid conditions were also recorded. Results At the time of diagnosis, 45.16% of our patients presented as underweight, 41.94% of patients had normal weight, 6.5% were overweight and obese, respectively. The mean BMI was 15.44 (±3.65). Our population had a statistically significant lower BMI, height, and weight mean z-scores at the time of diagnosis. Conclusion A significant number of children diagnosed with celiac disease in our center had low weight, height, and BMI at the time of diagnosis. However, we emphasize that having normal growth parameters does not rule out the diagnosis of celiac disease.
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16
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Odhaib SA, Mohammed MJ, Hammadi S. Efficacy of Gastrointestinal Endoscopy in 398 Patients With Iron Deficiency Anemia Who Lack Gastrointestinal Symptoms: Basrah Experience. Cureus 2020; 12:e9206. [PMID: 32821560 PMCID: PMC7430437 DOI: 10.7759/cureus.9206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction The diagnosis of iron deficiency anemia (IDA) relies heavily on symptom presentation, and patients lacking typical gastrointestinal (GI) symptoms represent a diagnostic challenge. IDA may be the initial manifestation of underlying pathology. This study sought to evaluate the effectiveness of different GI endoscopic studies in patients with IDA who lack GI symptoms. Methods We conducted an observational, multicenter retrospective analysis of 398 asymptomatic IDA patients admitted for GI endoscopic diagnosis from 2006 to 2016. Baseline measurements included hemoglobin, serum ferritin, mean corpuscular volume, serum iron, total iron-binding capacity, and transferrin saturation. We analyzed demographic characteristics, duration of hospital stay, the degree of severity of anemia, and endoscopic findings. Results The mean age of the study population was 52±9 years (range, 23 to 85 years), and 53% were men. Most patients were older than 45 years (n=353, 89%) with mild to moderate IDA. Patients underwent esophagogastroduodenoscopy (EGD, n=102), colonoscopy (n=271), or bidirectional endoscopy (n=25). The mean hospital stay was 2.72±1.66 days. The most common EGD results were atrophic gastritis (n=31), peptic ulcer (n=25), and negative findings (n=25). The most common colonoscopic results were negative findings (n=118), nonspecific colonic inflammatory changes (n=117), and non-bleeding hemorrhoids (n=29). We found no significant association between any endoscopic findings and age, gender, the severity of anemia, and length of hospitalization. Conclusions The presence of symptoms is of limited value in guiding diagnostic procedures concerning GI etiologies. Asymptomatic patients with IDA patients should receive an endoscopic examination irrespective of iron parameters, age, or gender for potentially treatable pathologies, especially for patients with suspected malignancies.
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Affiliation(s)
- Samih A Odhaib
- Adult Endocrinology, Faiha Specialized Diabetes, Endocrine and Metabolism Center, University of Basrah College of Medicine, Basrah, IRQ
| | - Miaad J Mohammed
- Diagnostic Radiology, Al-Refaee General Hospital. Thi-Qar Health Directorate, Thi-Qar, IRQ
| | - Saad Hammadi
- Internal Medicine, University of Basrah College of Medicine, Basrah, IRQ
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Severity of Villous Atrophy at Diagnosis in Childhood Does Not Predict Long-term Outcomes in Celiac Disease. J Pediatr Gastroenterol Nutr 2020; 71:71-77. [PMID: 32097370 DOI: 10.1097/mpg.0000000000002675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Current pediatric guidelines allow noninvasive diagnosis of celiac disease in selected children. We investigated in a large cohort study whether the severity of villous atrophy at diagnosis is associated with clinical characteristics or long-term health outcomes, thus having a prognostic significance. METHODS Comprehensive medical data on 906 children with celiac disease were analyzed. Long-term health outcomes of 503 adult patients diagnosed in childhood were moreover assessed with a specific study questionnaire and validated Gastrointestinal Symptom Rating Scale (GSRS) and Psychological General Well-Being (PGWB) questionnaires. Patients were classified into 3 groups according to the severity of villous atrophy at diagnosis, and all variables were compared. RESULTS Altogether 34% of the patients had partial, 40% subtotal, and 26% total villous atrophy. Children with milder lesions were diagnosed more recently (median year 2007 vs 2006 vs 2001, respectively, P < 0.001), more often by screening (30% vs 25% vs 17%, P < 0.001) and they suffered less often from anemia (16% vs 21% vs 32%, P < 0.001) and growth disturbances (22% vs 36% vs 54%, P < 0.001) and had lower transglutaminase-2 antibody levels (median 64 U/L vs 120 U/L vs 120 U/L, P < 0.001). There was no difference in other disease features.Altogether 212 adults diagnosed in childhood completed the questionnaires. Severity of villous atrophy at childhood diagnosis did not predict presence of complications or comorbidities, persistent symptoms, and self-perceived health, quality of life or adherence to a gluten-free diet in adulthood. CONCLUSION Presence of advanced villous atrophy at diagnosis is associated with more severe clinical characteristics but not with poorer long-term health and treatment outcomes.
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18
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Potter MD, Hunt JS, Walker MM, Jones M, Liu C, Weltman M, Talley NJ. Duodenal eosinophils as predictors of symptoms in coeliac disease: a comparison of coeliac disease and non-coeliac dyspeptic patients with controls. Scand J Gastroenterol 2020; 55:780-784. [PMID: 32536237 DOI: 10.1080/00365521.2020.1775880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction: Duodenal eosinophilia is a key feature of functional dyspepsia, particularly in those with early satiety. Duodenal eosinophilia is also recognised in coeliac disease, although its relevance to symptoms is not understood. We aimed to determine if duodenal eosinophilia is present in patients with coeliac disease presenting with dyspepsia, and whether other histological characteristics were associated with clinical features on presentation.Methods: The coeliac study population comprised 61 patients with a new presentation of coeliac disease to a single centre from 2003 to 2013. A standard symptom assessment was documented for all patients. The control population (55 adults) presenting for endoscopy without coeliac disease was drawn from the same centre with similar demographics for age and gender. Duodenal biopsies from both groups were assessed for eosinophil counts and histological features.Results: Dyspepsia was present in 18.0% of coeliac patients and early satiety in 24.6%. The eosinophil counts were significantly higher in the stomach (12.1/mm2 vs. 4.0/mm2, p < .001) and duodenum (60.4/mm2 vs. 18.0/mm2, p < .001) of coeliac patients compared with controls. There was no significant difference in the mean duodenal eosinophil count in coeliac disease with and without early satiety (55.4/mm2 vs. 66.9/mm2, p = .51). Duodenal eosinophilia was not associated with the severity of coeliac enteropathy. The degree of villous atrophy was associated with iron deficiency at presentation (p = .01), but not symptoms.Conclusions: Although duodenal eosinophil counts are higher in coeliac disease than controls, we were not able to demonstrate an association with presenting symptoms or markers of disease severity.
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Affiliation(s)
- Michael D Potter
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,Department of Gastroenterology and Hepatology, John Hunter Hospital, Newcastle, Australia
| | - James S Hunt
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, Australia
| | - Marjorie M Walker
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Mike Jones
- Psychology Department, Macquarie University, Sydney, Australia
| | - Cheng Liu
- Department of Pathology, Nepean Hospital, Sydney, Australia
| | - Martin Weltman
- Department of Gastroenterology and Hepatology, Nepean Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Nicholas J Talley
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,Department of Gastroenterology and Hepatology, John Hunter Hospital, Newcastle, Australia
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Chetcuti Zammit S, Sanders DS, Sidhu R. Coeliac disease: older patients have the most extensive small bowel involvement on capsule endoscopy. Eur J Gastroenterol Hepatol 2019; 31:1496-1501. [PMID: 31464789 DOI: 10.1097/meg.0000000000001503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The relation between symptomatology, serology and findings on small bowel capsule endoscopy (SBCE) in patients with coeliac disease (CD) remains unclear. Clarifying such associations will help to determine whether symptoms and serology can predict severity and extent of disease on SBCE. METHODS Patients with newly diagnosed CD were recruited. Information on SBCE was recorded. Signs and symptoms at presentation, serological markers and histological classification of the disease in the duodenum were noted. RESULTS Sixty patients with newly diagnosed CD (mean age: 44.9 years, SD: ±17.4, 17-76) were included in this study. Older patients (P = 0.025) and patients presenting with iron deficiency anaemia had more extensive small bowel (SB) involvement (25.7% vs. 13.5%; P = 0.026). Those with weight loss were more likely to have SB involvement beyond the duodenum (37.5% vs. 5.8%; P = 0.027). Patients presenting with iron deficiency anaemia (53.5 vs. 42.4 years; P = 0.038) and weight loss (60.5 vs. 42.4 years; P = 0.009) were significantly older at diagnosis. Serum albumin was lower in those patients diagnosed later on in life (Pearson correlation -0.0361; P = 0.007). There was no significant association between anti-tissue transglutaminase antibody (P = 0.396) and extent of affected SB mucosa. Patients with more severe Marsh scores on histology from the duodenal bulb had more extensive SB involvement (P = 0.017). CONCLUSIONS This is the largest study on the use of SBCE in newly diagnosed CD. Older patients are likely to have more extensive disease on SBCE at diagnosis. Symptoms and serology had no impact on the findings on SBCE apart from weight loss and iron deficiency anaemia.
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20
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Statement on Best Practices in the Use of Pathology as a Diagnostic Tool for Celiac Disease: A Guide for Clinicians and Pathologists. Am J Surg Pathol 2019; 42:e44-e58. [PMID: 29923907 DOI: 10.1097/pas.0000000000001107] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Small intestinal biopsy interpretation has been the cornerstone for the diagnosis of celiac disease for over 50 years. Despite the existence of sensitive and specific serological tests, duodenal mucosal biopsies continue to be obtained in the vast majority of patients in whom a diagnosis of celiac disease is being considered. The accurate evaluation of these biopsies requires coordination and information sharing between the gastroenterologist, laboratory, and pathologist in order to optimize tissue sampling, preparation and interpretation. This document, a collaboration between the Rodger C. Haggitt Gastrointestinal Pathology Society and the North American Association for the Study of Celiac Disease, is intended to provide clinicians and pathologists with a summary of best practices in the use of endoscopy and biopsy for patients with suspected celiac disease. The authors present a comprehensive and critical appraisal of the literature with respect to the topics of endoscopic findings, best methods for the obtaining biopsies, completing the pathology form and pathologic assessment, including evaluating intraepithelial lymphocytes and villous architecture. A discussion of conditions with overlapping pathologic findings in duodenal mucosal biopsies is presented. In order to provide additional guidance for challenging situations, the authors include an appendix containing practical suggestions. This review may be utilized in interdisciplinary discussions to optimize care for patients with possible celiac disease.
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21
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Lagana SM, Bhagat G. Biopsy Diagnosis of Celiac Disease: The Pathologist's Perspective in Light of Recent Advances. Gastroenterol Clin North Am 2019; 48:39-51. [PMID: 30711210 DOI: 10.1016/j.gtc.2018.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Celiac disease is a common immune-mediated disorder that occurs in individuals with permissive genetics (HLA-DQ2/DQ8 genotype) following exposure to certain wheat proteins. The histopathologic manifestations of small intestinal mucosal injury (villus atrophy, crypt hyperplasia, and intraepithelial lymphocytosis) are well recognized. However, these findings are not specific for celiac disease, because they are observed in other small intestinal disorders. These mimics include common and rare entities, the list of which continues to grow. This article discusses the histopathology and differential diagnosis of celiac disease and provides the pathologist's perspective on biopsy adequacy, evaluation, and reporting in light of current knowledge.
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Affiliation(s)
- Stephen M Lagana
- Columbia University, New York Presbyterian Hospital, 622 West 168th Street, VC14-209, New York, NY 10032, USA.
| | - Govind Bhagat
- Columbia University, New York Presbyterian Hospital, 622 West 168th Street, VC14-228, New York, NY 10032, USA
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22
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Chetcuti Zammit S, Sanders DS, Sidhu R. Capsule endoscopy for patients with coeliac disease. Expert Rev Gastroenterol Hepatol 2018; 12:779-790. [PMID: 29886766 DOI: 10.1080/17474124.2018.1487289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coeliac disease is an autoimmune mediated condition in response to gluten. A combination of innate and adaptive immune responses results in villous shortening in the small bowel (SB) that can be morphologically picked up on capsule endoscopy. It is the only imaging modality that can provide mucosal views of the entire SB, while histology is generally limited to the proximal SB. Radiological modalities are not designed to pick up changes in villous morphology. Areas covered: In this review, we provide a comprehensive analysis on the justified use of small bowel capsule endoscopy (SBCE) in the assessment of patients with coeliac disease; compare SBCE to histology, serology, and symptomatology; and provide an overview on automated quantitative analysis for the detection of coeliac disease. We also provide insight into future work on SBCE in relation to coeliac disease. Expert commentary: SBCE has opened up new avenues for the diagnosis and monitoring of patients with coeliac disease. However, larger studies with new and established coeliac disease patients and with greater emphasis on morphological features on SBCE are required to better define the role of SBCE in the setting of coeliac disease.
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Affiliation(s)
| | - David S Sanders
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
| | - Reena Sidhu
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
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23
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Dermatitis Herpetiformis: A Common Extraintestinal Manifestation of Coeliac Disease. Nutrients 2018; 10:nu10050602. [PMID: 29757210 PMCID: PMC5986482 DOI: 10.3390/nu10050602] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 12/20/2022] Open
Abstract
Dermatitis herpetiformis (DH) is a common extraintestinal manifestation of coeliac disease presenting with itchy papules and vesicles on the elbows, knees, and buttocks. Overt gastrointestinal symptoms are rare. Diagnosis of DH is easily confirmed by immunofluorescence biopsy showing pathognomonic granular immunoglobulin A (IgA) deposits in the papillary dermis. A valid hypothesis for the immunopathogenesis of DH is that it starts from latent or manifest coeliac disease in the gut and evolves into an immune complex deposition of high avidity IgA epidermal transglutaminase (TG3) antibodies, together with the TG3 enzyme, in the papillary dermis. The mean age at DH diagnosis has increased significantly in recent decades and presently is 40⁻50 years. The DH to coeliac disease prevalence ratio is 1:8 in Finland and the United Kingdom (U.K.). The annual DH incidence rate, currently 2.7 per 100,000 in Finland and 0.8 per 100,000 in the U.K., is decreasing, whereas the reverse is true for coeliac disease. The long-term prognosis of DH patients on a gluten-free diet is excellent, with the mortality rate being even lower than for the general population.
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Semwal P, Gupta RK, Sharma R, Garg K. Comparison of Endoscopic and Histological Findings between Typical and Atypical Celiac Disease in Children. Pediatr Gastroenterol Hepatol Nutr 2018; 21:86-92. [PMID: 29713605 PMCID: PMC5915695 DOI: 10.5223/pghn.2018.21.2.86] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/07/2017] [Accepted: 12/29/2017] [Indexed: 01/27/2023] Open
Abstract
PURPOSE Celiac disease is a common non-communicable disease with varied presentations. Purpose of this study was to find the duodeno-endoscopic features in celiac disease and to compare duodeno-endoscopic and histological findings between typical and atypical celiac disease in children. METHODS Hospital based observational study was conducted at Sir Padampat Mother and Child Health Institute, Jaipur from June 2015 to May 2016. Patients were selected and divided in two groups- typical and atypical celiac disease based upon the presenting symptoms. Upper gastrointestinal endoscopy and duodenal biopsy was performed for serology positive patients. Results were analysed using appropriate statistical test of significance. RESULTS Out of 101 enrolled patients, 47.5% were male. Age ranged from 1 to 18 years. Study showed that 54.5% were typical and 45.5% were atypical. Patients presenting with atypical symptoms were predominantly of older age group. On endoscopy, scalloping, mosaic pattern, reduced fold height and absent fold height; and in histology, advanced Marsh stage were significantly higher in the typical group. CONCLUSION Awareness of atypical presentations as well as duodeno-endoscopic features may have considerable practical importance for the diagnosis of celiac disease in children. Scalloping, mosaic pattern, reduced fold height and nodularity are main endoscopic markers of celiac disease in children. Endoscopic markers of duodenal mucosa may be important in early diagnosis of celiac disease, in children subjected to endoscopy for atypical presentations or indication other than suspected celiac disease.
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Affiliation(s)
- Pooja Semwal
- Department of Paediatric Medicine, Sawai Man Singh Medical College, Jaipur, India
| | - Raj Kumar Gupta
- Department of Paediatric Medicine, Sawai Man Singh Medical College, Jaipur, India
| | - Rahul Sharma
- Department of Community Medicine, University College of Medical Sciences, Delhi, India
| | - Kapil Garg
- Department of Paediatric Medicine, Sawai Man Singh Medical College, Jaipur, India
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25
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Zylberberg HM, Lebwohl B, RoyChoudhury A, Walker MD, Green PHR. Predictors of improvement in bone mineral density after celiac disease diagnosis. Endocrine 2018; 59:311-318. [PMID: 29230636 DOI: 10.1007/s12020-017-1488-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Low bone density is frequently found in patients newly diagnosed with celiac disease (CD), and improvement is variable. This study was performed to assess changes in bone mineral density (BMD) by dual x-ray absorptiometry (DXA) at the lumbar spine, hip, and distal one-third radius as well as clinical predictors of BMD changes after the diagnosis and treatment of CD. METHODS Adult CD patients who had serial DXA at the Celiac Disease Center at Columbia University Medical Center were included (N = 103). We assessed within-person changes in BMD with paired t-tests. Multiple regression was utilized to assess baseline clinical and laboratory predictors of BMD improvement after diagnosis and treatment. RESULTS The mean age of our sample was 45.6 years (±SD 15.1) and 60% were female. After a median follow-up of 21 months, lumbar spine BMD increased by 1.7 ± 5.5% (p = 0.006) after CD diagnosis. There was a similar trend at the total hip (1.6 ± 6.3%, p = 0.06), but no change at the femoral neck or distal one-third radius. Lower baseline serum calcium predicted a greater increase in lumber spine BMD (ß = -0.0470 g/cm2, p = 0.002). At the hip, higher baseline creatinine clearance (ß = 0.005, p = 0.02) was associated with greater gains in BMD. CONCLUSION BMD increases at the lumbar spine after the diagnosis of CD and greater BMD improvement is associated with lower baseline serum calcium. This suggests that those with the lowest calcium, which is likely a surrogate for the greatest malabsorption, may have the greatest potential for improvement in skeletal health after treatment of CD.
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Affiliation(s)
- Haley M Zylberberg
- Celiac Disease Center, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Benjamin Lebwohl
- Celiac Disease Center, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
| | - Arindam RoyChoudhury
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
| | - Marcella D Walker
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Peter H R Green
- Celiac Disease Center, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA.
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26
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Pecoraro A, Nappi L, Crescenzi L, D'Armiento FP, Genovese A, Spadaro G. Chronic Diarrhea in Common Variable Immunodeficiency: a Case Series and Review of the Literature. J Clin Immunol 2017; 38:67-76. [PMID: 29138951 DOI: 10.1007/s10875-017-0461-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 11/08/2017] [Indexed: 01/15/2023]
Abstract
Common variable immunodeficiency (CVID) is a primary immunodeficiency characterized by reduced immunoglobulin serum levels and absent or impaired antibody production. Clinical manifestations, including infections, inflammatory and autoimmune diseases, and malignancies, also involve various segments of the gastrointestinal tract. Chronic diarrhea is one of the most common gastrointestinal symptoms and may cause a wide spectrum of potentially life-threatening conditions as malabsorption and protein-energy malnutrition. We describe three female CVID adult patients presenting with chronic diarrhea, weight loss, and protein-energy malnutrition due to different underlying conditions. Our review of the literature explores the various gastrointestinal involvements in CVID and points out several histopathological findings proper of the disease, thus highlighting the relevance of the endoscopic and histological assessment in CVID patients presenting with chronic diarrhea.
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Affiliation(s)
- Antonio Pecoraro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology. Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Liliana Nappi
- Department of Translational Medical Sciences, Allergy and Clinical Immunology. Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Ludovica Crescenzi
- Department of Translational Medical Sciences, Allergy and Clinical Immunology. Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Francesco P D'Armiento
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Arturo Genovese
- Department of Translational Medical Sciences, Allergy and Clinical Immunology. Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy.
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology. Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy
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Latiglutenase Improves Symptoms in Seropositive Celiac Disease Patients While on a Gluten-Free Diet. Dig Dis Sci 2017; 62:2428-2432. [PMID: 28755266 PMCID: PMC5709215 DOI: 10.1007/s10620-017-4687-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/19/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Celiac disease (CD) is a widespread condition triggered by dietary gluten and treated with a lifelong gluten-free diet (GFD); however, inadvertent exposure to gluten can result in episodic symptoms. A previous trial of latiglutenase (clinicaltrials.gov; NCT01917630), an orally administered mixture of two recombinant gluten-specific proteases, was undertaken in symptomatic subjects with persistent injury. The primary endpoint for histologic improvement was not met, presumably due to a trial effect. In this post hoc analysis, we investigated the efficacy of latiglutenase for reducing symptoms in subgroups of the study participants based on their seropositivity. METHODS The study involved symptomatic CD patients following a GFD for at least one year prior to randomization. Patients were treated for 12 weeks with latiglutenase or placebo. Of 398 completed patients, 173 (43%) were seropositive at baseline. Symptoms were recorded daily, and weekly symptom scores were compiled. p values were calculated by analysis of covariance. RESULTS A statistically significant, dose-dependent reduction was detected in the severity and frequency of symptoms in seropositive but not seronegative patients. The severity of abdominal pain and bloating was reduced by 58 and 44%, respectively, in the cohort receiving the highest latiglutenase dose (900 mg, n = 14) relative to placebo (n = 54). Symptom improvement increased from week 6 to week 12. There was also a trend toward greater symptom improvement with greater baseline symptom severity. CONCLUSIONS Seropositive CD patients show symptomatic improvement from latiglutenase taken with meals and would benefit from the availability of this treatment.
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Kivelä L, Kaukinen K, Huhtala H, Lähdeaho ML, Mäki M, Kurppa K. At-Risk Screened Children with Celiac Disease are Comparable in Disease Severity and Dietary Adherence to Those Found because of Clinical Suspicion: A Large Cohort Study. J Pediatr 2017; 183:115-121.e2. [PMID: 28153477 DOI: 10.1016/j.jpeds.2016.12.077] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 11/17/2016] [Accepted: 12/30/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess whether children at risk for celiac disease should be screened systematically by comparing their baseline and follow-up characteristics to patients detected because of clinical suspicion. STUDY DESIGN Five hundred four children with celiac disease were divided into screen-detected (n = 145) and clinically detected cohorts (n = 359). The groups were compared for clinical, serologic, and histologic characteristics and laboratory values. Follow-up data regarding adherence and response to gluten-free diet were compared. Subgroup analyses were made between asymptomatic and symptomatic screen-detected patients. RESULTS Of screen-detected patients, 51.8% had symptoms at diagnosis, although these were milder than in clinically detected children (P < .001). Anemia (7.1% vs 22.9%, P < .001) and poor growth (15.7% vs 36.9%, P < .001) were more common, and hemoglobin (126 g/l vs 124 g/l, P = .008) and albumin (41.0 g/l vs 38.0 g/l, P = .016) were lower in clinically detected patients. There were no differences in serology or histology between the groups. Screen-detected children had better dietary adherence (91.2% vs 83.2%, P = .047). The groups showed equal clinical response (97.5% vs 96.2%, P = .766) to the gluten-free diet. In subgroup analysis among screen-detected children, asymptomatic patients were older than symptomatic (9.0 vs 5.8 years of age, P = .007), but the groups were comparable in other variables. CONCLUSIONS More than one-half of the screen-detected patients with celiac disease had symptoms unrecognized at diagnosis. The severity of histologic damage, antibody levels, dietary adherence, and response to treatment in screen-detected cases is comparable with those detected on a clinical basis. The results support active screening for celiac disease among at-risk children.
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Affiliation(s)
- Laura Kivelä
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Katri Kaukinen
- School of Medicine, University of Tampere, Tampere, Finland; Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Tampere School of Health Sciences, University of Tampere, Tampere, Finland
| | - Marja-Leena Lähdeaho
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Markku Mäki
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Kalle Kurppa
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
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The Decreasing Prevalence of Severe Villous Atrophy in Dermatitis Herpetiformis: A 45-Year Experience in 393 Patients. J Clin Gastroenterol 2017; 51:235-239. [PMID: 27136959 DOI: 10.1097/mcg.0000000000000533] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
GOALS We analyzed from our prospectively collected series of patients with dermatitis herpetiformis (DH) whether small-bowel histologic findings are changing and how serum tissue transglutaminase (TG2) IgA antibodies correlate to mucosal damage. BACKGROUND DH is an extraintestinal manifestation of celiac disease presenting with itchy blistering rash and pathognomonic IgA deposits in the skin. Prominent gastrointestinal symptoms are rare, and small-bowel findings range from severe villous atrophy (SVA) and partial villous atrophy (PVA) to normal mucosa with inflammatory changes. METHODS The cohort included 393 patients (214 male and 179 female) with DH having small-bowel biopsies performed at Tampere University Hospital since 1970. The small-bowel findings were calculated in the three 15-year periods, and in the last period they were correlated with serum IgA class TG2 antibody levels measured by enzyme-linked immunosorbent assay. RESULTS The prevalence of SVA decreased significantly (P=0.032), from 42% in the first study period to 29% in the last study period. A concomitant increase was seen in PVA, from 33% to 41%, and normal villous architecture, from 25% to 30%. The patients with SVA (P<0.001) and PVA (P=0.046) had significantly higher TG2 antibody levels than those with normal villous architecture. CONCLUSIONS This long-term study in patients with DH disclosed a significant decrease in the occurrence of SVA. Serum IgA TG2 antibody levels correlated to damage in the small bowel. The trend toward milder small-bowel histology in DH suggests that a similar pattern could occur in the pool of undiagnosed celiac disease from which DH develops.
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Radmard AR, Hashemi Taheri AP, Salehian Nik E, Kooraki S, Kolahdoozan S, Mirminachi B, Sotoudeh M, Ekhlasi G, Malekzadeh R, Shahbazkhani B. MR enterography in nonresponsive adult celiac disease: Correlation with endoscopic, pathologic, serologic, and genetic features. J Magn Reson Imaging 2017; 46:1096-1106. [DOI: 10.1002/jmri.25646] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/10/2017] [Indexed: 12/11/2022] Open
Affiliation(s)
- Amir Reza Radmard
- Department of Radiology, Shariati Hospital; Tehran University of Medical Sciences; Tehran Iran
| | | | - Elham Salehian Nik
- Department of Radiology, Shariati Hospital; Tehran University of Medical Sciences; Tehran Iran
| | - Soheil Kooraki
- Department of Radiology, Shariati Hospital; Tehran University of Medical Sciences; Tehran Iran
| | - Shadi Kolahdoozan
- Autoimmune and Motility Disorders of the Gastro-Intestinal Tract Research Center, Digestive Diseases Research Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Babak Mirminachi
- Autoimmune and Motility Disorders of the Gastro-Intestinal Tract Research Center, Digestive Diseases Research Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Masoud Sotoudeh
- Department of Pathology, Shariati Hospital; Tehran University of Medical Sciences; Tehran Iran
| | - Golnaz Ekhlasi
- Autoimmune and Motility Disorders of the Gastro-Intestinal Tract Research Center, Digestive Diseases Research Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Reza Malekzadeh
- Autoimmune and Motility Disorders of the Gastro-Intestinal Tract Research Center, Digestive Diseases Research Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Bijan Shahbazkhani
- Autoimmune and Motility Disorders of the Gastro-Intestinal Tract Research Center, Digestive Diseases Research Institute; Tehran University of Medical Sciences; Tehran Iran
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Ierardi E, Losurdo G, Iannone A, Piscitelli D, Amoruso A, Barone M, Principi M, Pisani A, Di Leo A. Lymphocytic duodenitis or microscopic enteritis and gluten-related conditions: what needs to be explored? Ann Gastroenterol 2017; 30:380-392. [PMID: 28655974 PMCID: PMC5479990 DOI: 10.20524/aog.2017.0165] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/10/2017] [Indexed: 02/07/2023] Open
Abstract
Microscopic enteritis (ME) is characterized by abnormal infiltration of intraepithelial lymphocytes in intestinal mucosa. It was described as duodenal lymphocytosis or lymphocytic duodenitis until the dedicated Consensus Conference of 2015. ME represents a common feature of several gluten-mediated and non-gluten related diseases; therefore, it is an umbrella term embracing several conditions. The most frequent causes of ME are gluten-related disorders (celiac disease, non-celiac gluten sensitivity, wheat allergy), Helicobacter pylori infection and drug-related damages. Less frequently, ME may be secondary to inflammatory bowel disease, some autoimmune conditions, immunoglobulin deficiencies, blood malignancies, infections and irritable bowel syndrome. Therefore, the differential diagnosis of ME may be challenging. The diagnosis of ME needs to be driven by predominant symptoms and patient history. However, it is often difficult to achieve an immediate identification of the underlying condition, and a broad variety of diagnostic tests may be required. Ultimately, long-term surveillance is needed for a final diagnosis in many cases, since a hidden or quiescent condition may be disclosed after a period of latency. In any case, strict collaboration between the clinician and the pathologist is pivotal. The treatment of ME should be personalized, depending on the underlying disease. For gluten-related conditions (celiac disease, gluten sensitivity, wheat allergy, dermatitis herpetiformis), a gluten-free diet may be proposed. For other conditions, a targeted etiologic treatment is necessary. In conclusion, ME represents a novel entity that is attracting increasing interest. The growing epidemiologic trend confirms that it will become a common condition in clinical practice.
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Affiliation(s)
- Enzo Ierardi
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
- Correspondence to: Prof. Enzo Ierardi, Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, Piazza Giulio Cesare, Bari, University of Bari, Italy, Tel.: +39 080 5594033, Fax: +39 080 5593088, e-mail:
| | - Giuseppe Losurdo
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Andrea Iannone
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Domenico Piscitelli
- Section of Pathology (Domenico Piscitelli), Department of Emergency and Organ Transplantation, AOU Policlinico, Piazza Giulio Cesare, Bari, University of Bari, Italy
| | - Annacinzia Amoruso
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Michele Barone
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Mariabeatrice Principi
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Antonio Pisani
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Alfredo Di Leo
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
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Classification chaos in coeliac disease: Does it really matter? Pathol Res Pract 2016; 212:1174-1178. [PMID: 27637158 DOI: 10.1016/j.prp.2016.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/30/2016] [Indexed: 02/07/2023]
Abstract
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.
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Silvester JA, Graff LA, Rigaux L, Walker JR, Duerksen DR. Symptomatic suspected gluten exposure is common among patients with coeliac disease on a gluten-free diet. Aliment Pharmacol Ther 2016; 44:612-9. [PMID: 27443825 PMCID: PMC5283559 DOI: 10.1111/apt.13725] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 04/22/2016] [Accepted: 06/21/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND A gluten-free diet is the only recommended treatment for coeliac disease. AIM To determine the prevalence and characteristics of reactions to gluten among persons with coeliac disease on a gluten-free diet. METHODS Adults with biopsy proven, newly diagnosed coeliac disease were prospectively enrolled. A survey related to diet adherence and reactions to gluten was completed at study entry and 6 months. The Coeliac Symptom Index, Coeliac Diet Assessment Tool (CDAT) and Gluten-Free Eating Assessment Tool (GF-EAT) were used to measure coeliac disease symptoms and gluten-free diet adherence. RESULTS Of the 105 participants, 91% reported gluten exposure <1 per month and median CDAT score was 9 (IQR 8-11), consistent with adequate adherence. A suspected symptomatic reaction to gluten was reported by 66%. Gluten consumption was unsuspected until a reaction occurred (63%) or resulted from problems ordering in a restaurant (29%). The amount of gluten consumed ranged from cross-contact (30%) to a major ingredient (10%). Median time to symptom onset was 1 h (range 10 min to 48 h), and median symptom duration was 24 h (range 1 h to 8 days). Common symptoms included abdominal pain (80%), diarrhoea (52%), fatigue (33%), headache (30%) and irritability (29%). CONCLUSIONS Reactions to suspected gluten exposure are common among patients with coeliac disease on a gluten-free diet. Eating at restaurants and other peoples' homes remain a risk for unintentional gluten exposure. When following individuals with coeliac disease, clinicians should include questions regarding reactions to gluten as part of their assessment of gluten-free diet adherence.
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Affiliation(s)
- Jocelyn A Silvester
- College of Medicine, University of Manitoba, Winnipeg, MB R3E 3P5,Celiac Research Program, Harvard Medical School, 300 Brookline Avenue, Boston, MA 02215
| | | | - Lisa Rigaux
- St Boniface Hospital, 409 Tache Avenue, Winnipeg, MB R2H 2A6
| | - John R Walker
- College of Medicine, University of Manitoba, Winnipeg, MB R3E 3P5
| | - Donald R Duerksen
- College of Medicine, University of Manitoba, Winnipeg, MB R3E 3P5,St Boniface Hospital, 409 Tache Avenue, Winnipeg, MB R2H 2A6
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Baghbanian M, Farahat A, Vahedian HA, Sheyda E, Zare-Khormizi MR. THE PREVALENCE OF CELIAC DISEASE IN PATIENTS WITH IRON-DEFICIENCY ANEMIA IN CENTER AND SOUTH AREA OF IRAN. ARQUIVOS DE GASTROENTEROLOGIA 2016; 52:278-82. [PMID: 26840468 DOI: 10.1590/s0004-28032015000400006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 08/04/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Celiac disease is an immune-mediated enteropathy due to a permanent sensitivity to gluten in genetically susceptible people. Iron-deficiency anemia is the most widely experienced anemia in humans. Iron-deficiency anemia additionally is a common extra intestinal manifestation of celiac disease. OBJECTIVE To investigate correlation between tTg levels and histological alterations and then to determine the prevalence of celiac disease in Center and South area patients of Iran with iron deficiency anemia. METHODS A total of 402 patients aged 12-78 years who presented with iron-deficiency anemia were included in this study. Hemoglobin, mean corpuscular volume and serum ferritin were determined. Venous blood samples for anti-tissue transglutaminase antibody immunoglobuline A and G were obtained from these patients. Upper gastrointestinal endoscopy was recommended to patients who had positive serology. RESULTS Of 402 patients with iron-deficiency anemia, 42 (10.4%) had positive serology for celiac disease. The small intestine biopsy of all patients with positive serology showed pathological changes (Marsh I, II & III). There was not significant difference in the mean hemoglobin level between iron-deficiency anemia patients with celiac disease and without celiac disease, duodenal biopsy results did not show significant relationship between the severity of pathological changes and levels of anti-tTG IgG (P -value: 0/869) but significant relationship was discovered between pathological changes and levels of anti-tTG IgA (P -value: 0/004). CONCLUSION Screening of celiac disease by anti-tissue transglutaminase antibody should be completed as a routine investigation in patients with iron-deficiency anemia. Also physicians must consider celiac disease as a possible reason of anemia in all patients with iron deficiency anemia.
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Affiliation(s)
- Mahmud Baghbanian
- Department of Gastroenterology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Ali Farahat
- School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hasan Ali Vahedian
- Department of Internal Medicine, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Elham Sheyda
- School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Tapsas D, Hollén E, Stenhammar L, Fälth-Magnusson K. The clinical presentation of coeliac disease in 1030 Swedish children: Changing features over the past four decades. Dig Liver Dis 2016; 48:16-22. [PMID: 26520057 DOI: 10.1016/j.dld.2015.09.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 08/26/2015] [Accepted: 09/28/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND The features of paediatric coeliac disease have changed in recent decades. We hypothesised that the age at diagnosis might continue to increase, whereas the severity of symptoms should decrease. METHODS In the present study, filed data on 1030 paediatric patients diagnosed with coeliac disease between 1973 and 2013 were analysed. The information available covered 99.8% of small bowel biopsies and included information on sex, age and clinical symptoms. RESULTS The age at diagnosis increased significantly, from a mean of 2.2 years during the first 10 years to 8.2 years in recent years. The proportion of children with severe symptoms declined from 92.8% to 78%, as did the proportion of biopsies characterised by severe pathology. In recent years, the monosymptomatic form of coeliac disease has been more common, and the number of patients detected at screening has increased. The frequency of patients with gastrointestinal symptoms, extra-intestinal symptoms, and failure to thrive and/or short stature at presentation decreased. CONCLUSIONS The mean age of newly diagnosed patients has increased over the last 15 years. Currently, coeliac disease shows a less severe picture in terms of symptoms and intestinal pathology. Younger children suffer primarily from gastrointestinal symptoms and growth failure, and adolescents from extra-intestinal manifestations.
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Affiliation(s)
- Dimitrios Tapsas
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Elisabet Hollén
- Division of Microbiology and Molecular Medicine, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Lars Stenhammar
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Pediatrics, Linköping University, Norrköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden
| | - Karin Fälth-Magnusson
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Pediatrics, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Patients with celiac disease may have normal weight or may even be overweight. Indian J Gastroenterol 2016; 35:20-4. [PMID: 26892766 DOI: 10.1007/s12664-016-0620-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 01/19/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND It is believed that patients with celiac disease (CeD) are likely to be underweight. Data from west suggest that 8% to 40% of them can be overweight or obese. We reviewed data on body mass index (BMI) of our patients with CeD and derived the correlations between BMI and other disease characteristics. METHODS We retrospectively studied case records of 210 adolescent and adult patients with CeD at the Celiac Disease Clinic. We classified BMI as underweight, normal weight, overweight, and obese based on the Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians for those with age >18 years and revised Indian Association of Pediatrics BMI-for-age charts for those between 12 and 18 years. RESULTS Of 210 patients, 76 (36.2%) were underweight, 115 (54.8%) were normal weight, 13 (6.2%) were overweight, and 6 (2.9%) were obese. There was no difference in the proportion of underweight between male and female patients with CeD. The mean age of underweight patients was similar to those having normal or overweight. There was no difference in the mean duration of symptoms; frequencies of diarrhea, anorexia, and weakness; anemia; titer of anti-tissue transglutaminase antibody; and severity of villous atrophy in those with underweight or normal weight or overweight. CONCLUSIONS In our practice, only one third of patients with CeD had low BMI. A diagnosis of CeD should not be excluded if patient has normal or high BMI.
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Nurminen S, Kivelä L, Taavela J, Huhtala H, Mäki M, Kaukinen K, Kurppa K. Factors associated with growth disturbance at celiac disease diagnosis in children: a retrospective cohort study. BMC Gastroenterol 2015; 15:125. [PMID: 26438321 PMCID: PMC4595273 DOI: 10.1186/s12876-015-0357-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/25/2015] [Indexed: 12/22/2022] Open
Abstract
Background Impaired growth is a well-known complication in celiac disease, but factors associated with it are poorly known. We investigated this issue in a large cohort of children. Methods 530 children with biopsy-proven celiac disease were included. The participants were divided into two groups on the basis of the presence (n = 182) or absence (n = 348) of growth disturbance at diagnosis. Histological, serological and clinical characteristics were compared between children with growth failure and those with normal growth. Further, patients with growth failure as the sole clinical presentation were compared to those with poor growth and concomitant other symptoms. Results Children with growth failure were younger (p < 0.001) and had lower hemoglobin (p = 0.016) and higher celiac antibody (p < 0.001), alanine aminotransferase (p = 0.035) and thyroid-stimulating hormone values (p = 0.013) than those with normal growth. Significantly associated with growth failure at diagnosis were age <3 years (OR 4.3 (95 % CI 2.5-7.5) vs older age), diagnosis before the year 2000 and in 2000–09 (OR 3.1 (1.8-5.4) and OR 1.8 (1.1-2.8) vs diagnosis in 2010–2013), presence of total and subtotal villous atrophy (OR 4.2 (2.5-7.0) and OR 2.0 (1.3-3.2) vs partial atrophy), severe symptoms (OR 3.4 (1.8-6.7) vs mild symptoms) and vomiting (OR 3.1 (1.5-6.3). The presence of abdominal pain reduced the risk (OR 0.5 (0.3-0.7)), while there was no effect of gender, diarrhea, constipation, other chronic diseases and celiac disease in the family. Children evincing poor growth as the sole clinical presentation were older (p < 0.001) and had higher hemoglobin (P < 0.001) and total iron (p = 0.010) values and lower TG2ab values (p = 0.009) than those with growth disturbance and other symptoms. Conclusions In particular young age and severe clinical and histological presentation were associated with growth disturbance at celiac disease diagnosis. Children with only poor growth are markedly different from those with other concomitant symptoms, suggesting different pathogenic mechanisms.
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Affiliation(s)
- Samuli Nurminen
- School of Medicine, University of Tampere, FIN-33014, Tampere, Finland. .,Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| | - Laura Kivelä
- School of Medicine, University of Tampere, FIN-33014, Tampere, Finland. .,Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| | - Juha Taavela
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| | - Heini Huhtala
- School of Health Sciences, University of Tampere, Tampere, Finland.
| | - Markku Mäki
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| | - Katri Kaukinen
- School of Medicine, University of Tampere, FIN-33014, Tampere, Finland. .,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland.
| | - Kalle Kurppa
- School of Medicine, University of Tampere, FIN-33014, Tampere, Finland. .,Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
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Prevalence of celiac disease in adult patients with iron-deficiency anemia of obscure origin in Kashmir (India). Indian J Gastroenterol 2015; 34:314-9. [PMID: 26374753 DOI: 10.1007/s12664-015-0586-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 08/05/2015] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the prevalence of celiac disease in adult patients with iron-deficiency anemia of obscure origin. METHODS One hundred and sixty-one consecutive patients with iron-deficiency anemia of obscure origin were evaluated. Tissue transglutaminase antibodies levels were done and duodenal biopsies were scored according to Marsh classification. Diagnosis was based on positive IgA anti-tissue transglutaminase antibodies and abnormal histopathology. Gluten-free diet (GFD) was adviced for celiac disease patients. One hundred and sixty healthy blood donors were tested for IgA anti-tissue transglutaminase antibodies, and positive controls were subjected to endoscopic duodenal biopsy. RESULTS Tissue transglutaminase antibodies were positive in 13 (8 %) patients with iron-deficiency anemia of obscure origin and 4 (2.5 %) in control group (p = 0.026) (odds ratio 3.42; 95 % confidence interval [CI]: 1.092-10.743). All 13 patients (8 %) and 2 out of 4 positive controls (1.25 %) had histopathology findings of celiac disease (p = 0.004). Duodenal biopsy showed Marsh grade 1 in 4, grade 2 in 4 (30.77 %), 3a in 1 (7.70 %), 3b in 2 (15.38 %), and 3c in 2 (15.38 %) patients. A statistically significant correlation was found between lower hemoglobin concentration and higher Marsh grading (Spearman's rho = -0.946, p = 0.001). Celiac disease patients adhered to GFD and after 6 months mean (SD) hemoglobin levels increased from 7.42 ± 0.96 to 10.47 ± 0.80 g/dL (p- < 0.001). CONCLUSION Patients with iron-deficiency anemia of obscure origin had increased prevalence of celiac disease. Gluten-free diet improved anemia in celiac disease patients irrespective of grade of duodenal involvement.
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Abstract
Celiac disease (CD) is an immune-based condition affecting multiple organ systems. Clinical manifestations are manifold in form and number due to the multisystem nature of CD. There has been a progressive change in the clinical manifestations over the recent decades with fewer patients, both adults and children, presenting with a diarrheal, classical form. This, in children, is seen in only the youngest, while growth issues, screening at-risk groups and recurrent abdominal pain are the most common modes of presentation among children. Among adults, diarrhea is the most common presentation followed by anemia. Screening at-risk groups, metabolic bone disease and incidental recognition at endoscopy performed for reflux are the other main modes of presentation. The bulk of those with CD remain undiagnosed. The symptoms are often common, and increased medical education should lead to greater awareness in the medical community and an increased rate of diagnosis.
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Rostami K, Aldulaimi D, Holmes G, Johnson MW, Robert M, Srivastava A, Fléjou JF, Sanders DS, Volta U, Derakhshan MH, Going JJ, Becheanu G, Catassi C, Danciu M, Materacki L, Ghafarzadegan K, Ishaq S, Rostami-Nejad M, Peña AS, Bassotti G, Marsh MN, Villanacci V. Microscopic enteritis: Bucharest consensus. World J Gastroenterol 2015; 21:2593-2604. [PMID: 25759526 PMCID: PMC4351208 DOI: 10.3748/wjg.v21.i9.2593] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 12/29/2014] [Accepted: 01/21/2015] [Indexed: 02/06/2023] Open
Abstract
Microscopic enteritis (ME) is an inflammatory condition of the small bowel that leads to gastrointestinal symptoms, nutrient and micronutrient deficiency. It is characterised by microscopic or sub-microscopic abnormalities such as microvillus changes and enterocytic alterations in the absence of definite macroscopic changes using standard modern endoscopy. This work recognises a need to characterize disorders with microscopic and submicroscopic features, currently regarded as functional or non-specific entities, to obtain further understanding of their clinical relevance. The consensus working party reviewed statements about the aetiology, diagnosis and symptoms associated with ME and proposes an algorithm for its investigation and treatment. Following the 5th International Course in Digestive Pathology in Bucharest in November 2012, an international group of 21 interested pathologists and gastroenterologists formed a working party with a view to formulating a consensus statement on ME. A five-step agreement scale (from strong agreement to strong disagreement) was used to score 21 statements, independently. There was strong agreement on all statements about ME histology (95%-100%). Statements concerning diagnosis achieved 85% to 100% agreement. A statement on the management of ME elicited agreement from the lowest rate (60%) up to 100%. The remaining two categories showed general agreement between experts on clinical presentation (75%-95%) and pathogenesis (80%-90%) of ME. There was strong agreement on the histological definition of ME. Weaker agreement on management indicates a need for further investigations, better definitions and clinical trials to produce quality guidelines for management. This ME consensus is a step toward greater recognition of a significant entity affecting symptomatic patients previously labelled as non-specific or functional enteropathy.
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Cooper WM, Kaniecki RG, Taylor FR. Abstracts and Citations. Headache 2015. [DOI: 10.1111/head.12533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bramanti E, Cicciù M, Matacena G, Costa S, Magazzù G. Clinical Evaluation of Specific Oral Manifestations in Pediatric Patients with Ascertained versus Potential Coeliac Disease: A Cross-Sectional Study. Gastroenterol Res Pract 2014; 2014:934159. [PMID: 25197270 PMCID: PMC4147289 DOI: 10.1155/2014/934159] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 07/25/2014] [Accepted: 07/25/2014] [Indexed: 12/30/2022] Open
Abstract
Patients involved on coeliac disease (CD) have atypical symptoms and often remain undiagnosed. Specific oral manifestations are effective risk indicators of CD and for this reason an early diagnosis with a consequent better prognosis can be performed by the dentist. There are not researches analysing the frequency of these oral manifestations in potential coeliac patients. The aim of this study is to investigate the oral hard and soft tissue lesions in potential and ascertained coeliac children in comparison with healthy controls. 50 ascertained children, 21 potential coeliac patients, and 54 controls were recruited and the oral examination was performed. The overall oral lesions were more frequently present in CD patients than in controls. The prevalence of oral soft tissue lesions was 62% in ascertained coeliac, 76.2% in potential coeliac patients, and 12.96% in controls (P < 0.05). Clinical dental delayed eruption was observed in 38% of the ascertained coeliac and 42.5% of the potential coeliac versus 11.11% of the controls (P < 0.05). The prevalence of specific enamel defects (SED) was 48% in ascertained coeliac and 19% in potential coeliac versus 0% in controls (P < 0.05; OR = 3.923). The SED seem to be genetically related to the histological damage and villous atrophy.
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Affiliation(s)
- Ennio Bramanti
- Resident Department of Clinical and Experimental Medicine and Stomatology, University of Messina, 98100 Messina, Italy
| | - Marco Cicciù
- Department of Human Pathology, School of Dentistry, University of Messina, Via Consolare Valeria, 98100 Messina, Italy
| | - Giada Matacena
- Resident Department of Clinical and Experimental Medicine and Stomatology, University of Messina, 98100 Messina, Italy
| | - Stefano Costa
- Department of Pediatric, Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, 98100 Messina, Italy
| | - Giuseppe Magazzù
- Department of Pediatric, Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, 98100 Messina, Italy
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Abstract
OBJECTIVES Limited data suggest complete mucosal healing in treated children with celiac disease (CD), but recent data from adult endoscopic biopsies have shown substantial numbers with persistent mucosal injury. We aimed to assess the rate of mucosal healing and indications for repeat small bowel (SB) biopsy in children with CD. METHODS We retrospectively reviewed records of children (ages 1-18 years) with CD who underwent a second SB biopsy. All of the children were seen at Mayo Clinic (Rochester, MN) from January 1997 through June 2013. RESULTS Forty children were identified (14 boys); average age at diagnosis was 8.5 years. Indications for second SB biopsy were abdominal pain (n = 20), diarrhea (n = 7), constipation (n = 5), non-celiac-related concern (n = 2), follow-up (n = 5), and persistent serology (n = 1). Average time between biopsies was 24 months (range 4-120 months). Histology on the second biopsy showed complete healing (n = 25), intraepithelial lymphocytes (n = 9), and persistent villous atrophy (n = 6). Of these, 3 patients had partial villous atrophy and 3 had with complete villous atrophy. Persistent villous atrophy was observed in 2 of 20 patients with abdominal pain and 1 of 7 with diarrhea. All of the patients with persistent constipation (n = 5) had complete resolution. CONCLUSIONS Mucosal healing in children with CD may not be complete as previously assumed. Abdominal pain was the most common indication for repeating the SB biopsy. Persistence of abdominal pain, diarrhea, and constipation was poorly associated with persistence of mucosal injury.
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Diamanti A, Capriati T, Basso MS, Panetta F, Di Ciommo Laurora VM, Bellucci F, Cristofori F, Francavilla R. Celiac disease and overweight in children: an update. Nutrients 2014; 6:207-20. [PMID: 24451308 PMCID: PMC3916856 DOI: 10.3390/nu6010207] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 02/07/2023] Open
Abstract
The clinical presentation of celiac disease in children is very variable and differs with age. The prevalence of atypical presentations of celiac disease has increased over the past 2 decades. Several studies in adults and children with celiac disease indicate that obesity/overweight at disease onset is not unusual. In addition, there is a trend towards the development of overweight/obesity in celiac patients who strictly comply with a gluten-free diet. However, the pathogenesis and clinical implications of the coexistence of classic malabsorption (e.g., celiac disease) and overweight/obesity remain unclear. This review investigated the causes and main clinical factors associated with overweight/obesity at the diagnosis of celiac disease and clarified whether gluten withdrawal affects the current trends of the nutritional status of celiac disease patients.
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Affiliation(s)
- Antonella Diamanti
- Gastroenterology-Hepatology and Nutrition Unit, "Bambino Gesù" Children's Hospital, Piazza Sant'Onofrio 4, Rome 00165, Italy.
| | - Teresa Capriati
- Gastroenterology-Hepatology and Nutrition Unit, "Bambino Gesù" Children's Hospital, Piazza Sant'Onofrio 4, Rome 00165, Italy.
| | - Maria Sole Basso
- Gastroenterology-Hepatology and Nutrition Unit, "Bambino Gesù" Children's Hospital, Piazza Sant'Onofrio 4, Rome 00165, Italy.
| | - Fabio Panetta
- Gastroenterology-Hepatology and Nutrition Unit, "Bambino Gesù" Children's Hospital, Piazza Sant'Onofrio 4, Rome 00165, Italy.
| | | | - Francesca Bellucci
- Gastroenterology-Hepatology and Nutrition Unit, "Bambino Gesù" Children's Hospital, Piazza Sant'Onofrio 4, Rome 00165, Italy.
| | - Fernanda Cristofori
- Gastroenterology Unit, Pediatric Clinic of University, Piazza Giulio Cesare 11, Bari 70124, Italy.
| | - Ruggiero Francavilla
- Gastroenterology Unit, Pediatric Clinic of University, Piazza Giulio Cesare 11, Bari 70124, Italy.
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Singh P, Chaturvedi MK, Rangan P, Bhat AS. Patients of celiac disease with mild villous atrophy are clinically similar to those with moderate to severe atrophy. Indian J Gastroenterol 2013; 32:413-4. [PMID: 23264025 DOI: 10.1007/s12664-012-0291-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Prashant Singh
- Center for Diarrheal Diseases and Nutrition Research, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110 029, India,
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Abu Daya H, Lebwohl B, Lewis SK, Green PH. Celiac disease patients presenting with anemia have more severe disease than those presenting with diarrhea. Clin Gastroenterol Hepatol 2013; 11:1472-7. [PMID: 23756221 DOI: 10.1016/j.cgh.2013.05.030] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 05/15/2013] [Accepted: 05/16/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Anemia is considered to be an atypical or silent presentation of celiac disease, compared with the classic presentation with diarrhea. However, little information is available about how these groups compare in terms of disease severity. We compared the severity of celiac disease between patients who present with anemia vs those who present with diarrhea. METHODS The study cohort was selected from a database of patients with celiac disease who were evaluated at a tertiary referral center between 1990 and 2011. Severity of celiac disease was assessed by the degree of villous atrophy and clinical and serologic parameters. Patients were compared according to mode of presentation and sex. Multivariable analyses, adjusting for age and sex, were conducted to assess the association between the mode of celiac disease presentation and cholesterol level, bone density, severity of villous atrophy, erythrocyte sedimentation rate, and level of anti-tissue transglutaminase. RESULTS Of 727 patients, 77% presented with diarrhea and 23% with anemia (92% iron deficient). On multiple regression analysis, presentation with anemia was associated with lower levels of total cholesterol (P = .02) and high-density lipoprotein (P = .002) and a higher erythrocyte sedimentation rate (P = .001) and level of anti-tissue transglutaminase (P = .01). Presentation with anemia was associated with lower level of cholesterol only in women. Anemic patients were more than 2-fold more likely to have severe villous atrophy and a low bone mass density at the time they were diagnosed with celiac disease than patients who presented with diarrhea. CONCLUSIONS Celiac disease patients who present with anemia have more severe disease than those who present with diarrhea. There also appear to be sex-specific differences with regard to the association between anemia and the different features of celiac disease.
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Affiliation(s)
- Hussein Abu Daya
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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Sharkey LM, Corbett G, Currie E, Lee J, Sweeney N, Woodward JM. Optimising delivery of care in coeliac disease - comparison of the benefits of repeat biopsy and serological follow-up. Aliment Pharmacol Ther 2013; 38:1278-91. [PMID: 24117503 DOI: 10.1111/apt.12510] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 03/01/2013] [Accepted: 09/06/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The majority of deleterious health consequences of coeliac disease (CD) are most likely to be secondary to intestinal inflammation; hence, mucosal recovery is a desirable goal of therapy. Follow-up in CD is controversial and serological response is often used as a surrogate for histological recovery. AIMS To inform the clinical management of CD using comparative serological and histological data from a biopsy-driven pathway of care. METHODS A retrospective analysis of the Cambridge Coeliac Clinic database of 595 patients routinely followed up by biopsy and serology. RESULTS Paired biopsy results were available for 391 patients (15% seronegative). Persisting villous atrophy (VA) occurred in 182 patients (47%). The sensitivity of anti-tissue transglutaminase (TTG) antibody for ongoing VA was only 43.6%. Information on dietetic management and further biopsy to assess response was available for 94 initially unresponsive patients, in whom targeted dietetic intervention by removal of identified gluten sources or avoidance of trace amounts of gluten led to resolution of persistent VA in 50%. The effects of institution of a formal care pathway are analysed in 298 patients. Discharge to primary care and clinical management was facilitated by the information derived from repeat biopsy. CONCLUSIONS Serology appears to be a poor surrogate marker for mucosal recovery on a gluten-free diet; dietary assessment fails to identify a potential gluten source in many patients with ongoing villous atrophy. The benefits of re-biopsy on diet include stratification of patients with coeliac disease suitable for early discharge from secondary care or those requiring more intensive clinical management.
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Affiliation(s)
- L M Sharkey
- Department of Gastroenterology and Clinical Nutrition, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Mild enteropathy celiac disease: a wolf in sheep's clothing? Clin Gastroenterol Hepatol 2013; 11:259-61. [PMID: 23142601 DOI: 10.1016/j.cgh.2012.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 11/01/2012] [Indexed: 02/07/2023]
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Taavela J, Kurppa K, Collin P, Lähdeaho ML, Salmi T, Saavalainen P, Haimila K, Huhtala H, Laurila K, Sievänen H, Mäki M, Kaukinen K. Degree of damage to the small bowel and serum antibody titers correlate with clinical presentation of patients with celiac disease. Clin Gastroenterol Hepatol 2013; 11:166-71.e1. [PMID: 23063678 DOI: 10.1016/j.cgh.2012.09.030] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 09/02/2012] [Accepted: 09/20/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND & AIMS In patients with celiac disease, gluten-induced lesions of the small-bowel mucosa develop gradually. However, it is not clear whether clinical presentation correlates with the degree of mucosal damage based on histology analysis. We investigated whether the degree of mucosal damage to the small bowel correlates with clinical presentation and serum markers of celiac disease. METHODS We collected results from serology tests and mucosal biopsy samples from 638 consecutive patients with celiac disease and compared them with reported gastrointestinal symptoms, health-related quality-of-life scores, results from laboratory tests, and bone mineral densities of patients. We assessed mucosal injury based on the ratio of villous height to crypt depth, numbers of intraepithelial CD3(+) cells, and semiquantitative Marsh classification criteria. Correlations were established based on the Pearson or Spearman coefficients. RESULTS The ratio of the villous height to crypt depth correlated with the severity of gastrointestinal symptoms, quality-of-life scores, laboratory test results, numbers of intraepithelial CD3(+) cells, and serum levels of antibodies associated with celiac disease. There was no correlation between the ratio of villous height to crypt depth and bone mineral density. The number of intraepithelial CD3(+) cells was not associated with symptoms, whereas the Marsh classification and serum levels of antibodies associated with celiac disease correlated with gastrointestinal symptoms, laboratory test results, and numbers of intraepithelial CD3(+) cells. CONCLUSIONS The ratio of small-bowel villous height to crypt depth and results from serology tests correlate with reported symptoms and quality of life of patients with celiac disease. Patient-reported outcomes are therefore of value, in addition to histology findings, in assessing patients with celiac disease.
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Affiliation(s)
- Juha Taavela
- Pediatric Research Centre, University of Tampere and Tampere University Hospital, Tampere, Finland
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