A tale of two cities: typical celiac sprue presenting symptoms are significantly more common in Turkish than in US Patients

Bedouin Children With Celiac Disease: Less Symptoms but More Severe Histological Features at Presentation

Background: The prevalence of celiac disease (CD) has dramatically increased with wide variability in clinical presentations between different geographical areas. However, the contribution of ethnic disparities in pediatric celiac disease is still unclear, especially in patients of Bedouin origin. Objective: We aimed to compare the clinical presentation and histological severity of celiac disease between Bedouin and Jewish children in southern Israel. Methods: This is a retrospective study in which we collected the demographic and clinical data, laboratory results, and histological severity of CD in two ethnic groups: Bedouins and Jews. The study included patients who were diagnosed between 1997 and 2015 in a tertiary hospital in southern Israel. Results: Data from 844 children with CD (271 Jewish and 573 Bedouins), 505 females (59.8%), were analyzed. Gastrointestinal symptoms and diabetes were more prevalent among the Jewish population (p < 0.001 and p = 0.008, respectively), while family history, failure to thrive, iron deficiency anemia, and histological severity were significantly more prevalent among the Bedouin group. Upon multivariate logistic regression analysis, only the presence of iron deficiency anemia and Bedouin origin were associated with more advanced histological disease (OR of 2.03 (95% C.I 1.31; 4.308) (P < 0.009) and OR 1.78 (95% C.I 1.31; 4.308) (P < 0.003) respectively). Conclusion: The clinical presentation of celiac disease in Bedouin children is characterized by anemia with less gastrointestinal symptoms, but more severe histological damage. These differences might be explained either by a delay in the diagnosis of the disease in this population or by variable environmental, cultural, and nutritional factors unique to this ethnic group.

The association between socioeconomic status and the symptoms at diagnosis of celiac disease: a retrospective cohort study

BACKGROUND

There are little data on patient factors that impact diagnosis rates of celiac disease. This study aims to evaluate the association between patient socioeconomic status and the symptoms at diagnosis of celiac disease.

METHODS

A total of 872 patients with biopsy-proven celiac disease were categorized based on the presence or absence of (1) diarrhea and (2) any gastrointestinal symptoms at diagnosis. Univariate and multivariate analyses were used to assess the association between socioeconomic status and symptoms.

RESULTS

Patients without diarrhea at presentation had a higher mean per capita income (US$34,469 versus US$32,237, p = 0.02), and patients without any gastrointestinal symptoms had a higher mean per capita income (US$36,738 versus US$31,758, p < 0.01) compared with patients having such symptoms. On multivariable analysis adjusting for sex, age, autoimmune or psychiatric comorbidities, and income, per capita income remained a significant predictor of diagnosis without gastrointestinal symptoms (odds ratio: 1.71, 95% confidence interval: 1.17-2.50, p < 0.01), and it showed a trend towards significance in diagnosis without diarrhea (odds ratio: 1.40, 95% confidence interval: 0.98-2.02, p = 0.06).

CONCLUSIONS

Patients with nonclassical symptoms of celiac disease are less likely to be diagnosed if they are of lower socioeconomic status. Celiac disease may be under-recognized in this population due to socioeconomic factors that possibly include lower rates of health-seeking behavior and access to healthcare.

Theoretical pharmacokinetic drug alterations in pediatric celiac disease

INTRODUCTION

The incidence of pediatric celiac disease has risen and many of these children will receive medications at some time in their life. However, the absorption of drugs in pediatric patients with celiac disease has never been studied. The few studies that do exist have only been performed in adults and indicate that drug concentrations can be altered for some drugs. It is also noteworthy that few researchers have conducted studies to determine if the distribution, metabolism, and excretion of drugs are altered in celiac disease.

AREAS COVERED

The pharmacokinetics of drugs greatly differ between children and adults. Combined with the pathophysiological changes known to occur with celiac disease, there is compelling evidence to support that drug exposure in pediatric celiac disease may be altered. Relevant characteristics of celiac disease that may affect drug disposition include intestinal atrophy, hypoalbuminemia, reduced CYP3A enzymes, and thyroid dysfunction.

EXPERT OPINION

The safety and efficacy of drug dosing in children with celiac disease can be enhanced with additional pharmacokinetic studies of commonly prescribed drugs in this population. Ideally, these studies should include drugs that have high bioavailability, are highly protein bound, undergo extensive CYP3A enzyme metabolism, and/or have a narrow therapeutic range.

Celiac disease in the developing world

The prevalence of celiac disease (CD) in many developing countries is similar to that of developed areas, in both low- and high-risk groups. The disorder is underestimated because of lack of disease awareness. CD is strongly associated with HLA-DQ2 in developing countries. Clinical presentation may be characterized by chronic diarrhea, anemia, stunting and increased mortality. Few studies have addressed atypical or silent CD. Diagnosis is initially made by serologic tests and is confirmed by small intestinal biopsies. In developing countries the adherence to the treatment is still difficult because of poor availability of dedicated gluten-free food.

Celiac disease in Middle Eastern and North African countries: A new burden?

Celiac disease (CD) is now recognized as a common disorder among Middle Eastern (ME) and North African (NA) populations. The aim of this review is to assess the available data regarding CD in the ME and NA and to compare this information with that of Western countries. A literature review was performed using the electronic databases PubMed and Medline (1950-2008) as search engines, and “celiac disease” was used as a Mesh term. The search was limited to ME and NA countries. The prevalence of CD in ME and NA countries among low risk populations is similar to that of Western countries, but is higher in high risk populations such as those with type 1 diabetes. It is underestimated because of lack of clinical suspicion and lack of patient awareness. Clinical presentations in term of gastrointestinal, hematologic, skeletal, and liver manifestations are similar between both populations except for a high prevalence of short stature in some ME and NA countries. Few studies have addressed atypical or silent CD. As in the West, diagnosis is initially made by serological tests and is confirmed by small intestinal biopsies. Gluten-free diet is the main mode of treatment with a higher apparent adherence rate than in the West. Most disease complications result from malabsorption. The disease is strongly associated with HLA DQ2 and to a lesser extent with HLA DQ8 alleles. In conclusion, CD prevalence is underestimated, with little data available about its malignant complications. Disease parameters in the ME and NA are otherwise similar to those in Western countries.