1
|
Zylberberg HM, Miller EBP, Ratner A, Hammill BG, Mehta P, Alesci S, Lebwohl B. Correlations Between Relative Prevalence of Celiac Disease and Sociodemographic Variables in the United States. Am J Gastroenterol 2024; 119:374-377. [PMID: 37787442 DOI: 10.14309/ajg.0000000000002541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/05/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION We evaluated the associations between celiac disease (CD) prevalence and regional sociodemographic variables in the United States. METHODS The outcome was CD relative prevalence, defined as number of patients with CD among those in a Medicare registry per 3-digit ZIP code. Linear regression models assessed associations between relative prevalence of CD and sociodemographic variables. RESULTS CD relative prevalence was positively correlated with median income, urban area, and proximity to a CD specialty center and negatively correlated with Black race, Latino/Hispanic ethnicity, and median social deprivation index score ( P < 0.01, all). DISCUSSION CD relative prevalence is associated with indicators of economic advantage.
Collapse
Affiliation(s)
- Haley M Zylberberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | | | - Amy Ratner
- Beyond Celiac, Ambler, Pennsylvania, USA
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Pooja Mehta
- Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| |
Collapse
|
2
|
Dochat C, Afari N, Satherley RM, Coburn S, McBeth JF. Celiac disease symptom profiles and their relationship to gluten-free diet adherence, mental health, and quality of life. BMC Gastroenterol 2024; 24:9. [PMID: 38166645 PMCID: PMC10759532 DOI: 10.1186/s12876-023-03101-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND A subgroup of adults with celiac disease experience persistent gastrointestinal and extraintestinal symptoms, which vary between individuals and the cause(s) for which are often unclear. METHODS The present observational study sought to elucidate patterns of persistent symptoms and the relationship between those patterns and gluten-free diet adherence, psychiatric symptoms, and various aspects of quality of life (QOL) in an online sample of adults with celiac disease. U.S. adults with self-reported, biopsy-confirmed celiac disease (N = 523; Mage = 40.3 years; 88% women; 93.5% White) voluntarily completed questionnaires as part of the iCureCeliac® research network: (a) Celiac Symptoms Index (CSI) for physical symptoms and subjective health; (b) Celiac Dietary Adherence Test for gluten-free diet adherence; (c) PROMIS-29, SF-36, and Celiac Disease Quality of Life Survey for psychiatric symptoms and QOL. Symptom profiles were derived using latent profile analysis and profile differences were examined using auxiliary analyses. RESULTS Latent profile analysis of CSI items determined a four-profile solution fit best. Profiles were characterized by: (1) little to no symptoms and excellent subjective health (37% of sample); (2) infrequent symptoms and good subjective health (33%); (3) occasional symptoms and fair to poor subjective health (24%); (4) frequent to constant symptoms and fair to poor subjective health (6%). Profiles 2 and 3 reported moderate overall symptomology though Profile 2 reported relatively greater extraintestinal symptoms and Profile 3 reported relatively greater gastrointestinal symptoms, physical pain, and worse subjective health. Profiles differed on anxiety and depression symptoms, limitations due to physical and emotional health, social functioning, and sleep, but not clinical characteristics, gluten-free diet adherence, or QOL. Despite Profile 3's moderate symptom burden and low subjective health as reported on the CSI, Profile 3 reported the lowest psychiatric symptoms and highest quality of life on standardized measures. CONCLUSIONS Adults with celiac disease reported variable patterns of persistent symptoms, symptom severity, and subjective health. Lack of profile differences in gluten-free diet adherence suggests that adjunctive dietary or medical assessment and intervention may be warranted. Lower persistent symptom burden did not necessarily translate to better mental health and QOL, suggesting that behavioral intervention may be helpful even for those with lower celiac symptom burden.
Collapse
Affiliation(s)
- Cara Dochat
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA.
| | - Niloofar Afari
- VA San Diego Healthcare System, San Diego, CA, USA
- University of California San Diego, La Jolla, CA, USA
| | | | - Shayna Coburn
- Children's National Health System, Washington, DC, USA
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | | |
Collapse
|
3
|
Roldan GA, Jamot S, Kopec K, Charoen A, Leffler D, Feller ER, Shah SA. Celiac Disease Presenting in a Community-Based Gastroenterology Practice: Obesity and Bone Disease Are Common. Dig Dis Sci 2023; 68:860-866. [PMID: 35650415 DOI: 10.1007/s10620-022-07521-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 04/12/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The description of the clinical presentation of celiac disease (CeD) has usually come from studies at referral centers. Data about CeD presentation in the community are sparse. AIMS We aim to describe the clinical presentation of patients with biopsy-proven CeD at a community-based adult gastroenterology practice and compare it to a referral center. METHODS We performed a retrospective study of two cohorts of patients diagnosed with CeD between 2000-2007 (n = 117) and 2013-2016 (n = 91) in a community practice, and a third cohort (n = 188) diagnosed between 2000 and 2007 in a tertiary referral center. The clinical presentation, body mass index, tissue-transglutaminase levels, DEXA scan, vitamin D levels, and vaccine recommendations were assessed. RESULTS Celiac disease presentation changed over time in the two community cohorts. Recently, fewer patients presented with diarrhea and anemia, but constipation and neurologic symptoms were more common. The most recent cohort had a higher proportion of patients who were overweight or obese than the first cohort. However, the body mass index in both community cohorts was higher than in the tertiary referral center. The frequency of osteopenia and osteoporosis was high in both community cohorts. The tertiary referral center patients were younger, presented with a higher proportion of diarrhea and a lower body mass index. CONCLUSIONS The clinical presentation of CeD differs between the community setting and a tertiary referral center. Patients with CeD presenting to the community setting tended to be older, overweight, and to have a high proportion of mineral bone disease.
Collapse
Affiliation(s)
- Giovanni A Roldan
- Internal Medicine Department, Jackson Memorial Hospital, University of Miami, Miami, FL, 33136, USA
- Celiac Center at Beth Israel Deaconess Medical Center, Boston, MA, 02115, USA
| | - Sehrish Jamot
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
| | | | - Amber Charoen
- Division of Gastroenterology, Department of Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI, 02904, USA
| | - Daniel Leffler
- Celiac Center at Beth Israel Deaconess Medical Center, Boston, MA, 02115, USA
| | - Edward R Feller
- Division of Medical Education, Warren Alpert Medical School of Brown University, Providence, RI, 02912, USA
| | - Samir A Shah
- Division of Gastroenterology, Department of Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI, 02904, USA.
- Gastroenterology Associates, Inc., 44 West River Street, Providence, RI, 02904, USA.
| |
Collapse
|
4
|
Rubio-Tapia A, Hill ID, Semrad C, Kelly CP, Greer KB, Limketkai BN, Lebwohl B. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Am J Gastroenterol 2023; 118:59-76. [PMID: 36602836 DOI: 10.14309/ajg.0000000000002075] [Citation(s) in RCA: 69] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/23/2022] [Indexed: 01/06/2023]
Abstract
This guideline presents an update to the 2013 American College of Gastroenterology Guideline on the Diagnosis and Management of Celiac Disease with updated recommendations for the evaluation and management of patients with celiac disease (CD). CD is defined as a permanent immune-mediated response to gluten present in wheat, barley, and rye. CD has a wide spectrum of clinical manifestations that resemble a multisystemic disorder rather than an isolated intestinal disease, and is characterized by small bowel injury and the presence of specific antibodies. Detection of CD-specific antibodies (e.g., tissue transglutaminase) in the serum is very helpful for the initial screening of patients with suspicion of CD. Intestinal biopsy is required in most patients to confirm the diagnosis. A nonbiopsy strategy for the diagnosis of CD in selected children is suggested and discussed in detail. Current treatment for CD requires strict adherence to a gluten-free diet (GFD) and lifelong medical follow-up. Most patients have excellent clinical response to a GFD. Nonresponsive CD is defined by persistent or recurrent symptoms despite being on a GFD. These patients require a systematic workup to rule out specific conditions that may cause persistent or recurrent symptoms, especially unintentional gluten contamination. Refractory CD is a rare cause of nonresponsive CD often associated with poor prognosis.
Collapse
Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ivor D Hill
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children Hospital, Columbus, Ohio, USA
| | - Carol Semrad
- Division of Gastroenterology, University of Chicago, Chicago, Illinois, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Katarina B Greer
- Department of Medicine, Section of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Berkeley N Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California, USA
| | - Benjamin Lebwohl
- Division of Gastroenterology and Hepatology, Columbia University, New York, USA
| |
Collapse
|
5
|
Ching CK, Lebwohl B. Celiac Disease in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2022; 20:238-249. [PMID: 36818495 PMCID: PMC9937540 DOI: 10.1007/s11938-022-00397-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 10/16/2022]
Abstract
Purpose of review This review highlights literature from the past several years and explores the impact on current understanding of celiac disease diagnosis, complications, and management in older adults. Recent findings Celiac disease in the elderly is becoming increasingly prevalent but remains underdiagnosed, with a high potential burden of downstream morbidity and modestly increased risk of mortality. Clinical presentations are often related to extraintestinal symptoms and can be subtle. Duodenal biopsy remains the gold-standard for diagnosis in older adults, along with supporting serologies. Refractory celiac disease is a particular concern in the aging population, and treatment for this rare condition remains unsatisfactory. Older adults exhibit lower rates of mucosal healing, though the reasons for this are poorly understood. Summary Current understanding of celiac disease in the elderly continues to advance, though significant knowledge gaps persist. Large, prospective studies are needed to further characterize celiac disease pathogenesis, complications, and management in older adults.
Collapse
Affiliation(s)
- Charlotte K. Ching
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
6
|
Enaud R, Tetard C, Dupuis R, Laharie D, Lamireau T, Zerbib F, Rivière P, Shili-Mismoudi S, Poullenot F. Compliance with Gluten Free Diet Is Associated with Better Quality of Life in Celiac Disease. Nutrients 2022; 14:nu14061210. [PMID: 35334866 PMCID: PMC8951042 DOI: 10.3390/nu14061210] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/06/2023] Open
Abstract
The quality of life (QOL) of patients with celiac disease (CD) can be altered by both symptoms of the disease and by the restrictions of the gluten-free diet (GFD). The objective was to determine the factors associated with better QOL in a large cohort of CD patients. A link to an online survey was sent to the members of the French Association of Gluten Intolerant People (AFDIAG). The French-Celiac Disease Questionnaire (F-CDQ), scoring from 0 to 100, was used to measure the QOL. Other data collected were sociodemographic characteristics, information on CD, purchasing and consumption habits of gluten-free products, and a self-assessment scale (ranging from 0 to 10) to determine the compliance with the GFD. Among the 907 CD patients who returned the questionnaire, 787 were analyzed (638 women (81%); median age: 49 years; 71% with self-assessed GFD compliance > 8). Their median F-CDQ was 73 (range: 59−82). In multivariate analysis, the main factors associated with a better quality of life were the long duration of the GFD, good compliance with the GFD, and the number of follow-up visits. Compliance with and duration of the GFD are associated with a better quality of life in patients with CD. Taking this into consideration would offset its restrictive aspect and improve its adherence.
Collapse
Affiliation(s)
- Raphaël Enaud
- CHU de Bordeaux, Hôpital des Enfants, Service d’Hépato-Gastroentérologie Pédiatriques, 33000 Bordeaux, France; (R.E.); (C.T.); (T.L.)
| | - Candice Tetard
- CHU de Bordeaux, Hôpital des Enfants, Service d’Hépato-Gastroentérologie Pédiatriques, 33000 Bordeaux, France; (R.E.); (C.T.); (T.L.)
- CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, 33000 Bordeaux, France; (R.D.); (D.L.); (F.Z.); (P.R.); (S.S.-M.)
| | - Raphaël Dupuis
- CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, 33000 Bordeaux, France; (R.D.); (D.L.); (F.Z.); (P.R.); (S.S.-M.)
| | - David Laharie
- CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, 33000 Bordeaux, France; (R.D.); (D.L.); (F.Z.); (P.R.); (S.S.-M.)
| | - Thierry Lamireau
- CHU de Bordeaux, Hôpital des Enfants, Service d’Hépato-Gastroentérologie Pédiatriques, 33000 Bordeaux, France; (R.E.); (C.T.); (T.L.)
| | - Frank Zerbib
- CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, 33000 Bordeaux, France; (R.D.); (D.L.); (F.Z.); (P.R.); (S.S.-M.)
| | - Pauline Rivière
- CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, 33000 Bordeaux, France; (R.D.); (D.L.); (F.Z.); (P.R.); (S.S.-M.)
| | - Sarah Shili-Mismoudi
- CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, 33000 Bordeaux, France; (R.D.); (D.L.); (F.Z.); (P.R.); (S.S.-M.)
| | - Florian Poullenot
- CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, 33000 Bordeaux, France; (R.D.); (D.L.); (F.Z.); (P.R.); (S.S.-M.)
- Correspondence:
| |
Collapse
|
7
|
Jansson-Knodell CL, Kessler WR. The role of female endoscopists: are women gastroenterologists better at obtaining biopsies for celiac disease than men? Scand J Gastroenterol 2021; 56:505-507. [PMID: 33599184 DOI: 10.1080/00365521.2021.1887926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Celiac disease (CD) is commonly found in women. Given the sex differences in diagnosed patients, we hypothesized sex differences in physicians obtaining biopsies for CD may exist. MATERIALS AND METHODS We retrospectively reviewed duodenal biopsies for suspected CD excluding pre-existing CD patients. Appropriate biopsy practice was defined as ≥5 specimens per ACG guidelines. RESULTS We included 125 patients (females, 92). There were 85 properly (68%) biopsied. Presence of a female endoscopist was associated with better adherence to biopsy guidelines (OR, 2.99, 95% CI, 1.19-7.54; p = .02) which remained significant after multivariable adjustment (adjusted OR, 2.7; p = .047). CONCLUSIONS Physician sex-based differences in biopsy patterns may exist.
Collapse
Affiliation(s)
- Claire L Jansson-Knodell
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - William R Kessler
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, IN, USA
| |
Collapse
|
8
|
Lebwohl B, Rubio-Tapia A. Epidemiology, Presentation, and Diagnosis of Celiac Disease. Gastroenterology 2021; 160:63-75. [PMID: 32950520 DOI: 10.1053/j.gastro.2020.06.098] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/22/2020] [Accepted: 06/06/2020] [Indexed: 12/16/2022]
Abstract
The incidence of celiac disease is increasing, partly because of improved recognition of, and testing for, the disease. The rise in incidence is also due to a real increase of this immune-based disorder, independent of disease detection. The reasons for this true rise in recent decades are unknown but may be related to environmental factors that may promote loss of tolerance to dietary gluten. Strategies to reduce the development of celiac disease have not been proven successful in randomized trials, but the quantity of early-life gluten exposure has been a major focus of prevention efforts. The criteria for the diagnosis of celiac disease are changing, but in adults, diagnosis still depends on the presence of duodenal villous atrophy while the patient is on a gluten-containing diet, along with findings from serology analysis. Although guidelines in the United States continue to mandate a biopsy at all ages, some children receive a diagnosis of celiac disease without a biopsy. If proven accurate and scalable, assays that detect gluten-HLA tetramer complexes might be used in diagnosis to be made in the context of a gluten-free diet without intestinal biopsy.
Collapse
Affiliation(s)
- Benjamin Lebwohl
- Department of Medicine, Columbia University Irving Medical Center, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
| | - Alberto Rubio-Tapia
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
9
|
Rockey DC, Altayar O, Falck-Ytter Y, Kalmaz D. AGA Technical Review on Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology 2020; 159:1097-1119. [PMID: 32828801 PMCID: PMC10824166 DOI: 10.1053/j.gastro.2020.06.045] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina
| | - Osama Altayar
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Yngve Falck-Ytter
- Department of Medicine and Gastroenterology, Case Western Reserve; University; Veterans Affairs Northeast Ohio Health System, Cleveland, Ohio
| | - Denise Kalmaz
- Division of Gastroenterology, University of California, San Diego, California
| |
Collapse
|
10
|
King JA, Jeong J, Underwood FE, Quan J, Panaccione N, Windsor JW, Coward S, deBruyn J, Ronksley PE, Shaheen AA, Quan H, Godley J, Veldhuyzen van Zanten S, Lebwohl B, Ng SC, Ludvigsson JF, Kaplan GG. Incidence of Celiac Disease Is Increasing Over Time: A Systematic Review and Meta-analysis. Am J Gastroenterol 2020; 115:507-525. [PMID: 32022718 DOI: 10.14309/ajg.0000000000000523] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To conduct a systematic review and meta-analysis that defines the worldwide incidence of celiac disease (CD) and examines temporal trends. METHODS MEDLINE and EMBASE were searched for population-based studies reporting the incidence of CD in the overall population, children, or adults. No limits were placed on year or language of publication. Studies solely examining at-risk populations (e.g., patients with type 1 diabetes) were excluded. Random-effects models were performed to meta-analyze sex- and age-specific incidence in the 21st century. Temporal trend analyses assessed the average annual percent change in CD incidence over time. RESULTS Of 11,189 citations, 86 eligible studies were identified for inclusion, of which 50 were deemed suitable for analyses. In the 21st century, the pooled female incidence of CD was 17.4 (95% confidence interval [CI]: 13.7, 21.1) (I = 99.5%) per 100,000 person-years, compared with 7.8 (95% CI: 6.3, 9.2) (I = 98.6%) in males. Child-specific incidence was 21.3 per 100,000 person-years (95% CI: 15.9, 26.7) (I = 99.7%) compared with 12.9 (95% CI: 7.6, 18.2) (I = 99.9%) in adults. Pooling average annual percent changes showed the incidence of CD to be increasing by 7.5% (95% CI: 5.8, 9.3) (I = 79.6%) per year over the past several decades. DISCUSSION Incidence of CD is highest in females and children. Overall, the incidence has been significantly rising in the latter half of the 20th century and into the 21st century throughout the Western world. Population-based studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of CD.
Collapse
Affiliation(s)
- James A King
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jocelyn Jeong
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Fox E Underwood
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joshua Quan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicola Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph W Windsor
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephanie Coward
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer deBruyn
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Abdel-Aziz Shaheen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jenny Godley
- Department of Sociology, University of Calgary, Calgary, Alberta, Canada
| | | | - Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong, China
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Gilaad G Kaplan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
11
|
Rates of Duodenal Biopsy During Upper Endoscopy Differ Widely Between Providers: Implications for Diagnosis of Celiac Disease. J Clin Gastroenterol 2019; 53:e61-e67. [PMID: 29095420 PMCID: PMC5930163 DOI: 10.1097/mcg.0000000000000957] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
GOAL The goal of this study is to determine factors associated with performance of duodenal biopsy during upper endoscopy. BACKGROUND Celiac disease (CD) prevalence approaches 1% in the United States and Europe, yet CD remains underdiagnosed, in part because of low rates of duodenal biopsy during upper endoscopy. We aimed to identify patient and provider factors associated with performance of duodenal biopsy during upper endoscopy. STUDY In our hospital-based endoscopy suite, we identified all patients not previously diagnosed with CD who underwent upper endoscopy during a 5-year period for one of the following indications: abdominal pain/dyspepsia, gastroesophageal reflux (GERD), anemia/iron deficiency, diarrhea, and weight loss. We employed univariate and multivariate analysis to determine the association between clinical factors and the performance of duodenal biopsy. RESULTS Of 8572 patients included in the study, 4863 (57%) underwent duodenal biopsy. Of those who underwent duodenal biopsy, 24 (0.49%) were found to have CD. On multivariate analysis, age, gender, indication, gross endoscopic appearance, physician affiliation with a celiac disease center, and absence of a participating trainee were all significantly associated with the performance of duodenal biopsy. There was wide variability among providers, with duodenal biopsy rates ranging from 27% to 91% during these procedures. CONCLUSIONS A duodenal biopsy is more likely to be performed in younger patients, females, and for key indications such as weight loss, diarrhea, and anemia. Providers varied widely in the performance of duodenal biopsy. Further study is warranted to better understand the decision to perform duodenal biopsy and to determine the optimal scenarios for its performance.
Collapse
|
12
|
Silvester JA, Faucher EA, McCarty CE, Kalansky A, Hintze ZJ, Mitchell PD, Goldsmith JD, Weir DC, Leichtner AM. Red Spot Lesions in the Duodenal Bulb Are a Highly Specific Endoscopic Sign of Celiac Disease: A Prospective Study. J Pediatr Gastroenterol Nutr 2019; 68:251-255. [PMID: 30247425 PMCID: PMC6344298 DOI: 10.1097/mpg.0000000000002158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We have recognized red spot lesions (RSLs) in the duodenal bulb in children with celiac disease (CD) and believe they may represent an underappreciated and distinct endoscopic sign of CD. A total of 171 pediatric patients undergoing esophagogastroduodenoscopy with duodenal biopsy for symptoms consistent with CD were prospectively recruited. There were 75 patients who met criteria for CD and the remaining 96 patients served as symptomatic controls. As compared to endoscopic markers frequently mentioned in literature, RSLs had comparable sensitivity, specificity, positive predictive value, and negative predictive value of 31%, 94%, 80%, and 64%, respectively. If RSLs are noted during endoscopy in a patient with gastrointestinal symptoms that might be the result of CD, then sufficient duodenal biopsies to make the diagnosis of CD should be obtained.
Collapse
Affiliation(s)
- Jocelyn A. Silvester
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA
- University of Manitoba, Winnipeg MB, CA
| | | | | | - Adie Kalansky
- Department of Internal Medicine; The Jewish Hospital of Cincinnati, Cincinnati, OH
| | - Zackary J. Hintze
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Paul D. Mitchell
- Institutional Centers for Clinical and Translational Research; Boston Children’s Hospital, Boston, MA
| | | | - Dascha C. Weir
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Alan M. Leichtner
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA
| |
Collapse
|
13
|
Abstract
Coeliac disease is increasingly recognized as a global problem in both children and adults. Traditionally, the findings of characteristic changes of villous atrophy and increased intraepithelial lymphocytosis identified in duodenal biopsy samples taken during upper gastrointestinal endoscopy have been required for diagnosis. Although biopsies remain advised as necessary for the diagnosis of coeliac disease in adults, European guidelines for children provide a biopsy-sparing diagnostic pathway. This approach has been enabled by the high specificity and sensitivity of serological testing. However, these guidelines are not universally accepted. In this Perspective, we discuss the pros and cons of a biopsy-avoiding pathway for the diagnosis of coeliac disease, especially in this current era of the call for more biopsies, even from the duodenal bulb, in the diagnosis of coeliac disease. In addition, a contrast between paediatric and adult guidelines is presented.
Collapse
|
14
|
Shamban L, Sorser S, Naydin S, Lebwohl B, Shukr M, Wiemann C, Yevsyukov D, Piper MH, Warren B, Green PHR. Factors associated with number of duodenal samples obtained in suspected celiac disease. Endosc Int Open 2017; 5:E1220-E1228. [PMID: 29218313 PMCID: PMC5718903 DOI: 10.1055/s-0043-120522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 06/26/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Many people with celiac disease are undiagnosed and there is evidence that insufficient duodenal samples may contribute to underdiagnosis. The aims of this study were to investigate whether more samples leads to a greater likelihood of a diagnosis of celiac disease and to elucidate factors that influence the number of samples collected. PATIENTS AND METHODS We identified patients from two community hospitals who were undergoing duodenal biopsy for indications (as identified by International Classification of Diseases code) compatible with possible celiac disease. Three cohorts were evaluated: no celiac disease (NCD, normal villi), celiac disease (villous atrophy, Marsh score 3), and possible celiac disease (PCD, Marsh score < 3). Endoscopic features, indication, setting, trainee presence, and patient demographic details were evaluated for their role in sample collection. RESULTS 5997 patients met the inclusion criteria. Patients with a final diagnosis of celiac disease had a median of 4 specimens collected. The percentage of patients diagnosed with celiac disease with one sample was 0.3 % compared with 12.8 % of those with six samples ( P = 0.001). Patient factors that positively correlated with the number of samples collected were endoscopic features, demographic details, and indication ( P = 0.001). Endoscopist factors that positively correlated with the number of samples collected were absence of a trainee, pediatric gastroenterologist, and outpatient setting ( P < 0.001). CONCLUSIONS Histological diagnosis of celiac disease significantly increased with six samples. Multiple factors influenced whether adequate biopsies were taken. Adherence to guidelines may increase the diagnosis rate of celiac disease.
Collapse
Affiliation(s)
- Leonid Shamban
- Gastroenterology, Genesys Regional Medical Center, Grand Blanc, Michigan, United States,Corresponding author Leonid Shamban, DO GastroenterologyGenesys Regional Medical CenterOne Genesys ParkwayGrand BlancMichigan 48439-1477United States+1-810-606-5990
| | - Serge Sorser
- Gastroenterology, Providence-Providence Park Hospital, Novi, Michigan, United States
| | - Stan Naydin
- Internal Medicine, Drexel University, Philadelphia, Pennsylvania, United States
| | - Benjamin Lebwohl
- Clinical Medicine, Columbia University, New York, New York, United States
| | - Mousa Shukr
- Internal Medicine, Providence-Providence Park Hospital, Southfield, Michigan, United States
| | - Charlotte Wiemann
- Internal Medicine, Providence-Providence Park Hospital, Southfield, Michigan, United States
| | - Daniel Yevsyukov
- Division of Solid Organ Transplant, University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, United States
| | - Michael H. Piper
- Gastroenterology, Providence-Providence Park, Southfield, Michigan, United States
| | - Bradley Warren
- Gastroenterology, Providence-Providence Park, Southfield, Michigan, United States
| | - Peter H. R. Green
- Clinical Medicine, Columbia University, New York, New York, United States
| |
Collapse
|
15
|
Paez MA, Gramelspacher AM, Sinacore J, Winterfield L, Venu M. Delay in Diagnosis of Celiac Disease in Patients Without Gastrointestinal Complaints. Am J Med 2017. [PMID: 28623177 DOI: 10.1016/j.amjmed.2017.05.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE The purpose of our study is to investigate the delay in diagnosis of patients with biopsy-proven celiac disease in those who present with gastrointestinal complaints vs nongastrointestinal complaints at our tertiary care center. Celiac disease is an autoimmune disorder that affects approximately 1% of the population worldwide. Celiac disease can have variable clinical presentations; it can be characterized by predominately gastrointestinal symptoms, or it may present without any gastrointestinal symptoms. METHODS We retrospectively reviewed the charts of 687 adult patients who carried the diagnosis of celiac disease. Patients included had biopsy-proven celiac disease and were categorized based on presence or absence of gastrointestinal symptoms prior to their diagnosis. RESULTS There were 101 patients with biopsy-proven celiac disease that met inclusion criteria. Fifty-two patients presented with gastrointestinal symptoms and 49 had nongastrointestinal complaints. Results from Mann-Whitney statistical analysis showed a median delay in diagnosis of 2.3 months for the gastrointestinal symptoms group and 42 months for the nongastrointestinal group (P <.001); 43.2% of patients with nongastrointestinal symptoms had abnormal thyroid-stimulating hormone, as opposed to 15.5% in the gastrointestinal symptom group (P = .004). Of patients with nongastrointestinal symptoms, 69.4% had anemia, compared with 11.5% of the gastrointestinal symptom group (P <.001). The majority of patients in the nongastrointestinal symptom group, 68%, were noted to have abnormal bone density scans, compared with 41% in the gastrointestinal symptom group. No sex differences were noted on chi-squared analysis between the 2 groups (P = .997). CONCLUSIONS Although there is growing awareness of celiac disease, the delay in diagnosis for patients without gastrointestinal symptoms remains prolonged, with an average delay of 3.5 years.
Collapse
Affiliation(s)
- Marco A Paez
- Division of Gastroenterology, Department of Medicine, Howard College of Medicine, Washington, DC
| | | | - James Sinacore
- Department of Public Health Sciences, Loyola University Medical Center, Maywood, Ill
| | - Laura Winterfield
- Department of Dermatology, Medical University of South Carolina, Charleston
| | - Mukund Venu
- Division of Gastroenterology, Department of Medicine, Loyola University Medical Center, Maywood, Ill.
| |
Collapse
|
16
|
Is duodenal biopsy appropriate in areas endemic for Helicobacter pylori? North Clin Istanb 2017; 4:13-21. [PMID: 28752138 PMCID: PMC5530152 DOI: 10.14744/nci.2017.85520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/05/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE: The primary reason for obtaining duodenal biopsy sample is to diagnose celiac disease. Helicobacter pylori (H. pylori) and drug injury are common causes of duodenitis. The aim of this retrospective study was to explore effects of H. pylori and drugs on duodenal mucosa. METHODS: Duodenal biopsy samples of patients who underwent upper gastrointestinal endoscopy (UGIE) between February 2014 and December 2014 were retrospectively examined. Clinical symptoms, referral indications, endoscopic findings, H. pylori status, and drug history were recorded. Duodenal biopsy findings were compared based on presence of H. pylori and drug history. RESULTS: Of 2389 patients who underwent UGIE, 206 had duodenal biopsy. Eight patients (3.9%) were diagnosed with celiac disease. After excluding cases with celiac disease, 76 patients of remaining 198 patients (36.9%) had duodenal histopathological abnormality. H. pylori was found in 95 (47.9%) patients. Drug usage was less common (42%). Of patients who had histopathological duodenitis, 59% were H. pylori-infected. Rate of duodenitis was higher in H. pylori (+) group than in H. pylori (-) group (45% vs 27.1%; odds ratio, 2.4; 95% confidence interval, 1.3–4.4; p=0.005). There was no difference between groups regarding drug use in terms of histopathological duodenitis. CONCLUSION: H. pylori is the major contributor to duodenitis in high prevalence regions. Serological testing may be more appropriate before performing duodenal biopsy in patients with suspected celiac disease.
Collapse
|
17
|
Iskandar H, Gray DM, Vu H, Mirza F, Rude MK, Regan K, Abdalla A, Gaddam S, Almaskeen S, Mello M, Marquez E, Meyer C, Bolkhir A, Kanuri N, Sayuk G, Gyawali CP. Coeliac disease screening is suboptimal in a tertiary gastroenterology setting. Postgrad Med J 2017; 93:472-475. [PMID: 28069744 DOI: 10.1136/postgradmedj-2016-134005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 12/13/2016] [Accepted: 12/16/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Coeliac disease (CD) is widely prevalent in North America, but case-finding techniques currently used may not be adequate for patient identification. We aimed to determine the adequacy of CD screening in an academic gastroenterology (GI) practice. METHODS Consecutive initial visits to a tertiary academic GI practice were surveyed over a 3-month period as a fellow-initiated quality improvement project. All electronic records were reviewed to look for indications for CD screening according to published guidelines. The timing of screening was noted (before or after referral), as well as the screening method (serology or biopsy). Data were analysed to compare CD screening practices across subspecialty clinics. RESULTS 616 consecutive patients (49±0.6 years, range 16-87 years, 58.5% females, 94% Caucasian) fulfilled inclusion criteria. CD testing was indicated in 336 (54.5%), but performed in only 145 (43.2%). The need for CD screening was highest in luminal GI and inflammatory bowel disease clinics, followed by biliary and hepatology clinics (p<0.0001); CD screening rate was highest in the luminal GI clinic (p=0.002). Of 145 patients screened, 4 patients (2.4%) had serology consistent with CD, of which 2 were proven by duodenal biopsy. Using this proportion, an additional 5 patients might have been diagnosed in 191 untested patients with indications for CD screening. CONCLUSIONS More than 50% of patients in a tertiary GI clinic have indications for CD screening, but <50% of indicated cases are screened. Case-finding techniques therefore are suboptimal, constituting a gap in patient care and an important target for future quality improvement initiatives.
Collapse
Affiliation(s)
- Heba Iskandar
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA.,Digestive Diseases Division, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Darrell M Gray
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA.,The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hongha Vu
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Faiz Mirza
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Mary Katherine Rude
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Kara Regan
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Adil Abdalla
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Srinivas Gaddam
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Sami Almaskeen
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Michael Mello
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Evelyn Marquez
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Claire Meyer
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Ahmed Bolkhir
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Navya Kanuri
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Gregory Sayuk
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA.,John Cochran Veterans Affairs Medical Center, St Louis, Missouri, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| |
Collapse
|
18
|
Stoven SA, Choung RS, Rubio-Tapia A, Absah I, Lam-Himlin DM, Harris LA, Ngamruengphong S, Vazquez Roque MI, Wu TT, Murray JA. Analysis of Biopsies From Duodenal Bulbs of All Endoscopy Patients Increases Detection of Abnormalities but has a Minimal Effect on Diagnosis of Celiac Disease. Clin Gastroenterol Hepatol 2016; 14:1582-1588. [PMID: 26965842 DOI: 10.1016/j.cgh.2016.02.026] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 02/11/2016] [Accepted: 02/18/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with positive results from serologic tests for celiac disease, analysis of tissues samples from the duodenal bulb, in addition to those from other parts of the small bowel, might increase the diagnostic yield. However, biopsies are not routinely collected from the duodenal bulb because of concerns that villous atrophy detected there could be caused by other disorders (Brunner glands or peptic duodenitis, gastric metaplasia, shorter villi, or lymphoid follicles). We investigated whether analysis of biopsies from duodenal bulbs of all patients undergoing endoscopy (a population with a low probability for celiac disease) increases diagnoses of celiac disease. METHODS We performed a retrospective analysis of data from 679 patients (63% female; mean age, 50 years) from whom duodenal bulb and small bowel biopsies were collected during endoscopy at 3 Mayo Clinic sites, from January 1, 2011 through December 31, 2011. Records were reviewed for age, sex, pathology findings, serology test results (HLA DQ2 or DQ), indications for biopsy analyses, and adherence to a gluten-free diet. Patients with celiac disease were identified on the basis of increased intraepithelial lymphocytosis, with or without villous atrophy and crypt hyperplasia, and results from serology tests. Findings from duodenal bulbs were compared with diagnoses using the Fisher exact test. RESULTS Of all patients undergoing endoscopy, 16 patients (2%) were found to have celiac disease. Analysis of the duodenal bulb biopsies identified 1 patient (0.1%) with celiac disease limited to this region. Of 399 patients whose celiac serology was not known before endoscopic examination, only 2 patients had histologic changes consistent with celiac disease but not limited to duodenal bulb. Abnormal duodenal histology was detected in 265 patients (39%), most commonly in the bulb (n = 241; P < .0001). Of abnormal bulb histologies, chronic peptic duodenitis was most common (observed in 114 patients, 47%). In patients with a normal distal duodenum (n = 576), the duodenal bulb had abnormal histology in 162 (28%). CONCLUSIONS In a low pretest probability cohort, separate sampling of the duodenal bulb had minimal effect on celiac disease detection. Abnormal histologic findings are more commonly detected in the duodenal bulb; although they do not seem to impair identification of celiac disease, their clinical implications are unclear.
Collapse
Affiliation(s)
- Samantha A Stoven
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Imad Absah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Dora M Lam-Himlin
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona
| | - Lucinda A Harris
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | | | | | - Tsung-Teh Wu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; Department of Immunology, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
19
|
Celiac disease diagnosis still significantly delayed - Doctor's but not patients' delay responsive for the increased total delay in women. Dig Liver Dis 2016; 48:1148-54. [PMID: 27401607 DOI: 10.1016/j.dld.2016.06.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/02/2016] [Accepted: 06/10/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is insufficient data on diagnostic delay and associated factors in celiac disease (CeD) as well as on its potential impact on the course of disease. METHODS Specifically taking its two components - patients' and doctors' delay - into account, we performed a large systematic patient survey study among unselected CeD patients in Switzerland. RESULTS We found a mean/median total diagnostic delay of 87/24 months (IQR 5-96), with a range from 0 up to 780 months and roughly equal fractions of patients' and doctors' delay. Both mean/median total (93.1/24 vs. 60.2/12, p<0.001) and doctors' (41.8/3 vs. 23.9/2, p<0.001) diagnostic delay were significantly higher in female vs. male patients, whereas patients' delay was similar, regardless of preceding irritable bowel syndrome diagnosis. Patients with a diagnostic delay shorter than 2 years were significantly less often in need of steroids and/or immunosuppressants, substitution for any nutritional deficiency but more often free of symptoms 6 and 12 months after diagnosis. CONCLUSIONS There is a substantial diagnostic delay in CeD, which is associated with a worse clinical outcome and significantly longer in female patients. This increased diagnostic delay in women is due to doctors' but not patients' delay and cannot be explained by antecedent IBS prior to establishing the CeD diagnosis.
Collapse
|
20
|
Krigel A, Turner KO, Makharia GK, Green PHR, Genta RM, Lebwohl B. Ethnic Variations in Duodenal Villous Atrophy Consistent With Celiac Disease in the United States. Clin Gastroenterol Hepatol 2016; 14:1105-11. [PMID: 27155557 PMCID: PMC4955830 DOI: 10.1016/j.cgh.2016.04.032] [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: 03/07/2016] [Revised: 04/13/2016] [Accepted: 04/18/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Celiac disease is a common disorder with a worldwide distribution, although the prevalence among different ethnicities varies. We aimed to measure the prevalence of duodenal villous atrophy among patients of different ethnicities throughout the United States. METHODS We performed a cross-sectional study of all patients who had duodenal biopsies submitted to a national pathology laboratory between January 2, 2008 and April 30, 2015. The prevalence of villous atrophy was calculated for the following ethnicities by using a previously published algorithm based on patient names: North Indian, South Indian, East Asian, Hispanic, Middle Eastern, Jewish, and other Americans. RESULTS Among all patients (n = 454,885), the median age was 53 years, and 66% were female. The overall prevalence of celiac disease was 1.74%. Compared with other Americans (n = 380,163; celiac disease prevalence, 1.83%), celiac disease prevalence was lower in patients of South Indian (n = 177, 0%; P = .08), East Asian (n = 4700, 0.15%; P ≤ .0001), and Hispanic (n = 31,491, 1.06%; P ≤ .0001) ethnicities. Celiac disease was more common in patients from the Punjab region (n = 617, 3.08%) than in patients from North India (n = 1195, 1.51%; P = .02). The prevalence of celiac disease among patients of Jewish (n = 17,806, 1.80%; P = .78) and Middle Eastern (n = 1903, 1.52%; P = .33) ethnicities was similar to that of other Americans. Among Jewish individuals (n = 17,806), the prevalence of celiac disease was 1.83% in Ashkenazi persons (n = 16,440) and 1.39% in Sephardic persons (n = 1366; P = .24). CONCLUSIONS Among patients undergoing duodenal biopsy, individuals from the Punjab region of India constitute the ethnic group in the United States with the highest prevalence of villous atrophy consistent with celiac disease. Compared with other Americans, villous atrophy prevalence on duodenal biopsy is significantly lower among U.S. residents of South Indian, East Asian, and Hispanic ancestry.
Collapse
Affiliation(s)
- Anna Krigel
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York
| | - Kevin O. Turner
- Miraca Life Sciences Research Institute, Irving, Texas, Department of Pathology, UT Southwestern Medical Center, Dallas, Texas
| | - Govind K. Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Peter HR Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York
| | - Robert M. Genta
- Miraca Life Sciences Research Institute, Irving, Texas, Department of Pathology, UT Southwestern Medical Center, Dallas, Texas
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
| |
Collapse
|
21
|
Abstract
BACKGROUND AND AIMS Celiac disease (CD) is increasingly diagnosed through screening of at-risk groups (relatives of individuals and associated autoimmune disorders). The impact of diagnosis and treatment on screen-detected CD patients is poorly studied, particularly in the United States. We therefore compared the quality of life (QOL) between screen-detected and symptom-detected CD patients. METHODS Patients with a known diagnosis of CD were invited to complete 3 validated survey instruments: the CD Quality of Life (CDQOL), the CD Adherence Test for dietary adherence and the general Psychological General Well-Being index. In addition, demographic details, mode of presentation, and compliance with gluten-free diet (GFD) were assessed. RESULTS The overall response rate was high at 69%. Of 226 responses received, 211 were eligible for inclusion; the median age was 47, and the median duration of GFD was 4 years. One third of the sample (71, 34%) was screen detected. Of these, 57 (80%) had a relative diagnosed with CD, whereas 14 (20%) had an associated condition. Despite being screen detected, 49 (69%) reported symptoms before diagnosis. GFD adherence was excellent and did not differ between groups. Overall, there were no significant differences between screen-detected and symptom-detected patients with regard to CDQOL, CD Adherence Test, and Psychological General Well-Being scores. CONCLUSIONS Screen-detected and symptom-detected CD patients do not differ with regard to QOL or disease adherence as measured by validated disease-specific instruments. A high proportion of screen-detected patients reported symptoms before diagnosis, which often improve with GFD.
Collapse
|
22
|
Mooney PD, Wong SH, Johnston AJ, Kurien M, Avgerinos A, Sanders DS. Increased Detection of Celiac Disease With Measurement of Deamidated Gliadin Peptide Antibody Before Endoscopy. Clin Gastroenterol Hepatol 2015; 13:1278-1284.e1. [PMID: 25632807 DOI: 10.1016/j.cgh.2015.01.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/07/2015] [Accepted: 01/09/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Celiac disease is underdiagnosed. Many patients are examined by endoscopy, but celiac disease is missed or not detected. We evaluated the accuracy of finger prick-based point-of-care tests in the detection of celiac disease and developed an algorithm for diagnosis. METHODS We performed a prospective study of 2 groups of patients with celiac disease evaluated at the Royal Hallamshire Hospital in Sheffield (United Kingdom) from March 2013 through February 2014. In group 1, patients at high risk of celiac disease who tested positive for endomysial antibody (n = 55) were evaluated using the Biocard test (BHR Pharmaceuticals, Nuneaton, UK) and the Celiac Quick Test (Biohit Healthcare UK, Ellesmere Port, UK), which measure antibodies to tissue transglutaminase (anti-tTG), and the Simtomax test (Tillotts Pharma, Rheinfelden, Switzerland), which measures deamidated gliadin peptide antibodies (DGP). Patients in group 2 (508 consecutive patients who underwent an endoscopy examination for any indication) received the DGP test, and also were evaluated using a diagnostic algorithm that incorporated results from the DGP test and data on symptoms. In both groups, point-of-care tests were taken at the time of endoscopy and results were compared with results from histologic analyses of duodenal biopsy specimens from all patients. RESULTS In group 1, the DGP test identified patients with celiac disease with 94.4% sensitivity, the Celiac Quick Test identified patients with 77.8% sensitivity (P = .03 vs the DGP test), and the Biocard test identified patients with 72.2% sensitivity (P = .008 vs the DGP test). In group 2, the DGP test identified patients with celiac disease with 92.7% sensitivity (95% confidence interval, 83.0-97.3), 85.2% specificity (95% confidence interval, 81.5-88.3), a positive predictive value of 49.2% (95% confidence interval, 40.3-58.2), and a negative predictive value of 98.7% (95% confidence interval, 96.8-99.5). Measurement of serum anti-tTG identified patients with celiac disease with 91.2% sensitivity (95% confidence interval, 81.1-96.4), 87.5% specificity (95% confidence interval, 84.0-90.4), a positive predictive value of 53.0% (95% confidence interval, 43.6-62.2), and a negative predictive value of 98.5% (95% confidence interval, 96.5-99.4). The algorithm identified patients with celiac disease with 98.5% sensitivity; its use could reduce duodenal biopsies by 35%. CONCLUSIONS In a prospective study, a test for DGP identified patients with celiac disease with similar levels of sensitivity and specificity as standard serologic analysis of anti-tTG. Use of the DGP test before endoscopy could increase the accuracy of the diagnosis of celiac disease. Further studies, in lower-prevalence populations, are required to assess the impact of the test in clinical practice.
Collapse
Affiliation(s)
- Peter D Mooney
- Royal Hallamshire Hospital, Sheffield, United Kingdom; University of Sheffield, Sheffield, United Kingdom.
| | - Simon H Wong
- University of Sheffield, Sheffield, United Kingdom
| | | | - Matthew Kurien
- Royal Hallamshire Hospital, Sheffield, United Kingdom; University of Sheffield, Sheffield, United Kingdom
| | | | - David S Sanders
- Royal Hallamshire Hospital, Sheffield, United Kingdom; University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
23
|
Dubin SM, Kwong WT, Kalmaz D, Savides TJ. Low yield of routine duodenal biopsies for evaluation of abdominal pain. World J Gastroenterol 2015; 21:7495-9. [PMID: 26139995 PMCID: PMC4481444 DOI: 10.3748/wjg.v21.i24.7495] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/23/2015] [Accepted: 04/16/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the yield of biopsying normal duodenal mucosa for investigation of abdominal pain. METHODS This is a retrospective chart review of consecutive patients who underwent esophagogastroduodenoscopy (EGD) with duodenal biopsies of normal appearing duodenal mucosa for an indication that included abdominal pain. All the patients in this study were identified from an electronic endoscopy database at a single academic medical center and had an EGD with duodenal biopsies performed over a 4-year period. New diagnoses that were made as a direct result of duodenal biopsies were identified. All duodenal pathology reports and endoscopy records were reviewed for indications to perform the examination as well as the findings; all the medical records were reviewed. Exclusion criteria included age less than 18 years, duodenal mass, nodule, or polyp, endoscopic duodenitis, duodenal scalloping, known celiac disease, positive celiac serology, Crohns disease, or history of bone marrow transplant. Information was collected in a de-identified database with pertinent demographic information including human immunodeficiency virus (HIV) status, and descriptive statistics were performed. RESULTS About 300 patients underwent EGD with biopsies of benign appearing or normal appearing duodenal mucosa. The mean age of patients was 44.1 ± 16.8 years; 189 of 300 (63%) were female. A mean of 4.3 duodenal biopsies were performed in each patient. In the subgroup of patients with abdominal pain without anemia, diarrhea, or weight loss the mean age was 43.4 ± 16.3 years. Duodenal biopsies performed for an indication that included abdominal pain resulting in 4 new diagnoses (3 celiac disease and 1 giardiasis) for an overall yield of 1.3%. 183 patients with abdominal pain without anemia, diarrhea, or weight loss (out of the total 300 patients) underwent duodenal biopsy of duodenal mucosa resulting in three new diagnoses (two cases of celiac disease and one giardiasis) for a yield of 1.6%. Duodenal biopsies of 19 HIV patients presenting for evaluation of abdominal pain did not reveal any new diagnoses. Information pertaining to new diagnoses is provided. CONCLUSION Routine biopsy of normal appearing duodena in patients with abdominal pain should be reserved for those with a high pre-test probability given its low diagnostic yield.
Collapse
|
24
|
Trends in celiac disease research. Comput Biol Med 2015; 65:369-78. [PMID: 26095989 DOI: 10.1016/j.compbiomed.2015.05.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 05/14/2015] [Accepted: 05/24/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND To improve diagnosis and treatment of celiac disease (CD), research efforts are being made in many different areas. However, the focus, trend, and direction of such efforts require clarity, so that future efforts and directions can be appropriately planned. METHOD In this study, MEDLINE was used to search for trends in CD research. The keyword 'celiac disease' and its variants were searched in tandem with keywords commonly associated with CD. This search was done for each year from 1960 to 2013. Year of first instance of the associated keyword, linear regression coefficient, and trend in terms of the slope of the regression line were tabulated. For perspective, the same keywords were searched in tandem with 'inflammatory bowel disease' (IBD). RESULTS CD appeared in the medical literature prior to 1960, and IBD first appeared in 1964. However, IBD overtook CD in terms of the number of research papers published per year, beginning in 1988. Keywords with strong positive trends (r(2)>0.7) in association with CD were: 'diagnosis', 'gluten', 'serology', 'autoimmune', 'treatment', 'gluten-free diet', 'endoscopy', 'villous atrophy', 'wasting', 'inflammation', and 'microbiome'. The keyword 'malabsorption' had the sole strong negative trend in association with CD. Keywords with strong positive trends (r(2)>0.7) in association with IBD also had strong positive association with CD: 'autoimmune', 'treatment, 'inflammation', and 'microbiome'. CONCLUSIONS The MEDLINE search approach is helpful to show first instance, association, and trend of keywords that are affiliated with CD in published biomedical research, and to compare CD research trends with those of other diseases.
Collapse
|
25
|
Lebwohl B. Celiac disease and the forgotten 10%: the "silent minority". Dig Dis Sci 2015; 60:1517-8. [PMID: 25875755 PMCID: PMC4456229 DOI: 10.1007/s10620-015-3572-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, Suite 936, New York, NY, 10032, USA,
| |
Collapse
|
26
|
Yap TWC, Chan WK, Leow AHR, Azmi AN, Loke MF, Vadivelu J, Goh KL. Prevalence of serum celiac antibodies in a multiracial Asian population--a first study in the young Asian adult population of Malaysia. PLoS One 2015; 10:e0121908. [PMID: 25799401 PMCID: PMC4370882 DOI: 10.1371/journal.pone.0121908] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 01/15/2015] [Indexed: 02/06/2023] Open
Abstract
Background Celiac disease (CD) is an immune-mediated disorder induced by the ingestion of gluten in genetically susceptible persons. The prevalence of CD in Malaysia is unknown. We aim to determine the seroprevalence of CD antibodies and also investigate the correlation between H. pylori infection and CD in the young and healthy multiracial Malaysian population. Methods Healthy young adult volunteers between the ages of 18–30 years were consecutively recruited from June 2012 to May 2014 at the University of Malaya Medical Centre (UMMC), Kuala Lumpur. Serum samples from all the participants were tested for anti-gliadin antibody immunoglobulin A/immunoglobulin G (IgA/IgG) and anti-tissue transglutaminase antibody (tTG) IgA/IgG. Samples positive for both anti-gliadin and anti-tTG were further validated for anti-human endomysial IgA antibodies (EmA). Serological diagnosis of CD was made when anti-gliadin, anti-tTG and anti-EmA were positive. Results 562 qualified participants with mean age 24 ± 2.4 years old were recruited into our study. CD was found in 7 participants where most of them were asymptomatic and unaware of their CD status. The median of anti-gliadin and anti-tTG IgA/IgG value was 38.2 U/ml (interquartile range, 28.3–60.4 U/ml) and 49.2 U/ml (interquartile range, 41.1–65.9 U/ml), respectively. Seroprevalence of CD antibodies was 1.9% (6 out of 324) in female while only 0.4% (1 out of 238) in male. Seroprevalence among Malay was 0.8% (2 of 236), Chinese was 1.7% (3 of 177) and Indian was 1.3% (2 of 149). Overall, seroprevalence of CD antibodies in healthy asymptomatic adults in the Malaysian population was 1.25% (95% CI, 0.78%-1.72%). No significant relationship was discovered between CD and H. pylori infection. Conclusions The seroprevalence of CD antibodies in healthy young adults in the Malaysian population was 1.25% (1 in 100). CD is underdiagnosed and it could be a much greater problem in Malaysia than previously thought.
Collapse
Affiliation(s)
- Theresa Wan-Chen Yap
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Weng-Kai Chan
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Alex Hwong-Ruey Leow
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Ahmad Najib Azmi
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Mun-Fai Loke
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Jamuna Vadivelu
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Khean-Lee Goh
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
- * E-mail:
| |
Collapse
|
27
|
Rate of celiac disease in children: view from the endoscopy suite. J Pediatr Gastroenterol Nutr 2015; 60:357-9. [PMID: 25714578 DOI: 10.1097/mpg.0000000000000602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The low rate of celiac disease diagnosed in children from the United States may be limited by the practice of "serology-led" diagnosis. The frequency of seronegative celiac disease is unknown, but is underestimated in children and may result in misdiagnosis of celiac disease. The aim of the present study was to investigate the rate of celiac disease after upper endoscopy (esophagogastroduodenescopy [EGD]) with no prior positive celiac serology compared with the rate of celiac disease followed by positive serology. METHODS Charts of all of the first diagnostic EGDs in children (2009-2013) were retrospectively reviewed. Patients with confirmed celiac disease were divided into 4 groups: group A, positive EGD/positive serology (histology-led diagnosis); group B, positive serology/positive histology (serology-led diagnosis); group C, positive histology followed by negative serology (control 1); and group D, positive serology followed by negative histology (control 2). RESULTS A total of 761 upper endoscopic charts were reviewed. Of these, 15 children were confirmed with celiac disease (1.97%). There was no significant difference in the demographic data or clinical symptoms between group A and group B. No significant difference was observed in the rate of celiac disease between histology-led celiac diagnosis (group A) and serology-led celiac diagnosis (group B) (1.18% vs 0.79%, P = 0.273). CONCLUSIONS The rate of celiac disease in endoscopy-led diagnosis was comparable to that in the serology-led diagnosis, suggesting that to increase the detection of celiac disease in children, an adequate number of intestinal biopsies should be performed in every diagnostic upper endoscopic procedure.
Collapse
|
28
|
|
29
|
Mooney PD, Kurien M, Evans KE, Chalkiadakis I, Hale MF, Kannan MZ, Courtice V, Johnston AJ, Irvine AJ, Hadjivassiliou M, Sanders DS. Point-of-care testing for celiac disease has a low sensitivity in endoscopy. Gastrointest Endosc 2014; 80:456-62. [PMID: 24685008 DOI: 10.1016/j.gie.2014.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 02/06/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Celiac disease (CD) is a common but underdiagnosed condition. A rapid point-of-care test (POCT) could reduce lead times and missed diagnoses. OBJECTIVE To assess the utility of an immunoglobulin (Ig) A tissue transglutaminase (TTG) antibody POCT in an endoscopic setting. DESIGN Prospective observational study. SETTING A single UK university hospital. PATIENTS Patients presenting with suspected CD, known CD, and routine endoscopy for upper GI symptoms. INTERVENTIONS All patients were tested with POCT, serum TTG, endomysial antibody (EMA), and upper GI endoscopy with duodenal biopsies at the same visit. MAIN OUTCOME MEASUREMENTS Comparison was made with histology in all cases, with villous atrophy regarded as diagnostic of CD. RESULTS A total of 576 patients (63.5% female, mean [± standard deviation] age 49.7 years [± 17.6 years]) were recruited. A total of 523 patients had no prior diagnosis of CD, and 53 patients had known CD coming for reassessment. A total of 117 patients were newly diagnosed with CD, and 82 were positively identified by the POCT. Sensitivity, specificity, positive predictive value, and negative predictive value were 70.1%, 96.6%, 85.4%, and 91.8%, respectively. In comparison, TTG and EMA both performed significantly better than the POCT. Sensitivity and specificity of TTG were 91.0% and 83.5%, respectively, and EMA were 83.8% and 97.5%, respectively. Of patients with known CD coming for reassessment, 26 had villous atrophy, and POCT results were positive in 16 (61.5%). There was poor agreement between POCT and standard serology. LIMITATIONS High pre-test probability of CD. CONCLUSION The performance of this POCT was disappointing compared with standard serology and cannot at present be recommended within the context of an endoscopy unit.
Collapse
Affiliation(s)
- Peter D Mooney
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Matthew Kurien
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Kate E Evans
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Ioannis Chalkiadakis
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Melissa F Hale
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Mohamad Z Kannan
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Victoria Courtice
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Alexander J Johnston
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Andrew J Irvine
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | | | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| |
Collapse
|
30
|
Ludvigsson JF, Bai JC, Biagi F, Card TR, Ciacci C, Ciclitira PJ, Green PHR, Hadjivassiliou M, Holdoway A, van Heel DA, Kaukinen K, Leffler DA, Leonard JN, Lundin KEA, McGough N, Davidson M, Murray JA, Swift GL, Walker MM, Zingone F, Sanders DS. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut 2014; 63:1210-28. [PMID: 24917550 PMCID: PMC4112432 DOI: 10.1136/gutjnl-2013-306578] [Citation(s) in RCA: 706] [Impact Index Per Article: 70.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A multidisciplinary panel of 18 physicians and 3 non-physicians from eight countries (Sweden, UK, Argentina, Australia, Italy, Finland, Norway and the USA) reviewed the literature on diagnosis and management of adult coeliac disease (CD). This paper presents the recommendations of the British Society of Gastroenterology. Areas of controversies were explored through phone meetings and web surveys. Nine working groups examined the following areas of CD diagnosis and management: classification of CD; genetics and immunology; diagnostics; serology and endoscopy; follow-up; gluten-free diet; refractory CD and malignancies; quality of life; novel treatments; patient support; and screening for CD.
Collapse
Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
| | - Julio C Bai
- Department of Medicine, Dr C. Bonorino Udaondo Gastroenterology Hospital, Del Salvador University, Buenos Aires, Argentina
| | - Federico Biagi
- Coeliac Centre/1st Department of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Timothy R Card
- University of Nottingham, Department of Epidemiology and Public Health, Nottingham City Hospital, Nottingham, UK
| | - Carolina Ciacci
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Paul J Ciclitira
- Gastroenterology, Division of Nutritional Sciences, King's College London, The Rayne Institute, St Thomas Hospital, London, UK
| | - Peter H R Green
- Coeliac Disease Center at Columbia University, New York, New York, USA
| | | | - Anne Holdoway
- Registered dietitian and representative of the British Dietetic Association, Bath, Somerset, UK
| | - David A van Heel
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Katri Kaukinen
- School of Medicine, University of Tampere, Tampere, Finland Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland Department of Medicine, Seinäjoki Central Hospital, Finland
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan N Leonard
- Department of Dermatology, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Knut E A Lundin
- Department of Gastroenterology, Centre for Immune Regulation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | | - Mike Davidson
- Patient Representative & Regional Chairman for Coeliac UK, Sheffield, UK
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Immunology Mayo Clinic, Rochester, Minnesota, USA
| | - Gillian L Swift
- Department of Gastroenterology, University Hospital Llandough, Wales, UK
| | - Marjorie M Walker
- Anatomical Pathology, University of Newcastle, Faculty of Health and Medicine, School of Medicine & Public Health, Callaghan, Australia
| | - Fabiana Zingone
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - David S Sanders
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital & University of Sheffield, Sheffield, UK
| | | | | |
Collapse
|
31
|
Lebwohl B, Murray JA, Rubio-Tapia A, Green PHR, Ludvigsson JF. Predictors of persistent villous atrophy in coeliac disease: a population-based study. Aliment Pharmacol Ther 2014; 39:488-95. [PMID: 24428688 PMCID: PMC4012428 DOI: 10.1111/apt.12621] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 12/11/2013] [Accepted: 12/27/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Villous atrophy (VA) with intraepithelial lymphocytosis is the histological hallmark of coeliac disease (CD), but reported rates of mucosal recovery are variable. AIM To determine the impact of age and other demographic variables on the probability of persistent VA on follow-up biopsy. METHODS We identified patients with VA on duodenal histology at all 28 Swedish pathology departments during the years spanning 1969-2008. We examined age, gender, calendar period, duration of disease and educational attainment to determine predictors of persistent VA. RESULTS Of 7648 patients with CD who underwent follow-up biopsy, persistent VA was present in 3317 (43%; 95% CI 42-44%). The effect of age on persistent VA varied according to time period; among those biopsied in the years spanning 2000-2008, the prevalence of persistent VA was 31%, and increasing age was associated with increasing rates of persistent VA (17% among those younger than 2 years compared to 56% among those ≥70 years). In contrast, persistent VA did not vary widely by age in earlier years. On multivariate analysis (restricted to the calendar period 2000-2008, 2-5 years after CD diagnosis), persistent VA was more common among males (OR 1.43; 95% CI 1.07-1.90) and less common among patients with higher educational attainment (OR for college degree vs. <2 years of high school 0.52, 95% CI 0.35-0.78). CONCLUSIONS The prevalence of persistent villous atrophy has changed over time, with greater rates of healing in recent years. Social differences in persistent villous atrophy suggest that access and/or education regarding the gluten-free diet impact mucosal healing.
Collapse
Affiliation(s)
- Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA,Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Joseph A. Murray
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, USA
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, USA
| | - Peter HR Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jonas F. Ludvigsson
- Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden,Department of Pediatrics, Örebro University Hospital, Sweden,Correspondence and reprint requests: Jonas F. Ludvigsson, Department of Pediatrics, Örebro University Hospital, Sweden, Phone: +46 (0) 19- 6021000, Fax: +46 (0) 19-187915,
| |
Collapse
|
32
|
Lebwohl B, Blaser MJ, Ludvigsson JF, Green PHR, Rundle A, Sonnenberg A, Genta RM. Decreased risk of celiac disease in patients with Helicobacter pylori colonization. Am J Epidemiol 2013; 178:1721-30. [PMID: 24124196 DOI: 10.1093/aje/kwt234] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The prevalence of celiac disease (CD) has increased in recent decades without a clear explanation. The "hygiene hypothesis" theorizes that decreased exposure to bacterial antigens may trigger autoimmunity. We aimed to determine whether Helicobacter pylori infection and CD were associated among patients undergoing upper gastrointestinal endoscopy. We performed a cross-sectional study of patients who underwent esophagogastroduodenoscopy with submission of gastric and duodenal biopsies to Miraca Life Sciences, Inc. (Irving, Texas), a US commercial pathology laboratory, during a 4.5-year period (January 2008-June 2012). We compared the prevalence of H. pylori in CD patients with that in persons without CD. We performed multiple logistic regression analysis, adjusting odds ratios for patient age, gender, and racial, ethnic, and socioeconomic factors. Among 136,179 patients, a total of 2,689 (2.0%) had CD. H. pylori prevalence was significantly lower in patients with CD (4.4%) than in those without CD (8.8%; P < 0.0001). After adjustment for the above covariates, this inverse relationship remained strong (adjusted odds ratio (OR) = 0.48, 95% confidence interval (CI): 0.40, 0.58). The relationships were similar in men (unadjusted OR = 0.51, 95% CI: 0.38, 0.69) and women (unadjusted OR = 0.46, 95% CI: 0.36, 0.58) and in all age groups. We conclude that H. pylori presence and CD are inversely associated, a relationship that persists after adjustment for socioeconomic factors. Future studies should address whether H. pylori modulates immune responses to ingested gluten.
Collapse
|
33
|
Abstract
BACKGROUND Although the prevalence of celiac disease in the USA approaches 1%, most cases are undiagnosed, in part, because of low adherence to the recommendation of submitting at least four specimens during duodenal biopsy. We aimed to determine whether physician and practice characteristics are associated with adherence to this recommendation. MATERIALS AND METHODS We used a large national pathology database to identify all adult patients who underwent duodenal biopsy during 2006-2009. Hierarchical modeling was used to determine whether procedure volume, the number of gastroenterologists per endoscopy suite, and the number of gastroenterologists per capita of the zip code of the practice were associated with adherence. RESULTS We identified 92 580 patients (67% female, mean age 53.5 years) who met our inclusion/exclusion criteria. Specimens were submitted by 669 gastroenterologists from 200 endoscopy suites, located in 191 zip codes, with a mean of 3.4 gastroenterologists per suite. On multivariate analysis, a higher procedure volume was associated with a decreased adherence [odds ratio (OR) for each additional 100 procedures, 0.92; 95% confidence interval (CI), 0.88-0.97; P=0.002]. An increased adherence was reported for gastroenterologists working at suites with higher numbers of gastroenterologists (OR for each additional gastroenterologist, 1.08; 95% CI, 1.04-1.13; P<0.001) but not for a higher gastroenterologist density in the zip code of the practice (OR for each additional gastroenterologist per capita, 1.01; 95% CI, 0.99-1.03; P=0.21). CONCLUSION High-volume physicians exhibit lower rates of adherence to biopsy guidelines, possibly because of the additional time required to submit at least four specimens. In contrast, a greater number of endoscopists working in an endoscopy suite are associated with an increased adherence, possibly because of peer education.
Collapse
|
34
|
Freeman HJ. Detection of adult celiac disease with duodenal screening biopsies over a 30-year period. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 27:405-8. [PMID: 23862172 PMCID: PMC3956015 DOI: 10.1155/2013/347902] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 05/06/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Serological studies suggest that celiac disease may be present in approximately 0.5% to 1% of the North American population. Screening data based on small intestinal biopsy performed during routine endoscopic evaluations are not available. METHODS Patients referred between January 1982 and December 2011 for evaluation of gastrointestinal symptoms and requiring elective investigative upper endoscopic evaluation underwent duodenal biopsies to determine whether changes of adult celiac disease were present. RESULTS A total of 9665 patients, including 4008 (41.5%) males and 5657 (68.5%) females, underwent elective endoscopies and duodenal biopsies. Of these, 234 (2.4%) exhibited changes of celiac disease including 73 males (1.8%) and 161 females (2.8%). During the first 20 years, the number of biopsy-positive patients in five-year intervals progressively decreased and, subsequently, during the next 10 years, the number progressively increased. CONCLUSIONS Celiac disease is far more common in specialist practice than has been suggested in the evaluation of healthy populations using serological screening studies. Endoscopic duodenal biopsy is an important method of identifying underlying celiac disease and should be routinely considered in all patients undergoing an elective endoscopic evaluation. Noninherited factors, possibly environmental, may play a role in the appearance of biopsy-defined celiac disease and alter detection over time.
Collapse
Affiliation(s)
- Hugh James Freeman
- Department of Medicine (Gastroenterology), University of British Columbia, Vancouver, British Columbia, Canada.
| |
Collapse
|
35
|
Lagergren J, Mattsson F, Lagergren P. Clinical implementation of a new antibiotic prophylaxis regimen for percutaneous endoscopic gastrostomy. BMJ Open 2013; 3:bmjopen-2013-003067. [PMID: 23793708 PMCID: PMC3668416 DOI: 10.1136/bmjopen-2013-003067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES This study was undertaken to test the extent to which a new antibiotic prophylaxis regimen for percutaneous endoscopic gastrostomy (PEG), identified as a justified and simpler alternative to conventional regimen in a randomised clinical trial, has been adopted in clinical practice. DESIGN A Swedish nationwide implementation survey, conducted in February 2013, assessed the level of clinical implementation of a 20 ml dose of oral solution of sulfamethoxazole and trimethoprim deposited in the PEG catheter immediately after insertion. All hospitals inserting at least five PEGs annually were identified from the Swedish Patient Registry. A clinician involved in the PEG insertions at each hospital participated in a structured telephone interview addressing their routine use of antibiotic prophylaxis. SETTING All Swedish hospitals inserting PEGs (n=60). PARTICIPANTS Representatives of PEG insertions at each of the 60 eligible hospitals participated (100% participation). MAIN OUTCOME MEASURES Use of routine antibiotic prophylaxis for PEG. RESULTS A total of 32 (53%) of the 60 hospitals had adopted the new regimen. It was more frequently adopted in university hospitals (67%) than in community hospitals (41%). An annual total of 1813 (70%) of 2573 patients received the new regimen. Higher annual hospital volume was associated with a higher level of adoption of the new regimen (80% in the highest vs 31% in the lowest). CONCLUSIONS The clinical implementation of the new antibiotic prophylaxis regimen for PEG was high and rapid (70% of all patients within 3 years), particularly in large hospitals.
Collapse
Affiliation(s)
- Jesper Lagergren
- Unit of Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Division of Cancer Studies, King's College London, London, UK
| | - Fredrik Mattsson
- Unit of Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Lagergren
- Unit of Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
36
|
Collin P, Kaukinen K. Celiac disease: clinch the diagnosis when it is just around the corner. Dig Dis Sci 2013; 58:1165-6. [PMID: 23535878 DOI: 10.1007/s10620-013-2651-8] [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: 12/09/2022]
|
37
|
Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol 2013; 108:656-76; quiz 677. [PMID: 23609613 PMCID: PMC3706994 DOI: 10.1038/ajg.2013.79] [Citation(s) in RCA: 1075] [Impact Index Per Article: 97.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This guideline presents recommendations for the diagnosis and management of patients with celiac disease. Celiac disease is an immune-based reaction to dietary gluten (storage protein for wheat, barley, and rye) that primarily affects the small intestine in those with a genetic predisposition and resolves with exclusion of gluten from the diet. There has been a substantial increase in the prevalence of celiac disease over the last 50 years and an increase in the rate of diagnosis in the last 10 years. Celiac disease can present with many symptoms, including typical gastrointestinal symptoms (e.g., diarrhea, steatorrhea, weight loss, bloating, flatulence, abdominal pain) and also non-gastrointestinal abnormalities (e.g., abnormal liver function tests, iron deficiency anemia, bone disease, skin disorders, and many other protean manifestations). Indeed, many individuals with celiac disease may have no symptoms at all. Celiac disease is usually detected by serologic testing of celiac-specific antibodies. The diagnosis is confirmed by duodenal mucosal biopsies. Both serology and biopsy should be performed on a gluten-containing diet. The treatment for celiac disease is primarily a gluten-free diet (GFD), which requires significant patient education, motivation, and follow-up. Non-responsive celiac disease occurs frequently, particularly in those diagnosed in adulthood. Persistent or recurring symptoms should lead to a review of the patient's original diagnosis to exclude alternative diagnoses, a review of the GFD to ensure there is no obvious gluten contamination, and serologic testing to confirm adherence with the GFD. In addition, evaluation for disorders associated with celiac disease that could cause persistent symptoms, such as microscopic colitis, pancreatic exocrine dysfunction, and complications of celiac disease, such as enteropathy-associated lymphoma or refractory celiac disease, should be entertained. Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice. Given the incomplete response of many patients to a GFD-free diet as well as the difficulty of adherence to the GFD over the long term, development of new effective therapies for symptom control and reversal of inflammation and organ damage are needed. The prevalence of celiac disease is increasing worldwide and many patients with celiac disease remain undiagnosed, highlighting the need for improved strategies in the future for the optimal detection of patients.
Collapse
Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ivor D Hill
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Ciarán P Kelly
- Celiac Center, Division of Gastroenterology, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts
| | - Audrey H Calderwood
- Gastroenterology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
38
|
Lebwohl B, Bhagat G, Markoff S, Lewis SK, Smukalla S, Neugut AI, Green PHR. Prior endoscopy in patients with newly diagnosed celiac disease: a missed opportunity? Dig Dis Sci 2013; 58:1293-8. [PMID: 23361572 PMCID: PMC3661753 DOI: 10.1007/s10620-012-2551-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 12/24/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Celiac disease (CD) is under-diagnosed in the United States, and factors related to the performance of endoscopy may be contributory. AIM To identify newly diagnosed patients with CD who had undergone a prior esophagogastroduodenoscopy (EGD) and examine factors contributing to the missed diagnosis. METHODS We identified all patients age ≥ 18 years whose diagnosis of CD was made by endoscopy with biopsy at our institution (n = 316), and searched the medical record for a prior EGD. We compared those patients with a prior EGD to those with without a prior EGD with regard to age at diagnosis and gender, and enumerated the indications for EGD. RESULTS Of the 316 patients diagnosed by EGD with biopsy at our center, 17 (5 %) had previously undergone EGD. During the prior non-diagnostic EGD, a duodenal biopsy was not performed in 59 % of the patients, and ≥ 4 specimens (the recommended number) were submitted in only 29 % of the patients. On the diagnostic EGD, ≥ 4 specimens were submitted in 94 %. The mean age of diagnosis of those with missed/incident CD was 53.1 years, slightly older than those diagnosed with CD on their first EGD (46.8 years, p = 0.11). Both groups were predominantly female (missed/incident CD: 65 vs. 66 %, p = 0.94). CONCLUSIONS Among 17 CD patients who had previously undergone a non-diagnostic EGD, non-performance of duodenal biopsy during the prior EGD was the dominant feature. Routine performance of duodenal biopsy during EGD for the indications of dyspepsia and reflux may improve CD diagnosis rates.
Collapse
Affiliation(s)
- Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York
| | - Govind Bhagat
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, New York,Department of Pathology and Cell Biology, Columbia University Medical Center, New York
| | - Sarah Markoff
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, New York
| | - Suzanne K. Lewis
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, New York
| | - Scott Smukalla
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, New York
| | - Alfred I. Neugut
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York
| | - Peter HR Green
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, New York
| |
Collapse
|