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Deb A, Moond V, Thongtan T, Deliwala S, Chandan S, Mohan BP, Adler DG. Role of Duodenal Bulb Biopsy in Diagnosing Suspected Celiac Disease in Adult Patients: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2024; 58:588-595. [PMID: 37646538 DOI: 10.1097/mcg.0000000000001913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/19/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND AIMS Current guidelines recommend multiple biopsies from the first (D1) and second (D2) part of duodenum to establish a diagnosis of celiac disease. In this meta-analysis we aimed to find whether D1 biopsy can increase the diagnostic yield of adult celiac disease. METHODS Literature databases were searched until January 2023 for studies reporting diagnosis of celiac disease in the adult population using D1 biopsy. Meta-analysis was done using a random-effects model. Heterogeneity was assessed by I 2 % and 95% prediction interval statistics. Measured outcomes were diagnostic yield with D1 and D2 biopsies and from 4 versus 2 biopsy samples. RESULTS A total of 16 studies were included in the final analysis. The pooled diagnostic rate of celiac disease from D1 biopsy was 77.4% [95% CI (64.7-86.5, I 2 94%)] and from D2 biopsy was 75.3% [60.8-85.7, I 2 96%]. The pooled rate of increase in diagnostic yield with D1 biopsy was 6.9% I [4.6-10.2, I 2 66%]. The pooled diagnosis rate with 2 biopsy samples were 77.3% [50-92, I 2 93%] and 86.4% I [58.4-96.7, I 2 87%] from D1 and D2 respectively, whereas that with 4 biopsy samples were 83.3% [49.8-96.2, I 2 76%] and 70.5% I [51-84.6, I 2 96%] from D1 and D2, respectively, the difference being non-significant. CONCLUSION Our study demonstrates that taking 4 biopsy samples does not incur any additional diagnostic value over taking 2 biopsy samples from each duodenum segment. Although biopsy from the D1 and D2 has similar diagnostic yield in the adult population, there was an overall increase in diagnostic yield with D1 biopsy, especially in those with a patchy disease distribution.
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Affiliation(s)
- Anasua Deb
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock
| | - Vishali Moond
- Department of Internal Medicine, Saint Peter's University Hospital/Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Thanita Thongtan
- Division of Gastroenterology & Hepatology, The University of Texas Rio Grande Valley, Edinburg, TX
| | - Smit Deliwala
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, Creighton University School of Medicine, Omaha, NE
| | - Babu P Mohan
- Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, UT
| | - Douglas G Adler
- Director, Center for Advanced Therapeutic Endoscopy, Centura Health, Porter Adventist Hospital, Denver, CO
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2
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Robert ME, Ciacci C, Lebwohl B. Opportunities for Improving Biopsy and Non-Biopsy-Based Diagnosis of Celiac Disease. Gastroenterology 2024; 167:79-89. [PMID: 38302007 DOI: 10.1053/j.gastro.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/17/2024] [Accepted: 01/24/2024] [Indexed: 02/03/2024]
Abstract
The accumulating data regarding a non-biopsy diagnosis of celiac disease has led to its adoption in certain scenarios, although debate on whether and when to use non-biopsy criteria in clinical practice is ongoing. Despite the growing popularity and evidence basis for a biopsy-free approach to diagnosis in the context of highly elevated serologies, there will continue to be a role for a biopsy in some groups. This review summarizes the current evidence supporting a non-biopsy approach and arguments supporting continued reliance on biopsy, and focuses on opportunities to improve both approaches.
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Affiliation(s)
- Marie E Robert
- Department of Pathology, Medicine (Digestive Diseases) and Human and Translational Immunology, Yale University School of Medicine, New Haven, Connecticut
| | - Carolina Ciacci
- Department of Medicine, Surgery, Dentistry, Scuola Medica Salernitana, University of Salerno, Baronissi, Salerno, Italy.
| | - Benjamin Lebwohl
- Department of Medicine, Columbia University Irving Medical Center, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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3
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Volta U, Rostami K, Auricchio R, Lundin KEA. Diagnosis of Seronegative and Ultrashort Celiac Disease. Gastroenterology 2024; 167:104-115. [PMID: 38286391 DOI: 10.1053/j.gastro.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 01/31/2024]
Abstract
In its conventional form, celiac disease (CeD) is characterized by both positive serology and flat villi in the duodenum, and is well known by gastroenterologists and general practitioners. The aim of this review was to shed light on 2 neglected and not yet well-defined celiac phenotypes, that is, seronegative and ultrashort CeD. Seronegative CeD can be suspected in the presence of flat villi, positive HLA-DQ2 and/or HLA-DQ8, and the absence of CeD antibodies. After ruling out other seronegative enteropathies, the diagnosis can be confirmed by both clinical and histologic improvements after 1 year of a gluten-free diet. Ultrashort CeD is characterized by the finding of flat villi in the duodenal bulb in the absence of mucosal damage in the distal duodenum and with serologic positivity. Data on the prevalence, clinical manifestations, histologic lesions, genetic features, and outcome of seronegative and ultrashort CeD are inconclusive due to the few studies available and the small number of patients diagnosed. Some additional diagnostic tools have been developed recently, such as assessing intestinal transglutaminase 2 deposits, flow cytometry technique, microRNA detection, or proteomic analysis, and they seem to be useful in the identification of complex cases. Further cooperative studies are highly desirable to improve the knowledge of these 2 still-obscure variants of CeD.
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Affiliation(s)
- Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Kamran Rostami
- Department of Gastroenterology MidCentral District Health Board, Palmerston, North New Zealand
| | - Renata Auricchio
- Department of Translational Medical Science, University Federico II, Naples, Italy
| | - Knut E A Lundin
- Department of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Norwegian Coeliac Disease Research Centre, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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4
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Johansen A, Sandve GKF, Ibsen JH, Lundin KEA, Sollid LM, Stamnaes J. Biopsy Proteome Scoring to Determine Mucosal Remodeling in Celiac Disease. Gastroenterology 2024:S0016-5085(24)00286-5. [PMID: 38467384 DOI: 10.1053/j.gastro.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/14/2024] [Accepted: 03/05/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND & AIMS Histologic evaluation of gut biopsies is a cornerstone for diagnosis and management of celiac disease (CeD). Despite its wide use, the method depends on proper biopsy orientation, and it suffers from interobserver variability. Biopsy proteome measurement reporting on the tissue state can be obtained by mass spectrometry analysis of formalin-fixed paraffin-embedded tissue. Here we aimed to transform biopsy proteome data into numerical scores that give observer-independent measures of mucosal remodeling in CeD. METHODS A pipeline using glass-mounted formalin-fixed paraffin-embedded sections for mass spectrometry-based proteome analysis was established. Proteome data were converted to numerical scores using 2 complementary approaches: a rank-based enrichment score and a score based on machine learning using logistic regression. The 2 scoring approaches were compared with each other and with histology analyzing 18 patients with CeD with biopsies collected before and after treatment with a gluten-free diet as well as biopsies from patients with CeD with varying degree of remission (n = 22). Biopsies from individuals without CeD (n = 32) were also analyzed. RESULTS The method yielded reliable proteome scoring of both unstained and H&E-stained glass-mounted sections. The scores of the 2 approaches were highly correlated, reflecting that both approaches pick up proteome changes in the same biological pathways. The proteome scores correlated with villus height-to-crypt depth ratio. Thus, the method is able to score biopsies with poor orientation. CONCLUSIONS Biopsy proteome scores give reliable observer and orientation-independent measures of mucosal remodeling in CeD. The proteomic method can readily be implemented by nonexpert laboratories in parallel to histology assessment and easily scaled for clinical trial settings.
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Affiliation(s)
- Anette Johansen
- K.G. Jebsen Coeliac Disease Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Geir Kjetil F Sandve
- K.G. Jebsen Coeliac Disease Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Informatics, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Jostein Holen Ibsen
- Department of Gastroenterology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Knut E A Lundin
- K.G. Jebsen Coeliac Disease Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Gastroenterology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Ludvig M Sollid
- K.G. Jebsen Coeliac Disease Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Immunology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Jorunn Stamnaes
- K.G. Jebsen Coeliac Disease Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Immunology, Oslo University Hospital-Rikshospitalet, Oslo, Norway.
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5
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Takeda T, Abe D, Asaoka D, Iwano T, Yamamoto M, Uchida R, Utsunomiya H, Oki S, Suzuki N, Ikeda A, Akazawa Y, Ueda K, Ueyama H, Hojo M, Nojiri S, Nagahara A. Risk Factors for Mucosal Redness in the Duodenal Bulb as Detected via Linked Color Imaging. Diagnostics (Basel) 2024; 14:508. [PMID: 38472980 DOI: 10.3390/diagnostics14050508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/22/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024] Open
Abstract
Linked color imaging (LCI) for image-enhanced endoscopy (IEE) highlights mucosal color differences. We investigated risk factors associated with mucosal redness of the duodenal bulb using LCI. Consecutive patients were retrospectively selected after their duodenal bulbs were observed via LCI. A symptom questionnaire (Izumo scale) was completed. The LCI of the duodenal bulb was subjectively evaluated on whether redness was present and objectively evaluated based on L* a* b* color values. The clinical characteristics of the 302 study participants were: male/female, 120/182; mean age, 70.9 years. Twenty-one cases (7.0%) were in the redness (+) group. After multiple regression analysis, independent predictors for the red component (a*) of the duodenal bulb using LCI were: age (β = -0.154, p < 0.01), female (β = -0.129, p < 0.05), body mass index (BMI; β = -0.136, p < 0.05), Helicobacter pylori eradication (β = 0.137, p < 0.05), endoscopic gastric mucosal atrophy score (EGAS; β = -0.149, p < 0.05), and constipation-related quality of life (QOL) (β = -0.122, p < 0.05) scores. Lower age, lower BMI, lower EGAS, a constipation-related QOL score, post-H. pylori eradication, and being male were associated with mucosal redness in the duodenal bulb with IEE using LCI.
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Affiliation(s)
- Tsutomu Takeda
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Daiki Abe
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Daisuke Asaoka
- Department of Gastroenterology, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo 136-0075, Japan
| | - Tomoyo Iwano
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Momoko Yamamoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Ryota Uchida
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Hisanori Utsunomiya
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Shotaro Oki
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Nobuyuki Suzuki
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Atsushi Ikeda
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Yoichi Akazawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Kumiko Ueda
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Mariko Hojo
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Shuko Nojiri
- Department of Medical Technology Innovation Center, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
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Shiha MG, Chetcuti Zammit S, Elli L, Sanders DS, Sidhu R. Updates in the diagnosis and management of coeliac disease. Best Pract Res Clin Gastroenterol 2023; 64-65:101843. [PMID: 37652646 DOI: 10.1016/j.bpg.2023.101843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/02/2023] [Indexed: 09/02/2023]
Abstract
Coeliac disease is a common autoimmune disorder induced by ingesting gluten, the protein component of wheat, barley, and rye. It is estimated that one-in-hundred people worldwide have coeliac disease, of whom the majority remain undiagnosed. Coeliac disease is characterized by a wide range of gastrointestinal and extraintestinal symptoms but can also present asymptomatically. Diagnosing coeliac disease depends on the concordance of clinical, serological and histopathological data. However, the diagnosis can be challenging and frequently overlooked. Undiagnosed coeliac disease is associated with an increased risk of complications and detrimental effects on quality of life. Early diagnosis and treatment of coeliac disease are necessary to reduce the risk of long-term complications.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.
| | | | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Reena Sidhu
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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7
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Diagnosis and Management of Celiac Disease. Am J Gastroenterol 2023; 118:383-385. [PMID: 36689731 DOI: 10.14309/ajg.0000000000002140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/29/2022] [Indexed: 01/25/2023]
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8
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Chen ZE, Lee HE, Wu TT. Histologic evaluation in the diagnosis and management of celiac disease: practical challenges, current best practice recommendations and beyond. Hum Pathol 2023; 132:20-30. [PMID: 35932826 DOI: 10.1016/j.humpath.2022.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 02/07/2023]
Abstract
Celiac disease (CD) is an immunoallergic enteropathy affecting genetically susceptible individuals upon dietary exposure to gluten. In current clinical practice, the diagnosis of CD is based on a combination of clinical, serologic, and histologic factors with the possible exception of pediatric patients. Histopathologic evaluation of small intestinal tissue plays a critical role in the disease diagnosis and management, despite many practical challenges. Recently published best practice guidelines help to standardize biopsy sample procurement, tissue preparation, histology interpretation, and reporting, to optimize patient care. In addition, an increasing demand for monitoring the disease course, particularly demonstrating the efficacy of dietary and nondietary interventions for disease management, calls for the use of quantitative histology. With the advent of a gradual transition toward digital pathology in routine diagnostic practice, quantitative histopathologic evaluation in CD shows a promising future.
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Affiliation(s)
- Zongming Eric Chen
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Hee Eun Lee
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Tsung-Teh Wu
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA.
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9
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Rubio-Tapia A, Hill ID, Semrad C, Kelly CP, Greer KB, Limketkai BN, Lebwohl B. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Am J Gastroenterol 2023; 118:59-76. [PMID: 36602836 DOI: 10.14309/ajg.0000000000002075] [Citation(s) in RCA: 69] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/23/2022] [Indexed: 01/06/2023]
Abstract
This guideline presents an update to the 2013 American College of Gastroenterology Guideline on the Diagnosis and Management of Celiac Disease with updated recommendations for the evaluation and management of patients with celiac disease (CD). CD is defined as a permanent immune-mediated response to gluten present in wheat, barley, and rye. CD has a wide spectrum of clinical manifestations that resemble a multisystemic disorder rather than an isolated intestinal disease, and is characterized by small bowel injury and the presence of specific antibodies. Detection of CD-specific antibodies (e.g., tissue transglutaminase) in the serum is very helpful for the initial screening of patients with suspicion of CD. Intestinal biopsy is required in most patients to confirm the diagnosis. A nonbiopsy strategy for the diagnosis of CD in selected children is suggested and discussed in detail. Current treatment for CD requires strict adherence to a gluten-free diet (GFD) and lifelong medical follow-up. Most patients have excellent clinical response to a GFD. Nonresponsive CD is defined by persistent or recurrent symptoms despite being on a GFD. These patients require a systematic workup to rule out specific conditions that may cause persistent or recurrent symptoms, especially unintentional gluten contamination. Refractory CD is a rare cause of nonresponsive CD often associated with poor prognosis.
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Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ivor D Hill
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children Hospital, Columbus, Ohio, USA
| | - Carol Semrad
- Division of Gastroenterology, University of Chicago, Chicago, Illinois, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Katarina B Greer
- Department of Medicine, Section of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Berkeley N Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California, USA
| | - Benjamin Lebwohl
- Division of Gastroenterology and Hepatology, Columbia University, New York, USA
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10
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Branchi F, Wiese JJ, Heldt C, Manna S, Dony V, Loddenkemper C, Bojarski C, Siegmund B, Schneider T, Daum S, Hummel M, Moos V, Schumann M. The combination of clinical parameters and immunophenotyping of intraepithelial lymphocytes allows to assess disease severity in refractory celiac disease. Dig Liver Dis 2022; 54:1649-1656. [PMID: 35850920 DOI: 10.1016/j.dld.2022.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 06/03/2022] [Accepted: 06/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Flow cytometry of intestinal lymphocytes is discussed to be a stronger predictor of enteropathy-associated T-cell lymphoma development in refractory celiac disease than T-cell clonality analysis. AIMS To investigate possible associations between clinical characteristics of refractory celiac disease patients and aberrant intraepithelial lymphocytes and to evaluate the accuracy of immunophenotyping for the identification of high-risk refractory celiac disease. METHODS Flow cytometry of isolated lymphocytes from duodenal biopsies of controls and celiac disease patients was performed and results were compared to clinical data. RESULTS Flow cytometry analysis was performed on 42 controls, 37 non-complicated celiac disease and 30 refractory celiac disease cases with or without T-cell receptor clonality. Elevated aberrant intraepithelial lymphocyte counts were significantly associated with severe malabsorption. A 15% cut-off (aberrant lymphocytes among all lymphocytes) had the best discriminatory ability to identify high-risk patients. However, this technique failed to identify some high-risk cases (sensitivity 63%, specificity 100%). The severity of malabsorption was added to the criteria for high-risk refractory celiac disease, improving the correct patients' allocation (sensitivity 100%, specificity 96%). CONCLUSION Immunophenotyping of aberrant intraepithelial lymphocytes is a good predictor for high-risk refractory celiac disease. Furthermore, adding the evaluation of malabsorption to the diagnostic assessment of refractory celiac disease optimizes accuracy.
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Affiliation(s)
- Federica Branchi
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany; Center for the Diagnosis and Prevention of Celiac Disease - Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122 Milan, Italy
| | - Jakob Johann Wiese
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Claudia Heldt
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Subhakankha Manna
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Violaine Dony
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christoph Loddenkemper
- PathoTres Gemeinschaftspraxis für Pathologie und Neuropathologie, Teltowkanalstrasse 2, 12247 Berlin, Germany
| | - Christian Bojarski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Britta Siegmund
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Thomas Schneider
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Severin Daum
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Michael Hummel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institut für Pathologie, Molekularpathologie, Charitéplatz 1, 10117 Berlin, Germany
| | - Verena Moos
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Michael Schumann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Hindenburgdamm 30, 12203 Berlin, Germany.
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11
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Tryfon S, Papadopoulou E, Psarros G, Agrafiotis M, Saroglou M. Celiac disease and idiopathic pulmonary hemosiderosis: A literature review of the Lane-Hamilton Syndrome. Postgrad Med 2022; 134:732-742. [PMID: 35912848 DOI: 10.1080/00325481.2022.2109121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Lane-Hamilton syndrome (LHS) presents a medical emergency, with 14% mortality due to Idiopathic Pulmonary Hemosiderosis (IPH) in acute phase. Despite the clinical severity of this entity, there has been no published review in the international literature, resulting in lack of awareness and delayed diagnosis.A rigorous search of international databases yielded a total of 80 LHS cases from January 1971 to August 2020. We analyzed 44 children (8.56±4.72years, 21boys) and 36 adults (33.61±13.41years, 12men), to present the clinical manifestations, radiological and immunological pattern, therapeutic approaches and outcome of LHS. We also elaborated on clinical and laboratory findings' associations to propose diagnostic indexes and clarified differences based on age distribution.Celiac Disease (CD) and IPH diagnosis was made concurrently in 46 patients, whereas in 21 patients the diagnosis of LHS was delayed for 2.5y (3mo-11y). Hemoptysis (n=56, 70%), dyspnea (n=47, 58.8%), anemia (n=72, 90%) and iron deficiency (n=54, 67.5%) were most commonly observed. Medical history revealed recurrent episodes of hemoptysis (n=38) and persistent iron deficiency anemia (n=25) in need of multiple blood transfusions or iron supplementation. Patchy infiltrate opacities to consolidation predominated in children, whereas bilateral diffuse ground glass opacities in adults. Duodenal biopsy was performed in 66 cases (diagnostic 87.8%), BAL in 51 (diagnostic 74.5%) and surgical lung biopsy in 20. Anti-tTG titer was positive in all 24 (54.6%) children and 19 (52.8%) adults that documented this assay. Prednisone or methylprednisolone pulse therapy and GFD were initiated in the acute phase, whereas chronic therapy included GFD, along with long-term prednisone in refractory cases. Three cases with severe respiratory failure or hemodynamic instability were intubated and a further 3 succumbed.A thorough understanding of LHS may reveal further diagnostic indexes and a consensus on therapy guidelines. Screening for CD is essential in all IPH cases for timely recognition and favorable outcome.
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Affiliation(s)
- Stavros Tryfon
- Pulmonary Department, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | | | | | - Michael Agrafiotis
- Respiratory Failure Unit, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Maria Saroglou
- Pulmonary Department, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
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12
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Anderson RP. Review article: Diagnosis of coeliac disease: a perspective on current and future approaches. Aliment Pharmacol Ther 2022; 56 Suppl 1:S18-S37. [PMID: 35815826 DOI: 10.1111/apt.16840] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/08/2022] [Accepted: 02/08/2022] [Indexed: 12/09/2022]
Abstract
Diagnostics will play a central role in addressing the ongoing dramatic rise in global prevalence of coeliac disease, and in deploying new non-dietary therapeutics. Clearer understanding of the immunopathogenesis of coeliac disease and the utility of serology has led to partial acceptance of non-biopsy diagnosis in selected cases. Non-biopsy diagnosis may expand further because research methods for measuring gluten-specific CD4+ T cells and the acute recall response to gluten ingestion in patients is now relatively straightforward. This perspective on diagnosis in the context of the immunopathogenesis of coeliac disease sets out to highlight current consensus, limitations of current practices, gluten food challenge for diagnosis and the potential for diagnostics that measure the underlying cause for coeliac disease, gluten-specific immunity.
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13
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Abstract
Celiac disease is a chronic, immune-mediated enteropathy driven by dietary gluten found in genetically susceptible hosts. It has a worldwide distribution, is one of the most common autoimmune disorders globally, and is the only autoimmune condition for which the trigger is known. Despite advances in characterizing mechanisms of disease, gaps in understanding of celiac disease pathogenesis remain. A "frontier" concept is considering what moves an HLA-DQ2 or DQ8-positive individual from asymptomatic gluten tolerance to celiac disease manifestation. In this arena, environmental triggers, including age at the time of initial gluten exposure, the occurrence of usual childhood viral infections, and microbiome alterations have emerged as key events in triggering the symptomatic disease. Pathologists play a major role in frontier aspects of celiac disease. This includes the discovery that duodenal mucosal histology in follow-up biopsies does not correlate with ongoing patient symptoms, antitissue transglutaminase antibody titers and diet adherence in celiac disease patients. Further, in light of recent evidence that the detection of monoclonal T-cell populations in formalin-fixed biopsies is not specific for type II refractory celiac disease, pathologists should resist performing such analyses until common causes of "apparent" refractoriness are excluded. The promise of therapies in celiac disease has led to clinical trials targeting many steps in the inflammatory cascade, which depend upon a pathologist's confirmation of the initial diagnosis and evaluation of responses to therapies. As pathologists continue to be active participants in celiac disease research, partnering with other stakeholders, we will continue to impact this important autoimmune disease.
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Affiliation(s)
- Natalie Patel
- El Camino Pathology Medical Group, Mountain View, CA
| | - Marie E Robert
- Department of Pathology and Medicine, Yale University School of Medicine, New Haven, CT
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14
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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: 70] [Impact Index Per Article: 23.3] [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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15
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Melson J, Trikudanathan G, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Jirapinyo P, Krishnan K, Kumta NA, Pannala R, Parsi MA, Sethi A, Trindade AJ, Watson RR, Maple JT, Lichtenstein DR. Video capsule endoscopy. Gastrointest Endosc 2021; 93:784-796. [PMID: 33642034 DOI: 10.1016/j.gie.2020.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pichamol Jirapinyo
- Department of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Amrita Sethi
- Department of Digestive and Liver Diseases, Columbia University Medical Center/New York-Presbyterian, New York, New York, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Rabindra R Watson
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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16
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Chetcuti Zammit S, McAlindon ME, Sanders DS, Sidhu R. Assessment of disease severity on capsule endoscopy in patients with small bowel villous atrophy. J Gastroenterol Hepatol 2021; 36:1015-1021. [PMID: 32808308 DOI: 10.1111/jgh.15217] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/14/2020] [Accepted: 08/09/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIM There is a lack of uniformity of reporting on features of celiac disease (CD) on small bowel capsule endoscopy (SBCE). This makes determining extent of disease and comparison of severity of disease challenging. METHODS De-identified SBCEs of 300 patients (78 CD [26%], 18 serology negative villous atrophy [6%], and 204 controls with normal duodenal histology [68%]) were included. Videos were reviewed by two experts. All patients had duodenal histology taken within 2 weeks of SBCE. The degree of agreement in CD features and extent of disease was then determined. The resulting score for each factor was used to determine overall severity of disease. RESULTS There was substantial agreement in the kappa coefficient for the detection of CD features between reviewers (0.67). Agreement for extent of affected small bowel (SB) mucosa was high (0.97). On multiple regression analysis, several features of CD correlated with extent of affected SB mucosa for both reviewers. The odds ratios derived from this analysis were then used to score features of CD, enabling scores of severity to be calculated for each patient. The median overall scores for patients increased significantly according to the independent classification of severity by the capsule reviewers: mild (20, 0-79), moderate (45, 25-123), and severe (89, 65-130) (P = 0.0001). CONCLUSION The good correlation of CD scores between expert reviewers confirms the validity of features of CD on SBCE. An objective score of CD features in the SB is useful in the follow up of patients with CD and serology negative villous atrophy.
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Affiliation(s)
| | - Mark E McAlindon
- Gastroenterology Department, Sheffield Teaching Hospitals, Sheffield, UK
| | - David S Sanders
- Gastroenterology Department, Sheffield Teaching Hospitals, Sheffield, UK
| | - Reena Sidhu
- Gastroenterology Department, Sheffield Teaching Hospitals, Sheffield, UK
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17
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Alwasaidi TA, Mustafa W, Osman H, Al-Hebshi A, Alfetayeh A. Multiple Autoimmune Syndrome With Alopecia Universalis and Immune Thrombocytopenic Purpura. Cureus 2021; 13:e13033. [PMID: 33665054 PMCID: PMC7924964 DOI: 10.7759/cureus.13033] [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] [Accepted: 01/31/2021] [Indexed: 11/05/2022] Open
Abstract
Multiple autoimmune syndrome (MAS) is a condition characterized by three or more autoimmune disorders in the same individual. The development of MAS involves genetic, immunological, and infectious factors. Here we report a case of a 40-year-old man who presented with four autoimmune diseases, namely autoimmune hypothyroidism, alopecia universalis, celiac disease, and immune thrombocytopenic purpura (ITP), which leads to a diagnosis of MAS. However, the patient does not fit in any category of MAS classification. In addition to the need for continued surveillance for the development of new autoimmune disease in predisposed patients, this case report suggests an additional fourth category of the classification of MAS that includes autoimmune hypothyroidism, alopecia universalis, celiac disease, and ITP.
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Affiliation(s)
- Turki A Alwasaidi
- Hematology Division/Internal Medicine Department, Prince Mohammed Bin Abdulaziz Hospital - Ministry of National Guard Health Affairs, Madinah, SAU
- Internal Medicine, Taibah University, Madinah, SAU
| | | | - Haitham Osman
- Hematology Division/Internal Medicine Department, Prince Mohammed Bin Abdulaziz Hospital - Ministry of National Guard Health Affairs, Madinah, SAU
| | - Abdulqader Al-Hebshi
- Pediatrics-Hematology Oncology, Prince Mohammed Bin Abdulaziz Hospital, Madinah, SAU
- Pediatrics, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Asma Alfetayeh
- Hematology, Prince Mohammed Bin Abdulaziz Hospital, Madinah, SAU
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18
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Brown I, Bettington M, Rosty C. The role of histopathology in the diagnosis and management of coeliac disease and other malabsorptive conditions. Histopathology 2020; 78:88-105. [PMID: 33382496 DOI: 10.1111/his.14262] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 12/17/2022]
Abstract
Most absorption of nutrients takes place in the proximal small intestine, and the most common disorders leading to malabsorption are associated with a morphological abnormality in the duodenal mucosa that is appreciable in histological sections of biopsy specimens. Coeliac disease is the most well-known example, causing intraepithelial lymphocytosis, inflammation and villous atrophy in the duodenum. Remarkably similar inflammatory changes can be induced by other processes, including medications, e.g. angiotensin II receptor blockers and immune checkpoint inhibitors, immune dysregulation disorders, e.g. common variable immunodeficiency and autoimmune enteropathy, infections, collagenous sprue, and tropical sprue. However, there are often subtle histological differences from coeliac disease in the type of inflammatory infiltrate, the presence of crypt apoptosis, and the extent and type of inflammation beyond the duodenum. The clinical setting and serological investigation usually allow diagnostic separation, but some cases remain challenging. Histopathology is also important in assessing the response to treatment, such as the change in villous architecture caused by a gluten-free diet, or the response to cessation of a potentially causative medication. This review examines the practical role that histopathology of duodenal biopsy specimens plays in the assessment and management of inflammatory malabsorptive processes of the proximal small intestine, with a particular emphasis on coeliac disease.
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Affiliation(s)
- Ian Brown
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Mark Bettington
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Christophe Rosty
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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19
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Rej A, Aziz I, Sanders DS. Coeliac disease and noncoeliac wheat or gluten sensitivity. J Intern Med 2020; 288:537-549. [PMID: 32573000 DOI: 10.1111/joim.13120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/15/2020] [Accepted: 04/21/2020] [Indexed: 12/15/2022]
Abstract
Coeliac disease (CD) and noncoeliac wheat or gluten sensitivity (NCWS/NCGS) are common gluten-related disorders. Both conditions can present with gastrointestinal and extraintestinal manifestations, which can be a challenge for physicians to discern between. Whilst coeliac serology and histological assessment are required for the diagnosis of CD, there are no clear biomarkers for the diagnosis of NCGS. The management of both conditions is with a gluten-free diet (GFD), although the duration, as well as strictness of adherence to a GFD in NCGS, is unclear. Adherence to a GFD in CD can also be challenging, with recent developments of noninvasive assessments, although histological assessment via duodenal biopsies remains the gold standard. The management of refractory coeliac disease remains particularly challenging, often requiring specialist input. Whilst wheat is noted to be a trigger for symptom generation in NCGS, it is unclear which components of wheat are responsible for symptom generation in this group, with further research required to elucidate the pathophysiology.
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Affiliation(s)
- A Rej
- From the, Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - I Aziz
- From the, Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, Academic Unit of Gastroenterology, University of Sheffield, Sheffield, UK
| | - D S Sanders
- From the, Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, Academic Unit of Gastroenterology, University of Sheffield, Sheffield, UK
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20
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Chetcuti Zammit S, Bull LA, Sanders DS, Galvin J, Dervilis N, Sidhu R, Worden K. Towards the Probabilistic Analysis of Small Bowel Capsule Endoscopy Features to Predict Severity of Duodenal Histology in Patients with Villous Atrophy. J Med Syst 2020; 44:195. [PMID: 33005996 PMCID: PMC7529615 DOI: 10.1007/s10916-020-01657-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 09/16/2020] [Indexed: 12/17/2022]
Abstract
Small bowel capsule endoscopy (SBCE) can be complementary to histological assessment of celiac disease (CD) and serology negative villous atrophy (SNVA). Determining the severity of disease on SBCE using statistical machine learning methods can be useful in the follow up of patients. SBCE can play an additional role in differentiating between CD and SNVA. De-identified SBCEs of patients with CD and SNVA were included. Probabilistic analysis of features on SBCE were used to predict severity of duodenal histology and to distinguish between CD and SNVA. Patients with higher Marsh scores were more likely to have a positive SBCE and a continuous distribution of macroscopic features of disease than those with lower Marsh scores. The same pattern was also true for patients with CD when compared to patients with SNVA. The validation accuracy when predicting the severity of Marsh scores and when distinguishing between CD and SNVA was 69.1% in both cases. When the proportions of each SBCE class group within the dataset were included in the classification model, to distinguish between the two pathologies, the validation accuracy increased to 75.3%. The findings of this work suggest that by using features of CD and SNVA on SBCE, predictions can be made of the type of pathology and the severity of disease.
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Affiliation(s)
- Stefania Chetcuti Zammit
- Academic Unit, Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK.
- Gastroenterology Department, Royal Hallamshire Hospital, Glossop Road, Sheffield, S102JF, UK.
| | - Lawrence A Bull
- Dynamics Research Group, Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
| | - David S Sanders
- Academic Unit, Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Jessica Galvin
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nikolaos Dervilis
- Dynamics Research Group, Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
| | - Reena Sidhu
- Academic Unit, Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Keith Worden
- Dynamics Research Group, Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
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21
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Stuckey BGA, Mahoney LA, Dragovic S, Brown SJ. Celiac disease and bone health: is there a gap in the management of postmenopausal osteoporosis? Climacteric 2020; 23:559-565. [PMID: 32960111 DOI: 10.1080/13697137.2020.1816957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Malabsorption due to celiac disease (CD) may contribute to postmenopausal osteoporosis. This study aimed to survey participants with CD regarding their bone density, fractures, and bone-preserving medications; to compare tolerance of bone-preserving medications in participants with and without CD; and to review the evidence for CD screening and osteoporosis therapies in the setting of CD. We recruited 131 participants with CD and 102 participants without CD. Of those with CD, 87% were diagnosed in adulthood and 40% had no recognized gastrointestinal symptoms. In 21% CD was diagnosed after the diagnosis of osteoporosis and in 9% after a fracture. No difference was found in the tolerability of bone medications between participants with CD and those without. Review of the literature found that, although monitoring of bone health is recommended for patients with CD, screening for CD is not generally accepted for patients with osteoporosis, although studies of the prevalence of CD in osteoporosis had incomplete ascertainment methods. There is a lack of well-conducted studies and therefore insufficient data for the efficacy and tolerability of bone medication in CD. In conclusion, both CD and menopause lead to bone loss. Identifying CD in postmenopausal women should lead to modification of osteoporosis management.
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Affiliation(s)
- B G A Stuckey
- Keogh Institute for Medical Research, Nedlands, WA, Australia.,Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,School of Medicine, University of Western Australia, Nedlands, WA, Australia
| | - L A Mahoney
- Keogh Institute for Medical Research, Nedlands, WA, Australia
| | - S Dragovic
- Keogh Institute for Medical Research, Nedlands, WA, Australia
| | - S J Brown
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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22
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Use of small-bowel capsule endoscopy in cases of equivocal celiac disease. Gastrointest Endosc 2020; 91:1312-1321.e2. [PMID: 31923404 DOI: 10.1016/j.gie.2019.12.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Seronegative villous atrophy (SNVA), raised intraepithelial lymphocytes (IELs), and crypt hyperplasia on duodenal histology can be secondary to celiac disease (CD) or other causes such as medications or infections. Our aims were to assess the role of small-bowel capsule endoscopy (SBCE) in these patients and to ascertain whether findings on SBCE at diagnosis can predict disease outcome. METHODS Patients (n = 177) with SNVA, IELs, ± crypt hyperplasia on duodenal histology were studied. These patients all had an equivocal diagnosis of CD. RESULTS Overall, 56 patients (31.6%) had a positive SBCE. Thirty-three patients (58.9%) had disease affecting the proximal third of the small bowel (SB). The diagnostic yield of SBCE was 40.0% (22 patients), 51.4% (18 patients), 27.0% (10 patients), and 14.0% (7 patients) in patients with an unknown cause for SNVA (SNVA-UO), patients with SNVA who responded to a gluten-free diet (SNVA-CD), patients with a known cause for SNVA, and patients with railed IELs ± crypt hyperplasia, respectively. In SNVA-UO, SBCE at diagnosis was more likely to be positive in patients with persistent SNVA (10, 90.9%) and persistent SNVA with lymphoproliferative features (4, 80.4%) than patients with spontaneous resolution of SNVA (8, 20.5%) (P = .0001). All patients in the SNVA-CD group who eventually developed adverse events had a positive SBCE (P = .022). They also had more extensive SB disease than those without adverse events (50% vs 1% P = .002). More extensive SB disease on SBCE correlated with a higher SNVA-related mortality in patients with SNVA-UO and SNVA-CD (P = .019). Severity of histology did not correlate with mortality (P = .793). CONCLUSIONS A positive SBCE at diagnosis predicts a worse outcome. More importantly, more extensive disease in these patients is associated with poor survival. Targeting patients with extensive disease at diagnosis with more aggressive therapy can help to improve prognosis.
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Duodenal bulb biopsy in the diagnostic work-up of coeliac disease. Virchows Arch 2020; 477:507-515. [PMID: 32405928 DOI: 10.1007/s00428-020-02832-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/21/2020] [Accepted: 04/28/2020] [Indexed: 12/20/2022]
Abstract
Coeliac disease (CD) is an autoimmune enteropathy which can present with patchy mucosal lesions. The aim of the present study is to investigate the significance of duodenal bulb biopsy in the diagnostic work-up of CD in both pediatric and adult patients, and to highlight the key points for pathologists. D1 (duodenal bulb) and D2 (distal duodenum) biopsies of 153 newly diagnosed serology-positive CD patients were evaluated for villous/crypt ratio and intraepithelial lymphocyte (IEL) counts on CD3-stained slides and were classified according to Marsh. Mucosal pathology was patchy in 15% (13% only D1 and 2% only D2) of patients, and 85% of patients had diffuse mucosal pathology involving both D1 and D2 biopsies which showed concordant histology in 60% and discordant in 25% of the cases. Though majority of the patients (75%) with only D1 involvement were pediatric cases, no significant difference was found between pediatric and adult patients when all cases were considered (17 vs 14%). Our results clearly indicate that without D1 sampling, diagnosis of CD would have been missed in a significant number of cases (13%), thereby highlighting the importance of taking duodenal biopsies from multiple sites in the diagnostic work-up of CD. We, therefore, conclude that every biopsy piece from both D1 and D2 should be carefully evaluated for the whole spectrum of mucosal changes caused by gluten ingestion and classified using a scheme based on Marsh to allow recognition of mild lesions.
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Abstract
PURPOSE OF REVIEW The aim of this review is to provide insight into the diagnosis and management of patients with refractory coeliac disease (RCD) and highlight recent advances in this field. RECENT FINDINGS The diagnosis of RCD can be more accurately confirmed with flow cytometry in addition to immunohistochemistry. Dietary input and excretion of gluten immunogenic peptides can help rule out gluten contamination, and therefore, substantiate a diagnosis of RCD type I. Small bowel capsule endoscopy (SBCE) is important at diagnosis and follow-up in addition to duodenal histology. Apart from ruling out complications, it can give information on extent of disease in the small bowel, and therefore, help assess response to therapy. Those patients with a poor response can have earlier intensification of therapy, which may result in an improved outcome. RCD also occurs in patients with serology negative coeliac disease but with an increased mortality compared with patients with serology-positive coeliac disease. SUMMARY Patients with RCD can present with persistent symptoms of malnutrition but can also be completely asymptomatic. Serology is not a reliable marker to detect refractory disease. Immunostaining and flow cytometry are necessary for a diagnosis of RCD. Small bowel endoscopy enables disease extent to be assessed and allows for small bowel biopsies to be taken in case of suspicious lesions. Small bowel radiology can be complementary to small bowel endoscopy.
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Bone Mineral Density in Patients With Celiac Disease: A Further Association With Extent of Disease on Capsule Endoscopy. J Clin Gastroenterol 2020; 54:294-295. [PMID: 31851101 DOI: 10.1097/mcg.0000000000001294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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A Robotic Biopsy Endoscope with Magnetic 5-DOF Locomotion and a Retractable Biopsy Punch. MICROMACHINES 2020; 11:mi11010098. [PMID: 31963402 PMCID: PMC7020148 DOI: 10.3390/mi11010098] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/11/2020] [Accepted: 01/15/2020] [Indexed: 12/20/2022]
Abstract
Capsule endoscopes (CEs) have emerged as an advanced diagnostic technology for gastrointestinal diseases in recent decades. However, with regard to robotic motions, they require active movability and multi-functionalities for extensive, untethered, and precise clinical utilization. Herein, we present a novel wireless biopsy CE employing active five degree-of-freedom locomotion and a biopsy needle punching mechanism for the histological analysis of the intestinal tract. A medical biopsy punch is attached to a screw mechanism, which can be magnetically actuated to extrude and retract the biopsy tool, for tissue extraction. The external magnetic field from an electromagnetic actuation (EMA) system is utilized to actuate the screw mechanism and harvest biopsy tissue; therefore, the proposed system consumes no onboard energy of the CE. This design enables observation of the biopsy process through the capsule's camera. A prototype with a diameter of 12 mm and length of 30 mm was fabricated with a medical biopsy punch having a diameter of 1.5 mm. Its performance was verified through numerical analysis, as well as in-vitro and ex-vivo experiments on porcine intestine. The CE could be moved to target lesions and obtain sufficient tissue samples for histological examination. The proposed biopsy CE mechanism utilizing punch biopsy and its wireless extraction-retraction technique can advance untethered intestinal endoscopic capsule technology at clinical sites.
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Abstract
Gluten-related disorders, including celiac disease, wheat allergy, and nonceliac gluten sensitivity (NCGS), are increasingly reported worldwide. Celiac disease is caused by an immune-mediated reaction to ingested gluten in genetically susceptible persons. NCGS is largely a diagnosis of exclusion when other causes of symptoms have been ruled out. All patients with celiac disease should be referred to a registered dietitian nutritionist with expertise in celiac disease and a gastroenterologist who specializes in celiac disease and malabsorptive disorders, and they should remain on a strict gluten-free diet indefinitely. This article provides an overview of gluten- and wheat-related disorders.
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Affiliation(s)
- Joshua Elliott Rubin
- University of California, San Diego School of Medicine, La Jolla, California (J.E.R., S.E.C.)
| | - Sheila E Crowe
- University of California, San Diego School of Medicine, La Jolla, California (J.E.R., S.E.C.)
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Molder A, Balaban DV, Jinga M, Molder CC. Current Evidence on Computer-Aided Diagnosis of Celiac Disease: Systematic Review. Front Pharmacol 2020; 11:341. [PMID: 32372947 PMCID: PMC7179080 DOI: 10.3389/fphar.2020.00341] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/09/2020] [Indexed: 02/05/2023] Open
Abstract
Celiac disease (CD) is a chronic autoimmune disease that occurs in genetically predisposed individuals in whom the ingestion of gluten leads to damage of the small bowel. It is estimated to affect 1 in 100 people worldwide, but is severely underdiagnosed. Currently available guidelines require CD-specific serology and atrophic histology in duodenal biopsy samples for the diagnosis of adult CD. In pediatric CD, but in recent years in adults also, nonbioptic diagnostic strategies have become increasingly popular. In this setting, in order to increase the diagnostic rate of this pathology, endoscopy itself has been thought of as a case finding strategy by use of digital image processing techniques. Research focused on computer aided decision support used as database video capsule, endoscopy and even biopsy duodenal images. Early automated methods for diagnosis of celiac disease used feature extraction methods like spatial domain features, transform domain features, scale-invariant features and spatio-temporal features. Recent artificial intelligence (AI) techniques using deep learning (DL) methods such as convolutional neural network (CNN), support vector machines (SVM) or Bayesian inference have emerged as a breakthrough computer technology which can be used for computer aided diagnosis of celiac disease. In the current review we summarize methods used in clinical studies for classification of CD from feature extraction methods to AI techniques.
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Affiliation(s)
- Adriana Molder
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Center of Excellence in Robotics and Autonomous Systems, Military Technical Academy Ferdinand I, Bucharest, Romania
| | - Daniel Vasile Balaban
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Gastroenterology Department, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
- *Correspondence: Daniel Vasile Balaban,
| | - Mariana Jinga
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Gastroenterology Department, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - Cristian-Constantin Molder
- Center of Excellence in Robotics and Autonomous Systems, Military Technical Academy Ferdinand I, Bucharest, Romania
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Statement on Best Practices in the Use of Pathology as a Diagnostic Tool for Celiac Disease: A Guide for Clinicians and Pathologists. Am J Surg Pathol 2019; 42:e44-e58. [PMID: 29923907 DOI: 10.1097/pas.0000000000001107] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Small intestinal biopsy interpretation has been the cornerstone for the diagnosis of celiac disease for over 50 years. Despite the existence of sensitive and specific serological tests, duodenal mucosal biopsies continue to be obtained in the vast majority of patients in whom a diagnosis of celiac disease is being considered. The accurate evaluation of these biopsies requires coordination and information sharing between the gastroenterologist, laboratory, and pathologist in order to optimize tissue sampling, preparation and interpretation. This document, a collaboration between the Rodger C. Haggitt Gastrointestinal Pathology Society and the North American Association for the Study of Celiac Disease, is intended to provide clinicians and pathologists with a summary of best practices in the use of endoscopy and biopsy for patients with suspected celiac disease. The authors present a comprehensive and critical appraisal of the literature with respect to the topics of endoscopic findings, best methods for the obtaining biopsies, completing the pathology form and pathologic assessment, including evaluating intraepithelial lymphocytes and villous architecture. A discussion of conditions with overlapping pathologic findings in duodenal mucosal biopsies is presented. In order to provide additional guidance for challenging situations, the authors include an appendix containing practical suggestions. This review may be utilized in interdisciplinary discussions to optimize care for patients with possible celiac disease.
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Cummins G, Cox BF, Ciuti G, Anbarasan T, Desmulliez MPY, Cochran S, Steele R, Plevris JN, Koulaouzidis A. Gastrointestinal diagnosis using non-white light imaging capsule endoscopy. Nat Rev Gastroenterol Hepatol 2019; 16:429-447. [PMID: 30988520 DOI: 10.1038/s41575-019-0140-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Capsule endoscopy (CE) has proved to be a powerful tool in the diagnosis and management of small bowel disorders since its introduction in 2001. However, white light imaging (WLI) is the principal technology used in clinical CE at present, and therefore, CE is limited to mucosal inspection, with diagnosis remaining reliant on visible manifestations of disease. The introduction of WLI CE has motivated a wide range of research to improve its diagnostic capabilities through integration with other sensing modalities. These developments have the potential to overcome the limitations of WLI through enhanced detection of subtle mucosal microlesions and submucosal and/or transmural pathology, providing novel diagnostic avenues. Other research aims to utilize a range of sensors to measure physiological parameters or to discover new biomarkers to improve the sensitivity, specificity and thus the clinical utility of CE. This multidisciplinary Review summarizes research into non-WLI CE devices by organizing them into a taxonomic structure on the basis of their sensing modality. The potential of these capsules to realize clinically useful virtual biopsy and computer-aided diagnosis (CADx) is also reported.
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Affiliation(s)
- Gerard Cummins
- School of Engineering and Physical Sciences, Heriot-Watt University, Edinburgh, UK.
| | | | - Gastone Ciuti
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Marc P Y Desmulliez
- School of Engineering and Physical Sciences, Heriot-Watt University, Edinburgh, UK
| | - Sandy Cochran
- School of Engineering, University of Glasgow, Glasgow, UK
| | - Robert Steele
- School of Medicine, University of Dundee, Dundee, UK
| | - John N Plevris
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, UK
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Lagana SM, Bhagat G. Biopsy Diagnosis of Celiac Disease: The Pathologist's Perspective in Light of Recent Advances. Gastroenterol Clin North Am 2019; 48:39-51. [PMID: 30711210 DOI: 10.1016/j.gtc.2018.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Celiac disease is a common immune-mediated disorder that occurs in individuals with permissive genetics (HLA-DQ2/DQ8 genotype) following exposure to certain wheat proteins. The histopathologic manifestations of small intestinal mucosal injury (villus atrophy, crypt hyperplasia, and intraepithelial lymphocytosis) are well recognized. However, these findings are not specific for celiac disease, because they are observed in other small intestinal disorders. These mimics include common and rare entities, the list of which continues to grow. This article discusses the histopathology and differential diagnosis of celiac disease and provides the pathologist's perspective on biopsy adequacy, evaluation, and reporting in light of current knowledge.
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Affiliation(s)
- Stephen M Lagana
- Columbia University, New York Presbyterian Hospital, 622 West 168th Street, VC14-209, New York, NY 10032, USA.
| | - Govind Bhagat
- Columbia University, New York Presbyterian Hospital, 622 West 168th Street, VC14-228, New York, NY 10032, USA
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Rates of Duodenal Biopsy During Upper Endoscopy Differ Widely Between Providers: Implications for Diagnosis of Celiac Disease. J Clin Gastroenterol 2019; 53:e61-e67. [PMID: 29095420 PMCID: PMC5930163 DOI: 10.1097/mcg.0000000000000957] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
GOAL The goal of this study is to determine factors associated with performance of duodenal biopsy during upper endoscopy. BACKGROUND Celiac disease (CD) prevalence approaches 1% in the United States and Europe, yet CD remains underdiagnosed, in part because of low rates of duodenal biopsy during upper endoscopy. We aimed to identify patient and provider factors associated with performance of duodenal biopsy during upper endoscopy. STUDY In our hospital-based endoscopy suite, we identified all patients not previously diagnosed with CD who underwent upper endoscopy during a 5-year period for one of the following indications: abdominal pain/dyspepsia, gastroesophageal reflux (GERD), anemia/iron deficiency, diarrhea, and weight loss. We employed univariate and multivariate analysis to determine the association between clinical factors and the performance of duodenal biopsy. RESULTS Of 8572 patients included in the study, 4863 (57%) underwent duodenal biopsy. Of those who underwent duodenal biopsy, 24 (0.49%) were found to have CD. On multivariate analysis, age, gender, indication, gross endoscopic appearance, physician affiliation with a celiac disease center, and absence of a participating trainee were all significantly associated with the performance of duodenal biopsy. There was wide variability among providers, with duodenal biopsy rates ranging from 27% to 91% during these procedures. CONCLUSIONS A duodenal biopsy is more likely to be performed in younger patients, females, and for key indications such as weight loss, diarrhea, and anemia. Providers varied widely in the performance of duodenal biopsy. Further study is warranted to better understand the decision to perform duodenal biopsy and to determine the optimal scenarios for its performance.
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Doyev R, Cohen S, Ben-Tov A, Weintraub Y, Amir A, Galai T, Moran-Lev H, Yerushalmy-Feler A. Ultra-short Celiac Disease Is a Distinct and Milder Phenotype of the Disease in Children. Dig Dis Sci 2019; 64:167-172. [PMID: 30311150 DOI: 10.1007/s10620-018-5323-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/03/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Approximately 10% of children with celiac disease (CD) have ultra-short celiac disease (USCD), where histological abnormalities are limited to the duodenal bulb. The aim of our retrospective study was to identify clinical and serological characteristics at baseline and at follow-up of children with USCD. METHODS All children that were diagnosed with CD in our unit during 7/2010-12/2017, in whom biopsies were taken from duodenal bulb and second part, were included. We compared disease characteristics and course between children with USCD and children with involvement in the second part of the duodenum. RESULTS Out of 3740 children who underwent upper gastrointestinal endoscopies, 648 were diagnosed with CD. Seventy-one (11%) of those children had limited involvement in the duodenal bulb. The USCD group included more females (P = 0.021), were older (P = 0.005), had a lower prevalence of diarrhea (P = 0.003), anemia (P = 0.007), anti-tissue transglutaminase (TTG) antibodies count (P < 0.001) at presentation, lower frequency of endoscopic abnormality, lower Marsh score, and a trend toward shorter time to the normalization of anti-TTG antibodies under a gluten-free diet compared to the extensive CD. There were no differences in body mass index or duration of symptoms before diagnosis. CONCLUSION Children with USCD presented with a distinct phenotype of milder symptoms, lower celiac serology, and milder endoscopic and histological findings, with a trend toward faster normalization under a gluten-free diet compared to those with extensive CD. Further studies are needed to determine the long-term course and prognosis of USCD.
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Affiliation(s)
- Reut Doyev
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Cohen
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel Aviv, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Amir Ben-Tov
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Weintraub
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Achiya Amir
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tut Galai
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Moran-Lev
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Yerushalmy-Feler
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Chetcuti Zammit S, Sanders DS, Sidhu R. A comprehensive review on the utility of capsule endoscopy in coeliac disease: From computational analysis to the bedside. Comput Biol Med 2018; 102:300-314. [PMID: 29980284 DOI: 10.1016/j.compbiomed.2018.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/23/2018] [Accepted: 06/24/2018] [Indexed: 11/29/2022]
Abstract
Small bowel capsule endoscopy (SBCE) can identify macroscopic changes of coeliac disease and assess the extent of disease in the small bowel beyond the duodenum. SBCE has a good sensitivity for the detection of coeliac disease in comparison to histology owing to several ideal features such as a high magnification. It also plays a useful role in detecting complications in patients with refractory coeliac disease. Several studies have been carried out on transforming images obtained from small bowel capsule endoscopy to enable the automated detection of features related to coeliac disease. This review discusses the current roles played by small bowel capsule endoscopy in coeliac disease. It identifies future potential roles of this technique and describes in great detail the role of computational analysis in the detection of coeliac disease and how it can be adapted to current available technology.
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Affiliation(s)
- Stefania Chetcuti Zammit
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK.
| | - David S Sanders
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
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McCarty TR, O’Brien CR, Gremida A, Ling C, Rustagi T. Efficacy of duodenal bulb biopsy for diagnosis of celiac disease: a systematic review and meta-analysis. Endosc Int Open 2018; 6:E1369-E1378. [PMID: 30410959 PMCID: PMC6221829 DOI: 10.1055/a-0732-5060] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/23/2018] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Although duodenal biopsy is considered the "gold standard" for diagnosis of celiac disease, the optimal location of biopsy within the small bowel for diagnosis remains unclear. The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the diagnostic utility of endoscopic duodenal bulb biopsy for celiac disease. Patients and methods Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed from 2000 through December 2017. Review of titles/abstracts, full review of potentially relevant studies, and data abstraction was performed. Measured outcomes of adult and pediatric patients included location of biopsy, mean number of biopsies performed, and diagnosis of celiac disease as defined by the modified Marsh-Oberhuber classification. Results A total of 17 studies (n = 4050) were included. Seven studies evaluated adults and 11 studies assessed pediatric populations. Mean age of adults and pediatric patients was 46.70 ± 2.69 and 6.33 ± 1.26 years, respectively. Overall, sampling from the duodenal bulb demonstrated a 5 % (95 % CI 3 - 9; P < 0.001) increase in the diagnostic yield of celiac disease. When stratified by pediatric and adult populations, duodenal bulb biopsy demonstrated a 4 % (95 % CI: 1 to 9; P < 0.001) and 8 % (95 % CI: 6 to 10; P < 0.001) increase in the diagnostic yield of celiac disease. Non-celiac histologic diagnoses including Brunner gland hyperplasia and peptic duodenitis were reported more commonly in the duodenal bulb as compared to the distal duodenum with an increase in diagnostic yield of 4 % (95 % CI 3 - 5; P < 0.001) and 1 % (95 % CI 1 - 2; P < 0.001), respectively. Conclusions Based upon our results, biopsy and histologic examination of duodenal bulb during routine upper endoscopy increases the diagnostic yield of celiac disease.
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Affiliation(s)
- Thomas R. McCarty
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Corey R. O’Brien
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Anas Gremida
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Christina Ling
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States,Corresponding author Tarun Rustagi, MD Division of Gastroenterology and HepatologyUniversity of New MexicoMSC10 5550, 1 University of New MexicoAlbuquerque NM 87131+1-505-272-9751
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Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Remes-Troche JM, Uscanga-Domínguez LF, Aceves-Tavares RG, Calderón de la Barca AM, Carmona-Sánchez RI, Cerda-Contreras E, Coss-Adame E, Icaza-Chávez ME, Lopéz-Colombo A, Milke-García MP, Morales-Arámbula M, Peláez-Luna M, Ramos Martínez P, Sánchez-Sosa S, Treviño-Mejía MC, Vázquez-Frías R, Worona-Dibner LB, Zamora-Nava LE, Rubio-Tapia A. Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2018; 83:434-450. [PMID: 30197183 DOI: 10.1016/j.rgmx.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/12/2018] [Accepted: 05/24/2018] [Indexed: 12/17/2022]
Abstract
Celiac disease, celiac sprue, or gluten-sensitive enteropathy, is a generalized autoimmune disease characterized by chronic inflammation and atrophy of the small bowel mucosa. It is caused by dietary exposure to gluten and affects genetically predisposed individuals. In Mexico, at least 800,000 are estimated to possibly have the disease, prompting the Asociación Mexicana de Gastroenterología to summon a multidisciplinary group of experts to develop the "Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico" and establish recommendations for the medical community, its patients, and the general population. The participating medical professionals were divided into three working groups and were given the selected bibliographic material by the coordinators (ART, LUD, JMRT), who proposed the statements that were discussed and voted upon in three sessions: two voting rounds were carried out electronically and one at a face-to-face meeting. Thirty-nine statements were accepted, and once approved, were developed and revised by the coordinators, and their final version was approved by all the participants. It was emphasized in the document that epidemiology and risk factors associated with celiac disease (first-degree relatives, autoimmune diseases, high-risk populations) in Mexico are similar to those described in other parts of the world. Standards for diagnosing the disease and its appropriate treatment in the Mexican patient were established. The guidelines also highlighted the fact that a strict gluten-free diet is essential only in persons with confirmed celiac disease, and that the role of gluten is still a subject of debate in relation to nonceliac, gluten-sensitive patients.
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Affiliation(s)
- J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, México.
| | - L F Uscanga-Domínguez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - R G Aceves-Tavares
- Servicio de Gastroenterología, Hospital General del Estado Dr. Ernesto Ramos, Bours, Hermosillo, Sonora, México
| | | | | | - E Cerda-Contreras
- ITESM. Medicina Interna y Gastroenterología Fundación Clínica Médica Sur, Ciudad de México, México
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Ciudad de México, México
| | - M E Icaza-Chávez
- Hospital Star Médica de Mérida, Gastroenterología de la UNIMAYAB, , Mérida, Yucatán, México
| | - A Lopéz-Colombo
- Dirección de Educación e Investigación en Salud, UMAE Hospital de Especialidades del Centro Médico Nacional Manuel Ávila Camacho, Instituto Mexicano del Seguro Social, Puebla, México
| | - M P Milke-García
- Dirección de Nutrición, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Ciudad de México, México
| | - M Morales-Arámbula
- Servicio de Gastroenterología y Endoscopía Gastrointestinal, Hospital Country 2000, Guadalajara, Jalisco, México
| | - M Peláez-Luna
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | - S Sánchez-Sosa
- Jefe de Patología, Hospital Ángeles de Puebla, Universidad de Las Américas Puebla (UDLAP), Puebla, México
| | - M C Treviño-Mejía
- Universidad Iberoamericana, Universidad Xochicalco, Tijuana, Baja California, México
| | - R Vázquez-Frías
- Universidad Iberoamericana, Universidad Xochicalco, Tijuana, Baja California, México
| | - L B Worona-Dibner
- Departamento de Gastroenterología y Nutrición, Hospital Infantil de México Federico Gómez, Ciudad de México, México
| | - L E Zamora-Nava
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - A Rubio-Tapia
- División de Gastroenterología y Hepatología, Mayo Clinic, Rochester, Minnesota, Estados Unidos de América
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Chetcuti Zammit S, Sanders DS, Sidhu R. Capsule endoscopy for patients with coeliac disease. Expert Rev Gastroenterol Hepatol 2018; 12:779-790. [PMID: 29886766 DOI: 10.1080/17474124.2018.1487289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coeliac disease is an autoimmune mediated condition in response to gluten. A combination of innate and adaptive immune responses results in villous shortening in the small bowel (SB) that can be morphologically picked up on capsule endoscopy. It is the only imaging modality that can provide mucosal views of the entire SB, while histology is generally limited to the proximal SB. Radiological modalities are not designed to pick up changes in villous morphology. Areas covered: In this review, we provide a comprehensive analysis on the justified use of small bowel capsule endoscopy (SBCE) in the assessment of patients with coeliac disease; compare SBCE to histology, serology, and symptomatology; and provide an overview on automated quantitative analysis for the detection of coeliac disease. We also provide insight into future work on SBCE in relation to coeliac disease. Expert commentary: SBCE has opened up new avenues for the diagnosis and monitoring of patients with coeliac disease. However, larger studies with new and established coeliac disease patients and with greater emphasis on morphological features on SBCE are required to better define the role of SBCE in the setting of coeliac disease.
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Affiliation(s)
| | - David S Sanders
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
| | - Reena Sidhu
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
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Gadermayr M, Wimmer G, Kogler H, Vécsei A, Merhof D, Uhl A. Automated classification of celiac disease during upper endoscopy: Status quo and quo vadis. Comput Biol Med 2018; 102:221-226. [PMID: 29739614 DOI: 10.1016/j.compbiomed.2018.04.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/23/2018] [Indexed: 02/08/2023]
Abstract
A large amount of digital image material is routinely captured during esophagogastroduodenoscopies but, for the most part, is not used for confirming the diagnosis process of celiac disease which is primarily based on histological examination of biopsies. Recently, considerable effort has been undertaken to make use of image material by developing semi- or fully-automated systems to improve the diagnostic workup. Recently, focus was especially laid on developing state-of-the-art deep learning architectures, exploiting the endoscopist's expert knowledge and on making systems fully automated and thereby completely observer independent. In this work, we summarize recent trends in the field of computer-aided celiac disease diagnosis based on upper endoscopy and discuss about recent progress, remaining challenges, limitations currently prohibiting a deployment in clinical practice and future efforts to tackle them.
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Affiliation(s)
- M Gadermayr
- Institute of Imaging & Computer Vision, RWTH Aachen University, 52074 Aachen, Germany.
| | - G Wimmer
- Department of Computer Sciences, University of Salzburg, 5020 Salzburg, Austria.
| | - H Kogler
- St. Anna Children's Hospital, Vienna, Austria
| | - A Vécsei
- St. Anna Children's Hospital, Vienna, Austria
| | - D Merhof
- Institute of Imaging & Computer Vision, RWTH Aachen University, 52074 Aachen, Germany
| | - A Uhl
- Department of Computer Sciences, University of Salzburg, 5020 Salzburg, Austria.
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Dhandhu BS, Gupta GK, Wanjari SJ, Sharma N, Nijhawan S. A prospective study to evaluate the role of duodenal bulb biopsy in the diagnosis of celiac disease. Indian J Gastroenterol 2018; 37:98-102. [PMID: 29435875 DOI: 10.1007/s12664-018-0821-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 01/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Celiac disease (CeD) requires a biopsy from the small intestine to confirm the diagnosis. Conventionally, duodenal bulb (D1) was avoided as a biopsy site due to histological confounding factors at this site. However, sometimes, the bulb mucosa is the only affected site. The aim of the present study was to assess changes in duodenal bulb histology and compare it to distal duodenal histology and to analyze whether the addition of duodenal bulb biopsy increases the diagnostic yield of the CeD. METHODS It was a prospective study comprising of 98 patients of CeD who were symptomatic clinically and had positive anti tissue transglutaminase (tTG) antibody. Endoscopically four mucosal biopsies were taken, two each from the bulb and distal duodenum, and morphology was graded as per modified Marsh grade. RESULTS Iron deficiency anemia (40%) was a most common clinical presentation followed by chronic diarrhea (30%). Sixty patients showed same Marsh grade and 38 showed different Marsh grade at both sites. Patients who were showing the difference in the Marsh grade at the two biopsy sites, in place of; descending duodenum showed higher grade in 24 patients while higher mucosal atrophy was documented in the bulb in 14 patients. No patient of CeD had isolated D1 involvement. In eight patients, the correct diagnosis of CeD could be made only because of bulb biopsy. CONCLUSION Majority of the patients had no classical symptoms. Different Marsh grade at the two biopsy sites was documented demonstrating the patchy distribution of CeD. Combining biopsy from both bulb and descending duodenum maximizes the diagnostic yield of the CeD.
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Affiliation(s)
- Bhanwar Singh Dhandhu
- Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur, 302 004, India
| | - Gaurav Kumar Gupta
- Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur, 302 004, India
| | - Shashank J Wanjari
- Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur, 302 004, India
| | - Nidhi Sharma
- Department of Pathology, Sawai Man Singh Medical College, J L N Marg, Jaipur, 302 004, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur, 302 004, India.
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Kou GJ, Guo J, Zuo XL, Li CQ, Liu C, Ji R, Liu H, Wang X, Li YQ. Prevalence of celiac disease in adult Chinese patients with diarrhea-predominant irritable bowel syndrome: A prospective, controlled, cohort study. J Dig Dis 2018; 19:136-143. [PMID: 29451364 DOI: 10.1111/1751-2980.12587] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Celiac disease is a chronic inflammatory enteropathy with a symptom spectrum similar to that of irritable bowel syndrome (IBS). It is a common but largely undiagnosed condition in the Western countries. However, it is extremely rare among Chinese individuals, and few studies have investigated its prevalence in China. The aim was to determine the prevalence of celiac disease in patients with IBS who were diagnosed using the Rome III criteria in a single center of northern China. METHODS This was a single-center, prospective, controlled cohort study performed in Qilu Hospital involving 246 patients with IBS and 246 healthy controls. Blood samples were drawn to assess serum tissue transglutaminase immunoglobulin A (tTg-IgA). Patients with a positive or equivocal tTg-IgA (≥15 U/mL) were subjected to probe-based confocal laser endomicroscopy (pCLE) and duodenal biopsy to confirm celiac disease. RESULTS Altogether 12 (4.9%) patients with IBS and two (0.8%) healthy controls were positive or equivocal for serum tTg-IgA. Of these, five patients with IBS underwent pCLE and a targeted biopsy; all were histopathologically found to have celiac disease, although one was eventually diagnosed with lymphoma. After implementation of a gluten-free diet, seven patients serologically positive for IBS showed clinical improvement, thus our study illustrated a minimum prevalence of 2.85% of celiac disease among patients with IBS in our center. CONCLUSIONS Celiac disease is not rare in Chinese individuals, particularly among those with IBS. Therefore, it should receive higher attention in clinical practice in China.
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Affiliation(s)
- Guan Jun Kou
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Jing Guo
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Xiu Li Zuo
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Chang Qing Li
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Chao Liu
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Rui Ji
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Han Liu
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Xiao Wang
- Department of Pathology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Yan Qing Li
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
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Abstract
CONTEXT - Patients who receive an upper gastrointestinal endoscopic examination frequently have biopsies taken from the duodenum. Accurate interpretation of duodenal biopsies is essential for patient care. Celiac disease is a common clinical concern, but pathologists need to be aware of other conditions of the duodenum that mimic celiac disease. OBJECTIVE - To review the normal histologic features of duodenal mucosa and describe the clinical and histologic findings in celiac disease and its mimics, listing the differentiating features of biopsies with villous atrophy and epithelial lymphocytosis. DATA SOURCES - The study comprises a literature review of pertinent publications as of November 30, 2016. CONCLUSIONS - Celiac disease is a common cause of abnormal duodenal histology. However, many of the histologic features found in the duodenal biopsy of patients with celiac disease are also present in other conditions that affect the small bowel. Diagnostic precision may be enhanced by obtaining a careful patient history and by ancillary laboratory testing, particularly for the presence of antitissue transglutaminase antibodies.
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Affiliation(s)
- Daniel R Owen
- From the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - David A Owen
- From the Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
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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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The identification of celiac disease in asymptomatic children: the Generation R Study. J Gastroenterol 2018; 53:377-386. [PMID: 28589338 PMCID: PMC5847176 DOI: 10.1007/s00535-017-1354-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 05/22/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND The objective of our study was to assess whether TG2A levels in the healthy childhood population can be predictive of subclinical CD. METHODS A total of 4442 children (median age, 6.0 years) participating in a population-based prospective cohort study were screened on serum TG2A. Those with positive TG2A (≥7 U/ml; n = 60, 1.4%) were invited for clinical evaluation (median age, 9.0 years). Medical history, physical examination, serum TG2A, and IgA-endomysium (EMA) were assessed, as well as HLA DQ 2.2/2.5/8 typing. Patients with positive serologies and genetic risk types underwent duodenal biopsies. TG2A levels at the time of biopsy were compared with the degree of enteropathy. RESULTS Fifty-one TG2A-positive children were included in the follow-up: 31 (60.8%) children had CD, ten (19.6%) did not have CD, and ten (19.6%) were considered potential CD cases because of inconclusive serologies. Duodenal biopsies were performed in 26/31 children. CD with Marsh 3a/b enteropathy was observed in 75% (15/20) of children having TG2A levels ≥10ULN at 6 years of age, as well as in 75% (6/8) of children having a positive TG2A <10 ULN (OR 1.00; 95% CI 0.15-6.64). CD cases had a lower BMI SDS (mean -0.49, SD 0.92) than children without CD (mean 0.47, SD 1.37; p = 0.02). No differences were observed in gastrointestinal symptoms. CONCLUSIONS Serum TG2A screening at 6 years of age in the healthy childhood population has a positive predictive value of 61% to detect subclinical CD. We did not find a positive correlation between serum TG2A levels and the degree of enteropathy.
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Gora MJ, Suter MJ, Tearney GJ, Li X. Endoscopic optical coherence tomography: technologies and clinical applications [Invited]. BIOMEDICAL OPTICS EXPRESS 2017; 8:2405-2444. [PMID: 28663882 PMCID: PMC5480489 DOI: 10.1364/boe.8.002405] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/20/2017] [Accepted: 03/27/2017] [Indexed: 05/07/2023]
Abstract
In this paper, we review the current state of technology development and clinical applications of endoscopic optical coherence tomography (OCT). Key design and engineering considerations are discussed for most OCT endoscopes, including side-viewing and forward-viewing probes, along with different scanning mechanisms (proximal-scanning versus distal-scanning). Multi-modal endoscopes that integrate OCT with other imaging modalities are also discussed. The review of clinical applications of endoscopic OCT focuses heavily on diagnosis of diseases and guidance of interventions. Representative applications in several organ systems are presented, such as in the cardiovascular, digestive, respiratory, and reproductive systems. A brief outlook of the field of endoscopic OCT is also discussed.
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Affiliation(s)
- Michalina J Gora
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
- ICube Laboratory, CNRS, Strasbourg University, 1 Place de l'Hopital, Strasbourg 67091, France
| | - Melissa J Suter
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
- Department of Medicine, Division of Pulmonary and Critical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Guillermo J Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Xingde Li
- Department of Biomedical Engineering, Department of Electrical and Computer Engineering, and Department of Oncology, Johns Hopkins University, 720 Rutland Avenue, Traylor 710, Baltimore, MD 21205, USA
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Charlesworth RPG, Andronicos NM, Scott DR, McFarlane JR, Agnew LL. Can the sensitivity of the histopathological diagnosis of coeliac disease be increased and can treatment progression be monitored using mathematical modelling of histological sections? - A pilot study. Adv Med Sci 2017; 62:136-142. [PMID: 28260668 DOI: 10.1016/j.advms.2016.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/30/2016] [Accepted: 06/01/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim of this pilot study was to attempt to define a set of equations from histological observations of tissue affected with coeliac disease (CD) to predict Marsh score. MATERIAL/METHODS Tissue from 15 patients with untreated CD, 6 patients with treated CD and 9 healthy control patients were stained using the standard H&E, Giemsa's staining for tissue sections and Alcian Blue protocols. A number of histological measures were then taken from each section and the data was used to ultimately design a set of linear predictive algorithms to calculate Marsh score. RESULTS Using MANOVA and discriminant analysis, two linear functions were defined which could accurately predict the Marsh score of patients 62.5% (full Marsh score) to 79.2% (simplified Marsh score) of the time. CONCLUSIONS This pilot study has shown that a set of objective histological measures can be used to define algorithms to predict Marsh score in CD patients and also monitor treatment compliance and progression.
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Affiliation(s)
| | | | - David R Scott
- Tamworth Rural Referral Hospital and Tamara Private Hospital, Tamworth, NSW, Australia
| | - James R McFarlane
- School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Linda L Agnew
- Brain Behaviour Research Group, University of New England, Armidale, NSW, Australia.
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Elli L, Branchi F, Sidhu R, Guandalini S, Assiri A, Rinawi F, Shamir R, Das P, Makharia GK. Small bowel villous atrophy: celiac disease and beyond. Expert Rev Gastroenterol Hepatol 2017; 11:125-138. [PMID: 28000520 DOI: 10.1080/17474124.2017.1274231] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Small bowel villous atrophy can represent a diagnostic challenge for gastroenterologists and pathologists. In Western countries small bowel atrophy and mild non-atrophic alterations are frequently caused by celiac disease. However, other pathology can mimic celiac disease microscopically, widening the differential diagnosis. The several novelties on this topic and the introduction of the device-assisted enteroscopy in the diagnostic flowchart make an update of the literature necessary. Areas covered: In this review, a description of the different clinical scenarios when facing with small bowel mucosal damage, particularly small bowel atrophy, is described. The published literature on this subject has been summarized and reviewed. Expert commentary: When an intestinal mucosal alteration is histologically demonstrated, the pathology report forms part of a more complex workup including serological data, clinical presentation and clinical history. A multidisciplinary team, including pathologists and enteroscopy-devoted endoscopists, is frequently required to manage patients with small bowel alterations, especially in cases of severe malabsorption syndrome.
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Affiliation(s)
- Luca Elli
- a Center for Prevention and Diagnosis of Celiac Disease , Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milano , Italy
| | - Federica Branchi
- a Center for Prevention and Diagnosis of Celiac Disease , Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milano , Italy
| | - Reena Sidhu
- b Department of Gastroenterology , University of Sheffield, Royal Hallamshire Hospital , Sheffield , United Kingdom
| | - Stefano Guandalini
- c Department of Pediatrics, Section of Pediatric Gastroenterology , Hepatology and Nutrition, Celiac Disease Center, University of Chicago , Chicago , IL , USA
| | - Asaad Assiri
- d Prince Abdullah Bin Khalid Coeliac Disease Research Chair King Saud University , Riyadh , Saudi Arabia
| | - Firas Rinawi
- e Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center , Petach Tikva , Israel
| | - Raanan Shamir
- f Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel AND Sackler Faculty of Medicine , Tel-Aviv University , Tel Aviv , Israel
| | - Prasenjit Das
- g Department of Pathology , All India Institute of Medical sciences , New Delhi , India
| | - Govind K Makharia
- h Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
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Stoven SA, Choung RS, Rubio-Tapia A, Absah I, Lam-Himlin DM, Harris LA, Ngamruengphong S, Vazquez Roque MI, Wu TT, Murray JA. Analysis of Biopsies From Duodenal Bulbs of All Endoscopy Patients Increases Detection of Abnormalities but has a Minimal Effect on Diagnosis of Celiac Disease. Clin Gastroenterol Hepatol 2016; 14:1582-1588. [PMID: 26965842 DOI: 10.1016/j.cgh.2016.02.026] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 02/11/2016] [Accepted: 02/18/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with positive results from serologic tests for celiac disease, analysis of tissues samples from the duodenal bulb, in addition to those from other parts of the small bowel, might increase the diagnostic yield. However, biopsies are not routinely collected from the duodenal bulb because of concerns that villous atrophy detected there could be caused by other disorders (Brunner glands or peptic duodenitis, gastric metaplasia, shorter villi, or lymphoid follicles). We investigated whether analysis of biopsies from duodenal bulbs of all patients undergoing endoscopy (a population with a low probability for celiac disease) increases diagnoses of celiac disease. METHODS We performed a retrospective analysis of data from 679 patients (63% female; mean age, 50 years) from whom duodenal bulb and small bowel biopsies were collected during endoscopy at 3 Mayo Clinic sites, from January 1, 2011 through December 31, 2011. Records were reviewed for age, sex, pathology findings, serology test results (HLA DQ2 or DQ), indications for biopsy analyses, and adherence to a gluten-free diet. Patients with celiac disease were identified on the basis of increased intraepithelial lymphocytosis, with or without villous atrophy and crypt hyperplasia, and results from serology tests. Findings from duodenal bulbs were compared with diagnoses using the Fisher exact test. RESULTS Of all patients undergoing endoscopy, 16 patients (2%) were found to have celiac disease. Analysis of the duodenal bulb biopsies identified 1 patient (0.1%) with celiac disease limited to this region. Of 399 patients whose celiac serology was not known before endoscopic examination, only 2 patients had histologic changes consistent with celiac disease but not limited to duodenal bulb. Abnormal duodenal histology was detected in 265 patients (39%), most commonly in the bulb (n = 241; P < .0001). Of abnormal bulb histologies, chronic peptic duodenitis was most common (observed in 114 patients, 47%). In patients with a normal distal duodenum (n = 576), the duodenal bulb had abnormal histology in 162 (28%). CONCLUSIONS In a low pretest probability cohort, separate sampling of the duodenal bulb had minimal effect on celiac disease detection. Abnormal histologic findings are more commonly detected in the duodenal bulb; although they do not seem to impair identification of celiac disease, their clinical implications are unclear.
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Affiliation(s)
- Samantha A Stoven
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Imad Absah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Dora M Lam-Himlin
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona
| | - Lucinda A Harris
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | | | | | - Tsung-Teh Wu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; Department of Immunology, Mayo Clinic, Rochester, Minnesota.
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Pace LA, Crowe SE. Duodenal Bulb Biopsies Remain Relevant in the Diagnosis of Adult Celiac Disease. Clin Gastroenterol Hepatol 2016; 14:1589-1592. [PMID: 27565522 PMCID: PMC5941945 DOI: 10.1016/j.cgh.2016.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 08/17/2016] [Accepted: 08/17/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Laura A Pace
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, Utah
| | - Sheila E Crowe
- Department of Medicine, Division of Gastroenterology, University of California San Diego, La Jolla, California
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Association of Tissue Transglutaminase Antibody Titer with Duodenal Histological Changes in Children with Celiac Disease. Gastroenterol Res Pract 2016; 2016:6718590. [PMID: 27867394 PMCID: PMC5102726 DOI: 10.1155/2016/6718590] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/04/2016] [Accepted: 07/26/2016] [Indexed: 12/20/2022] Open
Abstract
Celiac disease is usually diagnosed by demonstrating gluten enteropathy in small bowel biopsy. Celiac specific antibodies are used as an initial screening test. The goal of this study is to test the relationship of the anti-tTG titer and severity of histological changes in Jordanian children with celiac disease. Method. The medical records of 81 children who had elevated anti-tTG titer and had duodenal biopsies available were retrospectively reviewed. Result. Assessing the association of anti-tTG titer with duodenal histopathological changes, 94% of those with high anti-tTG titer (≥180 U/mL) had histological evidence of celiac disease. There was statistically significant positive association between high anti-tTG titer and Marsh grading as 82% of patients with Marsh III had high anti-tTG titer (Chi2 18.5; P value 0.00; Odds Ratio 8.5). The fraction of patients with Marsh III who were correctly identified as positive by anti-tTG titer ≥ 180 U/mL was high (sensitivity = 81.6). Moreover, the fraction of patients with anti-tTG titer ≥ 180 U/mL who had Marsh III was also high (positive predictive value = 78.4). Conclusion. Anti-tTG titer ≥ 180 U/mL had significant positive association with Marsh III histopathological changes of celiac disease.
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