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Wieser H, Ciacci C, Soldaini C, Gizzi C, Santonicola A. Gastrointestinal and Hepatobiliary Manifestations Associated with Untreated Celiac Disease in Adults and Children: A Narrative Overview. J Clin Med 2024; 13:4579. [PMID: 39124845 PMCID: PMC11312480 DOI: 10.3390/jcm13154579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 08/02/2024] [Accepted: 08/03/2024] [Indexed: 08/12/2024] Open
Abstract
Celiac disease (CeD) is a chronic inflammatory disease of the small intestine, produced by ingesting dietary gluten products in susceptible people. Gluten causes an impairment of the mucosal surface and, consequently, an abnormal absorption of nutrients. Although malabsorption of essential nutrients is a major risk factor for various CeD-associated morbidities, genetic, immunological, and environmental factors also play an important role. The clinical presentation of CeD widely varies and can range from asymptomatic to full-blown symptoms due to the multi-system nature of CeD. The typical gastrointestinal (GI) manifestations of CeD include abdominal pain, diarrhea, bloating, and weight loss, but several hepatobiliary manifestations and a poor nutritional status have also been described. Currently, a gluten-free diet (GFD) is the only current evidence-based treatment that leads to the complete recovery of mucosal damage and the reversibility of its progression. Conversely, undiagnosed CeD might have severe consequences in children as well as in adult patients. This narrative overview aims to characterize the GI and hepatobiliary manifestations, nutritional deficiencies, and delayed pediatric development associated with unrecognized CeD in order to identify it promptly. Moreover, the role of GFD and how it could prevent long-term complications of CeD are described.
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Affiliation(s)
- Herbert Wieser
- Hamburg School of Food Science, Institute of Food Chemistry, University of Hamburg, 20146 Hamburg, Germany;
| | - Carolina Ciacci
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84131 Salerno, Italy; (C.S.); (C.G.); (A.S.)
| | - Carlo Soldaini
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84131 Salerno, Italy; (C.S.); (C.G.); (A.S.)
| | - Carolina Gizzi
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84131 Salerno, Italy; (C.S.); (C.G.); (A.S.)
| | - Antonella Santonicola
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84131 Salerno, Italy; (C.S.); (C.G.); (A.S.)
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Akinsanya A, González IA. Liver manifestation of patients with celiac disease: A single center experience. Ann Diagn Pathol 2024; 71:152327. [PMID: 38754356 DOI: 10.1016/j.anndiagpath.2024.152327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES Characterize the clinicopathologic features of liver biopsies from patients with celiac disease (CD). METHODS Single center, retrospective search for liver biopsies from patients with CD. RESULTS 36 unique patients were included, median age of 46 years (range: 2-75), including 5 pediatric patients, with an overall female predominance (25, 69 %) but in in children a male predominance was seen (p = 0.023). Most cases (75 %) had an underlying condition including autoimmune hepatitis (AIH) (11 %), AIH/primary biliary cholangitis (PBC) overlap (3 %) and PBC (3 %). The median body mass index was 28, with 4 (11 %) underweight and 22 (61 %) overweight/obese patients. The most common histologic pattern was steatosis (18, 50 %), considered severe in 5 (14 %) and in 7 (19 %) regarded as steatohepatitis. The other histologic patterns included a nonspecific portal and/or lobular inflammation ("celiac hepatitis") in 9 cases (25 %), autoimmune hepatitis (3, 8 %), chronic cholestatic pattern (3, 8 %), chronic hepatitis (1, 3 %), acute lobular hepatitis (1, 3 %) and stablished cirrhosis (1, 3 %). Additionally, 2 of the cases with steatosis show cirrhosis. CONCLUSIONS The biopsy findings from patients with CD are heterogenous and in most represent a concomitant underlying disease, particularly metabolic dysfunction-associated steatotic liver disease. Additionally, CD injury should remain in the differential diagnosis in liver biopsies with a nonspecific portal and/or lobular inflammation.
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Affiliation(s)
- Adeyinka Akinsanya
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Iván A González
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America.
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Lungaro L, Costanzini A, Manza F, Caputo F, Remelli F, Volpato S, De Giorgio R, Volta U, Caio G. Celiac Disease: A Forty-Year Analysis in an Italian Referral Center. Nutrients 2024; 16:2292. [PMID: 39064734 PMCID: PMC11279732 DOI: 10.3390/nu16142292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/13/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Celiac disease (CD) is an autoimmune disorder triggered by gluten ingestion. Herein, we assessed clinical, serological and histopathological findings of a single-center, large cohort of CD patients diagnosed and followed-up over forty years. METHODS From January 1980 to December 2020, 1547 CD patients (1170 females; age range: 8-81 years; F:M ratio = 3.1:1) were diagnosed in an Italian tertiary referral center. Comorbidities and complications were recorded at diagnosis and during follow-up. RESULTS CD diagnoses quadrupled after 2000. The most frequent phenotype was the non-classical CD (63.3%), and the most prevalent histotype was Marsh 3C (44.7%). Gastrointestinal manifestations, detectable in 51% of patients, were diarrhea (24.3%), bloating (28%) and aphthous stomatitis (19.7%). The most common CD-associated disorder was osteopenia (59.9%), predominant in females (64.3%); extraintestinal manifestations included anemia (35.8% iron-deficiency; 87% folic acid malabsorption), cryptogenic hypertransaminasemia (27.9%), and recurrent miscarriages (11.5%). Thyroiditis (26.9%), type 1 diabetes mellitus (2.9%), and dermatitis herpetiformis (1.4%) were the most common CD-related autoimmune disorders. Six patients had inflammatory bowel disease. Complications and mortality rate occurred in 1.8% and 1.9%, respectively. CONCLUSIONS This single-center, large cohort analysis confirmed that CD presentation changed over the years, with an increase of non-classical and subclinical clinical phenotypes.
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Affiliation(s)
- Lisa Lungaro
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Anna Costanzini
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Francesca Manza
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Fabio Caputo
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Francesca Remelli
- Department of Medical Science, University of Ferrara, 44124 Ferrara, Italy; (F.R.); (S.V.)
| | - Stefano Volpato
- Department of Medical Science, University of Ferrara, 44124 Ferrara, Italy; (F.R.); (S.V.)
- Geriatrics Unit, Azienda Ospedaliero-Universitaria of Ferrara, 44124 Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Giacomo Caio
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, MA 02114, USA
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Rižnik P, Kamhi Trop T, Klemenak M, Krenčnik T, Milanič-Koron T, Mojškerc EM, Pavlin T, Požek Šavs T, Zupančič J, Dolinšek J. Beyond diagnosis: exploring coeliac disease incidence alongside clinical and laboratory characteristics of newly diagnosed children in Slovenia. Eur J Gastroenterol Hepatol 2024:00042737-990000000-00384. [PMID: 38973532 DOI: 10.1097/meg.0000000000002826] [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: 07/09/2024]
Abstract
OBJECTIVE Coeliac disease is characterized by a wide array of clinical presentations. The focus of our study was to comprehensively assess the clinical manifestations of coeliac disease in newly diagnosed children in Slovenia. Our objectives include estimating the incidence of the disease in children in 2022. METHODS In this prospective study, Slovenian paediatric gastroenterologists were invited to provide patient data using medical records of children under 19 diagnosed with coeliac disease from March 2021 to October 2023. Patient data were collected through a dedicated web-based form adapted from the CD SKILLS project, including data on clinical manifestations and laboratory results. Furthermore, the study included an estimation of the incidence of coeliac disease in children and adolescents in Slovenia in 2022. RESULTS Analysis involved data from 160 children and adolescents (median age: 8 years; 61.9% female). Overall, 16.9% were asymptomatic at diagnosis and 29.4% belonged to a high-risk group for coeliac disease. Among symptomatic cases (N = 133), abdominal pain was the leading symptom (44.4%), followed by anaemia (12.0%) and diarrhoea (10.5%). Malabsorption symptoms were more prevalent in very young children. Anaemia was found in 22.8 and 10.7% had abnormal alanine aminotransferase levels. The estimated incidence of coeliac disease in Slovene children in 2022 was 17.5/100 000. CONCLUSION Abdominal pain emerged as the primary symptom of coeliac disease in children and adolescents, except in very young children where malabsorption symptoms were predominant. Our observation of a lower prevalence of abnormal liver function tests suggests subclinical coeliac disease may be less common in children. Moreover, the calculated coeliac disease incidence in Slovenia aligns with existing data.
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Affiliation(s)
- Petra Rižnik
- Gastroenterology, Hepatology and Nutrition Unit, Paediatric Department, University Medical Centre Maribor, Maribor
| | - Tina Kamhi Trop
- Clinical Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Children's Hospital Ljubljana, Ljubljana
| | - Martina Klemenak
- Gastroenterology, Hepatology and Nutrition Unit, Paediatric Department, University Medical Centre Maribor, Maribor
| | - Tomaž Krenčnik
- Gastroenterology, Hepatology and Nutrition Unit, Paediatric Department, University Medical Centre Maribor, Maribor
| | | | | | - Tatjana Pavlin
- Paediatric Department, General Hospital Novo Mesto, Novo Mesto
| | | | | | - Jernej Dolinšek
- Gastroenterology, Hepatology and Nutrition Unit, Paediatric Department, University Medical Centre Maribor, Maribor
- Paediatric Department, Faculty of Medicine, University of Maribor, Maribor, Slovenia
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Cazac GD, Mihai BM, Ștefănescu G, Gîlcă-Blanariu GE, Mihai C, Grigorescu ED, Onofriescu A, Lăcătușu CM. Celiac Disease, Gluten-Free Diet and Metabolic Dysfunction-Associated Steatotic Liver Disease. Nutrients 2024; 16:2008. [PMID: 38999756 PMCID: PMC11243569 DOI: 10.3390/nu16132008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 06/21/2024] [Accepted: 06/22/2024] [Indexed: 07/14/2024] Open
Abstract
Celiac disease (CD) is a chronic autoimmune disorder triggered by the ingestion of gluten-containing food by genetically predisposed individuals. Hence, treatment of CD consists of permanent avoidance of wheat, rye, barley, and other gluten-containing foods. Lifelong adherence to a gluten-free diet (GFD) improves the symptoms of CD, but recent evidence suggests it is also associated with a higher risk for hepatic steatosis and the coexistence or emergence of other cardiometabolic risk factors. Moreover, a higher risk for liver steatosis is also reported by some authors as a potential extraintestinal complication of the CD itself. Recent nomenclature changes designate the association between hepatic steatosis and at least one of five cardiometabolic risk factors as metabolic dysfunction-associated steatotic liver disease (MASLD). An extended network of potentially causative factors underlying the association between MAFLD and CD, before and after dietary therapy is implemented, was recently described. The individualized treatment of these patients is less supported by evidence, with most of the current recommendations relying on empiric clinical judgment. This review focuses on the causative associations between CD and hepatic injury, either as an extraintestinal manifestation of CD or a side effect of GFD, also referring to potential therapeutic strategies for these individuals.
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Affiliation(s)
- Georgiana-Diana Cazac
- Unit of Diabetes, Nutrition, and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (G.-D.C.); (A.O.); (C.-M.L.)
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Bogdan-Mircea Mihai
- Unit of Diabetes, Nutrition, and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (G.-D.C.); (A.O.); (C.-M.L.)
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Gabriela Ștefănescu
- Unit of Medical Semiology and Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (G.Ș.); (G.-E.G.-B.); (C.M.)
- Institute of Gastroenterology and Hepatology, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Georgiana-Emmanuela Gîlcă-Blanariu
- Unit of Medical Semiology and Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (G.Ș.); (G.-E.G.-B.); (C.M.)
- Institute of Gastroenterology and Hepatology, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Cătălina Mihai
- Unit of Medical Semiology and Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (G.Ș.); (G.-E.G.-B.); (C.M.)
- Institute of Gastroenterology and Hepatology, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Elena-Daniela Grigorescu
- Unit of Diabetes, Nutrition, and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (G.-D.C.); (A.O.); (C.-M.L.)
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Alina Onofriescu
- Unit of Diabetes, Nutrition, and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (G.-D.C.); (A.O.); (C.-M.L.)
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Cristina-Mihaela Lăcătușu
- Unit of Diabetes, Nutrition, and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (G.-D.C.); (A.O.); (C.-M.L.)
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
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Adams DW, Moleski S, Jossen J, Tye-Din JA. Clinical Presentation and Spectrum of Gluten Symptomatology in Celiac Disease. Gastroenterology 2024; 167:51-63. [PMID: 38636679 DOI: 10.1053/j.gastro.2024.01.052] [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: 11/03/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 04/20/2024]
Abstract
Views on the clinical presentation and symptomatology of celiac disease have evolved alongside advances in disease detection and understanding of disease pathogenesis. Although historically regarded as a pediatric illness characterized by malabsorption, it is now better viewed as an immune illness of gluten-specific T cells with systemic manifestations affecting all ages. Its broad presentation, including frequent extraintestinal manifestations and asymptomatic disease, contributes to suboptimal disease detection. Adverse symptoms greatly impact patient quality of life and can result from chronic gluten exposure in untreated disease or those poorly responsive to the gluten-free diet. They can also present as acute symptoms after episodic gluten exposure. Functional gastrointestinal disease is a common comorbidity. Biomarkers like interleukin-2 that are highly sensitive and specific for celiac disease highlight a role for gluten-specific T cells in acute gluten symptomatology. A mechanistic understanding of symptoms will inform approaches to better measure and treat them effectively.
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Affiliation(s)
- Dawn W Adams
- Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephanie Moleski
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jacqueline Jossen
- Departments of Medicine and Pediatrics, The Celiac Disease Center at Columbia University, New York, New York
| | - Jason A Tye-Din
- Immunology Division, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia; Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia; Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
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7
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Narciso-Schiavon JL, Fonseca KK, Silva JS, Rodrigues SST, I-Ching L, Gentili AC, De Meireles CZ, Fonseca JS, Lacombe LA, Schiavon LDL. Acute abdominal perforation as a clinical presentation of coeliac disease. Arab J Gastroenterol 2024; 25:64-66. [PMID: 37989674 DOI: 10.1016/j.ajg.2023.10.003] [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: 10/06/2022] [Revised: 09/26/2023] [Accepted: 10/13/2023] [Indexed: 11/23/2023]
Abstract
Intestinal perforation is described in coeliac disease in the setting of refractoriness or Enteropathy-Associated T-cell Lymphoma (EATL). We report the case of a man with untreated coeliac disease who presented intestinal perforation and was diagnosed with EATL over one year later.
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Affiliation(s)
- Janaína Luz Narciso-Schiavon
- Gastroenterology, Internal Medicine Department - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Gastroenterology Division, Digestive System Unit, University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
| | - Karoline Kuhnen Fonseca
- Gastroenterology Division, Digestive System Unit, University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Jandir Santos Silva
- Gastroenterology Division, Digestive System Unit, University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Sarah Sayuri Tiemi Rodrigues
- Gastroenterology Division, Digestive System Unit, University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Lee I-Ching
- Pathological Anatomy Division - University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Arthur Conelian Gentili
- Pathological Anatomy Division - University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Cintia Zimmermann De Meireles
- Digestive Endoscopy, Digestive System Unit, University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Janaina Sant'Ana Fonseca
- Gastroenterology Division, Digestive System Unit, University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Luiz Augusto Lacombe
- Gastroenterology Division, Digestive System Unit, University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Leonardo De Lucca Schiavon
- Gastroenterology, Internal Medicine Department - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Gastroenterology Division, Digestive System Unit, University Hospital - Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
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8
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Vauquelin B, Rivière P. [Celiac disease]. Rev Med Interne 2023; 44:539-545. [PMID: 37558601 DOI: 10.1016/j.revmed.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/12/2023] [Accepted: 07/25/2023] [Indexed: 08/11/2023]
Abstract
Celiac disease is a frequent auto-immune disease characterized by villous atrophy related to gluten intake in patients with genetic susceptiblity. Patients do not present symptoms in the majority of cases. Presence of the disease must be investigated in case of digestive symptoms or presence of auto-immune disease. Diagnosis is based on anti-transglutaminase antibody and dudodenal biospies. The only available treatment is gluten-free diet. Associated auto-immune diseases must be investigated, especially thyroiditis. Complications related to nutritional deficiency must be accounted for also.
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Affiliation(s)
- B Vauquelin
- Service d'hépato-gastroentérologie et oncologie digestive, centre médico-chirurgical Magellan, CHU de Bordeaux, Bordeaux, France
| | - P Rivière
- Service d'hépato-gastroentérologie et oncologie digestive, centre médico-chirurgical Magellan, CHU de Bordeaux, Bordeaux, France.
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Bari Z, Hadipour M, Fakheri H, Kazemi A, Maleki I, Taghvaei T, Hosseini V, Valizadeh SM, Masoumi D, Shahbazkhani B, Shokri Shirvani J, Tirgar Fakheri S, Ebrahimi R. Epidemiological, Endoscopic, Clinical, and Pathological Features of Patients with Celiac Diseases in Southern Littoral of Caspian Sea. Middle East J Dig Dis 2023; 15:257-262. [PMID: 38523893 PMCID: PMC10955989 DOI: 10.34172/mejdd.2023.355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/29/2023] [Indexed: 03/26/2024] Open
Abstract
Background: Celiac disease is an autoimmune disorder resulting from gluten consumption in genetically predisposed individuals. The present study investigated the epidemiological, endoscopic, and clinicopathological features of patients with celiac disease in the southern littoral of the Caspian Sea. Methods: 140 patients with celiac disease were interviewed and examined regarding demographic characteristics, clinical symptoms, and serologic, endoscopic, and pathological findings. Results: 44 (31.4%) of the patients were male and 68.6% were female. The mean age of the patients at diagnosis was 27.13±13.4 years (ranging from 2 to 60 years). The most common gastrointestinal (GI) symptoms were bloating (47.8%), abdominal pain (47.1%) and diarrhea (30.7%), respectively. Also, 17 (12.1%) patients did not complain of any GI symptoms.18 (12.8%) patients had aphthous stomatitis, 10.7% had dermatitis herpetiformis, 3.6% suffered from itching without a rash, two (1.4%) mentioned psoriasis and one (0.7%) had lichen planus. 19 (19.7%) of the female patients complained of menstrual bleeding disorders, 4% mentioned infertility, and 2% experienced primary amenorrhea. The most common comorbid condition was hypothyroidism in 16 (11.4%) patients. The most common endoscopic finding was duodenal scalloping (37.25%). In addition, 7.8% of the patients had a normal endoscopic appearance. 43 (30.7%) patients were classified as Marsh IIIC, 25.7% Marsh IIIB, 17.8% Marsh IIIA, 12.8% Marsh II and 12.8% were classified as Marsh I. Conclusion: Since celiac disease can present with non-GI manifestations and the majority of our patients had Marsh III classification, it seems that celiac disease must be considered as a routine screening test in GI clinics, and also, it should be kept in mind as a differential diagnosis in other specialty fields.
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Affiliation(s)
- Zohreh Bari
- Department of Internal Medicine, Gut and Liver Research Center, Non-communicable Disease Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Hafez Fakheri
- Department of Internal Medicine, Gut and Liver Research Center, Non-communicable Disease Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Arash Kazemi
- Department of Internal Medicine, Gut and Liver Research Center, Non-communicable Disease Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Iradj Maleki
- Department of Internal Medicine, Gut and Liver Research Center, Non-communicable Disease Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Tarang Taghvaei
- Department of Internal Medicine, Gut and Liver Research Center, Non-communicable Disease Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Vahid Hosseini
- Department of Internal Medicine, Gut and Liver Research Center, Non-communicable Disease Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Seyed Mohammad Valizadeh
- Department of Internal Medicine, Gut and Liver Research Center, Non-communicable Disease Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Danial Masoumi
- Student of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Bijan Shahbazkhani
- Department of Gastroenterology, Imam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Shokri Shirvani
- Department of Internal Medicine, Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Sepehr Tirgar Fakheri
- Gut and Liver Research Center, Non-communicable Disease Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Reyhaneh Ebrahimi
- Gut and Liver Research Center, Non-communicable Disease Research Institute, Mazandaran University of Medical Sciences, Sari, Iran
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Ventura I, Rodriguez B, Suescum S, Revert F, Revert-Ros F, Moreno MA, Prieto-Ruiz JA, Pérez-Bermejo M. More Than Three Years for Normalisation of Routine Laboratory Values after Gluten Withdrawal in Paediatric Coeliac Patients. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1580. [PMID: 37761542 PMCID: PMC10529408 DOI: 10.3390/children10091580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
The assessment of the nutritional and inflammatory status of paediatric patients with coeliac disease is an interesting approach to early diagnosis and functional follow-up. Most authors agree that the normalisation of symptoms takes about one year. The aim of the study was to evaluate the clinical manifestation and normalisation of routine analytics in Spanish children diagnosed with celiac disease. METHODS We performed a retrospective case-control study in Spanish paediatric patients, including 21 celiac patients and 20 healthy controls. The 21 patients selected in the case-control study were followed for 5 years after starting a gluten-free diet (GFD). All patients had type 3 villous atrophy according to the Marsh-Oberhuber classification. A total of 39 blood samples were taken before the start of the GFD, and 109 were taken after. Twenty control sera from healthy donors were used for comparison. RESULTS We found that patients had a subclinical but statistically significant increase in blood calcium, transaminases, and white blood cells, and a decrease in serum iron, at the time of diagnosis. Our study also shows that analytical values normalise within five years on a gluten-free diet. CONCLUSIONS The use of a combination of subclinical changes, including low iron, high calcium, elevated leukocytes, lymphocytes, and ALT levels in blood samples, together with a low growth percentile, is pertinent in detecting coeliac disease. This set of parameters could help in the diagnosis of patients without clinical symptoms. We can also show that the levels of Fe, Ca, transaminases, and leucocytes remain subclinically altered after 3 years, despite the gluten-free diet.
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Affiliation(s)
- Ignacio Ventura
- Molecular and Mitochondrial Medicine Research Group, School of Medicine and Health Sciences, Universidad Católica de Valencia ‘San Vicent Mártir’, 46001 Valencia, Spain; (I.V.); (B.R.); (S.S.); (F.R.); (F.R.-R.); (M.A.M.); (J.A.P.-R.)
- Translational Research Center “San Alberto Magno” CITSAM, Universidad Católica de Valencia ‘San Vicente Mártir’, 46001 Valencia, Spain
| | - Belén Rodriguez
- Molecular and Mitochondrial Medicine Research Group, School of Medicine and Health Sciences, Universidad Católica de Valencia ‘San Vicent Mártir’, 46001 Valencia, Spain; (I.V.); (B.R.); (S.S.); (F.R.); (F.R.-R.); (M.A.M.); (J.A.P.-R.)
| | - Sandra Suescum
- Molecular and Mitochondrial Medicine Research Group, School of Medicine and Health Sciences, Universidad Católica de Valencia ‘San Vicent Mártir’, 46001 Valencia, Spain; (I.V.); (B.R.); (S.S.); (F.R.); (F.R.-R.); (M.A.M.); (J.A.P.-R.)
| | - Fernando Revert
- Molecular and Mitochondrial Medicine Research Group, School of Medicine and Health Sciences, Universidad Católica de Valencia ‘San Vicent Mártir’, 46001 Valencia, Spain; (I.V.); (B.R.); (S.S.); (F.R.); (F.R.-R.); (M.A.M.); (J.A.P.-R.)
- Translational Research Center “San Alberto Magno” CITSAM, Universidad Católica de Valencia ‘San Vicente Mártir’, 46001 Valencia, Spain
| | - Francisco Revert-Ros
- Molecular and Mitochondrial Medicine Research Group, School of Medicine and Health Sciences, Universidad Católica de Valencia ‘San Vicent Mártir’, 46001 Valencia, Spain; (I.V.); (B.R.); (S.S.); (F.R.); (F.R.-R.); (M.A.M.); (J.A.P.-R.)
- Translational Research Center “San Alberto Magno” CITSAM, Universidad Católica de Valencia ‘San Vicente Mártir’, 46001 Valencia, Spain
| | - María Antonia Moreno
- Molecular and Mitochondrial Medicine Research Group, School of Medicine and Health Sciences, Universidad Católica de Valencia ‘San Vicent Mártir’, 46001 Valencia, Spain; (I.V.); (B.R.); (S.S.); (F.R.); (F.R.-R.); (M.A.M.); (J.A.P.-R.)
- Department of Pediatrics, Manises Hospital, 46940 Manises, Spain
| | - Jesús A. Prieto-Ruiz
- Molecular and Mitochondrial Medicine Research Group, School of Medicine and Health Sciences, Universidad Católica de Valencia ‘San Vicent Mártir’, 46001 Valencia, Spain; (I.V.); (B.R.); (S.S.); (F.R.); (F.R.-R.); (M.A.M.); (J.A.P.-R.)
- Translational Research Center “San Alberto Magno” CITSAM, Universidad Católica de Valencia ‘San Vicente Mártir’, 46001 Valencia, Spain
| | - Marcelino Pérez-Bermejo
- SONEV Research Group, Faculty of Medicine and Health Sciences, Catholic University of Valencia, 46001 Valencia, Spain
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11
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Farmer PF, Boyle B, Hill I, Kiel A, Ediger T. Single-Center Analysis of Essential Laboratory Testing in Patients with Newly Diagnosed Celiac Disease. J Pediatr 2023; 259:113487. [PMID: 37201683 DOI: 10.1016/j.jpeds.2023.113487] [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: 04/04/2023] [Revised: 04/25/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To analyze laboratory testing results from pediatric patients newly diagnosed with celiac disease to determine the usefulness of each test derived from recommended guidelines. METHODS Serological testing at the time of diagnosis from patients enrolled in our celiac disease registry from January 2018 through December 2021 was reviewed. The incidence of abnormal laboratory results, routinely obtained as per the recommendations of Snyder et al and our institution's Celiac Care Index, was assessed. Rates of abnormal laboratory values and estimated costs associated with these screening measures were analyzed. RESULTS Our data demonstrated abnormalities in all serological testing obtained at celiac diagnosis. Hemoglobin, alanine aminotransferase, ferritin, iron, and vitamin D screening were found to be abnormal with notable frequency. Only 7% of patients had an abnormal thyroid-stimulating hormone and <0.1% had an abnormal free T4. Nonresponse to hepatitis B vaccination was prominent, with 69% of patients considered nonimmune. Screening protocols as currently outlined in our Celiac Care Index resulted in an estimated cost of approximately $320 000 during our study. CONCLUSIONS Review of screening laboratory results at our center reveals that abnormal values for several recommended measures are uncommon. Thyroid screening was infrequently abnormal and the usefulness of screening for hepatitis B at diagnosis is uncertain. Similarly, our data suggest that iron deficiency screening may be condensed effectively into hemoglobin and ferritin testing, eliminating the need for initial iron studies. Decreasing baseline screening measures could safely decrease the burden of testing on patients and overall healthcare expenditures.
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Affiliation(s)
- Peter F Farmer
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH.
| | - Brendan Boyle
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Ivor Hill
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Ashley Kiel
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Tracy Ediger
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
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12
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Machado MV. New Developments in Celiac Disease Treatment. Int J Mol Sci 2023; 24:ijms24020945. [PMID: 36674460 PMCID: PMC9862998 DOI: 10.3390/ijms24020945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/18/2022] [Accepted: 01/01/2023] [Indexed: 01/06/2023] Open
Abstract
Celiac disease (CD) is a common autoimmune disease affecting around 1% of the population. It consists of an immune-mediated enteropathy, triggered by gluten exposure in susceptible patients. All patients with CD, irrespective of the presence of symptoms, must endure a lifelong gluten-free diet (GFD). This is not an easy task due to a lack of awareness of the gluten content in foods and the extensive incorporation of gluten in processed foods. Furthermore, a GFD imposes a sense of limitation and might be associated with decreased quality of life in CD patients. This results in gluten contamination in the diet of four out of five celiac patients adhering to a GFD. Furthermore, one in three adult patients will report persistent symptoms and two in three will not achieve full histological recovery when on a GFD. In recent years, there has been extensive research conducted in the quest to find the holy grail of pharmacological treatment for CD. This review will present a concise description of the current rationale and main clinical trials related to CD drug therapy.
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Affiliation(s)
- Mariana Verdelho Machado
- Gastroenterology Department, Hospital de Vila Franca de Xira, Estrada Carlos Lima Costa, Nª 2, 2600-009 Vila Franca de Xira, Portugal; ; Tel.: +351-263-006-500
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Avenida Prof. Egas Moniz, 1649-028 Lisbon, Portugal
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13
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Milk Thistle Oilseed Cake Flour Fractions: A Source of Silymarin and Macronutrients for Gluten-Free Bread. Antioxidants (Basel) 2022; 11:antiox11102022. [PMID: 36290745 PMCID: PMC9598143 DOI: 10.3390/antiox11102022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022] Open
Abstract
The utilization of plant by-products as functional food ingredients has received increasing attention in the last decade. One such by-product generated during milk thistle oil pressing is oilseed cakes, which could be used as a novel food ingredient. Therefore, the study aimed at investigating the effects of the addition of milk thistle oilseed cake (MTOC) flour fractions obtained via dry sieving, differing in particle size (unsieved; coarse: >710 µm; medium: 315−710 µm; and fine: <315 µm), on the quality of gluten-free bread and stability of silymarin during breadmaking. The 10% addition of the fractions into gluten-free bread increased the protein, fibre, fat, ash and silymarin content. The breads with the coarse fraction had the highest content of fibre, whereas the breads with the fine fraction excelled in protein, fat and ash content. The medium fraction was characterized as the richest source of silymarin, whilst the fine fraction was the poorest. Silymarin constituents were slightly released during dough rising but also partially decomposed during baking; moreover, silydianin was the most susceptible and degraded the most. The enriched breads had better sensory and textural properties compared to the control bread. The results suggest that MTOC flour fractions can improve the potential health benefits and nutritional profile of gluten-free bread.
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14
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Singh P, Singh AD, Ahuja V, Makharia GK. Who to screen and how to screen for celiac disease. World J Gastroenterol 2022; 28:4493-4507. [PMID: 36157923 PMCID: PMC9476868 DOI: 10.3748/wjg.v28.i32.4493] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/03/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
Celiac disease (CeD) is a chronic gluten-induced enteropathy with plethoric manifestations. The typical manifestations of CeD such as chronic diarrhea and malabsorption are widely recognized, however, many patients have atypical manifestations like iron deficiency anemia, idiopathic short stature, hypertransaminesemia or infertility, etc. These patients often present to the primary care physicians and/or non-gastrointestinal specialties. However, due to a lack of awareness among the healthcare professionals about the various atypical manifestations, many patients are not screened for CeD. In this review, we have summarized the available literature about the prevalence of CeD in various gastrointestinal (chronic diarrhea) and non-gastrointestinal conditions (iron deficiency anemia, short stature, cryptogenic hypertransaminesemia, cryptogenic cirrhosis or idiopathic ataxia etc.) where the diagnosis of CeD should be con-sidered. In addition, we also discuss special scenarios where screening for CeD should be considered even in absence of symptoms such as patients with type 1 diabetes, Down’s syndrome, and first-degree relatives of patients with CeD. Further, we discuss the diagnostic performance and limitations of various screening tests for CeD such as IgA anti-tissue transglutaminase antibodies, anti-endomysial antibodies and anti-deamidated gliadin antibodies. Based on the current recommendations, we propose a diagnostic algorithm for patients with suspected CeD.
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Affiliation(s)
- Prashant Singh
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI 48109, United States
| | | | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India
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15
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Aggarwal M, Garg R, Kumar P, Lindenmeyer CC, Wakim-Fleming J, Jansson-Knodell C, Rubio-Tapia A. Bi-directional Relationship Between Celiac Disease and Liver Chemistries: A Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 68:1369-1380. [PMID: 36002677 DOI: 10.1007/s10620-022-07663-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/05/2022] [Indexed: 12/20/2022]
Abstract
AIMS Previous studies have reported conflicting results regarding prevalence of elevated LC (2-70%) in celiac disease (CD). This systematic review and meta-analysis assessed the prevalence of elevated LC at time of CD diagnosis and associated response to GFD. We also report the prevalence of CD in patients with unexplained elevation of LC. METHODS Studies assessing LC (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in CD patients were eligible. Studies with < 50 cases or in pediatric populations were excluded. RESULTS In total, 20 studies assessing prevalence of elevated LC in 4,265 participants with newly diagnosed CD (mean age = 35.6 ± 6.5 years, 69.8% female) were included. Pooled prevalence of elevated LC was 18.7% (95% CI 13.8-24.8; I2 = 95%). Normalization of elevated LC was seen in 83.1% (95% CI 73.4-89.7; I2 = 79%, 11 studies) of patients after GFD. On meta-regression, age at CD diagnosis, gender, and Marsh grading were not associated with elevated LC. Among 979 participants (7 studies) with unexplained elevation of LC, pooled seroprevalence and biopsy-proven CD was 6.4% (95% CI 2.9-10.3, I2 = 71%) and 4.5% (95% CI 2.6-7.7, I2 = 67%), respectively. CONCLUSION Elevated LC are seen in approximately one-fifth of patients at CD diagnosis with majority normalizing after GFD. Age, gender, and degree of intestinal damage are not predictive of elevated LC. In the appropriate clinical scenario, liver tests should be serially monitored in CD reserving workup for additional causes after a trial of GFD. Patients with unexplained elevation of liver tests should be screened for celiac disease.
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Affiliation(s)
- Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.,Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Rajat Garg
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Prabhat Kumar
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Christina C Lindenmeyer
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Jamile Wakim-Fleming
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Claire Jansson-Knodell
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA.,Celiac Disease Program, Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, A3-208, Cleveland, OH, 44195, USA
| | - Alberto Rubio-Tapia
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA. .,Celiac Disease Program, Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, A3-208, Cleveland, OH, 44195, USA.
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16
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Felber J, Bläker H, Fischbach W, Koletzko S, Laaß M, Lachmann N, Lorenz P, Lynen P, Reese I, Scherf K, Schuppan D, Schumann M, Aust D, Baas S, Beisel S, de Laffolie J, Duba E, Holtmeier W, Lange L, Loddenkemper C, Moog G, Rath T, Roeb E, Rubin D, Stein J, Török H, Zopf Y. Aktualisierte S2k-Leitlinie Zöliakie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:790-856. [PMID: 35545109 DOI: 10.1055/a-1741-5946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jörg Felber
- Medizinische Klinik II - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Hendrik Bläker
- Institut für Pathologie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | | | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum München, München, Deutschland.,Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Polen
| | - Martin Laaß
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Nils Lachmann
- Institut für Transfusionsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Pia Lorenz
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Petra Lynen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Imke Reese
- Ernährungsberatung und -therapie Allergologie, München, Deutschland
| | - Katharina Scherf
- Institute of Applied Biosciences Department of Bioactive and Functional Food Chemistry, Karlsruhe Institute of Technology (KIT), Karlsruhe, Deutschland
| | - Detlef Schuppan
- Institut für Translationale Immunologie, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland.,Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael Schumann
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
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17
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Regev A, Ben-Tov A, Yerushalmy-Feler A, Weintraub Y, Moran-Lev H, Cohen S, Amir AZ. Elevated liver enzymes of newly diagnosed pediatric celiac patients-a prospective-observational study. Eur J Pediatr 2022; 181:753-762. [PMID: 34586475 DOI: 10.1007/s00431-021-04259-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 02/07/2023]
Abstract
Celiac disease clinical presentation is constantly changing. We set to determine the prevalence of elevated transaminases in newly diagnosed celiac patients and to evaluate this sub-group of patients for associated clinical and laboratory findings and assess their natural course of disease following therapeutic diet initiation. We conducted a prospective-observational study of all newly diagnosed pediatric celiac patients, between August 2016 and April 2018, in a pediatric gastroenterology clinic. Clinical data, anthropometrics, and blood test results were recorded at diagnosis and at 3, 6, and 12 months, respectively, of follow-up. We compared patients with normal and elevated transaminases at diagnosis. ALT threshold was set at 24 U/l. Of 125 newly diagnosed celiac patients, 31 (24.8%) had elevated ALT at diagnosis; two (1.6%) with over 3 × ULN. Patients with elevated ALT at diagnosis were significantly younger (mean age 5.5 (SD 3.4) vs. 7.3 (SD 3.7) years, p < 0.01) and more commonly presented with diarrhea (32.3% vs. 14.9%, p = 0.03). Eighty percent of patients with elevated ALT levels normalized their ALT within 3 months and all within 1 year. Following gluten-free diet initiation, patients with elevated ALT had similar clinical course, growth, serology normalization rate, and laboratory results, compared to patients with normal ALT over a 1-year follow-up. A single patient was simultaneously co-diagnosed with celiac disease and autoimmune hepatitis.Conclusion: Clinically significant ALT abnormalities are rare among newly diagnosed pediatric celiac patients. Significant elevations failing to normalize on a gluten-free diet should raise concern of a concomitant primary liver disease and warrant further investigations. What is Known: • Elevated liver enzymes may be an extra-intestinal manifestation of celiac disease. • Reported prevalences of ALT elevations among children with a new diagnosis of celiac disease ranges between 5 and 40%. What is New: • ALT elevations are present in 25% of children with a new diagnosis of celiac disease. • Significant elevations (>3 × ULN) are rare (1.6%). • Elevated liver enzymes are associated with earlier age at diagnosis. • The natural history of patients with elevated liver enzymes at diagnosis is comparable to those without.
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Affiliation(s)
- Asaf Regev
- Pediatrics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. .,Dana-Dwek Children's Hospital, the Tel-Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel.
| | - Amir Ben-Tov
- The Pediatric Gastroenterology, Hepatology & Nutrition Clinic, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Dana-Dwek Children's Hospital, the Tel-Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Anat Yerushalmy-Feler
- The Pediatric Gastroenterology, Hepatology & Nutrition Clinic, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Dana-Dwek Children's Hospital, the Tel-Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Yael Weintraub
- The Pediatric Gastroenterology, Hepatology & Nutrition Clinic, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Dana-Dwek Children's Hospital, the Tel-Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Hadar Moran-Lev
- The Pediatric Gastroenterology, Hepatology & Nutrition Clinic, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Dana-Dwek Children's Hospital, the Tel-Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Shlomi Cohen
- The Pediatric Gastroenterology, Hepatology & Nutrition Clinic, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Dana-Dwek Children's Hospital, the Tel-Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Achiya Z Amir
- The Pediatric Gastroenterology, Hepatology & Nutrition Clinic, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. .,Dana-Dwek Children's Hospital, the Tel-Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel.
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18
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A Potential Role for Bile Acid Signaling in Celiac Disease-Associated Fatty Liver. Metabolites 2022; 12:metabo12020130. [PMID: 35208205 PMCID: PMC8879761 DOI: 10.3390/metabo12020130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 02/06/2023] Open
Abstract
Celiac disease (CeD) is a chronic autoimmune disorder characterized by an intolerance to storage proteins of many grains. CeD is frequently associated with liver damage and steatosis. Bile acid (BA) signaling has been identified as an important mediator in gut–liver interaction and the pathogenesis of non-alcoholic fatty liver disease (NAFLD). Here, we aimed to analyze BA signaling and liver injury in CeD patients. Therefore, we analyzed data of 20 CeD patients on a gluten-free diet compared to 20 healthy controls (HC). We furthermore analyzed transaminase levels, markers of cell death, BA, and fatty acid metabolism. Hepatic steatosis was determined via transient elastography, by MRI and non-invasive scores. In CeD, we observed an increase of the apoptosis marker M30 and more hepatic steatosis as compared to HC. Fibroblast growth factor 19 (FGF19) was repressed in CeD, while low levels were associated with steatosis, especially in patients with high levels of anti-tissue transglutaminase antibodies (anti-tTG). When comparing anti-tTG-positive CeD patients to individuals without detectable anti-tTG levels, hepatic steatosis was accentuated. CeD patients with significant sonographic steatosis (defined by CAP ≥ 283 db/m) were exclusively anti-tTG-positive. In summary, our results suggest that even in CeD patients in clinical remission under gluten-free diet, alterations in gut–liver axis, especially BA signaling, might contribute to steatotic liver injury and should be further addressed in future studies and clinical practice.
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19
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Tarar ZI, Zafar MU, Farooq U, Basar O, Tahan V, Daglilar E. The Progression of Celiac Disease, Diagnostic Modalities, and Treatment Options. J Investig Med High Impact Case Rep 2021; 9:23247096211053702. [PMID: 34693776 PMCID: PMC8767653 DOI: 10.1177/23247096211053702] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Celiac disease (CD) is an autoimmune disorder that affects genetically predisposed individuals who are sensitive to gluten and related proteins. It affects children and adults with increasing prevalence in the older age groups. Both adaptive and innate immune responses play role in CD pathogenesis which results in damage of lamina propria and deposition of intraepithelial lymphocytes. There are other proposed mechanisms of CD pathogenesis like gastrointestinal infections, intestinal microbiota, and early introduction of gluten. The diagnosis of CD is based on clinical symptoms and serological testing, though a majority of cases are asymptomatic, and small intestinal biopsies are required to confirm the diagnosis. Celiac disease is generally associated with other autoimmune diseases, and it is advisable to test these patients for diseases like type 1 diabetes mellitus, Addison’s disease, thyroid diseases, inflammatory bowel disease, and autoimmune hepatitis. The patient with a new diagnosis of CD requires close follow-up after starting treatment to see symptom improvement and check dietary compliance. A newly diagnosed patient is advised to follow with a dietitian to better understand the dietary restrictions as about 20% of patients stay symptomatic even after starting treatment due to noncompliance or poor understanding of diet restrictions. The most effective treatment for CD is a gluten-free diet, but work on non-dietary therapy is in process and few medications are in the clinical trial phase.
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Affiliation(s)
| | | | - Umer Farooq
- Loyola Medicine/MacNeal Hospital, Berwyn, IL, USA
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20
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Voss J, Schneider CV, Kleinjans M, Bruns T, Trautwein C, Strnad P. Hepatobiliary phenotype of individuals with chronic intestinal disorders. Sci Rep 2021; 11:19954. [PMID: 34620902 PMCID: PMC8497585 DOI: 10.1038/s41598-021-98843-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/03/2021] [Indexed: 02/06/2023] Open
Abstract
Despite the known functional relationship between the gut and the liver, the clinical consequences of this circuit remain unclear. We assessed the hepatobiliary phenotype of cohorts with celiac disease (CeD), Crohn´s disease (CD) and ulcerative colitis (UC). Baseline liver function tests and the frequency of hepatobiliary diseases were analyzed in 2377 CeD, 1738 CD, 3684 UC subjects and 488,941 controls from the population-based UK Biobank cohort. In this cohort study associations were adjusted for age, sex, BMI, diabetes, and alcohol consumption. Compared to controls, cohorts with CeD, but not CD/UC displayed higher AST/ALT values. Subjects with CD/UC but not CeD had increased GGT levels. Elevated ALP and cholelithiasis were significantly more common in all intestinal disorders. Non-alcoholic steatohepatitis and hepatocellular carcinoma (HCC) were enriched in CeD and CD (NASH: taOR = 4.9 [2.2-11.0] in CeD, aOR = 4.2 [1.7-10.3] in CD, HCC: aOR = 4.8 [1.8-13.0] in CeD, aOR = 5.9 [2.2-16.1] in CD), while cholangitis was more common in the CD/UC cohorts (aOR = 11.7 [9.1-15.0] in UC, aOR = 3.5 [1.8-6.8] in CD). Chronic hepatitis, autoimmune hepatitis (AIH) and cirrhosis were more prevalent in all intestinal disorders. In UC/CD, a history of intestinal surgery was associated with elevated liver enzymes and increased occurrence of gallstones (UC: aOR = 2.9 [2.1-4.1], CD: 1.7 [1.2-2.3]). Our data demonstrate that different intestinal disorders predispose to distinct hepatobiliary phenotypes. An increased occurrence of liver cirrhosis, NASH, AIH and HCC and the impact of surgery warrant further exploration.
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Affiliation(s)
- Jessica Voss
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Carolin V Schneider
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Moritz Kleinjans
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Tony Bruns
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Christian Trautwein
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Pavel Strnad
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
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21
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Diagnosis and management of secondary causes of steatohepatitis. J Hepatol 2021; 74:1455-1471. [PMID: 33577920 DOI: 10.1016/j.jhep.2021.01.045] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/09/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023]
Abstract
The term non-alcoholic fatty liver disease (NAFLD) was originally coined to describe hepatic fat deposition as part of the metabolic syndrome. However, a variety of rare hereditary liver and metabolic diseases, intestinal diseases, endocrine disorders and drugs may underlie, mimic, or aggravate NAFLD. In contrast to primary NAFLD, therapeutic interventions are available for many secondary causes of NAFLD. Accordingly, secondary causes of fatty liver disease should be considered during the diagnostic workup of patients with fatty liver disease, and treatment of the underlying disease should be started to halt disease progression. Common genetic variants in several genes involved in lipid handling and metabolism modulate the risk of progression from steatosis to fibrosis, cirrhosis and hepatocellular carcinoma development in NAFLD, alcohol-related liver disease and viral hepatitis. Hence, we speculate that genotyping of common risk variants for liver disease progression may be equally useful to gauge the likelihood of developing advanced liver disease in patients with secondary fatty liver disease.
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22
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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: 141] [Impact Index Per Article: 47.0] [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.
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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
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23
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De Leo L, Naviglio S, Vatta S, Benelli E, Stera G, Santon D, Ziberna F, Taddio A, Martelossi S, Giudici F, Giuffrida P, Di Sabatino A, Corazza GR, Ventura A, Not T. Circulating PV-1 as a marker of celiac disease-associated liver injury. Biomark Med 2020; 14:1675-1681. [PMID: 33346700 DOI: 10.2217/bmm-2020-0281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To investigate the role of endothelial PV-1 in patients with untreated celiac disease (CD)-associated liver injury. Materials & methods: PV-1 and PV-1 mRNA were measured in intestinal biopsies from untreated CD patients with elevated or normal alanine transaminase levels, controls, patients with inflammatory bowel disease and patients with toxic liver injury. Circulating PV-1 levels were also evaluated. Results: Circulating PV-1 levels were significantly increased in the serum of patients with CD-associated liver injury and reverted to normal following a gluten-free diet. Mucosal PV-1 and PV-1 mRNA were no different in patients with CD-associated liver injury. Conclusion: Serum but not mucosal PV-1 represents a marker of gluten-dependent liver injury and response to a gluten-free diet in patients with untreated CD.
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Affiliation(s)
- Luigina De Leo
- Institute for Maternal & Child Health IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, Trieste, 34137, Italy
| | - Samuele Naviglio
- Institute for Maternal & Child Health IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, Trieste, 34137, Italy
| | - Serena Vatta
- Institute for Maternal & Child Health IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, Trieste, 34137, Italy
| | - Elisa Benelli
- Department of Medicine, Surgery & Health Sciences, University of Trieste, Strada di Fiume 447, Trieste, 34149, Italy
| | - Giacomo Stera
- Department of Medicine, Surgery & Health Sciences, University of Trieste, Strada di Fiume 447, Trieste, 34149, Italy
| | - Daniela Santon
- Institute for Maternal & Child Health IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, Trieste, 34137, Italy
| | - Fabiana Ziberna
- Institute for Maternal & Child Health IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, Trieste, 34137, Italy
| | - Andrea Taddio
- Institute for Maternal & Child Health IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, Trieste, 34137, Italy.,Department of Medicine, Surgery & Health Sciences, University of Trieste, Strada di Fiume 447, Trieste, 34149, Italy
| | - Stefano Martelossi
- Institute for Maternal & Child Health IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, Trieste, 34137, Italy
| | - Fabiola Giudici
- Department of Medicine, Surgery & Health Sciences, University of Trieste, Strada di Fiume 447, Trieste, 34149, Italy
| | - Paolo Giuffrida
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, P.le C. Golgi 2, Pavia, 27100, Italy
| | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, P.le C. Golgi 2, Pavia, 27100, Italy
| | - Gino R Corazza
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, P.le C. Golgi 2, Pavia, 27100, Italy
| | - Alessandro Ventura
- Institute for Maternal & Child Health IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, Trieste, 34137, Italy.,Department of Medicine, Surgery & Health Sciences, University of Trieste, Strada di Fiume 447, Trieste, 34149, Italy
| | - Tarcisio Not
- Institute for Maternal & Child Health IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, Trieste, 34137, Italy.,Department of Medicine, Surgery & Health Sciences, University of Trieste, Strada di Fiume 447, Trieste, 34149, Italy
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24
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Celiac Disease, Gluten-Free Diet, and Metabolic and Liver Disorders. Nutrients 2020; 12:nu12040940. [PMID: 32231050 PMCID: PMC7230624 DOI: 10.3390/nu12040940] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 12/13/2022] Open
Abstract
Celiac disease (CD) is a chronic autoimmune enteropathy triggered by the ingestion of gluten in genetically predisposed individuals. At the time of diagnosis, the frequency of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis in individuals with CD appears to be similar to that of the general population, although a lower body mass index and a lower rate of hypercholesterolemia and type 2 diabetes mellitus are observed at diagnosis in CD patients. The effect of a gluten-free diet (GFD) in individuals with these liver and metabolic disorders is still a matter of debate. The aim of this study was to investigate the links between a GFD and metabolic/liver disorders in CD patients. A systematic electronic search of the literature from January 2009 to December 2019 was performed using Medline, Web of Science, Scopus, and the Cochrane Library. Only papers written in English concerning metabolic and liver disorders in adult patients with CD were included. Out of 1195 citations, 14 eligible studies were identified. Increases in the frequency of NAFLD, weight gain, and alterations of the lipid profile suggest that important changes happen in celiac patients on a GFD, though the physiopathology of these conditions is unclear. Although a GFD is the only effective treatment available for CD, liver function, body weight, and metabolic and nutritional profiles should be monitored in patients on a GFD.
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25
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Nutrition Assessment, Interventions, and Monitoring for Patients with Celiac Disease: An Evidence Analysis Center Scoping Review. J Acad Nutr Diet 2020; 120:1381-1406. [PMID: 31953154 DOI: 10.1016/j.jand.2019.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Indexed: 11/21/2022]
Abstract
The objectives of this scoping review were to identify and characterize studies examining nutrition assessment, interventions, and measures to monitor gluten-free diet (GFD) adherence/compliance in patients with celiac disease (CD). An electronic literature search of four databases (Cochrane Database for systematic reviews, CINAHL, Embase, and Ovid MEDLINE) was conducted to identify articles examining nutrition care in CD individuals. Except for narrative review, grey literature, and case study/report, all types of peer-reviewed articles published between January 2007 and August 2018 were eligible. There were a total of 10,823 records; 10,368 were excluded during the first round of screening due to irrelevancy and/or duplication. Of the 455 full-text articles that were assessed, 292 met the criteria and were included. Most of the studies were observational studies (n=212), followed by experimental trials (n=50), evidence-based practice guideline (EBPG)/report/statement (n=16), and systematic review (SR) (n=14). Nine original studies examined assessment, focusing mainly on different tools/ways to assess GFD adherence. The majority of the included original articles (n=235) were in the nutrition intervention category with GFD, oats, and prebiotics/probiotics as the top-three most studied interventions. There were eight SRs on GFD and five on oats. One SR and 21 original studies investigated the effectiveness of different measures to monitor GFD adherence/compliance. Although recent CD EBPGs were identified, different methods with varying levels of rigor, in terms of literature search and assessment of evidence strength, were used. Based on this scoping review, interventions focused on gluten-free diet and oats have been significantly covered by either SRs or EBPGs. Studies related to prebiotics/probiotics and education program/counseling focused interventions, as well as assessment, in CD patients have increased in recent years. Thus, it might be beneficial to conduct SRs/EBPGs focused on these topics to guide practitioners.
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Abstract
Celiac disease is a common form of enteropathy with frequent extraintestinal manifestations (EIM). Misrecognition of these presentations may lead to significant delays in diagnosis. Any organ may be involved, either through an immune/inflammatory phenomenon, or nutritional deficiencies. Some EIM, such as gluten ataxia, may be irreversible if left untreated, but most will improve with a gluten-free diet. Knowledge of the various EIM, as well as the associated conditions which do not improve on a gluten-free diet, will avoid delays in the diagnosis and management of celiac disease and associated manifestations.
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Affiliation(s)
- Amelie Therrien
- Department of Medicine, Celiac Center, Division of Gastroenterology, Beth Israel Deaconess Medical Center
- Celiac Research Program, Harvard Medical School
| | - Ciaran P Kelly
- Department of Medicine, Celiac Center, Division of Gastroenterology, Beth Israel Deaconess Medical Center
- Celiac Research Program, Harvard Medical School
| | - Jocelyn A Silvester
- Celiac Research Program, Harvard Medical School
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children Hospital, Boston, MA
- Rady College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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27
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Oxentenko AS, Rubio-Tapia A. Celiac Disease. Mayo Clin Proc 2019; 94:2556-2571. [PMID: 31806106 DOI: 10.1016/j.mayocp.2019.02.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/08/2019] [Accepted: 02/14/2019] [Indexed: 12/16/2022]
Abstract
Celiac disease (CD) affects approximately 1% of the general population, although most cases remain unrecognized. Because CD is a multisystem disorder with protean clinical manifestations, a high index of suspicion is needed to make an appropriate diagnosis. A diagnosis of CD is made in a patient who is genetically predisposed based on the presence of compatible clinical features, positive highly specific celiac serologic findings, duodenal biopsies that document enteropathy, and improvement with a gluten-free diet. The differential diagnoses for the clinical features and the histologic findings seen in patients with CD are numerous and need to be considered; because the management of celiac disease consists of a lifelong gluten-free diet, ensuring that the diagnosis is correctly established is of utmost importance. The aim of this review is to provide practicing clinicians with the most current information on the diagnosis and management of CD, including new developments and the approach to controversial issues.
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Affiliation(s)
- Amy S Oxentenko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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28
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Abstract
Celiac disease is a multisystem disorder. Celiac hepatitis characterized by gluten-responsive mild elevation of transaminases is the more common liver manifestation of celiac disease. Celiac disease may also be associated or coexist with other chronic liver disorders. Shared genetic risk and increased intestinal permeability have been suggested to be the most relevant events in the pathogenesis of liver injury in celiac disease. The aim of this article is to review the full spectrum of liver disorders in patients with celiac disease.
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Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905
| | - Joseph A. Murray
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905
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29
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Cvetkovic L, Bernard G, Galette N, Hétu PO, Vincent C, Bouin M, Therrien A. Discordance Between Serology and Histology for Celiac Disease in a Cohort with Coexisting Liver Disorders. J Can Assoc Gastroenterol 2019; 3:185-193. [PMID: 32671328 PMCID: PMC7338843 DOI: 10.1093/jcag/gwz010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 03/20/2019] [Indexed: 12/13/2022] Open
Abstract
Background The liver and celiac disease (CeD) share a complex relationship. While in some patients, isolated hypertransaminasemia is the only manifestation of CeD, liver diseases (LD) may also be associated with the presence of isolated tissue transglutaminase antibodies IgA (tTG IgA) without histologic evidence of CeD. Aims To examine the yield of tTG IgA testing (a) in the workup for chronic liver disease (CLD) or cytolysis and (b) to identify biopsy-confirmed CeD (BxCeD) among patients with concomitant LD. Methods Retrospective study including two cohorts. Cohort 1 represented 444 consecutive individuals without known CeD for which liver specialists requested tTG IgA. Incidence of positive tTG and BxCeD was evaluated. Cohort 2 included 212 consecutive individuals with positive tTG IgA and subsequent duodenal biopsies. The frequency and clinical characteristics of individuals without BxCeD were examined, with and without concurrent LD. Results The rate of first time positive tTG IgA among the tests requested by a liver specialist (cohort 1) was 2.0% (n = 9). However, 33.0% (n = 3) of these patients did not have BxCeD. Cohort 2 included 33 individuals with coexisting LD, of which 42.4% did not have BxCeD, compared with 16.2% of the patients without LD (P < 0.001). The majority of the patients without BxCeD (65.1%) showed an increase < 3 times upper limit of normal of tTG IgA. Conclusions Although there is clinical value in testing for CeD in the context of LD, there could be a high rate of positive CeD serology unaccompanied by histologic signs in patients with coexisting LD.
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Affiliation(s)
- Lena Cvetkovic
- Department of Medicine - Division of Gastroenterology, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Gabriel Bernard
- Department of Medicine - Division of Gastroenterology, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Nathanaelle Galette
- Department of Medicine - Division of Gastroenterology, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Pierre-Olivier Hétu
- Department of Biochemistry, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Catherine Vincent
- Department of Medicine, Division of Hepatology, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Mickael Bouin
- Department of Medicine - Division of Gastroenterology, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Amelie Therrien
- Department of Medicine - Division of Gastroenterology, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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Abstract
OBJECTIVES Available data indicate that liver involvement is present in a significant proportion of children with celiac disease (CD) at the diagnosis (elevated transaminases 15%-57%, autoimmune liver disease 1%-2%). We sought to evaluate prevalence, clinical course, and risk factors for liver involvement in a large cohort of children with CD. METHODS Children (age 0-18 years) diagnosed with CD from March 2010 to April 2016 were enrolled. Liver involvement was considered to be present when alanine transaminase (ALT) levels were >40 U/L (hypertransaminasemia [HTS]). Patients with HTS were re-evaluated after at least 12 months of a gluten-free diet. RESULTS CD was diagnosed in 806 patients during the study period; of these, ALT levels were available for 700 patients (86.9%), and were elevated in 27 (3.9%, HTS group); median ALT and aspartate transaminase levels in the HTS group were 57 U/L (interquartile range 49-80 U/L) and 67 U/L (interquartile range 53-85 U/L), respectively. Younger age, malabsorption symptoms, and low hemoglobin or ferritin were significantly more common in the HTS group at univariate analysis. At multivariate analysis, only age ≤4.27 years correlated with risk of liver involvement (odds ratio 3.73; 95% confidence interval: 1.61-8.66). When retested on a gluten-free diet, all but 3 patients normalized ALT levels; of these, 1 was diagnosed with sclerosing cholangitis. CONCLUSIONS Liver involvement in celiac children is now less frequent than previously reported, possibly due to changing CD epidemiology. Younger age is the only risk factor. Associated autoimmune liver disease is rare.
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Hujoel IA, Reilly NR, Rubio-Tapia A. Celiac Disease: Clinical Features and Diagnosis. Gastroenterol Clin North Am 2019; 48:19-37. [PMID: 30711209 DOI: 10.1016/j.gtc.2018.09.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The presentation in celiac disease is shifting from the classical malabsorptive presentation to more nonclassical presentations, requiring clinicians to maintain a high level of suspicion for the disease and to be aware of the possible extraintestinal manifestations. The diagnosis of celiac disease is guided by initial screening with serology, followed by confirmation with an upper endoscopy and small intestinal biopsy. In some pediatric cases, biopsy may be avoided.
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Affiliation(s)
- Isabel A Hujoel
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Norelle R Reilly
- Division of Pediatric Gastroenterology, Columbia University Medicine Center, 630 West 168th Street, PH-17, New York, NY 10032, USA
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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32
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Hota D, Bhalla K, Nanda S, Gupta A, Mehra S. Beneficial effects of gluten free diet on IgA tissue transglutaminase levels and various growth parameters in celiac disease patients. J Family Med Prim Care 2019; 8:823-827. [PMID: 31041208 PMCID: PMC6482799 DOI: 10.4103/jfmpc.jfmpc_56_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Context: In the resource poor country like India it is difficult to get HLA screening and EMA testing in patients with celiac disease in small centres. Aims: To study the effect of gluten free diet on IgA tissue transglutaminase levels and various growth parameters in patients with celiac disease. Settings and Design: This was a prospective study conducted in the department of paediatrics of a tertiary referral hospital in north India in 3 stages viz. on presentation, after 3 months and 6 months of initial presentation. Materials and Methods: 392 patients with symptoms suggestive of celiac disease were screened for IgA tTG levels more than 10 folds of upper limit of normal. 50 cases (who followed up for 6 months regularly) were enrolled in the study. Spectrum of various growth and clinical parameters were also studied. Statistical analysis used: Statistical analysis was performed by the SPSS version 20.0. Data were checked for normality before statistical analysis. p value less than 0.05 was considered statistically significant. Results: 50 cases were enrolled in study. After initiation of gluten free diet, improvements were seen in various growth factors like height (12.71%) and weight (3.47 cm) after 6 months. Serum tTG(IgA) levels decreased to 94.88±55.35 U/mL from baseline level of 202±83.96 U/mL after 6 months. Conclusions: Gluten free diet has major role in improvement in growth parameters as well as anemia. So, early detection of celiac disease is an important step in prevention of morbidity associated with this chronic disease.
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Affiliation(s)
- Dayanand Hota
- Department of Paediatrics, All India Institutes of Medical Sciences, Raipur, Chhattisgarh, India
| | - Kapil Bhalla
- Department of Paediatrics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Sanjiv Nanda
- Department of Paediatrics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Ashish Gupta
- Department of Trauma Centre, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Shuchi Mehra
- Department of Microbiology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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Comorbidities in Childhood Celiac Disease: A Phenome Wide Association Study Using the Electronic Health Record. J Pediatr Gastroenterol Nutr 2018; 67:488-493. [PMID: 29746339 DOI: 10.1097/mpg.0000000000002020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Celiac disease (CD) is associated with a variety of extraintestinal autoimmune and inflammatory findings that manifest clinically as symptoms and comorbidities. Understanding these comorbidities may improve identification of the disease and prevent sequelae. In this study, we use an unbiased electronic health record (EHR)-based Phenome Wide Association Study (PheWAS) method to confirm known comorbidities, discover novel associations and enhance characterization of the clinical presentation of CD in children. METHODS Data were extracted from the Nationwide Children's Hospital EHR. Confirmed CD cases (n = 433) were matched with 4330 randomly selected controls. Utilizing an EHR-based PheWAS method to analyze associations of phenotypes with CD, we conducted an unbiased screening of all International Classification of Diseases, 10th revision diagnostic codes and examined significance by performing Fisher's Exact tests. We further tested for the association between CD and 14 previously identified comorbidities in an a priori fashion. RESULTS We found 45 International Classification of Diseases, 10th revision codes significantly associated with CD. Thirteen are known comorbidities and nine are expected symptoms of CD, thus validating our study methods. Further investigation found symptoms that characterized CD clinically and discovered a significant association between eosinophilic disorders of the esophagus and CD. Of 14 previously identified comorbidities, 8 were significantly associated with CD. CONCLUSIONS An EHR-based PheWAS method is a powerful, efficient, and cost-effective method to screen for possible CD comorbidities and validate associations at the population level. Ours is the first PheWAS of CD to confirm a significant association of eosinophilic disorders of the esophagus with CD in a controlled study.
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Jinga M, Popp A, Balaban DV, Dima A, Jurcut C. Physicians' attitude and perception regarding celiac disease: A questionnaire-based study. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2018; 29:419-426. [PMID: 30249556 PMCID: PMC6284647 DOI: 10.5152/tjg.2018.17236] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND/AIMS Despite its high prevalence, affecting about 1% of the general population, celiac disease (CD) remains heavily underdiagnosed. Among the reasons for underdiagnosis, awareness among medical professionals has been little studied. The aim of this survey was to determine physicians' knowledge in regard to CD in adult patients. MATERIALS AND METHODS An 18-items questionnaire pointing out general features, clinical presentation, diagnosis and management of CD patients was addressed to physicians from different medical specialties, in training or board-certified, from one universitary center. RESULTS Altogether 153 physicians were invited to complete the survey (69.3% female, 35.9% gastroenterologists). Overall, 69.9% of the physicians questioned considered CD as a rare disorder. Lymphoma increased risk was highlighted in significant higher proportion by gastroenterologists when compared with physicians of other medical specialty. Chronic diarrhea, weight loss, iron-deficiency anemia, and abdominal pain were the first four conditions recognized as associated with CD, by 94.1%, 76.5%, 61.4%, and 54.2% study participants, respectively. About one-third of respondents (34.5%) affirmed to perform total serum IgA testing in all patients tested for CD. Intestinal biopsy confirmation of a positive celiac serology was reported by 65.4% physicians, with a higher proportion among gastroenterologists: 81.5% versus 56.6%. In regard to CD management, both groups concluded that referral to specialized centers should be recommended. CONCLUSION This study highlights poor awareness among the physicians' in regard to important CD features and diagnostic recommendations in adult patients. More efforts are warranted to improve awareness on CD features among physicians of different medical specialties.
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Affiliation(s)
- Mariana Jinga
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Dr Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - Alina Popp
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Alessandrescu-Rusescu Institute for Mother and Child Health, Bucharest, Romania
| | | | - Alina Dima
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ciprian Jurcut
- Dr Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
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What is causing transaminitis in this 25-year-old patient? JAAPA 2018; 31:55-56. [DOI: 10.1097/01.jaa.0000532130.68777.ad] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lerner A, Shoenfeld Y, Matthias T. Adverse effects of gluten ingestion and advantages of gluten withdrawal in nonceliac autoimmune disease. Nutr Rev 2017; 75:1046-1058. [DOI: 10.1093/nutrit/nux054] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Kang GL, Xu Y, Bao J, Liu XM, Hou YG, Li QL. Clinical features of celiac disease in patients with autoimmune liver disease: Report of 10 cases. Shijie Huaren Xiaohua Zazhi 2017; 25:1968-1975. [DOI: 10.11569/wcjd.v25.i21.1968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the clinical features and prognosis of celiac disease (CD) in patients with autoimmune liver disease (AILD) to improve the level of diagnosis and therapy of this disorder.
METHODS Forty-four patients were enrolled at the First Affiliated Hospital of Zhengzhou University from 2012 to 2016, including 10 CD patients with AILD and 34 CD patients without AILD. Clinical data and survival were evaluated and compared between the two groups.
RESULTS Clinical manifestations and baseline biochemical data in the two groups were comparable (P > 0.05), including no symptoms, fatigue, anorexia, stomachache, diarrhea, dryness of mouth or eye, albumin, prothrombin activity, K+, Na+, immunoglobulin M (IgM), γ-globulin, hemoglobin (Hb) and titers of specific antibodies. There were significant differences in the two groups with regard to jaundice, weight loss, glutamic-pyruvic transaminase (ALT), glutamic-oxaloacetic transaminase (AST), γ-glutamyl transferase (GGT), alkaline phosphatase (ALP), total bilirubin (TBil), and immunoglobulin G (IgG) (P < 0.05). After treatment, 7 (7/10) cases with CD plus had persistently normalized clinical, biochemical parameters, although 3 (3/10) cases did not respond to the treatment and died. In the CD alone group, 33 (33/34) cases had improvement after treatment, and only one patient died. The prognosis in the two groups was significantly different (P = 0.032).
CONCLUSION CD in patients with AILD is not rare. Most of these patients have primary biliary cirrhosis (PBC) or autoimmune hepatitis (AIH) + PBC overlap syndrome. The clinical manifestations of CD with AILD are quite atypical and some patients have no gastrointestinal symptoms. Gluten-free diet (GFD) with glucocorticoid, azathioprine or ursodesoxycholic acid is effective. There is diversity in clinical manifestations and IgG level in CD patients with AILD, and the prognosis is much worse in CD patients with AILD.
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Ivanova II, Dukova DY, Boikova PG, Grudeva LS, Shalev IB, Kotzev IA. Chronic Hepatitis Due to Gluten Enteropathy - a Case Report. Folia Med (Plovdiv) 2017; 59:228-231. [PMID: 28704189 DOI: 10.1515/folmed-2017-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 11/09/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Celiac disease is an immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals. CASE DESCRIPTION A 45-year-old Caucasian woman presented with severe iron-deficient anemia and mild elevation of liver enzymes. Upper endoscopy was done in the context of evaluation of anemia, which revealed reduced duodenal folds and mosaic pattern of the mucosa, but also grade II esophageal varices and portal hypertensive gastropathy. Duodenal biopsy showed total villous atrophy, diffuse mainly lymphocytic infiltrate, presence of intra-epithelial lymphocytes. Serology test confirmed celiac disease by the typical pattern of high titer positive IgA and IgG antibodies to tissue transglutaminase. Liver biopsy was performed for staging and etiological evaluation, because laboratory screening ruled out common viral, metabolic and autoimmune liver disease. Liver morphology was consistent with chronic hepatitis without findings for extensive fibrosis. Our patient had poor dietary compliance, so we failed to established improvement of liver enzymes and resolution of anemia during follow-up. CONCLUSIONS We would like to stress on the diverse clinical manifestations of celiac disease and the importance of serologic screening with antibodies to tissue transglutaminase in differential diagnosis of chronic liver disease.
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Affiliation(s)
- Irina I Ivanova
- Department of Internal Medicine, Prof. Paraskev Stoyanov Medical University, Varna, Bulgaria,Clinic of Gastroenterology, St. Marina University Hospital, Varna, Bulgaria
| | - Denitsa Y Dukova
- Department of Internal Medicine, Prof. Paraskev Stoyanov Medical University, Varna, Bulgaria,Clinic of Gastroenterology, St. Marina University Hospital, Varna, Bulgaria
| | - Pavlina G Boikova
- Department of Internal Medicine, Prof. Paraskev Stoyanov Medical University, Varna, Bulgaria,Clinic of Gastroenterology, St. Marina University Hospital, Varna, Bulgaria
| | - Lili S Grudeva
- Clinic of Gastroenterology, St. Marina University Hospital, Varna, Bulgaria
| | - Ivan B Shalev
- Department of Internal Medicine, Prof. Paraskev Stoyanov Medical University, Varna, Bulgaria,Clinic of Gastroenterology, St. Marina University Hospital, Varna, Bulgaria
| | - Iskren A Kotzev
- Department of Internal Medicine, Prof. Paraskev Stoyanov Medical University, Varna, Bulgaria,Clinic of Gastroenterology, St. Marina University Hospital, Varna, Bulgaria
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Choung RS, Murray JA. Reply. Gastroenterology 2017; 152:1244-1245. [PMID: 28268094 DOI: 10.1053/j.gastro.2017.03.001] [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: 12/02/2022]
Affiliation(s)
- Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Pellicano R. A Question on Liver Function Tests in Patients With Celiac Disease. Gastroenterology 2017; 152:1244. [PMID: 28273437 DOI: 10.1053/j.gastro.2017.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/19/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Rinaldo Pellicano
- Unit of Gastroenterology and Hepatology, Molinette Hospital, Turin, Italy
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Al-Bawardy B, Codipilly DC, Rubio-Tapia A, Bruining DH, Hansel SL, Murray JA. Celiac disease: a clinical review. Abdom Radiol (NY) 2017; 42:351-360. [PMID: 28078381 DOI: 10.1007/s00261-016-1034-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Celiac disease (CD) is an immune-mediated inflammatory enteropathy triggered by gluten exposure in genetically susceptible individuals. It has a high prevalence approaching 1% of the US population. A high index of suspicion is warranted to diagnose CD as frequently patients present with extraintestinal or atypical manifestations. CD is diagnosed by a combination of serum serologies and duodenal biopsies. The majority of patients will respond to a lifelong gluten-free diet which is the cornerstone of therapy. Complications such as refractory CD, ulcerative jejunoileitis, enteropathy associated T-cell lymphoma and small bowel adenocarcinoma occur in a minority of patients.
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Affiliation(s)
- Badr Al-Bawardy
- Division of Gastroenterology & Hepatology, Mayo Clinic, 200 First Street, S.W., Rochester, MN, 55905, USA.
| | | | - Alberto Rubio-Tapia
- Division of Gastroenterology & Hepatology, Mayo Clinic, 200 First Street, S.W., Rochester, MN, 55905, USA
| | - David H Bruining
- Division of Gastroenterology & Hepatology, Mayo Clinic, 200 First Street, S.W., Rochester, MN, 55905, USA
| | - Stephanie L Hansel
- Division of Gastroenterology & Hepatology, Mayo Clinic, 200 First Street, S.W., Rochester, MN, 55905, USA
| | - Joseph A Murray
- Division of Gastroenterology & Hepatology, Mayo Clinic, 200 First Street, S.W., Rochester, MN, 55905, USA
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ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries. Am J Gastroenterol 2017; 112:18-35. [PMID: 27995906 DOI: 10.1038/ajg.2016.517] [Citation(s) in RCA: 600] [Impact Index Per Article: 85.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 09/01/2016] [Indexed: 02/06/2023]
Abstract
Clinicians are required to assess abnormal liver chemistries on a daily basis. The most common liver chemistries ordered are serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase and bilirubin. These tests should be termed liver chemistries or liver tests. Hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels. Cholestatic injury is defined as disproportionate elevation of alkaline phosphatase level as compared with AST and ALT levels. The majority of bilirubin circulates as unconjugated bilirubin and an elevated conjugated bilirubin implies hepatocellular disease or cholestasis. Multiple studies have demonstrated that the presence of an elevated ALT has been associated with increased liver-related mortality. A true healthy normal ALT level ranges from 29 to 33 IU/l for males, 19 to 25 IU/l for females and levels above this should be assessed. The degree of elevation of ALT and or AST in the clinical setting helps guide the evaluation. The evaluation of hepatocellular injury includes testing for viral hepatitis A, B, and C, assessment for nonalcoholic fatty liver disease and alcoholic liver disease, screening for hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency. In addition, a history of prescribed and over-the-counter medicines should be sought. For the evaluation of an alkaline phosphatase elevation determined to be of hepatic origin, testing for primary biliary cholangitis and primary sclerosing cholangitis should be undertaken. Total bilirubin elevation can occur in either cholestatic or hepatocellular diseases. Elevated total serum bilirubin levels should be fractionated to direct and indirect bilirubin fractions and an elevated serum conjugated bilirubin implies hepatocellular disease or biliary obstruction in most settings. A liver biopsy may be considered when serologic testing and imaging fails to elucidate a diagnosis, to stage a condition, or when multiple diagnoses are possible.
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Albuquerque A, Rodrigues S, Macedo G. High levels of immunoglobulin A anti-tissue transglutaminase antibodies at diagnosis are a predictive factor for celiac hepatitis. Scand J Gastroenterol 2016; 51:1316-20. [PMID: 27387923 DOI: 10.1080/00365521.2016.1203017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Celiac hepatitis is characterized by the presence of liver injury in patients with celiac disease that resolves after gluten-free diet. AIM To evaluate predictive factors of celiac hepatitis at celiac disease diagnosis. METHODS Retrospective study including 46 adult patients with the diagnosis of celiac disease. RESULTS Eighty-seven percent were women, with a mean age of 33 ± 11 years, 87% had a Marsh 3 and 46% (n = 21) had celiac hepatitis. These patients had a median Immunoglobulin A anti-tissue transglutaminase antibody (TTG-IgA) level of 208.0 U/ml (p25-p75: 89-1316 U/ml), a mean aspartate aminotransferase of 42 ± 24 U/L, alanine aminotransferase 50 ± 28 U/L, alkaline phosphatase 111 ± 64 U/L, at the time of diagnosis. Median TTG-IgA one year after diagnosis was 9U/ml (p25-p75: 4.5-30.5 U/ml) and 33% of the patients had normal values. At diagnosis, patients without celiac hepatitis had a median TTG-IgA of 77U/ml (p25-p75: 24-288 U/ml), mean aspartate aminotransferase of 23 ± 4 U/L, alanine aminotransferase 20 ± 6 U/L, alkaline phosphatase 69 ± 17 U/L. Median of TTG-IgA one year after diagnosis was 6 U/ml (p25-p75: 3-19 U/ml) and 48% had normal values. The celiac hepatitis group patients had higher values of TTG-IgA (p = 0.007) at diagnosis. There was a statistically significant positive correlation between TTG-IgA and alanine aminotransferase (r = 0.324, p = 0.028) at diagnosis. The odds of having celiac hepatitis was almost 5-fold higher in patients with a TTG-IgA level higher than 310 U/ml (OR = 4.8, 95%CI = 1.213-18.781, p = 0.025). CONCLUSIONS Higher TTG-IgA levels are a predictive factor for celiac hepatitis in adult patients with celiac disease at diagnosis.
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Affiliation(s)
- Andreia Albuquerque
- a Department of Gastroenterology , Centro Hospitalar São João , Porto , Portugal
| | - Susana Rodrigues
- a Department of Gastroenterology , Centro Hospitalar São João , Porto , Portugal
| | - Guilherme Macedo
- a Department of Gastroenterology , Centro Hospitalar São João , Porto , Portugal
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Prevalence and associated factors of abnormal liver values in children with celiac disease. Dig Liver Dis 2016; 48:1023-9. [PMID: 27338852 DOI: 10.1016/j.dld.2016.05.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 05/23/2016] [Accepted: 05/24/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prevalence and factors associated with transaminasemia in celiac disease are poorly known. AIMS To investigate these issues in paediatric celiac patients and controls. METHODS Alanine aminotransferase (ALT) was studied in 150 children with untreated celiac disease, 161 disease controls and 500 population-based controls. The association between ALT and clinical and histological variables and the effect of a gluten-free diet were investigated in celiac patients. RESULTS ALT was >30U/l: celiac disease 14.7%, ulcerative colitis 37.2%, Crohn's disease 16.7%, reflux disease 16.2%, functional gastrointestinal symptoms 8.9%, and controls 3.6%. Factors associated with increased ALT were poor growth (45.5% vs 24.2%, P=0.039) and severe villous atrophy (median 23.0U/l vs partial atrophy 19.0U/l, P=0.008), but not age, sex, body-mass index, type or severity of symptoms and co-morbidities. ALT had a moderate correlation with endomysial (r=0.334, P<0.001) and transglutaminase antibodies (r=0.264, P=0.002) and ferritin (r=-0.225, P=0.03), but not with other laboratory values. On gluten-free diet median ALT decreased from 22.0U/l to 18.0U/l (P=0.002) and 80% of the high values normalized. CONCLUSION Increased ALT is associated with more advanced serological and histological celiac disease. Adherence to a gluten-free diet appears to result in normalization or reduction of ALT levels.
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Abstract
OBJECTIVES The aim of the present study was to determine the proportion of pediatric patients with celiac disease (CD) who had transaminases obtained at diagnosis and to determine the proportion with hypertransaminasemia. METHODS Data from newly diagnosed patients with CD at Nationwide Children's Hospital from February 2007 to March 2014 were retrospectively reviewed. Alanine transaminase (ALT) and aspartate transaminase (AST) values at diagnosis and after initiation of a gluten-free diet (GFD) were assessed. RESULTS Of 388 patients (mean age 10.1 ± 4.4 years, 235 girls), 185 (47.7%) had transaminases obtained at the time of diagnosis. Twenty-eight of one hundred eighty-five (15.1%) had an elevated ALT and/or AST level with an average ALT 2.52 × upper limit of normal (ULN) and AST 1.87 × ULN. Those with hypertransaminasemia were younger than those with normal levels (6.31 ± 4.75 vs 11.00 ± 4.28 years, P < 0.0001). Sex, symptoms at diagnosis, and weight, height, and body mass index z scores were not predictive of elevated transaminases. Of the 21 patients with hypertransaminasemia at diagnosis who had repeat laboratory test results after starting the GFD, 15 (71.4%) normalized whereas 6 (28.6%) remained elevated. CONCLUSIONS There is variation in practice among pediatric gastroenterologists in the assessment of transaminases in children with CD. Hypertransaminasemia is present at diagnosis in a significant proportion of children with CD although at a lower frequency than previously reported. Younger patients are more likely to have an elevation in transaminases. Abnormal transaminases normalize in the majority of patients within 1 year after initiation of a GFD.
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46
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Tran MMA, Browne M. Coeliac disease presenting as apparent haemochromatosis. Intern Med J 2016; 46:860-2. [PMID: 27405898 DOI: 10.1111/imj.13083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 11/04/2015] [Accepted: 11/04/2015] [Indexed: 11/28/2022]
Affiliation(s)
- M M A Tran
- Westmead Hospital, Sydney, New South Wales, Australia
| | - M Browne
- North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
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Marciano F, Savoia M, Vajro P. Celiac disease-related hepatic injury: Insights into associated conditions and underlying pathomechanisms. Dig Liver Dis 2016; 48:112-9. [PMID: 26711682 DOI: 10.1016/j.dld.2015.11.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/11/2015] [Accepted: 11/17/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Celiac disease (CD) is the most common autoimmune enteropathy. Clinical manifestations may range from a typical malabsorption syndrome to several apparently unrelated extra-intestinal symptoms. AIM Here we specifically focus on the spectrum of CD-related liver disorders and the underlying pathomechanisms. METHODS A computer-based search up to August 2015 was completed using appropriate keywords. References from selected papers were also reviewed and used if relevant. RESULTS An unexplained hypertransaminasemia with nonspecific histologic hepatic changes is the most common hepatic presentation. CD however can coexist with a number of liver disorders such as Autoimmune Hepatitis, Autoimmune Cholangitis, Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis requiring a specific treatment in addition to gluten-free diet. CD has also been associated with Viral Hepatitis, Fatty Liver, Non-Alcoholic Steatohepatitis and some severe cryptogenic hepatopaties in the liver transplantation list. Pathomechanisms underlying hepatic injury in CD are multiple, appear still not completely defined and may probably co-occur. CONCLUSIONS An ever-increasing number of CD-related liver injuries exist, probably representing a continuum of a same disorder where genetic predisposition, timing, and duration of previous gluten exposure might influence the reversibility of liver damage. Evidences, although not conclusive, support therefore testing for CD also in cryptogenic hepatobiliary conditions where the relationship with CD has not yet been fully investigated.
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Affiliation(s)
- Francesca Marciano
- Department of Molecular Medicine and Medical Biotechnology, University of Naples "Federico II", Naples, Italy.
| | - Marcella Savoia
- Department of Molecular Medicine and Medical Biotechnology, University of Naples "Federico II", Naples, Italy.
| | - Pietro Vajro
- Department of Medicine and Surgery, Pediatrics Section, University of Salerno, Baronissi, Italy; ELFID, University of Naples "Federico II", Naples, Italy.
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Abstract
Coeliac disease is a common disorder that can arise at any age and typically presents with a broad spectrum of symptoms. The disease is thought to be underdiagnosed, in part owing to the fact that coeliac disease is often characterized by associated conditions and extraintestinal manifestations that can misdirect and impede diagnosis. Some of these manifestations are direct consequences of autoimmunity, such as dermatitis herpetiformis or gluten ataxia, whereas others are indirectly related to inflammation and/or malabsorption including anaemia, osteoporosis, short stature and delayed puberty. Any organ from the central nervous system to joints, liver or teeth can be affected. In some cases, extraintestinal symptoms are the only clinical manifestations of coeliac disease or occur in conjunction with diarrhoea and malabsorptive symptoms. An increased awareness among medical practitioners of the variety of extraintestinal manifestations of coeliac disease is essential to improve diagnosis and treatment.
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Affiliation(s)
- Daniel A Leffler
- The Celiac Centre at Beth Israel Deaconess Medical Centre, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Peter H R Green
- Celiac Disease Centre at Columbia University, 180 Fort Washington Avenue, HP 934, New York, NY 10032, USA
| | - Alessio Fasano
- Centre for Celiac Research, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Rathi S, Dhiman RK. Hepatobiliary Quiz (Answers)-15 (2015). J Clin Exp Hepatol 2015; 5:269-71. [PMID: 26628847 PMCID: PMC4632104 DOI: 10.1016/j.jceh.2015.08.008] [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: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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