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Verdelho Machado M. Refractory Celiac Disease: What the Gastroenterologist Should Know. Int J Mol Sci 2024; 25:10383. [PMID: 39408713 PMCID: PMC11477276 DOI: 10.3390/ijms251910383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Revised: 09/20/2024] [Accepted: 09/25/2024] [Indexed: 10/20/2024] Open
Abstract
Fewer than 1% of patients with celiac disease (CD) will develop refractory CD (RCD). As such, most gastroenterologists might never need to manage patients with RCD. However, all gastroenterologists must be familiarized with the basic concepts of RCD and non-responsive CD (NRCD), since it can present as a severe disease with high mortality, not only due to intestinal failure, but also due to progression to enteropathy-associated T cell lymphoma (EATL) and a higher susceptibility to life-threatening infections. The diagnostic workup and differential diagnosis with other causes of gastrointestinal symptoms and villous atrophy, as well as the differentiation between type I and II RCD, are complex, and may require specialized laboratories and reference hospitals. Immunosuppression is efficient in the milder RCDI; however, the treatment of RCDII falls short, with current options probably only providing transient clinical improvement and delaying EATL development. This review summarizes the current diagnostic and therapeutic approach for patients with RCD that all doctors that manage patients with CD should know.
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Affiliation(s)
- Mariana Verdelho Machado
- Gastroenterology Department, Hospital de Vila Franca de Xira, 2600-009 Lisbon, Portugal; ; Tel.: +351-912620306
- Gastroenterology Department, Faculdade de Medicina, Lisbon University, 1649-028 Lisboa, Portugal
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Wall E, Semrad CE. Celiac Disease, Gluten Sensitivity, and Diet Management. Curr Gastroenterol Rep 2024; 26:191-199. [PMID: 38865028 DOI: 10.1007/s11894-024-00931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE OF REVIEW Celiac disease is a common chronic inflammatory condition of the small bowel triggered by gluten in wheat, rye and barley in the diet. Non-celiac gluten sensitivity presents with symptoms similar to celiac disease with the ingestion of gluten or other components of wheat. In this article, we review challenges presented by a gluten free diet for the treatment of both disorders. RECENT FINDINGS Wheat is ubiquitous in the diet and medications/products. A registered dietitian is mandatory for patient education on the gluten free diet. Naturally gluten free foods provide a healthy diet for those with celiac disease. Whole grains labelled gluten free, including oats, are encouraged in the diet as refined grains may be deficient in fiber, protein, and micronutrients, particularly folate. Gluten contamination is the most common cause of persistent symptoms in celiac disease though shared equipment of food preparation may not be as large a problem as suspected. Most with celiac disease on a gluten free diet will fully recover and gain weight that poses a problem for those overweight to start. The gluten free diet may have a negative impact on quality of life for both celiac patients and their families. Those with hypervigilance of the gluten free diet and avoidance of dining out have the lowest quality of life. The gluten free diet is currently the only effective treatment for celiac disease. A registered dietitian is needed to educate patients on the complexity of the gluten free diet with a goal of healthy eating, maintaining a healthy weight, and avoiding disordered eating or diet hypervigilance; key to a good quality of life.
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Affiliation(s)
- Elizabeth Wall
- Clinical Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Carol E Semrad
- Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA.
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Luque V, Crespo-Escobar P, Hård Af Segerstad EM, Koltai T, Norsa L, Roman E, Vreugdenhil A, Fueyo-Díaz R, Ribes-Koninckx C. Gluten-free diet for pediatric patients with coeliac disease: A position paper from the ESPGHAN gastroenterology committee, special interest group in coeliac disease. J Pediatr Gastroenterol Nutr 2024; 78:973-995. [PMID: 38291739 DOI: 10.1002/jpn3.12079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND AND OBJECTIVE Coeliac disease is a chronic, immune-mediated disorder for which the only treatment consists of lifelong strict adherence to gluten-free diet (GFD). However, there is a lack of evidence-based guidelines on the GFD dietary management of coeliac disease. This position paper, led by the Special Interest Group in coeliac disease of the European Society of Pediatric, Gastroenterology Hepatology, and Nutrition, supported by the Nutrition Committee and the Allied Health Professionals Committee, aims to present evidence-based recommendations on the GFD as well as how to support dietary adherence. METHODS A wide literature search was performed using the MeSH Terms: "diet, gluten free," "gluten-free diet," "diets, gluten-free," "gluten free diet," and "coeliac disease" in Pubmed until November 8th, 2022. RESULTS The manuscript provides an overview of the definition of the GFD, regulations as basis to define the term "gluten-free," which foods are naturally gluten-free and gluten-containing. Moreover, it provides recommendations and educational tips and infographics on suitable food substitutes, the importance of reading food labels, risk of gluten cross-contact at home and in public settings, nutritional considerations as well as factors associated to dietary adherence based on available evidence, or otherwise clinical expertise. CONCLUSIONS This position paper provides guidance and recommendations to support children with coeliac disease to safely adhere to a GFD.
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Affiliation(s)
- Veronica Luque
- Serra Húnter, Universitat Rovira i Virgili, Reus, Spain
- Paediatric Nutrition and Development Research Unit, IISPV, Reus, Spain
| | - Paula Crespo-Escobar
- Health Sciences Department, ADVISE Research Group, Miguel de Cervantes European University, Valladolid, Spain
- Nutrition and Dietetics Unit, Hospital Recoletas Campo Grande, Valladolid, Spain
| | - Elin M Hård Af Segerstad
- Paediatric Department, Skane University Hospital, Malmoe, Sweden
- Department of Clinical Sciences, Celiac Disease and Diabetes Unit, Faculty of Medicine, Lund University, Malmoe, Sweden
| | - Tunde Koltai
- Direction Board, Association of European Coeliac Societies, Brussels, Belgium
| | - Lorenzo Norsa
- Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Enriqueta Roman
- Paediatric Gastroenterology and Nutrition, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Anita Vreugdenhil
- Department of Pediatrics, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ricardo Fueyo-Díaz
- Department of Psychology and Sociology, Aragonese Primary Care Research Group (GAIAP, B21_20R), University of Zaragoza, Zaragoza, Spain
| | - Carmen Ribes-Koninckx
- Paediatric Gastroenterology, Hepatology and Nutrition, La Fe University Hospital & La Fe Research Institute, Valencia, Spain
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Bulut M, Tokuc M, Aydin MN, Ayyildiz Civan H, Polat E, Dogan G, Altuntas C, Bayrak NA, Beser OF. Nutrition and oral health in children with recently and previously diagnosed celiac disease. Clin Oral Investig 2023:10.1007/s00784-023-04971-x. [PMID: 36961593 DOI: 10.1007/s00784-023-04971-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 03/19/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVES To evaluate the nutritional and oral health status of children with previously diagnosed celiac disease (CD) who follow a gluten-free diet and recently diagnosed CD patients. MATERIALS AND METHODS Previously and recently diagnosed groups were formed from children with CD, aged 4 to 15 years. A questionnaire was completed about the children's dental history and nutritional and oral hygiene habits. All the children underwent an oral examination, and dmft-DMFT indices were determined. Dental plaque status, periodontal health, and dental enamel defects were recorded. Oral soft tissues were examined for the presence of lesions. Unstimulated salivary flow rate and pH value were evaluated. RESULTS A statistically significant difference was determined between the previously and recently diagnosed patients in terms of toothpaste preference (p=0.003), frequency of going to the dentist (p=0.039), and the types of dental treatment they had received (p=0.001). A statistically significant difference was determined between the previously and recently diagnosed patient groups in terms of dmft values (p=0.005). CONCLUSIONS Children with CD should be directed to a pediatric dentist to improve oral and dental health, relieve the symptoms of oral mucosal lesions, be informed about enamel defects, and be encouraged to use gluten-free oral care products. CLINICAL RELEVANCE The collaboration of pediatric gastroenterologists and pediatric dentists can prevent the progression of oral symptoms in children with CD and eliminate long-term complications in terms of both oral health and multisystemic problems.
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Affiliation(s)
- M Bulut
- Department of Pediatric Dentistry, Faculty of Dentistry, Istanbul Okan University, Istanbul, Türkiye.
| | - M Tokuc
- Department of Pediatric Dentistry, Faculty of Dentistry, Istanbul Okan University, Istanbul, Türkiye
| | - M N Aydin
- Department of Pediatric Dentistry, Faculty of Dentistry, Istanbul Okan University, Istanbul, Türkiye
| | - H Ayyildiz Civan
- Pediatric Gastroenterology, Hepatology and Nutrition, I.A.U. VM Medical Park Hospital Florya, Istanbul, Türkiye
| | - E Polat
- Pediatric Gastroenterology, Hepatology and Nutrition, Sancaktepe Sehit Prof Dr Ilhan Varank Training & Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - G Dogan
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Bezmialem Vakif University Faculty of Medicine, Istanbul, Türkiye
| | - C Altuntas
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Istinye University Faculty of Medicine, Istanbul, Türkiye
| | - N A Bayrak
- Pediatric Gastroenterology, Hepatology and Nutrition, Zeynep Kamil Women & Children's Training & Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - O F Beser
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
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Verma AK, Mandal S, Tiwari A, Monachesi C, Catassi GN, Srivastava A, Gatti S, Lionetti E, Catassi C. Current Status and Perspectives on the Application of CRISPR/Cas9 Gene-Editing System to Develop a Low-Gluten, Non-Transgenic Wheat Variety. Foods 2021; 10:foods10102351. [PMID: 34681400 PMCID: PMC8534962 DOI: 10.3390/foods10102351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/10/2021] [Accepted: 09/28/2021] [Indexed: 12/23/2022] Open
Abstract
Wheat gluten contains epitopes that trigger celiac disease (CD). A life-long strict gluten-free diet is the only treatment accepted for CD. However, very low-gluten wheat may provide an alternative treatment to CD. Conventional plant breeding methods have not been sufficient to produce celiac-safe wheat. RNA interference technology, to some extent, has succeeded in the development of safer wheat varieties. However, these varieties have multiple challenges in terms of their implementation. Clustered Regularly Interspaced Short Palindromic Repeats-associated nuclease 9 (CRISPR/Cas9) is a versatile gene-editing tool that has the ability to edit immunogenic gluten genes. So far, only a few studies have applied CRISPR/Cas9 to modify the wheat genome. In this article, we reviewed the published literature that applied CRISPR/Cas9 in wheat genome editing to investigate the current status of the CRISPR/Cas9 system to produce a low-immunogenic wheat variety. We found that in recent years, the CRISPR/Cas9 system has been continuously improved to edit the complex hexaploid wheat genome. Although some reduced immunogenic wheat varieties have been reported, CRISPR/Cas9 has still not been fully explored in terms of editing the wheat genome. We conclude that further studies are required to apply the CRISPR/Cas9 gene-editing system efficiently for the development of a celiac-safe wheat variety and to establish it as a "tool to celiac safe wheat".
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Affiliation(s)
- Anil K. Verma
- Celiac Disease Research Laboratory, Polytechnic University of Marche, 60123 Ancona, Italy;
- Correspondence: or ; Tel.: +39-0715962834
| | - Sayanti Mandal
- Institute of Bioinformatics and Biotechnology, Savitribai Phule Pune University, Ganeshkhind Road, Pune 411007, Maharashtra, India;
| | - Aadhya Tiwari
- Department of System Biology, MD Anderson Cancer Center, Houston, TX 77030, USA;
- Laboratory of Cell Biology, Department of Orthopaedic Surgery, University Hospital of Tübingen, Waldhörnlestraße 22, D-72072 Tübingen, Germany
| | - Chiara Monachesi
- Celiac Disease Research Laboratory, Polytechnic University of Marche, 60123 Ancona, Italy;
| | - Giulia N. Catassi
- Division of Pediatrics, DISCO Department, Polytechnic University of Marche, 60123 Ancona, Italy; (G.N.C.); (S.G.); (E.L.); (C.C.)
| | - Akash Srivastava
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02906, USA;
| | - Simona Gatti
- Division of Pediatrics, DISCO Department, Polytechnic University of Marche, 60123 Ancona, Italy; (G.N.C.); (S.G.); (E.L.); (C.C.)
| | - Elena Lionetti
- Division of Pediatrics, DISCO Department, Polytechnic University of Marche, 60123 Ancona, Italy; (G.N.C.); (S.G.); (E.L.); (C.C.)
| | - Carlo Catassi
- Division of Pediatrics, DISCO Department, Polytechnic University of Marche, 60123 Ancona, Italy; (G.N.C.); (S.G.); (E.L.); (C.C.)
- Mucosal Immunology and Biology Research Center, Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, Boston, MA 02114, USA
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Food Safety and Cross-Contamination of Gluten-Free Products: A Narrative Review. Nutrients 2021; 13:nu13072244. [PMID: 34210037 PMCID: PMC8308338 DOI: 10.3390/nu13072244] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 02/06/2023] Open
Abstract
A gluten-free diet (GFD) is currently the only effective treatment for celiac disease (CD); an individual’s daily intake of gluten should not exceed 10 mg. However, it is difficult to maintain a strict oral diet for life and at least one-third of patients with CD are exposed to gluten, despite their best efforts at dietary modifications. It has been demonstrated that both natural and certified gluten-free foods can be heavily contaminated with gluten well above the commonly accepted threshold of 20 mg/kg. Moreover, meals from food services such as restaurants, workplaces, and schools remain a significant risk for inadvertent gluten exposure. Other possible sources of gluten are non-certified oat products, numerous composite foods, medications, and cosmetics that unexpectedly contain “hidden” vital gluten, a proteinaceous by-product of wheat starch production. A number of immunochemical assays are commercially available worldwide to detect gluten. Each method has specific features, such as format, sample extraction buffers, extraction time and temperature, characteristics of the antibodies, recognition epitope, and the reference material used for calibration. Due to these differences and a lack of official reference material, the results of gluten quantitation may deviate systematically. In conclusion, incorrect gluten quantitation, improper product labeling, and poor consumer awareness, which results in the inadvertent intake of relatively high amounts of gluten, can be factors that compromise the health of patients with CD.
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The Contribution of Non-Food-Based Exposure to Gluten on the Management of Coeliac Disease. GASTROINTESTINAL DISORDERS 2020. [DOI: 10.3390/gidisord2020014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The management of coeliac disease involves the life-long adherence to a strict gluten free diet. There have been concerns about exposure to gluten or other cereal components that are not contained in foods. This manuscript reviews the available literature focused on the potential for exposure to non-food-based gluten and the potential relevance of this to the ongoing management of individuals with coeliac disease. The products of consideration included dental and oral hygiene products, cosmetics and packaging products. Each of these items has been considered, with caution noted in regards to dental products and potential concern about novel packaging applications. Accidental ingestion by younger children of items such as play-dough during play also requires care. In conclusion, there is currently little firm data to guide individuals with coeliac disease, other than caution about specific items.
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