Prevalence of undiagnosed coeliac syndrome in osteoporotic women

Bone Fragility in Gastrointestinal Disorders

Osteoporosis is a common systemic disease of the skeleton, characterized by compromised bone mass and strength, consequently leading to an increased risk of fragility fractures. In women, the disease mainly occurs due to the menopausal fall in estrogen levels, leading to an imbalance between bone resorption and bone formation and, consequently, to bone loss and bone fragility. Moreover, osteoporosis may affect men and may occur as a sequela to different diseases or even to their treatments. Despite their wide prevalence in the general population, the skeletal implications of many gastrointestinal diseases have been poorly investigated and their potential contribution to bone fragility is often underestimated in clinical practice. However, proper functioning of the gastrointestinal system appears essential for the skeleton, allowing correct absorption of calcium, vitamins, or other nutrients relevant to bone, preserving the gastrointestinal barrier function, and maintaining an optimal endocrine-metabolic balance, so that it is very likely that most chronic diseases of the gastrointestinal tract, and even gastrointestinal dysbiosis, may have profound implications for bone health. In this manuscript, we provide an updated and critical revision of the role of major gastrointestinal disorders in the pathogenesis of osteoporosis and fragility fractures.

The Prevalence of Celiac Disease in a Fracture Liaison Service Population

Celiac disease (CD) is a known risk factor for osteoporosis and fractures. The prevalence of CD in patients with a recent fracture is unknown. We therefore systematically screened patients at a fracture liaison service (FLS) to study the prevalence of CD. Patients with a recent fracture aged ≥ 50 years were invited to VieCuri Medical Center's FLS. In FLS attendees, bone mineral density (BMD) and laboratory evaluation for metabolic bone disorders and serological screening for CD was systematically evaluated. If serologic testing for CD was positive, duodenal biopsies were performed to confirm the diagnosis CD. Data were collected in 1042 consecutive FLS attendees. Median age was 66 years (Interquartile range (IQR) 15), 27.6% had a major and 6.9% a hip fracture, 26.4% had osteoporosis and 50.8% osteopenia. Prevalent vertebral fractures were found in 29.1%. CD was already diagnosed in two patients (0.19%), one still had a positive serology. Three other patients (0.29%) had a positive serology for CD (one with gastro-intestinal complaints). In two of them, CD was confirmed by duodenal histology (0.19%) and one refused further evaluation. The prevalence of biopsy-proven CD was therefore 0.38% (4/1042) of which 0.19% (2/1042) was newly diagnosed. The prevalence of CD in patients with a recent fracture at the FLS was 0.38% and within the range of reported prevalences in the Western-European population (0.33-1.5%). Newly diagnosed CD was only found in 0.19%. Therefore, standard screening for CD in FLS patients is not recommended.

Systematic review with meta-analysis: the prevalence of coeliac disease in patients with osteoporosis

BACKGROUND

Earlier studies have produced highly varying risk estimates for the prevalence of coeliac disease (CD) in osteoporosis.

AIMS

To investigate the prevalence of CD among individuals with osteoporosis.

METHODS

We conducted a systematic review of articles published in PubMed, Medline or EMBASE through May 2017 to identify studies looking at prevalence of CD in patients with osteoporosis. Search terms included "coeliac disease" combined with "fractures", "bone disease", "bone density", "densitometry", "osteoporos*", "osteomal*", "osteodys" or "dexa" or "dxa" or "skelet". Non-English papers with English-language abstracts were included. We used fixed-effects inverse variance-weighted models, and tested heterogeneity through subgroup analysis as well as through meta-regression.

RESULTS

We identified eight relevant studies, comprising data from 3188 individuals with osteoporosis. Of these, 59 individuals (1.9%) had CD. A weighted pooled analysis demonstrated biopsy-confirmed CD in 1.6% (95% CI = 1.1%-2.0%) of individuals with osteoporosis. The heterogeneity was moderate (I²  = 40.1%), and influenced by the underlying CD prevalence in the general population. After adding four studies (n = 814) with CD defined as positive tissue transglutaminase or endomysial antibodies, the pooled prevalence was comparable (1.6%; 95% CI = 1.2%-2.0%).

CONCLUSIONS

About 1 in 62 individuals with osteoporosis, or 1.6%, have biopsy-verified CD. This prevalence is comparable to that in the general population. These findings argue against routinely screening patients with osteoporosis for CD, which is contrary to current guideline recommendations. Additional studies are needed to determine the true utility of such screening programs.

Risk of Fractures in Youths with Celiac Disease-A Population-Based Study

OBJECTIVE

To assess the risk of any fracture requiring hospital care in a cohort of individuals with celiac disease diagnosed in childhood/adolescence compared with reference individuals matched by age and sex.

STUDY DESIGN

Our study cohort consisted of 213 635 people born and residing in Friuli-Venezia Giulia Region, Italy, in 1989-2011. We selected, through pathology reports, hospital discharge records, or co-payment exemptions, 1233 individuals with celiac disease (aged 0-17 years at diagnosis) and compared them with 6167 reference individuals matched by sex and year of birth. Fractures were identified through hospital discharge records. We calculated hazard ratios (HRs) for any fracture after celiac disease diagnosis (or index date for reference individuals) with Cox regression and ORs for any fracture before celiac disease diagnosis with conditional logistic regression.

RESULTS

During the follow-up period (maximum 23 years), 22 individuals with celiac disease (9394 person-years) and 128 reference individuals (47 308 person-years) experienced a fracture, giving an overall HR of 0.87 (95% CI 0.55-1.37). The risk was not modified by sex, age at diagnosis, or calendar period of diagnosis. We obtained similar HRs when excluding fractures occurring after the age of 18 years and adjusting for maternal education or vitamin D supplementation. The odds of previous fracture also did not differ between subjects with celiac disease and reference individuals (22 and 96 cases, respectively: OR 1.15; 95% CI 0.72-1.84).

CONCLUSIONS

We did not find any evidence of an increased risk of fractures during childhood and youth among patients with celiac disease.

A Serological Diagnosis of Coeliac Disease Is Associated with Osteoporosis in Older Australian Adults

Previously thought to be mainly a disorder of childhood and early adult life, coeliac disease (CeD) is increasingly diagnosed in older adults. This may be important given the association between CeD and osteoporosis. The primary aim of this study was to determine the seroprevalence of undiagnosed CeD (‘at-risk serology’) in an older Australian community and relate this to a diagnosis of osteoporosis and fractures during a follow-up period of 12 years. We included participants from the Hunter Community Study (2004–2007) aged 55–85, who had anti-tissue transglutaminase (tTG) titres, human leukocyte antigen (HLA) genotypes, and bone mineral density measurements at baseline. Follow-up data included subsequent diagnosis of CeD and fractures using hospital information. ‘At-risk’ serology was defined as both tTG and HLA positivity. Complete results were obtained from 2122 patients. The prevalence of ‘at-risk’ serology was 5%. At baseline, 3.4% fulfilled criteria for a diagnosis of osteoporosis. During a mean of 9.7 years of follow-up, 7.4% of the cohort suffered at least one fracture and 0.7% were subsequently diagnosed with CeD. At-risk serology was significantly associated with osteoporosis in a multivariate model (odds ratio 2.83, 95% confidence interval 1.29–6.22); there was insufficient power to look at the outcome of fractures. The results of this study demonstrate that at-risk CeD serology was significantly associated with concurrent osteoporosis but not future fractures. Most individuals with a serological diagnosis of CeD were not diagnosed with CeD during the follow-up period according to medical records. Coeliac disease likely remains under-diagnosed.

Vitamin D deficiency as a risk factor for the development of autoantibodies in patients with ASIA and silicone breast implants: a cohort study and review of the literature

The development of autoimmunity and/or autoimmune diseases is multifactorial. Vitamin D is one of the factors that might play a role. We postulated that both the presence of adjuvants and insufficient levels of vitamin D may result in the development of autoimmunity in patients with autoimmune/inflammatory syndrome induced by adjuvants (ASIA) in relation to silicone implant incompatibility. We measured vitamin D levels in 135 patients with ASIA in relation to silicone implant incompatibility and related findings to the presence of autoantibodies that are commonly used to diagnose systemic autoimmune diseases. Furthermore, we systematically reviewed the literature regarding vitamin D deficiency as a risk factor for the development of autoantibodies. Vitamin D measurements were available for analysis in 131 of 135 patients with ASIA in relation to SIIS. Twenty-three patients (18%) tested positive for autoantibodies, from which 18 patients (78%) had either a vitamin D deficiency or insufficiency (median vitamin D level 60.5 mmol/L), whereas five patients (22%) had sufficient vitamin D levels. The risk to develop autoantibodies was significantly increased in vitamin D deficient and/or insufficient patients [RR 3.14; 95% CI, 1.24–7.95; p = 0.009]. Reviewed literature suggested an association between vitamin D levels and the presence and/or titer levels of autoantibodies in different autoimmune diseases. From our current study and from our review of the literature, we conclude that vitamin D deficiency is related to the presence of autoantibodies. Whether vitamin D supplementation results in a decrease of autoimmunity needs to be studied prospectively.

Secondary osteoporosis and metabolic bone disease in patients 50 years and older with osteoporosis or with a recent clinical fracture: a clinical perspective

PURPOSE OF REVIEW

The purpose of this review is to provide guidance to clinicians about which laboratory tests should be performed in patients with osteoporosis or with a recent fracture.

RECENT FINDINGS

Newly diagnosed secondary osteoporosis and other metabolic bone diseases (SECOB) have been found in 5-48% of patients with osteoporosis. In patients with a recent fracture, new SECOB is found in 10-47% of patients with osteoporosis, and in 26-51% if all patients with a fracture regardless of bone mineral density (BMD) are screened. More than one SECOB can be found in the same patient, even when they have already known SECOB. In primary hyperparathyroidism, hyperthyroidism, hypercortisolism, and multiple myeloma, both SECOB and its treatment have an impact on BMD and fractures. For other SECOBs, no treatment is available, or there are no data about the effect of treatment of the SECOB on BMD and fractures.

SUMMARY

We recommend performing the following tests in all patients with osteoporosis or a recent clinical fracture: calcium, phosphate, creatinine, albumin, erythrocyte sedimentation rate in all patients, 24 h urine calcium in men and serum testosterone in men less than 70 years. On indication, additional tests can be performed.

Factors Affecting 25-Hydroxyvitamin D Concentration in Response to Vitamin D Supplementation

Sun exposure is the main source of vitamin D. Due to many lifestyle risk factors vitamin D deficiency/insufficiency is becoming a worldwide health problem. Low 25(OH)D concentration is associated with adverse musculoskeletal and non-musculoskeletal health outcomes. Vitamin D supplementation is currently the best approach to treat deficiency and to maintain adequacy. In response to a given dose of vitamin D, the effect on 25(OH)D concentration differs between individuals, and it is imperative that factors affecting this response be identified. For this review, a comprehensive literature search was conducted to identify those factors and to explore their significance in relation to circulating 25(OH)D response to vitamin D supplementation. The effect of several demographic/biological factors such as baseline 25(OH)D, aging, body mass index(BMI)/body fat percentage, ethnicity, calcium intake, genetics, oestrogen use, dietary fat content and composition, and some diseases and medications has been addressed. Furthermore, strategies employed by researchers or health care providers (type, dose and duration of vitamin D supplementation) and environment (season) are other contributing factors. With the exception of baseline 25(OH)D, BMI/body fat percentage, dose and type of vitamin D, the relative importance of other factors and the mechanisms by which these factors may affect the response remains to be determined.

Celiac disease and risk of fracture in adults--a review

Patients with celiac disease (CD) have low bone mineral density. Evidence of increased fracture risk in these patients is conflicting, and the indication for bone mineral density screening of all adult CD patients is debated. Our aim was to review current published data on fractures in CD. Cross-sectional cohort studies and one case study were identified by searching Medline and Embase. Although the identified studies are heterogeneous and difficult to compare, the overall findings indicate a positive association between CD and risk of fracture. Adult patients with CD should be considered for bone densitometry in order to estimate fracture risk.

[Anti-transglutaminase, antigladin and ultra purified anti-gladin antibodies in patients with a diagnosis of rheumatoid arthritis]

Celiac disease (CD) is an enteric disease caused by dietary gluten in individuals with genetic predisposition. One of the clinical manifestations of CD is the peripheral arthritis that may simulate RA.

OBJECTIVE

To determine the frequency of anti-gliadin (aGL), anti-tissue transglutaminase (aTGT) and ultra purified anti-gliadin (AGLU) antibodies in patients with RA.

METHODS

Cross-sectional study. We included consecutive patients diagnosed as RA (ACR). Demographic and clinical data was registered by direct interview and serum levels of aGL, aTGT y aGLU were determined using ELISA.

RESULTS

Eighty-five RA patients were included; 87% were women. Mean age was 44±12 years, mean disease duration 12 ±9 years. aGL IgG antibodies were positive in 16 patients, IgA aGL antibodies in 29 patients, aGLU in 14 patients and only one patient had aTGT.

CONCLUSIONS

It is possible that CD may be the correct diagnosis in a patient with polyarthritis, even if the patient meets the ACR criteria for RA. In other words, CD should be considered among the differential diagnoses in a patient with poly-arthritis.

[Clinical manifestations of adult celiac disease]

Celiac disease is an enteropathy due to gluten intake in genetically predisposed persons (HLA DQ2/DQ8). Celiac disease occurs in adults and children at rates approaching 1% of population in Europe and USA. Celiac disease is extremely various and anaemia, oral aphthous stomatis, amenorrhea or articular symptoms may be the only revealing symptoms. Diagnosis releases on evidence of histological villous atrophy in proximal small bowel and presence of specific serum antibodies. Treatment relies on eviction of gluten. Gluten free diet allows prevention of malignant complications such as small bowel adenocarcinoma and lymphoma and osteopenia. The main cause of resistance to gluten free diet is its bad observance. On the contrary, serious complications of celiac disease, such as clonal refractory celiac sprue and intestinal T-cell lymphoma need to be screen.

Celiac disease: an underappreciated issue in women’s health

Celiac disease (CD) is an immune-mediated enteropathy that is secondary to gluten ingestion and classically associated with gastrointestinal symptoms. Diagnosis is based on serology and confirmatory duodenal biopsy, and the only treatment is lifelong avoidance of gluten. CD has been increasingly recognized to encompass a wide variety of manifestations that are relevant to women’s health, including infertility, adverse pregnancy outcomes and reduced BMD. Currently, CD is underdiagnosed, largely owing to lack of recognition of the diverse manifestations by general practitioners. Increased awareness of the clinical spectrum of this disease, as well as targeted testing in at-risk individuals (including women with unexplained infertility and previous adverse pregnancy outcomes, and in specific populations with reduced BMD) is greatly needed in order to improve rates of diagnosis.

Morbidity and mortality among older individuals with undiagnosed celiac disease

BACKGROUND & AIMS

Outcomes of undiagnosed celiac disease (CD) are unclear. We evaluated the morbidity and mortality of undiagnosed CD in a population-based sample of individuals 50 years of age and older.

METHODS

Stored sera from a population-based sample of 16,886 Olmsted County, Minnesota, residents 50 years of age and older were tested for CD based on analysis of tissue transglutaminase and endomysial antibodies. A nested case-control study compared serologically defined subjects with CD with age- and sex-matched, seronegative controls. Medical records were reviewed for comorbid conditions.

RESULTS

We identified 129 (0.8%) subjects with undiagnosed CD in a cohort of 16,847 older adults. A total of 127 undiagnosed cases (49% men; median age, 63.0 y) and 254 matched controls were included in a systematic evaluation for more than 100 potentially coexisting conditions. Subjects with undiagnosed CD had increased rates of osteoporosis and hypothyroidism, as well as lower body mass index and levels of cholesterol and ferritin. Overall survival was not associated with CD status. During a median follow-up period of 10.3 years after serum samples were collected, 20 cases but no controls were diagnosed with CD (15.2% Kaplan-Meier estimate at 10 years).

CONCLUSIONS

With the exception of reduced bone health, older adults with undiagnosed CD had limited comorbidity and no increase in mortality compared with controls. Some subjects were diagnosed with CD within a decade of serum collection, indicating that although most cases of undiagnosed CD are clinically silent, some result in symptoms. Undiagnosed CD can confer benefits and liabilities to older individuals.

[Celiac disease]

Celiac disease is an enteropathy due to gluten intake in genetically predisposed individuals (HLA DQ2/DQ8). Celiac disease occurs in adults and children at rates approaching 1% of population in Europe and USA. Clinical features observed in celiac disease are extremely various and anaemia, oral aphthous stomatis, amenorrhea or articular symptoms may be the only presenting manifestations. Diagnosis relies on the evidence of histological villous atrophy in proximal small bowel and the presence of specific serum antibodies. Treatment relies on eviction of gluten (wheat, barley, rye) from diet. Gluten free diet allows prevention of malignant complications such as small bowel adenocarcinoma and lymphoma, and osteopenia. The main cause of resistance to gluten free diet is its poor observance. If not the case, serious complications of celiac disease, such as clonal refractory celiac sprue and intestinal T-cell lymphoma should be suspected. Current therapeutic challenges concern alternative to gluten free diet and new efficient treatments of lymphomatous complications.

Coeliac disease-specific tissue transglutaminase autoantibodies are associated with osteoporosis and related fractures in middle-aged women

OBJECTIVE

To investigate whether the serological marker for coeliac disease, tissue transglutaminase autoantibody (tTGAb), is associated with decreased bone mass density (BMD) and increased frequency of fractures in middle-aged women screened for osteoporosis.

MATERIAL AND METHODS

The study comprised 6480 women (mean age 56 years, range 50-64) who answered a number of questionnaires and who underwent dual X-ray absorptiometry of the wrist bone. Serum samples were analysed for tTGAb using radioligand binding assays. A tTGAb level of >4 U/ml was used to determine a positive value and a level of >17 U/ml was used as an alternative discrimination of high levels.

RESULTS

A tTGAb level >4 U/ml was found among 90/6480 (1.4%) women and correlated with lower BMD (multiple linear regression coefficient -382.1; 95% CI = - 673.6-90.7, p=0.011) and with fracture frequency (r=0.18, p=0.023). The 59 women with tTGAb levels >or=17 U/ml had a lower BMD (0.41+/-0.08 g/cm(2) versus 0.44+/-0.08 g/cm(2), p=0.001) and a lower T-score (-1.40+/-1.28 versus -0.90+/-1.40, p=0.003) as well as a higher prevalence of osteoporosis (13.4% versus 6.5%, p=0.008) compared with the remaining 6421 women with tTGAb levels <17 U/ml. Furthermore, fracture frequency was more pronounced in women with tTGAb levels >or=17 U/ml, among whom 19/59 (32.2%) had fractures during the study period compared with 1204/6421 (18.8%) among women with tTGAb levels <17 U/ml (p=0.009).

CONCLUSIONS

High levels of tTGAb indicating coeliac disease are associated with lower BMD and higher fracture frequency in women between 50 and 64 years of age. Osteometry is therefore warranted in middle-aged women detected with tTGAb.

Screening for celiac disease in patients with osteoporosis

OBJECTIVE

Whether patients with osteoporosis should be screened for celiac disease is controversial. The objective of this study was to measure the prevalence of asymptomatic celiac disease in a cohort of patients with osteoporosis.

METHODS

We studied 140 patients (133 postmenopausal women and 7 men) aged 40-75 years (mean age, 62.9+/-9.4 years) with primary osteoporosis diagnosed by absorptiometry (spine or hip T-score <-2.5SD). We routinely measured serum and urinary calcium, serum phosphate, alkaline phosphatase, 25-OH-vitamin D3, and IgG and IgA antigliadin antibodies. Patients with positive antigliadin antibody tests were tested for antitransglutaminase antibodies.

RESULTS

A history of fractures were noted in 52 (37%) patients, with 57 peripheral and 54 vertebral fractures overall. Vitamin D deficiency was found in 60 (43%) patients. IgG antigliadin antibodies were positive in 11 (8%) patients, IgA antigliadin antibodies in 11 (8%) patients, and both antibodies in 4 (3%) patients. Antitransglutaminase antibodies were negative in all patients. No significant differences in laboratory test or absorptiometry results were found between patients with versus without IgA antigliadin antibodies. The T-score at the spine was nonsignificantly lower in patients with than without IgG antigliadin antibodies (-3.17+/-0.49 and -2.82+/-0.77, P=0.076).

CONCLUSION

We found no excess risk of celiac disease in our cohort of patients with osteoporosis. Despite the small sample size, our results cast doubt on the need for celiac-disease screening in osteoporotic patients who have no gastrointestinal symptoms.

Is there any requirement for celiac disease screening routinely in postmenapausal women with osteoporosis?

Screening studies indicate a prevalence of celiac disease (CD) of up to 1% in populations of European ancestry, yet the majority of cases remain undiagnosed. One of the common complication of CD is intestinal osteopathy or osteoporosis [bone mineral density (BMD) based diagnosis]. Available data regarding the prevalence of CD in the patients with osteoporosis are limited and controversial. The objective of this study was to perform serological testing to screen for CD among postmenopausal women with osteoporosis. We studied 192 postmenopausal women with low BMD with a mean age of 62.75 +/- 8.58 years. Among the patients, a total of 137 had osteoporosis and 55 had osteopenia. Venous blood samples were obtained for serological screening of CD and evaluation of bone metabolism. The serological screening protocol consisted of determining serum level of IgA antigliadin antibodies (AGA), IgG-AGA, IgA endomysial antibody (EMA), IgG-EMA. Subjects who were positive for both IgA-AGA and IgA-EMA were classified as having CD. Bone metabolism was evaluated by serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, 25 (OH) vitamin D, osteocalcin, serum C-telopeptide cross-linked collagen type I levels. Of the 192 patients evaluated, only one (0.5%) was found to have positive for both IgA-AGA and IgA EMA tests and accepted as having CD. Prevelance of CD in postmenopausal women with low BMD (0.5%) did not differ from prevelance of CD in normal healthy population (0.3-1%). BMD values at proximal femur level were significantly lower in IgA-AGA (+) patients when compared to IgA-AGA (-) patients. However, the mean levels of bone metabolism markers were found similiar in both IgA-AGA (+) and (-) patients. In conclusion, the results of our study suggest that there is no need for routine screening of CD in postmenopausal women with osteoporosis.

Systematic review: The evidence base for long-term management of coeliac disease

BACKGROUND

While gluten-free diet is an effective treatment for coeliac disease, the need for and goals of long-term management of patients are poorly defined.

AIM

To review systematically the complications and associations of coeliac disease, to identify potential risk factors, to define ways of assessing risk factors and to provide a strategy for management.

METHODS

Review of medical literature from 1975.

RESULTS

There is an increasing list of potential complications and/or conditions associated with coeliac disease, in particular, autoimmune disease, malignancy and bone disease. Risk factors that may predict or influence long-term outcomes include genetic susceptibility, environmental factors predominantly gluten ingestion, persistent small intestinal inflammation/injury and nutritional deficiencies. Genotyping of patients is yet to have an established clinical role in long-term management. Assessment of adherence to the gluten-free diet largely relies upon skilled dietary history, but the ultimate test is duodenal histopathology, which is the only currently established means of assessing healing. Symptoms, serology or other non-invasive means are poor predictors of healing and the likelihood of complications.

CONCLUSION

Evidence (albeit limited) that adherence to a gluten-free diet and mucosal healing prevent and/or ameliorate complications indicates that a planned long-term strategy for follow-up is essential.

Chronic pediatric inflammatory diseases: effects on bone

In children, chronic inflammatory diseases present a significant challenge to long-term skeletal health. These conditions are often associated with poor appetite and suboptimal overall nutrition, altered nutrient utilization, delayed puberty, inactivity, and reduced muscle mass, all of which can alter bone metabolism. In addition, bone cell activity is susceptible to the effects of the immune response that characterizes these diseases. Moreover, drugs used to treat these maladies, notably glucocorticoids, may have negative effects on bone formation and on linear growth in developing children. As a result, predicted peak bone mass may not be achieved, and fracture risk may be increased in the short term or in the future. Studies using primarily dual energy X-ray absorptiometry have documented that deficits in bone mass are common in these diseases. However, there are wide variations in the prevalence of low bone mass, largely due to differences in the characteristics of each study population. Recent studies provide insight into the pathogenesis of decreased bone mass in these conditions. In this paper we will provide an overview of the effects of chronic inflammatory conditions on bone mass in children. We will also present relevant data from adult patients, when pediatric data are scant or not available.

[Case report: recently diagnosed celiac disease as aggravating factor of osteoporosis in an old woman]

Sixty-three-year-old woman requested medical attention for osteoporosis. Bone densitometry revealed: T(spine (L1-L4))= -3.5 SD [Bone mineral density (BMD): 0.766 g/cm(2)]. T(femoral neck) = -2.4 SD (BMD: 0.716 g/cm(2)). She has been in calcium and vitamin D supplementation for 2 years. She informed a 5-year-history of hypothyroidism in levothyroxine replacement. Alendronate sodium 70 mg/week was initiated with significant increase in BMD in the first year (6.1% equally in spine and femoral neck). After a 5-year follow-up, the patient presented with weight loss, anemia and decrease in BMD (12.6% in spine and 20.9% in femoral neck). Clinical history revealed intermittent diarrhea episodes for 2 years and the hypothesis of celiac disease was suspected. Anti-gliadin and anti-endomysium antibodies were positive: 25.3 U/mL (< 20) e 1/5 U/mL (RV: negative), respectively. Bone biochemical parameters revealed normal levels of calcium and phosphate, increased parathyroid hormone: 283 pg/mL (10-65) and increased levels of bone reabsortion markers, consistent with secondary hyperparathyroidism in response to malabsorptive syndrome. One year after gluten-free diet, patient improved of malabsorptive symptoms and gained BMD (47.3% in spine and 31.6% in femoral neck), confirming the hypothesis of celiac disease as aggravating factor of osteoporosis in this patient.

Osteoporosis in celiac disease and in endocrine and reproductive disorders

As the increase in lifespan brings to light diseases that were previously not clinically detectable, osteoporosis has become an issue of worldwide significance. The disease is marked by a loss of bone mass; the bones become less dense, fragile and more prone to fracturing. Because it is regulated by endocrine and environmental factors, osteoporosis presents a multifactorial etiopathogenesis, with the genetic component accounting for 70% of an individual variation in bone mass density (BMD), the principal determinant, with age, of fracture risk. Pathological conditions such as celiac disease (CD) exacerbate the process of bone loss, so that the occurrence of osteoporosis in celiac subjects is of particular note: indeed, the screening of osteoporosis patients for this disease is advisable, since it may be the only sign of undiagnosed CD. An increase in interleukin IL-1β, of the IL-1 system, in the relatives of celiac patients confirms the genetic predisposition to osteoporosis and its presence is evidence of an association between the two conditions. The direct effect on the bones of CD is secondary to poor absorption of calcium and vitamin D. In women osteoporosis is indirectly associated with early menopause and amenorrhea, and it may follow prolonged breast-feeding and frequent pregnancies, while in men it is associated with hypogonadism and GH deficit. These endocrine and non-endocrine factors exert their effects on bones by modulating the RANK/RANK-L/OPG system. An appropriate lifestyle from adolescence onwards, together with early diagnosis of and treatment for CD and primary and secondary endocrine pathologies are important for the prevention of damage to the bones.

Hypocalcemia after Alendronate Therapy in a Patient with Celiac Disease

OBJECTIVE

To describe a patient with osteoporosis who was treated with alendronate and developed hypocalcemia, which ultimately led to the diagnosis of celiac sprue.

METHODS

We present the clinical and laboratory findings in a patient with osteoporosis, in whom hypocalcemia developed after treatment with alendronate. This patient was subsequently diagnosed with celiac sprue. The pertinent literature regarding orally administered bisphosphonate-induced hypocalcemia is reviewed.

RESULTS

A 79-year-old man who was diagnosed with osteoporosis was treated with alendronate. He was subsequently found to have asymptomatic hypocalcemia (serum calcium concentration, 8.3 mg/dL), which resolved after alendronate therapy was discontinued. He was then treated with calcium, vitamin D, and calcitonin nasal spray, which did not cause hypocalcemia. Because of his reduced bone density, however, he was subsequently referred for endocrine consultation. Evaluation at that time showed normal levels of serum calcium, phosphorus, creatinine, alkaline phosphatase, 25-hydroxyvitamin D, thyrotropin, and parathyroid hormone as well as 24-hour urine calcium excretion. An endomysial antibody titer was dramatically elevated. Upper endoscopy showed villous atrophy, and small bowel biopsy confirmed the presence of villous blunting and chronic inflammation, consistent with celiac sprue. He was treated with a gluten-free diet and then subsequently treated with orally administered risedronate, which he tolerated well without evidence of hypocalcemia.

CONCLUSION

To the best of our knowledge, this is the first report of orally administered bisphosphonate-induced hypocalcemia, which subsequently led to the diagnosis of previously unrecognized, otherwise asymptomatic celiac sprue. Patients with unexplained hypocalcemia should be screened for celiac sprue, even in the absence of gastrointestinal symptoms.

Prevalence of IgA-antiendomysial antibody in a patient cohort with idiopathic low bone mineral density

AIM: To investigate the frequency of serum IgA-antiendomysial antibody positivity in patients with low bone mineral density and to assess the risk group for screening of celiac disease.

METHODS: One hundred and thirty-five patients (14 male, 121 female) with idiopathic low bone mineral density were evaluated. The median age was 57.2 years (24-81). Antiendomysial antibody was determined by the immunofluorescence method using a commercial kit (INOVA Diagnostics Inc., CA, USA), which employs a 5 μm thin cryostat section of monkey esophagus as a substrate.

RESULTS: Of the 135 patients evaluated, 13 were found to have positive IgA antiendomysial antibody test (9.6%) response. None of the patients had IgA deficiency. Endoscopic appearance and histological examination were normal in all of these patients. Seropositive patients had significantly lower age (48.9 ± 4.3 vs 59.2 ± 6.2, P < 0.05), higher ratio of male gender (61.5% vs 4.9%, P < 0.01) and pre-menopausal status (8.7% vs 1.3%, P < 0.01). Lumbar spine and femoral neck z-scores, but not t-scores were significantly lower in seropositive patients. Seropositive patients had lower serum 25 (OH) vitamin D, calcium and higher serum parathormone levels than seronegative patients.

CONCLUSION: The screening of celiac disease in idiopathic osteoporosis should be restricted to patients without classical risk factors (younger, pre-menopausal, male gender) for osteoporosis. Bone mineral density measurements using z-scores should be considered for identifying risk groups for celiac disease.

Nouvelles définitions de l'insuffisance vitaminique D, retentissement sur les normes de PTH

SCOPE

Knowledge concerning vitamin D has greatly improved during the past few years. Vitamin D can no longer be considered only as a preventive therapy for rickets-osteomalacia. Indeed, beside its role in the prevention of osteoporotic fractures in the elderly, many data suggest that it may be involved in the prevention of various diseases including cancers and auto-immune diseases.

CURRENT SITUATION AND SALIENT POINTS

Vitamin D status may be easily assessed by the measurement of 25OHD serum concentration. However, many specialists in the field regard most 25OHD reference values as being too low, and believe that the 25OHD threshold below which vitamin D status can be considered as insufficient is somewhere between 50 and 100 nmol/L (20 to 40 ng/mL). It then appears that usually recommended amounts of supplemental vitamin D may be too low to reach these 25OHD concentrations, and thus need to be revised. We have proposed that PTH reference values should be established in healthy subjects with a normal vitamin D status. This supposes that 25OHD is measured in the reference population beforehand, and that the subjects with vitamin D insufficiency are eliminated from the reference group.

PERSPECTIVES

Although more complicated than the usual way to establish normative data, we have shown that it decreases the upper limit of normal by 25-35%, enhancing thus the diagnostic sensitivity for hyperparathyroidism without a decrease in specificity.

Unusual manifestations of celiac disease

Celiac disease is multifaced autoimmune disorder with several extraintestinal manifestations and connections to other autoimmune diseases and other conditions. The recognition of the complex clinical picture of the disease helps doctors to search and diagnose celiac disease even if the gastrointestinal symptoms are lacking. Individuals at risk for celiac disease should be thoroughly investigated and individuals with unusual manifestations of the disease should be screened actively.

Practical considerations in PTH testing

New knowledge concerning PTH biology have accumulated during the past few years. The finding that the so-called "intact" PTH assays measure a "non-1-84" PTH fragment in addition to full-length PTH has led to the development of new assays. These new assays, which were initially thought to measure 1-84 PTH only, have been shown to recognize also another PTH species called "amino-PTH". As the various names given to the different assay methods are highly confusing, there is a need for a simplified nomenclature. A simple way would be to identify the older "intact" PTH assays as second-generation assays and the new assays (Whole, CAP, BioIntact) as third-generation assays. Although of considerable potential interest for the comprehension of PTH physiology, the third-generation PTH assays have not yet proved to be superior to the second-generation assays in clinical practice. There is thus currently no recommendation to switch from the second-generation to the third-generation assays in clinical practice, or to use a ratio derived from the concommitent measurement of PTH with both assay-generation. Because second- and third-generation PTH assays are usually highly correlated, significant differences in the clinical information provided by these methods are unlikely. However, our opinion is that more definitive bone biopsy studies in dialyzed patients selected according to their bone- and calcium-related treatment are still needed to reach a consensus. Finally, we have proposed that PTH reference values should be established in healthy subjects with a normal vitamin D status. This supposes that 25OHD is measured in the reference population beforehand, and that the subjects with vitamin D insufficiency are eliminated from the reference group. Although more complicated than the usual way to establish normative data, we have shown that it decreases the upper limit of normal by 25-35%, enhancing thus the diagnostic sensitivity for hyperparathyroidism without a decrease in specificity.

Hypocalcaemia associated with low serum vitamin D metabolite concentrations in two dogs with protein-losing enteropathies

Protein-losing enteropathies were diagnosed in two dogs that were initially presented with diarrhoea and weight loss. Plasma biochemistry in both cases revealed low concentrations of albumin, calcium and ionised calcium. Both dogs had an elevated plasma parathyroid hormone concentration and low serum 25-hydroxyvitamin D (25[OH]D) concentration. The first dog was diagnosed with lymphangiectasia on postmortem examination, and the second dog was diagnosed with chronic lymphocytic/ plasmacytic enteritis and severe cystic mucoid changes based on endoscopic duodenal biopsies. While a causal effect was not demonstrated, the protein-losing enteropathies may have caused reduced intestinal absorption of vitamin D leading to low plasma concentrations of ionised calcium and secondary hyperparathyroidism. To the authors' knowledge, this is the first report of low ionised calcium concentrations, low 25(OH)D and 1,25-dihydroxyvitamin D concentrations, and high parathyroid hormone concentrations in dogs with protein-losing enteropathies.

Celiac sprue (the great modern-day imposter)

PURPOSE OF REVIEW

To review the current epidemiological information on celiac disease and the various presentations and associated.

RECENT FINDINGS

Epidemiologic studies reveal celiac disease to be common, occurring in approx. 1% of the population. It is being diagnosed worldwide, even in developing countries. The classic mode of presentation has become less common, with diarrhea or a malabsorption syndrome as the mode of presentation in fewer than 50% of individuals. The other major modes of presentation are iron-deficiency anemia, osteoporosis, screening of family members, or incidentally at endoscopy done for dyspepsia or reflux. Neurological presentations may include peripheral neuropathy or ataxia. Arthritis is commonly found in patients with celiac disease when systematically sought. Patients often have a previous diagnosis of irritable bowel syndrome. Autoimmune diseases occur more frequently (three to ten times more) in those with celiac disease than the general population. However, this increased incidence of autoimmune diseases is not prevented by early diagnosis of celiac disease.

SUMMARY

We will review the various associated diseases/presentations of celiac disease. The heterogeneity of the symptoms can make the diagnosis challenging and certainly the great modern-day imposter.

Secondary osteoporosis

Secondary osteoporosis occurs as a consequence of various lifestyle factors (eg, eating disorders, smoking, alcoholism), disease processes (eg, endocrinopathies, gastrointestinal tract disease, hepatobiliary disease), and treatment regimens that comprise corticosteroids or chemotherapeutic agents. Some of the disease entities underlying secondary osteoporosis may be clinically silent and identified only during evaluation for documented osteoporosis. The pathogenesis of osteoporosis in these settings is typically multifactorial. The loss of bone may be direct or indirect but ultimately is related to altered osteoblast or osteoclast function. Causes of secondary osteoporosis should especially be investigated in men at all ages and in premenopausal women with atraumatic fractures. In addition, patients with known risk factors should be evaluated. Early recognition and intervention are essential to prevent further loss of bone mass and to prevent fragility fractures.

Tissue transglutaminase antibodies in celiac disease, comparison of an enzyme linked immunosorbent assay and a dot blot assay

AIMS

The purpose of our study is to determine the sensitivity, specificity and predictive values of an enzyme linked immunosorbent assay (ELISA) and a dot blot assay for the detection of IgA class anti-tissue transglutaminase antibodies (IgA-AtTGA) and to compare these results with those of IgA class anti-endomysium antibodies (IgA-AEA), IgA class anti-reticulin antibodies (IgA-ARA) and IgA class anti-gliadin antibodies (IgA-AGA).

PATIENTS

Serum samples from 143 patients (97 children, 46 adults) with untreated celiac disease (CD) confirmed by intestinal biopsy and 74 disease controls (64 children, 10 adults) were studied. Methods. - The anti-tissue transglutaminase antibodies were detected by dot blot assay and an ELISA using guinea pig tissue transglutaminase (gp-tTG) as antigen. The anti-endomysium antibodies were detected by an indirect immunofluorescence technique on cryostat sections of human umbilical cord. The anti-reticulin antibodies were also investigated by indirect immunofluorescence on cryostat sections of kidney, liver and stomach of rat. The anti-gliadin antibodies were determined by an ELISA.

RESULTS

The sensitivity of an ELISA for the detection of anti-tissue transglutaminase antibodies was 86% in children and 87% in adults and the sensitivity of dot blot assay was 57% in children and 54% in adults. The specificity of an ELISA and dot blot for the detection for anti-tissue transglutaminase antibodies was, respectively, 96% and 88% lower than that of anti-endomysium antibodies (100%). The sensitivity of anti-gliadin antibodies was 97% in children and 91% in adults and their specificity was 85%. The sensitivity of anti-reticulin antibodies was 94% in children and 87% in adults. Their specificity was 100%.

CONCLUSIONS

The sensitivity and specificity of an ELISA for the detection of anti-tissue transglutaminase antibodies were better than that of dot blot assay. However, this dot blot assay could screen four celiac patients who have not had anti-tissue transglutaminase antibodies by an ELISA. The sensitivity of anti-endomysium antibodies was better than that of anti-tissue transglutaminase antibodies, anti-reticulin antibodies and anti-gliadin antibodies but in children aged less than 2 years, the sensitivity of anti-gliadin antibodies was better than that of anti-tissue transglutaminase antibodies.

The prevalence of celiac disease in average-risk and at-risk Western European populations: a systematic review

Until recently, celiac disease (CD) was felt to be a rare disease in the United States. The aim of this study was to conduct a systematic review of the prevalence of CD in general Western populations and in populations at high risk for CD. Standard systematic review methodology was used. A literature search was conducted in MEDLINE (1966 to October 2003) and EMBASE (1974 to December 2003) databases. Qualitative and quantitative prevalence estimates were produced after assessing study heterogeneity. The prevalence of CD in general Western populations is close to 1% and is somewhat higher in certain Western European populations. The prevalence of CD in populations at risk for CD is as follows: 3%-6% in type 1 diabetic patients, up to 20% in first-degree relatives, 10%-15% in symptomatic iron-deficiency anemia (IDA), 3%-6% in asymptomatic IDA, and 1%-3% in osteoporosis. The prevalence of CD in patients suspected of having CD varied depending on the reasons for suspecting CD and on whether the study was conducted in a referral center. In general, the prevalence ranged from 5% to 15%, but was up to 50% in symptomatic patients evaluated in a tertiary referral center. CD is a common medical condition. The prevalence is higher still in high-risk groups. Clinicians in a variety of specialties should have a high index of suspicion for the diagnosis of CD and in particular need to pay close attention to the identified high-risk groups.

Celiac disease in patients with an affected member, type 1 diabetes, iron-deficiency, or osteoporosis?

Celiac disease (CD) may be a much under recognized condition, in part because it is not considered in those patients at high risk or in clinical conditions that may be a manifestation of CD. Screening high-risk groups may reveal a higher prevalence than seen in the general population. Several diseases have been described to have an association with CD that may be greater than by chance alone. The presence of autoimmune conditions such as insulin-dependent diabetes mellitus (T1DM) or a family history of CD or dermatitis herpetiformis may increase the risk of coexisting CD. The prevalence of CD may be increased in certain patient groups, including the following: osteoporosis or low bone mass or iron-deficiency anemia. Many studies, including population-based work, suggest a prevalence of CD of 3%-7% of T1DM and 4%-10% of first-degree family members. Anemia and osteoporosis are common in patients with newly diagnosed CD. Conversely, CD is common in referral populations with those conditions but makes a relatively small contribution to the overall community prevalence of anemia or postmenopausal osteoporosis. Most screen-found patients tend to have little or no gastrointestinal symptoms. In conclusion, significant reservoirs of CD can be found in some at-risk groups, such as those with T1DM, family members, and referred patients with osteoporosis and anemia. It is not clear what impact CD has on the quality of life of these individuals.

Case-finding for adult celiac disease in patients with reduced bone mineral density

The aim of this study was to assess the value of case-finding for unrecognized adult celiac disease (CD) in patients with reduced bone mineral density (BMD), verified by dual-energy X-ray absorptiometry (DXA). Patients attending for a DXA scan were investigated for CD using immunoglobulins, IgG/IgA antigliadin antibodies (AGA), and endomysial antibodies (EMA). All patients with a positive IgA AGA, EMA, or only IgG AGA in the presence of IgA deficiency had a small bowel biopsy. There were 12 cases of CD (12/978), a prevalence of 1.2% for the whole cohort. The prevalence of CD was 0.7% (2/304) for those with a normal BMD, 1.2% (5/431) for patients with osteopenia, and 2.1% (5/243) for patients with osteoporosis. Direct questioning revealed that all patients with unrecognized CD had subtle gastrointestinal symptoms or a history of anemia. Excluding patients without these symptoms would give a prevalence of 3.9% for osteoporosis (5/127) and 2.6% for osteopenia (5/191 ). This study suggests that there is no value of unselected case-finding for CD in patients with a reduced BMD. However, a targeted case-finding approach may be more valid and cost-effective with the initial selection of patients who should be investigated for CD based on questioning about gastrointestinal symptoms or anemia.

IgA anti-transglutaminase antibodies as a tool for screening atypical forms of coeliac disease in a French at-risk paediatric population

OBJECTIVE

The diagnosis of coeliac disease (CD) is often delayed because many children are free from the major symptoms characteristic of this enteropathy. The aim of the present study was to determine the efficacy of antibodies directed against tissue transglutaminase (tTG Abs) for early detection of CD in a population with few symptoms of the disease, as well as in children with an autoimmune disorder.

METHODS

This was a prospective study in a paediatric population including 638 patients with clinical symptoms frequently associated with CD, autoimmune diseases such as type 1 diabetes mellitus (DM1), autoimmune thyroiditis or hepatitis, and Turner's syndrome. Anti-endomysium, tTG Abs and antigliadin antibodies were analysed in these patients using an indirect immunofluorescence technique and enzyme-linked immunosorbent assay techniques. Intestinal biopsies were performed for some patients with positive or negative antibodies.

RESULTS

tTG Abs were detected in 2.6% of children with symptoms associated with CD, such as digestive signs and growth failure, and in 5.4% of children with DM1. No other autoimmune disease was positive for tTG Abs. Biopsies performed in the patients with positive tTG Abs showed mucosal atrophy confirming the diagnosis of CD in all cases.

CONCLUSION

Children displaying minimal symptoms frequently associated with CD and children with DM1 should be systematically screened for tTG Abs.

Coeliac disease in subjects with secondary hyperparathyroidism

OBJECTIVE

Coeliac disease (CD) may present in its classical form with diarrhoea and weight loss, but also with atypical symptoms that are both related and unrelated to malabsorption. Osteomalacia or osteopenia following malabsorption of calcium and vitamin D is known to occur in patients with CD, and in such cases secondary hyperparathyroidism (SHP) caused by low serum calcium levels is frequently found. However, the prevalence of CD in subjects with SHP has not been reported.

MATERIAL AND METHODS

In the Tromsø study 2001, serum parathyroid hormone (PTH) and calcium were measured in 7954 subjects of whom 6061 were eligible for follow-up. From this group, 97 subjects with SHP (serum PTH> or =6.5 pmol/l and serum calcium <2.40 mmol/l) and 104 matched control subjects were re-examined with serological tests for CD (anti-tissue transglutaminase, anti-gluten IgA and IgG).

RESULTS

CD was diagnosed in 4 subjects, all from the original SHP group. At the re-examination, only 29 of the 97 subjects with SHP still had elevated serum PTH levels. Among these were 3 of the subjects with CD. When grouping the serological test results as negative, borderline or positive, there was a significant difference between the SHP group and the controls for anti-tissue transglutaminase and anti-gluten IgA (p<0.05).

CONCLUSIONS

Subjects with SHP, at least when SHP is persistent, should be tested for CD.

Celiac disease in the Turkish population

Celiac disease (CD) is characterized by malabsorption of nutrients in the small intestine. The availability of highly specific and sensitive serologic tests has facilitated its diagnosis, increasing the disease prevalence. The aim of this study was to determine the clinical, laboratory, and histopathological features of CD in Turkish adults. Between 1968 and 2002, CD patients presenting to the Gastroenterology Unit were evaluated retrospectively. From 2002, newly diagnosed patients were prospectively followed up. Sixty patients (39 female, 21 male) were included in the study. Mean body mass index was 22.2 +/- 5.4 kg/m2. The most common symptoms were diarrhea, weight loss, and flatulence. Most common comorbidities were anemia, osteoporosis, type 1 diabetes mellitus, and steatohepatitis. Six (10.0%) patients had a family history of diabetes mellitus; one (1.7%) patient had a family history of CD. Plasma glucose and serum gamma-glutamyltransferase levels were significantly higher in females than males. Most common histopathological findings were increased lymphocytes in the lamina propria (76.2%) and villus epithelium (59.5%). Over the years, the cumulative frequency of CD increased more in females than males. This is the first study in the literature showing the characteristics of CD in Turkish adults. In our previous recent study, the prevalence of tissue transglutaminase antibody positivity in Turkish healthy blood donors was 1.3%, indicating a high prevalence of CD in our population. In this study, the cumulative frequency of CD increased more in females than males. With the better understanding and increased suspicion of the disease, more patients are being diagnosed in our population.

Serological screening for celiac disease in premenopausal women with idiopathic osteoporosis

The aim of this study was to perform serological testing to screen for celiac disease (CD) among premenopausal women with idiopathic osteoporosis and to investigate the bone turnover in patients who are seropositive for CD. We studied 89 premenopausal women with idiopathic osteoporosis. The serological screening protocol was based on a two-level evaluation. The first level consisted of determining serum level of IgA antigliadin antibodies (AGA). Subjects who were negative for IgA AGA were classified as not having CD, while samples testing positive for IgA AGA underwent a second level of the screening process. For the second level of screening, the serum IgA endomysial antibody (EMA) test was performed. Bone metabolism was evaluated by serum calcium (Ca), phosphorus, alkaline phosphatase, parathyroid hormone (PTH), 25 (OH) vitamin D, osteocalcin (OC), urinary deoxypyridinoline (dPD), and 24-h urinary calcium levels. Of the 89 patients evaluated, 17 were found to have positive IgA AGA tests (19%) and 9 were found to be positive for EMA (10.11%). EMA-positive patients showed lower values of serum Ca (p<0.05) and 25 (OH) vitamin D (p<0.01) and significantly higher values of PTH (p<0.01) compared with the EMA-negative patients. The level of urinary dPD was found to be significantly higher in EMA-positive patients (p<0.05). The results of this study suggest that all patients with idiopathic osteoporosis should be screened for CD by measurement of EMA. Additionally, we believe that serological screening for CD and detection of such patients will allow determination of the most convenient treatment strategies for osteoporosis.

Osteitis fibrosa cystica, coeliac disease and Turner syndrome. A case report

Today, osteitis fibrosa cystica is seldom present in primary hyperparathyroidism while it is mainly observed in uraemic osteodystrophy. We describe the case of a 54-year-old woman who was found to have huge bone cysts due to osteitis fibrosa cystica in the long bones. A parathyroid adenoma was identified and removed. Coeliac disease and Turner syndrome were diagnosed. Metabolic bone disease due to secondary hyperparathyroidism is common in coeliac disease; however, osteitis fibrosa cystica has not yet been described.

La maladie cœliaque de l’adulte : aspects nouveaux

INTRODUCTION

Celiac disease also known as gluten-sensitive enteropathy is a complex disorder where genetically susceptible individuals develop in typical cases signs of malabsorption after ingestion of cereals. Malabsorption is due to total or subtotal atrophy of the small intestinal mucosa regressing after adherence to a gluten-free diet. The only effective therapy is life-long strict abstinence from wheat, rye and barley.

CURRENT KNOWLEDGE AND KEY POINTS

During the last two decades spectrum of clinical features of adult celiac disease has been modified. About 60% of cases are now revealed by extraintestinal manifestations. Moreover, recent studies that used serological methods revealed existence of both latent and silent celiac sprue. The finding of the high frequency of atypical celiac sprue contributed to underestimation of the true prevalence of celiac disease until now, and explained that celiac disease could be unknown for a long time, with increased risk of nutritional deficiencies and malignancy. Concurrently, the finding that celiac disease is primarily associated to a few HLA class II molecules, and recent advent of tissue transglutaminase as the main auto-antigen eliciting anti-endomysial antibodies allowed to propose new pathogenesis hypothesis and efficient screening tests for celiac disease diagnosis.

FUTURE PROSPECTS AND PROJECTS

New epidemiological data concerning adult celiac disease must incite to a more systematic screening in patients with atypical but evocative features, or in at-risk subjects. Introduction of enzyme linked immunosorbent assays (ELISA) for the detection for anti-tissue transglutaminase antibodies allows to make use of a new available and efficient diagnosis parameter, which could constitute the main screening test in the near future.

Coeliac disease

Coeliac disease is a genetically-determined chronic inflammatory intestinal disease induced by an environmental precipitant, gluten. Patients with the disease might have mainly non-gastrointestinal symptoms, and as a result patients present to various medical practitioners. Epidemiological studies have shown that coeliac disease is very common and affects about one in 250 people. The disease is associated with an increased rate of osteoporosis, infertility, autoimmune diseases, and malignant disease, especially lymphomas. The mechanism of the intestinal immune-mediated response is not completely clear, but involves an HLA-DQ2 or HLA-DQ8 restricted T-cell immune reaction in the lamina propria as well as an immune reaction in the intestinal epithelium. An important component of the disease is the intraepithelial lymphocyte that might become clonally expanded in refractory sprue and enteropathy-associated T-cell lymphoma. Study of the mechanism of the immune response in coeliac disease could provide insight into the mechanism of inflammatory and autoimmune responses and lead to innovations in treatment.

Management of osteoporosis in patients with gastrointestinal diseases

Osteoporosis is a frequent complication in the course of various gastrointestinal disorders. Since its pathogenesis is complex, and incompletely understood in comparison to the well-known pathomechanism of postmenopausal osteoporosis, adequate management is difficult. We first summarize those therapeutic options which have strong evidence in postmenopausal osteoporosis and, thereafter, we review those in the context of different gastrointestinal diseases. Treatment of the underlying intestinal disorder seems to be most important to normalise altered bone metabolism and to prevent osteoporosis in patients with coeliac disease. In patients with osteoporosis associated with Crohn's disease, various treatment strategies (such as vitamin D, sodium fluoride, bisphosphonates) are discussed. In contrast to postmenopausal osteoporosis, interventional studies in secondary osteoporosis are often limited by the small study population and data about the efficacy of any treatment in prevention of fractures are therefore lacking. Well-conducted, controlled studies with the endpoint of preventing fractures are therefore required to optimise the treatment of osteoporosis in these patients.

Clinical evaluation for osteoporosis

The clinical evaluation of the osteoporotic patient should include a careful assessment of risk factors for low bone mass, falls, and fractures; quantitation of BMD; a thorough medical history and physical examination; and a targeted set of laboratory, radiographic, and other diagnostic studies as indicated. Among the elderly, vitamin D deficiency ranks high as one of the most underdiagnosed and yet reversible causes of osteoporosis. Regardless of age, every patient with low bone mass or fractures deserves an evaluation to uncover reversible, treatable disorders and to detect serious underlying illnesses.

New developments in celiac disease

Celiac disease remains a challenge to the clinician and scientist. It is clearly more prevalent than was previously suspected. Much interest is seen in identifying the genetic factors, which predispose to disease and the environmental agents that can trigger it. Genome-wide searches have identified a number of chromosomal susceptibility loci. Specific gliadin epitopes are being analyzed. New diagnostic options include the tissue transglutaminase enzyme-linked immunosorbent assay. Neurologic disease and bone disease are intriguing complications of celiac disease and are gradually being defined.