Celiac sprue presenting during the puerperium: a report of three cases and a review of the literature

Fulminant Celiac Disease Presenting in the Postpartum Period

Celiac disease (CD) is an immune-mediated disorder of the small intestine triggered by dietary exposure to gluten in genetically susceptible individuals. Adult CD usually has an insidious onset with gastrointestinal symptoms, most often diarrhea and weight loss. The association between CD and reproductive abnormalities has been well described in the literature, but it is uncommon for CD to initially manifest during pregnancy or the postpartum period. We report a case of adult CD in a previously healthy woman with a life-threatening presentation during the postpartum period.

Navigating the Challenges of Gluten Enteropathy and Infertility: The Role of Celiac-Related Antibodies and Dietary Changes

Celiac disease (CD) is an autoimmune condition that is initiated in genetically susceptible individuals by the exposure of the intestines to gluten, and the early start of symptoms is related to malabsorption. Atypical variants of the illness are often identified in adulthood and are frequently associated with manifestations outside of the intestines, including metabolic osteopathy, anemia, and dermatitis herpetiformis. But also, empirical data suggest a correlation between CD and reproductive abnormalities, including repeated abortions. Infertility and repeated miscarriages frequently manifest in women diagnosed with CD and may serve as the initial clinical indication of a subclinical form. Furthermore, the condition may manifest as amenorrhea, infertility, and the delivery of infants with a low birth weight. Regarding the mechanisms of CD in infertility, along with the anti-tTG action to hinder the invasiveness of trophoblast, these antibodies could damage endometrial angiogenesis, which has been shown in in vitro models with human endometrial cells and in vivo in murine models. Another important aspect is the role of nutrient deficiencies, such as zinc deficiency (connected to impaired hormone production, secondary amenorrhea, and pre-eclampsia) and folic acid, etc. Therefore, our objective was to conduct a comprehensive review of the existing literature pertaining to this specific topic and to elucidate the role of the autoantibodies in its pathogenesis.

A case of celiac disease presenting with celiac crisis: rare and life threatening presentation

A 20 year old male with past medical history of Type 1 Diabetes and Hypothyroidism presented to our hospital with severe hypocalcemia. His calcium was 5.8 mg/dl (normal range 8.6–10.3 mg/dl). He had been complaining of generalized weakness for weeks. Vital signs were within normal limits. Physical exam was significant for positive Chvostek sign. Other labs revealed low magnesium, low potassium, low vitamin D, low albumin, metabolic acidosis and low ferritin. He was started on supplements. Tissue transglutaminase antibody IgG was elevated. Upper gastrointestinal endoscopy showed scalloped and blunted duodenal mucosa. Duodenal biopsy showed villous blunting with intraepithelial lymphocytosis suggestive of celiac disease. He was started on gluten free diet. His symptoms improved and he was discharged home. Celiac disease can present in fulminant form with hemodynamic instability and is called celiac crisis. Celiac crisis is usually manifested by severe gastrointestinal manifestations, hypoproteinemia and metabolic and electrolyte disturbances requiring hospitalization. It is diagnosed by criteria proposed by Jamma et al. Celiac crisis is a rare presentation of celiac disease and is associated with high morbidity and mortality. Most of the cases respond to gluten withdrawal and nutritional suport and few require steroids.

Abbreviation: Type 1 DM -Type 1 Diabetes Mellitus

Urinary Tract Infection Associated with a Celiac Crisis: A Preceding or Precipitating Event?

Celiac crisis is a rare life-threatening presentation of celiac disease that manifests as profuse diarrhea, hypoproteinemia, and severe metabolic disturbances. It may be precipitated by a general immune stimulus such as surgery, infection, or pregnancy. We report the case of a 26-year-old woman who presented with a celiac crisis, potentially triggered by a preceding urinary tract infection. Metabolic derangement is caused by malabsorption and profuse diarrhea, which can be unremitting unless the celiac crisis is recognized, and treatment with gluten restriction is initiated.

Bread and Other Edible Agents of Mental Disease

Perhaps because gastroenterology, immunology, toxicology, and the nutrition and agricultural sciences are outside of their competence and responsibility, psychologists and psychiatrists typically fail to appreciate the impact that food can have on their patients' condition. Here we attempt to help correct this situation by reviewing, in non-technical, plain English, how cereal grains-the world's most abundant food source-can affect human behavior and mental health. We present the implications for the psychological sciences of the findings that, in all of us, bread (1) makes the gut more permeable and can thus encourage the migration of food particles to sites where they are not expected, prompting the immune system to attack both these particles and brain-relevant substances that resemble them, and (2) releases opioid-like compounds, capable of causing mental derangement if they make it to the brain. A grain-free diet, although difficult to maintain (especially for those that need it the most), could improve the mental health of many and be a complete cure for others.

Reproductive changes associated with celiac disease

Celiac disease is a mucosal disorder of the small intestine that may be triggered by dietary exposure to gluten in genetically-susceptible individuals. The disorder is often associated with diarrhea, malabsorption and weight loss along with other extra-intestinal complications. Reproductive changes have been described, including impaired fertility and adverse pregnancy outcomes possibly related to immune-mediated mechanisms or nutrient deficiency. Other possible pathogenetic factors that may alter placental function include maternal celiac disease autoantibodies binding to placental transglutaminase, and genetic mutations that may facilitate microthrombus formation. Reports noting activation during pregnancy or the puerperium may be important, and suggest that celiac disease may also be hypothetically precipitated by maternal exposure to one or more fetal antigens.

Celiac crisis is a rare but serious complication of celiac disease in adults

BACKGROUND & AIMS

Celiac crisis is a life-threatening syndrome in which patients with celiac disease have profuse diarrhea and severe metabolic disturbances. Celiac crisis is rare among adults and not well documented. To improve awareness of this condition and to facilitate diagnosis, we reviewed cases of celiac crisis to identify presenting features, formulate diagnostic criteria, and develop treatment strategies.

METHODS

Cases of biopsy-proven celiac disease were reviewed. Celiac crisis was defined as acute onset or rapid progression of gastrointestinal symptoms that could be attributed to celiac disease and required hospitalization and/or parenteral nutrition, along with signs or symptoms of dehydration or malnutrition.

RESULTS

Twelve patients met preset criteria for celiac crisis; 11 developed celiac crisis before they were diagnosed with celiac disease. Eleven patients had increased titres of transglutaminase antibodies and 1 had immunoglobulin A deficiency. Results of biopsy analyses of duodenum samples from all patients were consistent with a Marsh 3 score (33% with total villous atrophy). Patients presented with severe dehydration, renal dysfunction, and electrolyte disturbances. All patients required hospitalization and intravenous fluids, 6 required corticosteroids, and 5 required parenteral nutrition. All patients eventually had a full response to a gluten-free diet.

CONCLUSIONS

Celiac crisis has a high morbidity and, although rarely described, occurs in adults and often has a clear precipitating factor. Patients who present with severe unexplained diarrhea and malabsorption should be tested for celiac disease; treatment with systemic steroids or oral budesonide should be considered. Nutritional support often is required in the short term but most patients ultimately respond to gluten avoidance.

Effect of gluten-free diet on pregnancy outcome in celiac disease patients with recurrent miscarriages

PURPOSE

Available literature data show that celiac disease (CD) is a frequent cause of recurrent miscarriage. However, data are lacking for pregnancy outcome when the patient is on a gluten-free diet (GFD). A case-control study about the effect of GFD on pregnancy was conducted from 1995 to 2006. A cohort of 13 women (mean age 32 years, range 22-38 years) affected by CD with recurrent miscarriages was observed. In all of them several causes of miscarriage (gynecological, endocrine, hematological, etc.) were excluded. All patients were started on a gluten-free diet and were reassessed throughout a long-term follow-up period to evaluate the outcome of pregnancy.

RESULTS

Six of 13 became pregnant (46.15%) as follows: 1 patient (7.69%) 1 year after GFD was started, 3 patients (23.07%) 2 years after GFD was started, 1 patient (7.69%) after 3 years, and finally 1 (7.69%) 4 years after GFD was started. Moreover, two patients (16.66%) had multiple pregnancies (one had had two childbirths and another had undergone three births within a 7-year follow-up period under GFD).

CONCLUSIONS

GFD seems to favor a positive outcome of pregnancy in most CD patients with recurrent miscarriage.

Screening for celiac disease in short bowel syndrome

BACKGROUND

Malabsorptive diarrhea due to short bowel syndrome (SBS) results in nutrition compromise, often requiring parenteral nutrition (PN). Activation of latent celiac disease can occur after gastrointestinal surgery. Our objective was to determine whether undiagnosed celiac disease contributes to malabsorption in patients with SBS.

METHODS

Adult subjects with SBS were tested for celiac disease using immunoglobulin A (IgA) tissue transglutaminase (TTG) antibody and total IgA level. Subjects with an elevated IgA tissue transglutaminase were offered upper endoscopy with biopsies of the duodenum.

RESULTS

Eighteen subjects were enrolled. The subjects were predominantly white, and the most common cause of SBS was Crohn's disease. The mean length of remaining small bowel was 93.1 +/- 54.6 cm. All subjects had undergone surgeries, resulting in loss of the ileocecal valve. Five subjects were found to have an elevated total IgA. A single patient was found to have an elevated IgA tissue transglutaminase antibody, and subsequent endoscopy demonstrated active gastroduodenal Crohn's disease, without features of celiac disease.

CONCLUSIONS

No subjects were IgA deficient, but 5 subjects were found to have elevated IgA levels. Undiagnosed celiac disease did not contribute to malabsorption in our small cohort of predominantly white SBS patients. Larger studies are warranted.

Silent celiac disease activated by pancreaticoduodenectomy

Diarrhea and weight loss are common after pancreaticoduodenectomy, and arise from varying etiologies. An uncommon but important cause for these symptoms is the postoperative activation of silent celiac disease. We sought to describe the clinical presentation, diagnosis, treatment, and follow-up of a series of patients with silent celiac disease unmasked after pancreaticoduodenectomy, and to summarize the existing case reports on this association. A search of the electronic medical record at our institution was performed cross-referencing terms associated with celiac disease and pancreaticoduodenectomy for the years 1976-2004. Cases were then reviewed to ensure that no signs or symptoms attributable to celiac disease were present preoperatively. Seven patients were identified; five were male, and the median age was 56. All patients underwent surgery for a presumed pancreatic or ampullary malignancy. Six patients developed symptoms ultimately attributable to celiac disease immediately after pancreaticoduodenectomy, most commonly diarrhea and weight loss. A single patient had silent celiac disease incidentally diagnosed at pancreaticoduodenectomy that remained silent postoperatively on an unrestricted diet. Symptoms completely resolved in 4 of 6 patients after initiation of a gluten-free diet, with partial improvement in the remaining 2 patients. The median delay from pancreaticoduodenectomy to diagnosis of celiac disease in the 6 symptomatic patients was 6 months. Clinicians should consider celiac disease as a potential diagnosis in patients with failure to thrive and diarrhea after pancreaticoduodenectomy. This entity is uncommon, but may be under-recognized. The underlying mechanism may relate to an increased antigenic load secondary to postsurgical changes in intestinal physiology.

Diagnosis of celiac disease in pregnancy and puerperium: think about it

We report 10 cases of celiac disease (CD) diagnosed after a pregnancy. During late pregnancy and/or puerperium a latent CD may be unmasked, so patients with mild gastrointestinal symptoms or anemia in pregnancy should be investigated to detect the disease before it might seriously affect maternofetal health.

Celiac disease: fertility and pregnancy

Celiac disease (gluten-sensitive enteropathy) may manifest clinically with an array of nongastrointestinal symptoms among which are: dermatitis herpetiformis; dementia; depression; various neurological symptoms; osteoporosis; osteomalacia; dental enamel defects, and anemia of various types. Important data have accumulated in recent years regarding the association between celiac disease, fertility and pregnancy. Many primary care obstetricians and gynecologists and perinatologists are not aware of these important relationships. The aim of this review, utilizing a MEDLINE search from 1966 through March 2000 of the English language, is to describe the possible effects of celiac disease and its treatment upon the reproductive cycle, fertility, pregnancy, and menopause. Review of the literature reveals that patients with untreated celiac disease sustain a significantly delayed menarche, earlier menopause, and an increased prevalence of secondary amenorrhea. Patients with untreated celiac disease incur higher miscarriage rates, increased fetal growth restriction, and lower birth weights. It appears that improvement of celiac disease, as reflected by restoration of small bowel mucosa associated with implementation of a gluten-free diet, may decrease miscarriage rates, improve fetal nutritional support and overall perinatal outcome.

A risk factor for female fertility and pregnancy: celiac disease

Celiac disease is a genetically-based intolerance to gluten. In the past, celiac disease has been considered a rare disease of infancy characterized by chronic diarrhea and delayed growth. Besides the overt enteropathy, there are many other forms which appear later in life; target organs are not limited to the gut, but include liver, thyroid, skin and reproductive tract. It is now recognized that celiac disease is a relatively frequent disorder; the overall prevalence is at least 1:300 in Western Europe. Celiac disease may impair the reproductive life of affected women, eliciting delayed puberty, infertility, amenorrhea and precocious menopause. Clinical and epidemiological studies show that female patients with celiac disease are at higher risk of spontaneous abortions, low birth weight of the newborn and reduced duration of lactation. No adequate studies are available on the rate of birth defects in the progeny of affected women; however, celiac disease induces malabsorption and deficiency of factors essential for organogenesis, e.g. iron, folic acid and vitamin K. The overall evidence suggests that celiac disease patients can be a group particularly susceptible to reproductive toxicants; however, the pathogenesis of celiac disease-related reproductive disorders still awaits clarification. At present, like the other pathologies associated with celiac disease, the possible prevention or treatment of reproductive effects can only be achieved through a life-long maintenance of a gluten-free diet.