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Husby S, Choung RS, Crawley C, Lillevang ST, Murray JA. Laboratory Testing for Celiac Disease: Clinical and Methodological Considerations. Clin Chem 2024:hvae098. [PMID: 39099386 DOI: 10.1093/clinchem/hvae098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 05/30/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Celiac disease (CeD) has an estimated prevalence of 1%-3%. The classical clinical presentation is malabsorption, but now patients may present with more subtle symptoms such as constipation, osteoporosis, or iron deficiency anemia. Children may also present with poor growth.CeD has a strong genetic component, and high-risk groups include first-degree relatives with CeD, patients with co-existing autoimmune diseases, and patients with chromosomal aberrations. CONTENT Diagnostic tests for CeD include duodenal histology, serology, and genetic testing. Duodenal histology has traditionally been the gold standard of diagnosis. However, serological tests, especially IgA tissue transglutaminase antibodies (TTG-IgA), are widely used and diagnostic algorithms are based primarily on TTG-IgA as a starting point. Human leukocyte antigen typing may also be incorporated to determine genetic risk for CeD. Guidelines for children endorse biopsy avoidance provided high levels of TTG-IgA, with diagnostic accuracy being comparable to duodenal biopsy. Confirmation may be achieved by identifying IgA endomysial antibodies in a separate blood sample. Subjects with low positive TTG-IgA levels and subjects with IgA deficiency need a biopsy to establish a diagnosis of CeD. The clinical follow-up of CeD usually includes a repeat TTG-IgA examination. In adults, healing may be delayed or incomplete, and a rare consequence of refractory celiac disease is transformation to enteric T-cell lymphoma. SUMMARY Laboratory testing, in particular TTG-IgA, plays a central role in the diagnosis and has an accuracy comparable to histology. Diagnostic algorithms utilizing laboratory testing are critical for the development of novel strategies to improve diagnosis.
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Affiliation(s)
- Steffen Husby
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Cæcilie Crawley
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Søren T Lillevang
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
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2
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Schuppan D, Rostami K. Further Progress to Quantify Histological Damage in Patients With Celiac Disease. Clin Gastroenterol Hepatol 2024; 22:1188-1189. [PMID: 38278199 DOI: 10.1016/j.cgh.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 01/10/2024] [Indexed: 01/28/2024]
Affiliation(s)
- Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immunotherapy, Center for Celiac Disease and Autoimmunity, Johannes-Gutenberg University, Mainz, Germany; Division of Gastroenterology, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts.
| | - Kamran Rostami
- Crest Hospital Specialist Centre, Palmerston North, New Zealand; Department of Gastroenterology MidCentral District Health Board & Crest Specialist Centre, Palmerston North, New Zealand
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3
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Gluten Induces Subtle Histological Changes in Duodenal Mucosa of Patients with Non-Coeliac Gluten Sensitivity: A Multicentre Study. Nutrients 2022; 14:nu14122487. [PMID: 35745217 PMCID: PMC9230100 DOI: 10.3390/nu14122487] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 02/07/2023] Open
Abstract
Background: Histological changes induced by gluten in the duodenal mucosa of patients with non-coeliac gluten sensitivity (NCGS) are poorly defined. Objectives: To evaluate the structural and inflammatory features of NCGS compared to controls and coeliac disease (CeD) with milder enteropathy (Marsh I-II). Methods: Well-oriented biopsies of 262 control cases with normal gastroscopy and histologic findings, 261 CeD, and 175 NCGS biopsies from 9 contributing countries were examined. Villus height (VH, in μm), crypt depth (CrD, in μm), villus-to-crypt ratios (VCR), IELs (intraepithelial lymphocytes/100 enterocytes), and other relevant histological, serologic, and demographic parameters were quantified. Results: The median VH in NCGS was significantly shorter (600, IQR: 400−705) than controls (900, IQR: 667−1112) (p < 0.001). NCGS patients with Marsh I-II had similar VH and VCR to CeD [465 µm (IQR: 390−620) vs. 427 µm (IQR: 348−569, p = 0·176)]. The VCR in NCGS with Marsh 0 was lower than controls (p < 0.001). The median IEL in NCGS with Marsh 0 was higher than controls (23.0 vs. 13.7, p < 0.001). To distinguish Marsh 0 NCGS from controls, an IEL cut-off of 14 showed 79% sensitivity and 55% specificity. IEL densities in Marsh I-II NCGS and CeD groups were similar. Conclusion: NCGS duodenal mucosa exhibits distinctive changes consistent with an intestinal response to luminal antigens, even at the Marsh 0 stage of villus architecture.
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Maestri E, Duszka K, Kuznetsov VA. Immunity Depletion, Telomere Imbalance, and Cancer-Associated Metabolism Pathway Aberrations in Intestinal Mucosa upon Short-Term Caloric Restriction. Cancers (Basel) 2021; 13:cancers13133180. [PMID: 34202278 PMCID: PMC8267928 DOI: 10.3390/cancers13133180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 11/16/2022] Open
Abstract
Systems cancer biology analysis of calorie restriction (CR) mechanisms and pathways has not been carried out, leaving therapeutic benefits unclear. Using metadata analysis, we studied gene expression changes in normal mouse duodenum mucosa (DM) response to short-term (2-weeks) 25% CR as a biological model. Our results indicate cancer-associated genes consist of 26% of 467 CR responding differential expressed genes (DEGs). The DEGs were enriched with over-expressed cell cycle, oncogenes, and metabolic reprogramming pathways that determine tissue-specific tumorigenesis, cancer, and stem cell activation; tumor suppressors and apoptosis genes were under-expressed. DEG enrichments suggest telomeric maintenance misbalance and metabolic pathway activation playing dual (anti-cancer and pro-oncogenic) roles. The aberrant DEG profile of DM epithelial cells is found within CR-induced overexpression of Paneth cells and is coordinated significantly across GI tract tissues mucosa. Immune system genes (ISGs) consist of 37% of the total DEGs; the majority of ISGs are suppressed, including cell-autonomous immunity and tumor-immune surveillance. CR induces metabolic reprogramming, suppressing immune mechanics and activating oncogenic pathways. We introduce and argue for our network pro-oncogenic model of the mucosa multicellular tissue response to CR leading to aberrant transcription and pre-malignant states. These findings change the paradigm regarding CR's anti-cancer role, initiating specific treatment target development. This will aid future work to define critical oncogenic pathways preceding intestinal lesion development and biomarkers for earlier adenoma and colorectal cancer detection.
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Affiliation(s)
- Evan Maestri
- Department of Biochemistry and Urology, SUNY Upstate Medical University, Syracuse, NY 13210, USA;
- Department of Biology, SUNY University at Buffalo, Buffalo, NY 14260, USA
| | - Kalina Duszka
- Department of Nutritional Sciences, University of Vienna, Althanstrasse 14, 1090 Vienna, Austria;
| | - Vladimir A. Kuznetsov
- Department of Biochemistry and Urology, SUNY Upstate Medical University, Syracuse, NY 13210, USA;
- Bioinformatics Institute, Biomedical Sciences Institutes A*STAR, Singapore 13867, Singapore
- Correspondence:
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5
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Penny HA, Raju SA, Lau MS, Marks LJS, Baggus EMR, Bai JC, Bassotti G, Bontkes HJ, Carroccio A, Danciu M, Derakhshan MH, Ensari A, Ganji A, Green PHR, Johnson MW, Ishaq S, Lebwohl B, Levene A, Maxim R, Mohaghegh Shalmani H, Rostami-Nejad M, Rowlands D, Spiridon IA, Srivastava A, Volta U, Villanacci V, Wild G, Cross SS, Rostami K, Sanders DS. Accuracy of a no-biopsy approach for the diagnosis of coeliac disease across different adult cohorts. Gut 2021; 70:876-883. [PMID: 33139268 PMCID: PMC8040155 DOI: 10.1136/gutjnl-2020-320913] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/29/2020] [Accepted: 07/18/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to determine the predictive capacity and diagnostic yield of a 10-fold increase in serum IgA antitissue transglutaminase (tTG) antibody levels for detecting small intestinal injury diagnostic of coeliac disease (CD) in adult patients. DESIGN The study comprised three adult cohorts. Cohort 1: 740 patients assessed in the specialist CD clinic at a UK centre; cohort 2: 532 patients with low suspicion for CD referred for upper GI endoscopy at a UK centre; cohort 3: 145 patients with raised tTG titres from multiple international sites. Marsh 3 histology was used as a reference standard against which we determined the performance characteristics of an IgA tTG titre of ≥10×ULN for a diagnosis of CD. RESULTS Cohort 1: the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 54.0%, 90.0%, 98.7% and 12.5%, respectively. Cohort 2: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 50.0%, 100.0%, 100.0% and 98.3%, respectively. Cohort 3: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 30.0%, 83.0%, 95.2% and 9.5%, respectively. CONCLUSION Our results show that IgA tTG titres of ≥10×ULN have a strong predictive value at identifying adults with intestinal changes diagnostic of CD. This study supports the use of a no-biopsy approach for the diagnosis of adult CD.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Michelle S Lau
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Lauren JS Marks
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Elisabeth MR Baggus
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Julio C Bai
- Medicine, Gastroenterology Hospital 'Dr C Bonorino Udaondo', Buenos Aires, Argentina
| | - Gabrio Bassotti
- Gastroenterology & Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - Hetty J Bontkes
- Department Clinical Chemistry, Amsterdam Gastroenterology and Metabolism and Infection and Immunity Institutes, Amsterdam UMC, Amsterdam, The Netherlands
| | - Antonio Carroccio
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Mihai Danciu
- Pathology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | | | - Arzu Ensari
- Department of Pathology, Ankara University Medical School, Ankara, Turkey
| | - Azita Ganji
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Matt W Johnson
- Gastroenterology, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group NHS Foundation Trust, Birmingham City University, Birmingham, UK
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Adam Levene
- Gastroenterology, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
| | - Roxana Maxim
- Gastroenterology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Hamid Mohaghegh Shalmani
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - David Rowlands
- Department of Gastroenterology, Queen Elizabeth II Hospital, Hertfordshire, UK
| | - Irene A Spiridon
- Pathology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | | | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Graeme Wild
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Simon S Cross
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Kamran Rostami
- Department of Gastroenterology, MidCentral District Health Board, Palmerston North, New Zealand
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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Balaban DV, Jinga M. Digital histology in celiac disease: A practice changer. Artif Intell Gastroenterol 2020; 1:1-4. [DOI: 10.35712/aig.v1.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023] Open
Abstract
Artificial intelligence (AI) has grown tremendously in the last decades and is undoubtedly the future era in medicine. Concerning digestive diseases, applications of AI include clinical gastroenterology, gastrointestinal endoscopy and imaging, and not least pathological diagnosis. Several gastrointestinal pathologies require histological confirmation for a positive diagnosis. Among them, celiac disease (CD) diagnosis has been in the spotlight over time, but controversy is still ongoing with regard to the so-called celiac-type histology. Despite efforts to improve histological diagnosis in CD, there are still several issues and pitfalls associated with duodenal histology reading. Several papers have assessed the accuracy of AI techniques in detecting CD on duodenal biopsy images and have shown high diagnostic performance over standard histology reading. We discuss the role of computer-assisted histology in improving the assessment of mucosal architectural injury and inflammation in CD patients, both for diagnosis and follow-up.
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Affiliation(s)
- Daniel Vasile Balaban
- Internal Medicine and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest 020021, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest 020021, Romania
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7
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Digital histology in celiac disease: A practice changer. Artif Intell Gastroenterol 2020. [DOI: 10.35712/wjg.v1.i1.1] [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: 02/06/2023] Open
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8
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Charlesworth RPG. Diagnosing coeliac disease: Out with the old and in with the new? World J Gastroenterol 2020; 26:1-10. [PMID: 31933510 PMCID: PMC6952296 DOI: 10.3748/wjg.v26.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/05/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
Coeliac disease (CD) is a complex condition resulting from an interplay between genetic and environmental factors. When diagnosing the condition, serological testing and genotyping are useful in excluding CD, although the gold standard of testing is currently histopathological examination of the small intestine. There are drawbacks associated with this form of testing however and because of this, novel forms of testing are currently under investigation. Before we develop completely novel tests though, it is important to ask whether or not we can simply use the data we gather from coeliac patients more effectively and build a more accurate snapshot of CD through statistical analysis of combined metrics. It is clear that not one single test can accurately diagnose CD and it is also clear that CD patients can no longer be defined by discrete classifications, the continuum of patient presentation needs to be recognised and correctly captured to improve diagnostic accuracy. This review will discuss the current diagnostics for CD and then outline novel diagnostics under investigation for the condition. Finally, improvements to current protocols will be discussed with the need for a holistic "snapshot" of CD using a number of metrics simultaneously.
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Caio G, Volta U, Sapone A, Leffler DA, De Giorgio R, Catassi C, Fasano A. Celiac disease: a comprehensive current review. BMC Med 2019; 17:142. [PMID: 31331324 PMCID: PMC6647104 DOI: 10.1186/s12916-019-1380-z] [Citation(s) in RCA: 445] [Impact Index Per Article: 89.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/27/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Celiac disease remains a challenging condition because of a steady increase in knowledge tackling its pathophysiology, diagnosis, management, and possible therapeutic options. MAIN BODY A major milestone in the history of celiac disease was the identification of tissue transglutaminase as the autoantigen, thereby confirming the autoimmune nature of this disorder. A genetic background (HLA-DQ2/DQ8 positivity and non-HLA genes) is a mandatory determinant of the development of the disease, which occurs with the contribution of environmental factors (e.g., viral infections and dysbiosis of gut microbiota). Its prevalence in the general population is of approximately 1%, with female predominance. The disease can occur at any age, with a variety of symptoms/manifestations. This multifaceted clinical presentation leads to several phenotypes, i.e., gastrointestinal, extraintestinal, subclinical, potential, seronegative, non-responsive, and refractory. Although small intestinal biopsy remains the diagnostic 'gold standard', highly sensitive and specific serological tests, such as tissue transglutaminase, endomysial and deamidated gliadin peptide antibodies, have become gradually more important in the diagnostic work-up of celiac disease. Currently, the only treatment for celiac disease is a life-long, strict gluten-free diet leading to improvement in quality of life, ameliorating symptoms, and preventing the occurrence of refractory celiac disease, ulcerative jejunoileitis, and small intestinal adenocarcinoma and lymphoma. CONCLUSIONS The present review is timely and provides a thorough appraisal of various aspects characterizing celiac disease. Remaining challenges include obtaining a better understanding of still-unclear phenotypes such as slow-responsive, potential (minimal lesions) and seronegative celiac disease. The identification of alternative or complementary treatments to the gluten-free diet brings hope for patients unavoidably burdened by diet restrictions.
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Affiliation(s)
- Giacomo Caio
- Department of Medical Sciences, University of Ferrara, Via Aldo Moro 8, Cona, 44124 Ferrara, Italy
- Center for Celiac Research and Treatment, Massachusetts General Hospital, Boston, MA 02114 USA
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Anna Sapone
- Center for Celiac Research and Treatment, Massachusetts General Hospital, Boston, MA 02114 USA
- Takeda Pharmaceuticals International Co, Cambridge, MA 02139 USA
| | - Daniel A. Leffler
- Takeda Pharmaceuticals International Co, Cambridge, MA 02139 USA
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02115 USA
| | - Roberto De Giorgio
- Department of Medical Sciences, University of Ferrara, Via Aldo Moro 8, Cona, 44124 Ferrara, Italy
| | - Carlo Catassi
- Center for Celiac Research and Treatment, Massachusetts General Hospital, Boston, MA 02114 USA
- Department of Pediatrics, Center for Celiac Research, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Alessio Fasano
- Center for Celiac Research and Treatment, Massachusetts General Hospital, Boston, MA 02114 USA
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Charlesworth RPG, Marsh MN. From 2-dimensional to 3-dimensional: Overcoming dilemmas in intestinal mucosal interpretation. World J Gastroenterol 2019; 25:2402-2415. [PMID: 31171885 PMCID: PMC6543240 DOI: 10.3748/wjg.v25.i20.2402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/04/2019] [Accepted: 04/19/2019] [Indexed: 02/06/2023] Open
Abstract
The purpose of this review is to provide a definitive account of small intestinal mucosal structure and interpretation. The coeliac lesion has been well known, but not well described to date and this review aims to identify the interpretative difficulties which have arisen over time with the histological assessment of coeliac disease. In early coeliac interpretation, there were significant inaccuracies, particularly surrounding intraepithelial lymphocyte counts and the degree of villous flattening which occurred in the tissue. Many of these interpretive pitfalls are still encountered today, increasing the potential for diagnostic errors. These difficulties are mostly due to the fact that stained 2-dimensional sections can never truly represent the 3-dimensional framework of the intestinal tissue under investigation. Therefore, this review offers a critical account occasioned by these 2-dimensional interpretative errors and which, in our opinion, should in general be jettisoned. As a result, we leave a framework regarding the true 3-dimensional knowledge of mucosal structure accrued over the 70-year period of study, and one which is available for future reference.
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Affiliation(s)
| | - Michael N Marsh
- Wolfson College, University of Oxford, Oxford OX2 6UD, United Kingdom
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11
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Ensari A, Marsh MN. Diagnosing celiac disease: A critical overview. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2019; 30:389-397. [PMID: 31060993 PMCID: PMC6505646 DOI: 10.5152/tjg.2018.18635] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 12/22/2018] [Indexed: 12/11/2022]
Abstract
The diagnosis of celiac disease (CD) no longer rests on a malabsorptive state or severe mucosal lesions. For the present, diagnosis will always require the gold-standard of a biopsy, interpreted through its progressive phases (Marsh classification). Marsh classification articulated the immunopathological spectrum of gluten-induced mucosal changes in association with the recognition of innate (Marsh I infiltration) and T cell-based adaptive (Marsh II, and the surface re-organisation typifying Marsh III lesions) responses. Through the Marsh classification the diagnostic goalposts were considerably widened thus, over its time-course, permitting countless patients to begin a gluten-free diet but who, on previous criteria, would have been denied such vital treatment. The revisions of this classification failed to provide additional insight in the interpretation of mucosal pathology. Morever, the subclassification of Marsh 3 imposed an enormous amount of extra work on pathologists with no aid in diagnosis, treatment, or prognosis. Therefore, it should now be apparent that if gastroenterologists ignore these sub-classifications in clinical decision-making, then on that basis alone, there is no need whatsoever for pathologists to persist in reporting them. Since new treatments are under critical assessment, we might have to consider use of some other higher level histological techniques sensitive enough to detect the changes sought. A promising alternative would be to hear more voices from imaginative histopathologists or morphologists together with some more insightful approaches, involving molecular-based techniques and stem cell research may be to evaluate mucosal pathology in CD.
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Affiliation(s)
- Arzu Ensari
- Department of Pathology, Ankara University School of Medicine, Ankara, Turkey
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12
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Rostami K, Srivastava A. Coeliac disease novel histological quantification. Comput Biol Med 2018; 106:149. [PMID: 30580816 DOI: 10.1016/j.compbiomed.2018.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Kamran Rostami
- Department of Gastroenterology, MidCentral District Health Board, Palmerston North Hospital, Palmerston North, New Zealand.
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13
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Gibiino G, Lopetuso L, Ricci R, Gasbarrini A, Cammarota G. Coeliac disease under a microscope: Histological diagnostic features and confounding factors. Comput Biol Med 2018; 104:335-338. [PMID: 30409469 DOI: 10.1016/j.compbiomed.2018.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
Coeliac disease (CD) and gluten-related disorders represent an important cornerstone of the daily practice of gastroenterologists, endoscopists and dedicated histopathologists. Despite the knowledge of clinical, serological and histological typical lesions, there are some conditions to consider for differential diagnosis. From the first description of histology of CD, several studies were conducted to define similar findings suggestive for microscopic enteritis. Considering the establishment of early precursor lesions, the imbalance of gut microbiota is another point still requiring a detailed definition. This review assesses the importance of a right overview in case of suspected gluten-related disorders and the several conditions mimicking a similar histology.
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Affiliation(s)
- Giulia Gibiino
- Internal Medicine and, Gastroenterology and Hepatic Diseases Unit, IRCCS Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Loris Lopetuso
- Internal Medicine and, Gastroenterology and Hepatic Diseases Unit, IRCCS Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Riccardo Ricci
- Institute of Pathology, IRCCS Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Gasbarrini
- Internal Medicine and, Gastroenterology and Hepatic Diseases Unit, IRCCS Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Cammarota
- Internal Medicine and, Gastroenterology and Hepatic Diseases Unit, IRCCS Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
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14
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Rostami K, Ensari A, Ciacci C, Srivastava A, Volta U, Villanacci V, Marsh MN. Coeliac biopsies: numbers are valid, alphabets not. Gut 2018; 67:2069-2070. [PMID: 29158235 DOI: 10.1136/gutjnl-2017-315517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Kamran Rostami
- Department of Gastroenterology, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Arzu Ensari
- Department of Pathology, Ankara University Medical School, Ankara, Turkey
| | - Carolina Ciacci
- Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Amitabh Srivastava
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Villanacci
- Department of Pathology, Institute of Pathology Spedali Civili, Brescia, Italy
| | - Michael N Marsh
- Department of Gastroenterology, Luton and Dunstable University Hospital, Luton, UK.,Wolfson College, University of Oxford, Oxford, United Kingdom
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Abstract
Coeliac disease is increasingly recognized as a global problem in both children and adults. Traditionally, the findings of characteristic changes of villous atrophy and increased intraepithelial lymphocytosis identified in duodenal biopsy samples taken during upper gastrointestinal endoscopy have been required for diagnosis. Although biopsies remain advised as necessary for the diagnosis of coeliac disease in adults, European guidelines for children provide a biopsy-sparing diagnostic pathway. This approach has been enabled by the high specificity and sensitivity of serological testing. However, these guidelines are not universally accepted. In this Perspective, we discuss the pros and cons of a biopsy-avoiding pathway for the diagnosis of coeliac disease, especially in this current era of the call for more biopsies, even from the duodenal bulb, in the diagnosis of coeliac disease. In addition, a contrast between paediatric and adult guidelines is presented.
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Rostami K, Marsh MN, Johnson MW, Mohaghegh H, Heal C, Holmes G, Ensari A, Aldulaimi D, Bancel B, Bassotti G, Bateman A, Becheanu G, Bozzola A, Carroccio A, Catassi C, Ciacci C, Ciobanu A, Danciu M, Derakhshan MH, Elli L, Ferrero S, Fiorentino M, Fiorino M, Ganji A, Ghaffarzadehgan K, Going JJ, Ishaq S, Mandolesi A, Mathews S, Maxim R, Mulder CJ, Neefjes-Borst A, Robert M, Russo I, Rostami-Nejad M, Sidoni A, Sotoudeh M, Villanacci V, Volta U, Zali MR, Srivastava A. ROC-king onwards: intraepithelial lymphocyte counts, distribution & role in coeliac disease mucosal interpretation. Gut 2017; 66:2080-2086. [PMID: 28893865 PMCID: PMC5749338 DOI: 10.1136/gutjnl-2017-314297] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 06/17/2017] [Accepted: 06/22/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Counting intraepithelial lymphocytes (IEL) is central to the histological diagnosis of coeliac disease (CD), but no definitive 'normal' IEL range has ever been published. In this multicentre study, receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off between normal and CD (Marsh III lesion) duodenal mucosa, based on IEL counts on >400 mucosal biopsy specimens. DESIGN The study was designed at the International Meeting on Digestive Pathology, Bucharest 2015. Investigators from 19 centres, eight countries of three continents, recruited 198 patients with Marsh III histology and 203 controls and used one agreed protocol to count IEL/100 enterocytes in well-oriented duodenal biopsies. Demographic and serological data were also collected. RESULTS The mean ages of CD and control groups were 45.5 (neonate to 82) and 38.3 (2-88) years. Mean IEL count was 54±18/100 enterocytes in CD and 13±8 in normal controls (p=0.0001). ROC analysis indicated an optimal cut-off point of 25 IEL/100 enterocytes, with 99% sensitivity, 92% specificity and 99.5% area under the curve. Other cut-offs between 20 and 40 IEL were less discriminatory. Additionally, there was a sufficiently high number of biopsies to explore IEL counts across the subclassification of the Marsh III lesion. CONCLUSION Our ROC curve analyses demonstrate that for Marsh III lesions, a cut-off of 25 IEL/100 enterocytes optimises discrimination between normal control and CD biopsies. No differences in IEL counts were found between Marsh III a, b and c lesions. There was an indication of a continuously graded dose-response by IEL to environmental (gluten) antigenic influence.
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Affiliation(s)
- Kamran Rostami
- Department of Gastroenterology and Pathology, Milton Keynes University Hospital, Milton Keynes, UK
| | - Michael N Marsh
- Department of Gastroenterology, Luton and Dunstable University Hospital, Luton, UK,Wolfson College, University of Oxford, Oxford, UK
| | - Matt W Johnson
- Department of Gastroenterology, Luton and Dunstable University Hospital, Luton, UK
| | - Hamid Mohaghegh
- Gastroenterology and Liver Diseases Research Centre, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, The Islamic Republic of Iran
| | - Calvin Heal
- Centre for Biostatistics, Faculty of Biology, Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Geoffrey Holmes
- Department of Gastroenterology, Royal Derby Hospital, Derby, UK
| | - Arzu Ensari
- Department of Pathology, Ankara University Medical School, Ankara, Turkey
| | - David Aldulaimi
- Department of Gastroenterology, Warwick Hospital, Warwick, UK
| | - Brigitte Bancel
- Service de Pathologie, Centre de Biologie et Pathologie Groupe Hospitalier du Nord, Hospices Civils de Lyon, Lyon, France
| | | | - Adrian Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gabriel Becheanu
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Anna Bozzola
- Institute of Pathology Spedali Civili, Brescia, Italy
| | - Antonio Carroccio
- Internal Medicine and Pathology Unit, University of Palermo, Giovanni Paolo II Hospital, Sciacca, Italy
| | - Carlo Catassi
- Department of Pediatrics and Surgical Pathology, Università Politecnica delle Marche, Ancona, Italy
| | - Carolina Ciacci
- Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Alexandra Ciobanu
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mihai Danciu
- Departments of Gastroenterology and Pathology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Mohammad H Derakhshan
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK,Digestive Disease Research Center, Tehran University Medical Science, Tehran, Iran
| | - Luca Elli
- Center for Prevention and Diagnosis of Coeliac Disease and Pathology Unit, Fondazione IRCCS Ca’ granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Stefano Ferrero
- Center for Prevention and Diagnosis of Coeliac Disease and Pathology Unit, Fondazione IRCCS Ca’ granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Michelangelo Fiorentino
- Department of Medical and Surgical Sciences, University of Bologna and Diagnostic and Experimental, University of Bologna, Bologna, Italy
| | - Marilena Fiorino
- Internal Medicine and Pathology Unit, University of Palermo, Giovanni Paolo II Hospital, Sciacca, Italy
| | - Azita Ganji
- Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - James J Going
- Department of Pathology, Southern General Hospital, Lanarkshire, UK
| | - Sauid Ishaq
- Dudley group of Hospitals, Birmingham City University, Birmingham, UK
| | - Alessandra Mandolesi
- Department of Pediatrics and Surgical Pathology, Università Politecnica delle Marche, Ancona, Italy
| | - Sherly Mathews
- Department of Gastroenterology and Pathology, Milton Keynes University Hospital, Milton Keynes, UK
| | - Roxana Maxim
- Departments of Gastroenterology and Pathology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Chris J Mulder
- Department of Hepatogastroenterology and Pathology, Free University Medical Centre, Amsterdam, The Netherlands
| | - Andra Neefjes-Borst
- Department of Hepatogastroenterology and Pathology, Free University Medical Centre, Amsterdam, The Netherlands
| | - Marie Robert
- Department of Pathology and Medicine, Yale University School of Medicine, New Haven, USA
| | - Ilaria Russo
- Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Centre, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, The Islamic Republic of Iran
| | - Angelo Sidoni
- University of Perugia Medical School, Perugia, Italy
| | - Masoud Sotoudeh
- Digestive Disease Research Center, Tehran University Medical Science, Tehran, Iran
| | | | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna and Diagnostic and Experimental, University of Bologna, Bologna, Italy
| | - Mohammad R Zali
- Gastroenterology and Liver Diseases Research Centre, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, The Islamic Republic of Iran
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Evolutionary Developments in Interpreting the Gluten-Induced Mucosal Celiac Lesion: An Archimedian Heuristic. Nutrients 2017; 9:nu9030213. [PMID: 28264483 PMCID: PMC5372876 DOI: 10.3390/nu9030213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/22/2017] [Indexed: 02/07/2023] Open
Abstract
The evolving history of the small intestinal biopsy and its interpretation—and misinterpretations—are described in this paper. Certain interpretative errors in the technical approaches to histological assessment are highlighted—even though we may never be rid of them. For example, mucosal “flattening” does not reduce individual villi to their cores, as still seems to be widely believed. Neither is the mucosa undergoing an atrophic process—since it can recover structurally. Rather, the intestinal mucosa manifests a vast hypertrophic response resulting in the formation of large plateaus formed from partially reduced villi and their amalgamation with the now increased height and width of the inter-villous ridges: this is associated with considerable increases in crypt volumes. Sections through mosaic plateaus gives an erroneous impression of the presence of stunted, flat-topped villi which continues to encourage both the continued use of irrelevant “atrophy” terminologies and a marked failure to perceive what random sections through mosaic plateaus actually look like. While reviewing the extensive 40+ year literature on mucosal analysis, we extracted data on intraepithelial lymphocytes (IEL) counts from 607 biopsies, and applied receiver-operating characteristic (ROC)-curve analysis. From that perspective, it appears that counting IEL/100 enterocyte nuclei in routine haematoxylin and eosin (H&E) sections provides the most useful discriminator of celiac mucosae at histological level, with an effective cut-off of 27 IEL, and offering a very high sensitivity with few false negatives. ROC-curve analysis also revealed the somewhat lesser accuracies of either CD3+ or γδ+ IEL counts. Current official guidelines seem to be somewhat inadequate in clearly defining the spectrum of gluten-induced mucosal pathologies and how they could be optimally interpreted, as well as in promoting the ideal manner for physicians and pathologists to interact in interpreting intestinal mucosae submitted for analysis. Future trends should incorporate 3-D printing and computerised modelling in order to exemplify the subtle micro-anatomical features associated with the crypt-villus interzone. The latter needs precise delineation with use of mRNA in-section assays for brush border enzymes such as alkaline phosphate and esterase. Other additional approaches are needed to facilitate recognition and interpretation of the features of this important inter-zone, such as wells, basins and hypertrophic alterations in the size of inter-villous ridges. The 3-D computerised models could considerably expand our understandings of the microvasculature and its changes—in relation both to crypt hypertrophy, in addition to the partial attrition and subsequent regrowth of villi from the inter-villous ridges during the flattening and recovery processes, respectively.
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