Federation of International Societies of Pediatric Gastroenterology, Hepatology, and Nutrition consensus report on celiac disease

Aerobic Exercise Associated with Fish Oil Supplementation Decreases C-Reactive Protein and Interleukin-6 in Celiac Disease Patients

Background

Several studies indicate that celiac disease patients present alterations within anthropometric, metabolic, and inflammatory parameters, while physical exercise and fish oil are known to activate modulatory pathways of such parameters.

Objective

To investigate the effects of a 12-week-long protocol of aerobic exercise and its association with fish oil supplementation in nineteen adult celiac disease patients. Material and Methods. The celiacs were divided into 2 groups: (A) FOS: supplementation (n = 11); and (B) EXE: supplementation and exercise (n = 8). The celiac groups were compared to the adult healthy control group (CTR) (n 12). Aerobic exercises were performed weekly, in three sessions of 60 minutes each, with a maximal heart rate intensity of 60–70%. The participants received 2 g/day of fish oil, a daily intake of 420 mg of eicosapentaenoic acid, and 230 mg of docosahexaenoic acid. The following measurements were taken in four phases: (A) anthropometry: body mass, height, body mass index, waist-to-hip ratio, fat mass, and fat-free mass; (B) metabolic profile: total cholesterol, triglycerides, HDL, and LDL; and (C) inflammatory profile: C-reactive protein and interleukin-6.

Results

Supplementation associated with aerobic exercise promoted a significant reduction in C-reactive protein (P < 0.01) and increased the proportion of individuals in the undetectable range of interleukin-6.

Conclusions

The associated interventions showed a corrective and preventive potential in relation to disorders associated with chronic inflammation; however, the experimental design does not allow us to discriminate between the biological effects that are dependent on the association between interventions and those exclusively dependent on aerobic exercise.

Effects of green coffee bean flour fortification on the chemical and nutritional properties of gluten-free cake

The objective of this study was the application of green coffee bean flour in gluten-free cakes with different percentages (4, 8 and 15% (w/w)), to evaluate the optimal value for fortification, and the products were characterized based on their centesimal composition and bioactive compounds (caffeine and total phenolic compounds). Significant differences (p ≤ 0.05) were observed in the content of lipids, total dietary fiber, insoluble fiber, energy values, sodium, caffeine, and total phenolics, mainly in the product in which 15% (w/w) green coffee bean flour was added. Caffeine content was only detected and quantified in products with > 8% (w/w) green coffee bean flour, whereas the total phenolic content was detected and quantified in products with > 4% (w/w) green coffee bean flour. Thus, fortification of these products with 15% green coffee bean flour promoted a higher content of total dietary fiber and lower content of lipids, calories, sodium, and increased bioactive compounds. Thus, green coffee bean flour is an excellent alternative for the production of innovative foods.

Impact of Gluten-Free Sorghum Bread Genotypes on Glycemic and Antioxidant Responses in Healthy Adults

Sorghum is used to provide good quality gluten-free products due to phytochemicals and low glycemic index (GI). This study aimed to determine the chemical composition, the antioxidant activity and capacity, and the glycemic and insulinemic responses of gluten-free (GF) sorghum bread. GF bread samples were produced with three different sorghum genotypes. The samples were analyzed for chemical composition, resistant starch and dietary fiber content; antioxidant activity by ORAC; antioxidant capacity by FRAP; GI; and insulinemic responses. This double-blind, crossover, randomized clinical trial was conducted with 10 healthy men aged 28.0 ± 4.9 years (77.6 ± 11.7 kg and 24.2 ± 2.3 kg/m2). All sorghum bread showed significantly more fiber than rice bread (control). Brown sorghum bread was classified as low GI, bronze and white as medium GI, and control as high GI. Brown sorghum bread presented a low carbohydrate content, a significant amount of fiber, and a significantly lower 3 h AUC glucose response than those of the control, aside from the highest antioxidant activity value (p ≤ 0.001). Therefore, brown sorghum was superior to other genotypes analyzed in this study, and its production should be encouraged to provide gluten-free products with a better nutritional profile. More research is required to explore the effects of different sorghum genotypes in food products on human health.

Celiac Disease Defined by Over-Sensitivity to Gliadin Activation and Superior Antigen Presentation of Dendritic Cells

The autoimmune condition, Celiac Disease (CeD), displays broad clinical symptoms due to gluten exposure. Its genetic association with DQ variants in the human leukocyte antigen (HLA) system has been recognised. Monocyte-derived mature dendritic cells (MoDCs) present gluten peptides through HLA-DQ and co-stimulatory molecules to T lymphocytes, eliciting a cytokine-rich microenvironment. Having access to CeD associated families prevalent in the Czech Republic, this study utilised an in vitro model to investigate their differential monocyte profile. The higher monocyte yields isolated from PBMCs of CeD patients versus control individuals also reflected the greater proportion of dendritic cells derived from these sources following lipopolysaccharide (LPS)/ peptic-tryptic-gliadin (PTG) fragment stimulation. Cell surface markers of CeD monocytes and MoDCs were subsequently profiled. This foremost study identified a novel bio-profile characterised by elevated CD64 and reduced CD33 levels, unique to CD14++ monocytes of CeD patients. Normalisation to LPS stimulation revealed the increased sensitivity of CeD-MoDCs to PTG, as shown by CD86 and HLA-DQ flow cytometric readouts. Enhanced CD86 and HLA-DQ expression in CeD-MoDCs were revealed by confocal microscopy. Analysis highlighted their dominance at the CeD-MoDC membrane in comparison to controls, reflective of superior antigen presentation ability. In conclusion, this investigative study deciphered the monocytes and MoDCs of CeD patients with the identification of a novel bio-profile marker of potential diagnostic value for clinical interpretation. Herein, the characterisation of CD86 and HLA-DQ as activators to stimulants, along with robust membrane assembly reflective of efficient antigen presentation, offers CeD targeted therapeutic avenues worth further exploration.

PARK7 Diminishes Oxidative Stress-Induced Mucosal Damage in Celiac Disease

Coeliac disease (CD) is a chronic, immune-mediated small intestinal enteropathy, accompanied with gluten-triggered oxidative damage of duodenal mucosa. Previously, our research group reported an increased mucosal level of the antioxidant protein Parkinson's disease 7 (PARK7) in children with CD. In the present study, we investigated the role of increased PARK7 level on the epithelial cell and mucosal integrity of the small intestine. The presence of PARK7 was investigated using immunofluorescent staining on duodenal mucosa of children with CD and on FHs74Int duodenal epithelial cells. To investigate the role of oxidative stress, FHs74Int cells were treated with H₂O₂ in the absence or presence of Comp23, a PARK7-binding compound. Intracellular accumulation of reactive oxygen species (ROS) was determined by DCFDA-based assay. Cell viability was measured by MTT, LDH, and Annexin V apoptosis assays. Disruption of cytoskeleton and cell adhesion was investigated by immunofluorescence staining and by real-time RT PCR. Effect of PARK7 on mucosal permeability was investigated ex vivo using intestinal sacs derived from control and Comp-23-pretreated mice. Comp23 treatment reduced the H₂O₂-induced intracellular accumulation of ROS, thus preserving the integrity of the cytoskeleton and also the viability of the FHs74Int cells. Accordingly, Comp23 treatment increased the expression of antioxidants (NRF2, TRX1, GCLC, HMOX1, NQO1), cell-cycle regulators (TP53, CDKN1A, PCNA, BCL2, BAX), and cell adhesion molecules (ZO1, CDH1, VCL, ITGB5) of H₂O₂-treated cells. Pretreatment with Comp23 considerably decreased the small intestinal permeability. In this study, we demonstrate that PARK7-binding Comp23 reduces the oxidative damage of duodenal epithelial cells, via increased expression of NRF2- and P53-regulated genes. Our results suggest that PARK7 plays a significant role in the maintenance of mucosal integrity in CD.

Knowledge and opinions of asymptomatic adolescents and their caregivers on celiac disease screening

Objectives

Celiac disease (CD) is an immune enteropathy caused by sensitivity to gluten affecting one per cent of the general population. Most people with CD are asymptomatic and some may be affected from childhood. Despite the latest recommendations of paediatric gastroenterology societies, targeted screening is still uncommon in clinical paediatric settings. A poor understanding of the asymptomatic population's opinions creates obstacles for broader implementation of CD screening. This study aims to fill this gap by reporting on the knowledge and opinions of adolescents and caregivers of children on CD screening.

Methods

Adolescents with absence of classical symptoms of CD and caregivers of presumably asymptomatic children were asked about their knowledge and opinions of CD through a self-administered questionnaire.

Results

There were 227 respondents including 76 adolescents and 151 caregivers. A minority of respondents (8% of caregivers and 23% of adolescents) were identified as having a CD-associated condition (such as hypothyroidism, type 1 diabetes, Down syndrome, etc.). A majority of caregivers (84%) and half of adolescents (49%) already knew about CD. Half of the respondents (46%) were in favour of screening asymptomatic paediatric populations and this agreement increased to 81.7% when they were confronted with hypothetical risks of 10%.

Conclusion

This study reveals an increased willingness to screen when participants were faced with increasing hypothetical risks. This suggests that screening recommendations targeting high-risk populations, such as those of paediatric and non-paediatric gastroenterology societies, may be more widely accepted.

Role of IL-24 in the mucosal remodeling of children with coeliac disease

BACKGROUND

Recently, involvement of IL-19, IL-20 and IL-24 has been reported in inflammatory diseases associated with tissue remodeling. However, their impact on the pathomechanism of coeliac disease (CD) is still completely unknown.

METHODS

Expression of IL19, IL20 and IL24 was measured by real-time RT-PCR, protein amount of IL-24, α smooth muscle actin (α-SMA) and fibronectin (FN) was determined by Western-blot analysis in the duodenal biopsies of therapy naive children with CD and controls. Localization of IL-24 and IL-20RB was investigated by immunofluorescent staining in the duodenal mucosa. Effect of recombinant IL-1β, TNF-α, TGF-β and IL-17 treatment on the expression of IL19, IL20, IL24 and their receptors was investigated by real-time RT-PCR in small intestinal epithelial cells (FHs74Int), in primary duodenal myofibroblasts (pdMFs) and in peripheral blood mononuclear cells (PBMCs). Effect of IL-24 on H₂O₂ treated FHs74Int cells and on pdMFs was measured by MTT, LDH, Annexin V assays, real-time RT-PCR and by fluorescent microscopy.

RESULTS

We found increased level of IL-24 (3.3×, p < 0.05), α-SMA (2.4×, p < 0.05) and FN (2.3×, p < 0.05) in the duodenal mucosa and increased expression of IL19 (3.6×, p < 0.05) and IL24 (5.2×, p < 0.05) in the PBMCs of children with CD compared to that of controls. IL-1β was a strong inducer of IL24 expression of FHs74Int cells (9.9×, p < 0.05), pdMFs (552.9×, p < 0.05) or PBMCs (17.2×, p < 0.05), as well. IL-24 treatment reduced the number of apoptotic cells (0.5×, p < 0.05) and decreased the expression of inflammatory factors, including IL1A, IL6 and TNF of H₂O₂-treated FHs74Int cells. IL-24 decreased the proliferation (0.6×, p < 0.05) of PDGF-B treated pdMFs. Moreover, IL-24 treatment altered the morphology of pdMFs by influencing the size of the angles between stress fibers and the longitudinal axis of the cells (2.0×, p < 0.05) and the expression of cytoskeletal components, including ACTA2, ACTB, VIM, SNAI1 and SNAI2.

CONCLUSION

Our results suggest that IL-24 plays a significant role in the maintenance of duodenal mucosal integrity in CD.

Nutrition Assessment, Interventions, and Monitoring for Patients with Celiac Disease: An Evidence Analysis Center Scoping Review

The objectives of this scoping review were to identify and characterize studies examining nutrition assessment, interventions, and measures to monitor gluten-free diet (GFD) adherence/compliance in patients with celiac disease (CD). An electronic literature search of four databases (Cochrane Database for systematic reviews, CINAHL, Embase, and Ovid MEDLINE) was conducted to identify articles examining nutrition care in CD individuals. Except for narrative review, grey literature, and case study/report, all types of peer-reviewed articles published between January 2007 and August 2018 were eligible. There were a total of 10,823 records; 10,368 were excluded during the first round of screening due to irrelevancy and/or duplication. Of the 455 full-text articles that were assessed, 292 met the criteria and were included. Most of the studies were observational studies (n=212), followed by experimental trials (n=50), evidence-based practice guideline (EBPG)/report/statement (n=16), and systematic review (SR) (n=14). Nine original studies examined assessment, focusing mainly on different tools/ways to assess GFD adherence. The majority of the included original articles (n=235) were in the nutrition intervention category with GFD, oats, and prebiotics/probiotics as the top-three most studied interventions. There were eight SRs on GFD and five on oats. One SR and 21 original studies investigated the effectiveness of different measures to monitor GFD adherence/compliance. Although recent CD EBPGs were identified, different methods with varying levels of rigor, in terms of literature search and assessment of evidence strength, were used. Based on this scoping review, interventions focused on gluten-free diet and oats have been significantly covered by either SRs or EBPGs. Studies related to prebiotics/probiotics and education program/counseling focused interventions, as well as assessment, in CD patients have increased in recent years. Thus, it might be beneficial to conduct SRs/EBPGs focused on these topics to guide practitioners.

Anthropometric Parameters in Celiac Disease: A Review on the Different Evaluation Methods and Disease Effects

This review compiled anthropometric data from 29 original articles, published between 1995 and 2015, corresponding to a total sample of 6368 celiac disease subjects. Body mass index was the main parameter for measuring anthropometry (82.1%), followed by body mass (78.6%), body fat (51.7%), bone mineral density and bone mineral content (46.4%), and fat-free mass (44.8%). The main evaluation method was dual x-ray absorptiometry (83.3%), followed by bioimpedance (16.6%), skinfold thickness (16.6%), and isotope dilution (5.5%). This compilation suggests that celiac disease patients without a gluten-free diet (WGFD) and celiac disease patients with a gluten-free diet (GFD) show a lower body mass than the control group, with inconclusive data about WGFD versus GFD. Body mass index is lower in WGFD and GFD compared to control group, and is lower in WGFD compared to GFD. We observed lower values of FM and FFM in WGFD and GFD versus the control group. No difference was found between WGFD versus GFD. BMD and BMC are lower in WGFD versus GFD and GFD versus the control group, with inconclusive data about WGFD versus GFD. The findings of this review suggest that celiac disease patients must be periodically evaluated through anthropometric parameters, since the pathology has the potential to modulate such values even in a gluten-free diet, with these variables reflecting their healthy status. In parallel, the screening of different anthropometric assessment methodologies can provide support for more accurate evaluations by scientists and clinical professionals who work with celiac disease patients.

Accidental Gluten Contamination in Traditional Lunch Meals from Food Services in Brasilia, Brazil

This study aimed to evaluate the occurrence of gluten contamination in naturally gluten-free meals from food services in the Federal District, Brazil. This is an exploratory cross-sectional quantitative study in which a total of 180 samples of naturally gluten-free dishes were collected from 60 food services in Brazil. The enzyme-linked immunosorbent assay was used for the quantification of gluten. As established by the Codex Alimentarius, the threshold of 20 ppm of gluten was considered as the accepted upper gluten level for gluten-free food. A total of 2.8% (95% CI: 0.3-5.2%) gluten contamination was found in the samples. Among the 60 food services, 6.7% (95% CI: 2.7-10.6%) displayed at least one contaminated food in our sample. The occurrence of gluten contamination in naturally gluten-free preparations was uncommon and low on a quantitative basis.

Dietary management of celiac disease: Revisiting the guidelines

OBJECTIVE

Medical nutrition therapy (MNT), by lifelong compliance with a gluten-free diet, is likely the only treatment for celiac disease (CD). Clinical practice guidelines (CPGs) regarding the management of CD emphasize the role of MNT over other treatment options. The aim of the present study was to review and critically appraise CD-specific MNT CPGs and identify areas in need of improvement for better adherence and outcomes.

METHODS

A comprehensive search was performed using PubMed, Guidelines International Network (GIN), Google Scholar, gray literature, and websites of CD scientific organizations for CPGs, consensus and practice papers on the dietary management of CD, published in the English language.

RESULTS

A total of 12 CPGs were retrieved and critically appraised by three independent reviewers using the Appraisal of Guidelines Research & Evaluation (AGREE) II instrument. All CPGs were of low quality based on AGREE II. Among the 12 CPGs, the National Institute for Health and Care Excellence guidelines achieved the highest score and were unanimously recommended without modifications by the three reviewers, whereas the American Gastroenterology Association, Alberta Health Services, British Society of Paediatric Gastroenterology, Hepatology and Nutrition, Clinical Resource Efficiency Support Team, and Federation of International Societies of Pediatric Gastroenterology, Hepatology and Nutrition guidelines received the lowest scores.

CONCLUSIONS

The present study reveals the low quality of guidelines regarding the MNT of CD patients, indicating the need for updated and improved guidelines taking into consideration the proposed items of AGREE II.

Rate and determinants of non-adherence to a gluten-free diet and nutritional status assessment in children and adolescents with celiac disease in a tertiary Brazilian referral center: a cross-sectional and retrospective study

Background

Compliance with a gluten-free diet (GFD) is difficult at all ages but particularly for teenagers due to social, cultural, economic, and practical pressures. The multidisciplinary team responsible for the treatment of patients with celiac disease and give support to their parents plays a special role on strengthening GFD and assessing the nutritional and physical health.

Methods

A cross-sectional and retrospective study including patients under 20 years of age, with biopsy-confirmed CD, followed regularly at the Department of Pediatrics, Division of Gastroenterology, Hospital das Clínicas, University of Sao Paulo, School of Medicine, Sao Paulo, Brazil, were surveyed using a questionnaire and serologic test applied between November 2011 and February 2012. A retrospective chart review of these patients was performed to collect the anthropometric data along with the results of the serologic test performed at the time of diagnosis and after at least 1 year of treatment with a GFD.

Results

We evaluated 35 patients aged between 2.4 and 19.9 years. Of these 68.6% were female, 88.6% had the typical form of the disease and 51.4% had other comorbidities. The mean age at diagnosis was 5.4 years. Despite dietary guidance, 20% reported non-adherence to the diet. Most children recovered the weight and height deficit after 5 years of treatment, and in some children, excessive weight gain became a concern.

Conclusion

The majority of transgressions occurred intentionally at home or at parties. There was a risk of excessive weight gain, especially in the first two years of treatment. More alternatives and easier access to low cost gluten-free foods, increasing the discussion about the benefits of adhering to a GFD among patients, families, and the general population, besides the acquisition of self-management skills, are crucial to fostering independent children and adolescents who have the knowledge and tools to manage life with CD.

Electronic supplementary material

The online version of this article (10.1186/s12876-018-0740-z) contains supplementary material, which is available to authorized users.

Coeliac disease: to biopsy or not?

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.

Celiac disease: From pathophysiology to treatment

Celiac disease, also known as "celiac sprue", is a chronic inflammatory disorder of the small intestine, produced by the ingestion of dietary gluten products in susceptible people. It is a multifactorial disease, including genetic and environmental factors. Environmental trigger is represented by gluten while the genetic predisposition has been identified in the major histocompatibility complex region. Celiac disease is not a rare disorder like previously thought, with a global prevalence around 1%. The reason of its under-recognition is mainly referable to the fact that about half of affected people do not have the classic gastrointestinal symptoms, but they present nonspecific manifestations of nutritional deficiency or have no symptoms at all. Here we review the most recent data concerning epidemiology, pathogenesis, clinical presentation, available diagnostic tests and therapeutic management of celiac disease.

Tissue Transglutaminase Levels Are Not Sufficient to Diagnose Celiac Disease in North American Practices Without Intestinal Biopsies

BACKGROUND

Celiac serology is crucial for the diagnosis of celiac disease in children. The American guideline for celiac disease in children suggested that positive serology should be followed by confirmatory intestinal histology. The relationship between high tissue transglutaminase titers and celiac disease in children has not been well investigated in children from North America.

AIMS

In the present study, we investigated whether different tissue transglutaminase titers in symptomatic children could predict celiac disease without the confirmation of intestinal histology.

METHODS

Data from biopsy confirmed celiac children were collected from four different clinics in North America. Clinical, serological, histological, and follow-up data were collected. The accuracy rates of various tissue transglutaminase titers to predict celiac disease in children were calculated.

RESULTS

The data from 240 children were calculated. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy rate of tissue transglutaminase titers at ≥10× upper limit of normal were 75.4, 48.8, 87.7, 29.0, and 70.8 %, respectively. Similar data were noted in the other tissue transglutaminase titers (≥3× upper limit of normal, >100 U/ml, or >100 U/ml and >10× upper limit of normal).

CONCLUSIONS

The positive predictive value of tissue transglutaminase titers at ≥3× upper limit of normal or higher was too low to predict celiac disease in children. Our data suggested that in routine clinical practice, high titers of tissue transglutaminase are not sufficient to diagnose celiac disease in North American children without intestinal biopsies.

Co-occurrence of eosinophilic esophagitis and potential/probable celiac disease in an adult cohort: a possible association with implications for clinical practice

We describe an adult cohort with eosinophilic esophagitis (EoE) and evidence of celiac disease (CD), propose a change in diagnostic practice to better characterize these conditions, and hypothesize new directions for research. Pediatric studies postulate association between gluten sensitivity and EoE. However, few publications describe the prevalence, detection, or therapeutic and pathophysiologic implications of such association in adults. Retrospective chart review was done on patients diagnosed with EoE from 2009 to 2010 at University of Utah Hospitals and Clinics. Data included sex, age, presentation, duodenal pathology, tissue transglutaminase immunoglobulin A antibody (TTG) positivity, human leukocyte antigen (HLA) type (when indicated), and gross and microscopic Esophagogastroduodenoscopy (EGD) findings. Duodenal biopsy, TTG results, and HLA type were correlated. Endoscopy was repeated after gluten-free diet. Forty-four of 75 patients were followed in EoE specialty clinic with duodenal biopsy and TTG testing per protocol. Six EoE patients had potential or probable CD. No sex or age differences were noted between those with findings of CD and EoE and those with EoE alone. Six patients with findings of CD and EoE followed gluten-free diet. Five underwent repeat endoscopy. Three had resolution of esophageal eosinophilia. Potential or probable CD was commonly found in adults with EoE. Diagnosis of CD may be challenging due to nonspecific symptoms and insufficient duodenal biopsy and serologic testing. Furthermore, gluten-free diet resolved EoE findings in some patients, suggesting possible shared pathophysiology in some cases of EoE and CD. TTG testing and adequate duodenal biopsy may further direct clinical care for EoE patients, and studies are needed to elucidate mechanisms linking EoE and CD.

Effect of Green Banana Peel Flour Substitution on Physical Characteristics of Gluten-Free Cakes

Celiac Disease is the most common food-sensitive entoropathy in humans that is triggered by the consumption of wheat gluten as well as related with protein in barley, rye and oat. The only treatment ever known for celiac disease is gluten-free diet. Most gluten-free food product on the market is rich in starch but poor in terms of other nutrients, functional and health benefitial ingredients. Green (unripe) banana is a good source of resistant starch, non-starch polysaccharides including dietary fiber, antioxidants, poliphenols, essential minerals such as potassium, various vitamins e.g. provitamin A, carotenoid, B1, B2, C which are important for human health. In this research, it is aimed to develop nutritious and functional gluten free cake formulations by substituting green banana peel flour (GBPF) with rice flour (5%, 10%, 15% and 20%) and to investigate physical properties of GBPF substituted cakes. Cake volume, specific volume, density, baking loss and height of the cakes were in the range of 831.44 – 1034.11 cm3, 1.91-2.41 cm3/g, 0.41-0.52 g/cm3, 16.38-18.14% and 4.36-5.77 cm respectively. As a result, GBPF substituted gluten free cakes were successfully produced. Physical analyses of gluten free cakes showed that 5% and 10% GBPF substitution did not affect gluten free cake volume, specific volume, density and baking loss negatively. 5% and 10% GBPF substituted cakes were not different from control cake statistically (p>0.05). However, substitution levels of 15% and 20% resulted in poorer physical properties. Sensory analysis (data not shown) indicated that all GBPF substitution levels were acceptable, as determined by hedonic scala tests. By developing a nutritious gluten free cake alternative, it is expected to provide an alternative in the dietary diversity of individuals with celiac disease.

Evidence-Informed Expert Recommendations for the Management of Celiac Disease in Children

Although the need for effective long-term follow-up for patients with celiac disease (CD) has been recognized by many expert groups, published practice guidelines have not provided a clear approach for the optimal management of these patients. In an attempt to provide a thoughtful and practical approach for managing these patients, a group of experts in pediatric CD performed a critical review of the available literature in 6 categories associated with CD to develop a set of best practices by using evidence-based data and expert opinion. The 6 categories included the following: bone health, hematologic issues, endocrine problems, liver disease, nutritional issues, and testing. Evidence was assessed by using standardized criteria for evaluating the quality of the data, grade of evidence, and strength of conclusions. Over 600 publications were reviewed, and 172 were chosen for inclusion. The thorough review of the results demonstrated that the quality of the data available was often insufficient to provide unequivocal best practices. However, using the available data and the clinical experience of the panel, a practical framework for the management of children with CD was created. These recommendations were developed by our expert panel and do not necessarily reflect the policy of the American Academy of Pediatrics. The potential usefulness of these best practices is underscored by the fact that consensus, measured by the outcome of anonymous voting, was reached by the panel for 24 of the 25 questions. We hope that these best practices may be useful to the pediatric gastroenterology and larger general pediatric communities.

Coeliac disease and gluten-related disorders in childhood

Gluten-related disorders such as coeliac disease, wheat allergy and noncoeliac gluten sensitivity are increasingly being diagnosed in children. Coeliac disease occurs frequently, affecting 1-3% of the Western population. The condition manifests at a very young age, more so in girls, and is related to the HLA genotype. Coeliac disease might be considered a public health problem and, as primary prevention is not possible, the debate on mass screening should be reopened. Wheat proteins, including gluten, are responsible for one of the most common food allergies in children: wheat allergy. Unlike coeliac disease and wheat allergy, noncoeliac gluten sensitivity is an unclear and controversial entity. These three gluten-related disorders are treated with a gluten-free diet. In coeliac disease, the diet should be strictly followed, whereas wheat allergy only requires wheat elimination and in noncoeliac gluten sensitivity occasional trials of gluten reintroduction can be done. A good diagnostic work-up is important for gluten-related disorders in childhood to avoid unnecessary restrictive diets in children. In this Review, we provide an overview of the pathogenesis, diagnosis and management of the most common gluten-related disorders in children.

Gluten-free diet or alternative therapy: a survey on what parents of celiac children want

OBJECTIVES

Celiac disease (CD) is treated by life-long gluten-free diet (GFD). Novel therapies are under development. Willingness of CD children's parents to alternative therapies and GFD impact were evaluated.

METHODS

Parents of celiac children on GFD were investigated on need and preference for novel CD therapies, children's enrolment in trials, compliance to and personal judgment on GFD, health status (HS) and quality of life (QoL).

RESULTS

About 59.5% surveyed parents expressed the need for alternative therapies with a preference for vaccine-based strategy (39.9%). About 37.7% would accept enrollment in an ad hoc trial, 20.3% would agree to endoscopy during the trial. GFD compliance was 97.4% and well accepted by 93.8%. HS and QoL significantly improved during GFD (p < 0.001).

CONCLUSIONS

The introduction of novel therapies for CD is desirable for over half of parents, with preference for vaccines. Parents frown upon enrolment in new clinical trials and the subsequent need for additional endoscopy.

Correlation of endoscopic and histological features in adults with suspected celiac disease in a referral center of Minas Gerais, Brazil

CONTEXT

Clinical presentation of celiac disease is extremely variable and the diagnosis relies on serologic tests, mucosal intestinal biopsy and clinic and serologic response to a gluten-free diet.

OBJECTIVES

To correlate the endoscopic and histological aspects of adult patients with suspicion of celiac disease and to evaluate the interobserver histological agreement.

METHODS

Endoscopic aspects of 80 adult patients were evaluated and correlated with the histological features according the Marsh-Oberhuber classification system. The interobserver histological agreement was based on kappa values.

RESULTS

The symptoms of the patients varied largely, with prominence for chronic diarrhea, present in 48 (60%) patients. The endoscopic aspects related with the duodenal villous atrophy had been observed in 32 (40%) patients. There were confirmed 46 cases of celiac disease, with prevalence of 57.5%. The sensitivity, specificity, positive predictive value and negative predictive value of the endoscopic markers for celiac disease diagnosis were of 60.9%, 88.2%, 87.5% and 62.5%. There was moderate interobserver histological agreement (kappa = 0.46).

CONCLUSIONS

The endoscopic markers of villous atrophy, although not diagnostic, had assisted in the suspicion and indication of the duodenal biopsies for diagnosis proposal. Histology is sometimes contradictory and new biopsies or opinion of another professional can provide greater diagnostic agreement.

Utilization of sorghum, rice, corn flours with potato starch for the preparation of gluten-free pasta

The aim of this study was to evaluate the use of mixture of sorghum-rice-corn flour and potato starch in the development of gluten-free pasta for celiac disease patients. The experiment was designed according to simplex-lattice method and different types of gluten-free flours were used, such as sorghum, rice, corn, and potato starch. The fifteen formulations were subjected to sensory analysis (Mixed Structured Scale - MSS) and seven formulations were selected in respect to taste and grittiness. These formulations were subjected to Quantitative Descriptive Analysis (QDA), which evaluated the attributes: appearance, color, odor, hardness, elasticity, stickiness, grittiness, taste, residual bitterness and overall quality. Results showed significant difference in appearance, color and hardness. The formulations that showed the best sensory results were submitted to chemical analysis and cooking quality of pasta. It was observed that the best results for mixing is sorghum flour, rice flour and potato starch.

The development of a composition database of gluten-free products

Objective

To develop a composition database of a number of foods representative of different categories of gluten-free products in the Italian diet.

Design

The database was built using the nutritional composition of the products, taking into consideration both the composition of the ingredients and the nutritional information reported on the product label.

Setting

The nutrient composition of each ingredient was obtained from two Italian databases (European Institute of Oncology and the National Institute for Food and Nutrition).

Subjects

The study developed a food composition database including a total of sixty foods representative of different categories of gluten-free products sold on the Italian market. The composition of the products included in the database is given in terms of quantity of macro- and micronutrients per 100 g of product as sold, and includes the full range of nutrient data present in traditional databases of gluten-containing foods.

Results

As expected, most of the products had a high content of carbohydrates and some of them can be labelled as a source of fibre (>3 g/100 g). Regarding micronutrients, among the products considered, breads, pizzas and snacks were especially very high in Na content (>400–500 mg/100 g).

Conclusions

This database provides an initial useful tool for future nutritional surveys on the dietary habits of coeliac people.

Clinical Evaluation of Specific Oral Manifestations in Pediatric Patients with Ascertained versus Potential Coeliac Disease: A Cross-Sectional Study

Patients involved on coeliac disease (CD) have atypical symptoms and often remain undiagnosed. Specific oral manifestations are effective risk indicators of CD and for this reason an early diagnosis with a consequent better prognosis can be performed by the dentist. There are not researches analysing the frequency of these oral manifestations in potential coeliac patients. The aim of this study is to investigate the oral hard and soft tissue lesions in potential and ascertained coeliac children in comparison with healthy controls. 50 ascertained children, 21 potential coeliac patients, and 54 controls were recruited and the oral examination was performed. The overall oral lesions were more frequently present in CD patients than in controls. The prevalence of oral soft tissue lesions was 62% in ascertained coeliac, 76.2% in potential coeliac patients, and 12.96% in controls (P < 0.05). Clinical dental delayed eruption was observed in 38% of the ascertained coeliac and 42.5% of the potential coeliac versus 11.11% of the controls (P < 0.05). The prevalence of specific enamel defects (SED) was 48% in ascertained coeliac and 19% in potential coeliac versus 0% in controls (P < 0.05; OR = 3.923). The SED seem to be genetically related to the histological damage and villous atrophy.

Celiac disease diagnosis: impact of guidelines on medical prescription in France

OBJECTIVE

Celiac disease is a complex autoimmune disease affecting patients of any age, who may present a wide variety of clinical manifestations. Different guidelines for the diagnosis and management of celiac disease have been recently published. The aim of this study was to determine whether the recommendations issued in these guidelines have been adopted by physicians in France when celiac disease was suspected.

METHODS

A total of 5521 physicians were asked to fill in a detailed questionnaire on diagnosing celiac disease to evaluate their medical practice, as to the type of symptoms leading to the suspicion of celiac disease, the prescription of duodenal biopsy or serological tests, the type of serological tests (anti-tissue transglutaminase, anti-endomysium, anti-gliadin and anti-reticulin antibodies, total immunoglobulin A measurement) prescribed to diagnose celiac disease.

RESULTS

The analysis of the responses of 256 general practitioners (GPs), 221 gastroenterologists and 227 pediatricians showed that the protean clinical presentations of celiac disease might be better recognized by gastroenterologists and pediatricians than by GPs. Gastroenterologists asked for duodenal biopsy much more often than GPs and pediatricians when celiac disease was suspected. Serological testing and knowledge of critical markers, prescribed to diagnose celiac disease, differed among GPs, gastroenterologists and pediatricians.

CONCLUSION

Analysis of medical prescriptions showed that the recommendations for celiac disease diagnosis are not necessarily followed by physicians, emphasizing the fact that the impact of national or international guidelines on medical behavior should be evaluated.

Cardiovascular disease risk factor profiles in children with celiac disease on gluten-free diets

AIM

To describe the cardiovascular disease (CVD) risk factors in a population of children with celiac disease (CD) on a gluten-free diet (GFD).

METHODS

This cross-sectional multicenter study was performed at Schneider Children's Medical Center of Israel (Petach Tiqva, Israel), and San Paolo Hospital (Milan, Italy). We enrolled 114 CD children in serologic remission, who were on a GFD for at least one year. At enrollment, anthropometric measurements, blood lipids and glucose were assessed, and compared to values at diagnosis. The homeostasis model assessment-estimated insulin resistance was calculated as a measure of insulin resistance.

RESULTS

Three or more concomitant CVD risk factors [body mass index, waist circumference, low density lipoprotein (LDL) cholesterol, triglycerides, blood pressure and insulin resistance] were identified in 14% of CD subjects on a GFD. The most common CVD risk factors were high fasting triglycerides (34.8%), elevated blood pressure (29.4%), and high concentrations of calculated LDL cholesterol (24.1%). On a GFD, four children (3.5%) had insulin resistance. Fasting insulin and HOMA-IR were significantly higher in the Italian cohort compared to the Israeli cohort (P < 0.001). Children on a GFD had an increased prevalence of borderline LDL cholesterol (24%) when compared to values (10%) at diagnosis (P = 0.090). Trends towards increases in overweight (from 8.8% to 11.5%) and obesity (from 5.3% to 8.8%) were seen on a GFD.

CONCLUSION

This report of insulin resistance and CVD risk factors in celiac children highlights the importance of CVD screening, and the need for dietary counseling targeting CVD prevention.

Correlation between antibodies and histology in celiac disease: incidence of celiac disease is higher than expected in the pediatric population

The present study aims to report on the correlation between the degree of negativity of anti-endomysial antibodies and anti-tissue transglutaminase antibodies in the IgA and IgG classes with regard to histological grade, in 44 newly diagnosed children with celiac disease (CD). Samples with negative antibodies, but a positive histology from a 5-year program searching for CD in the pediatric population were collected. A total of 4247 biopsy samples were used in this study. We documented that certain pediatric patients are seronegative, while the disease is active and the incidence of CD is higher than expected in the pediatric population. This is an important finding, which demonstrates the lack of association between autoantibodies and lesions, and justifies the use of biopsies for an accurate CD diagnosis and the importance of revising the diagnostic criteria in a clinical, endoscopic and serological context. We recommend a more active search for incidences of the disease in the pediatric population. Serological markers are not the main method for the diagnosis of CD as they are considered to only have a supporting role clinically. Biopsies of the small intestine are always necessary for the diagnosis of CD in these patients.

Type 1 diabetes mellitus and celiac disease: endothelial dysfunction

Many reports indicate a hypercoagulative state in diabetes mellitus as result of endothelial damage. Experimental evidence suggests that a metabolic derangement triggers a cascade of biochemical events that lead to vascular dysfunction. The net effect is to convert the endothelium from thromboresistant to thrombogenic surface. In literature, a strong association between type 1 diabetes mellitus (DM1) and celiac disease (CD) has been reported. We do not have information about the hemostatic system in these associated conditions. Our study aims at evaluating whether the presence of CD in a group of DM1 patients is associated with a different expression of some hemostatic factors and with a different manifestation and/or progression of microvascular complications of DM1 in comparison with patients with only diabetes. Ninety-four adult DM1 patients were enrolled in the study and subsequently screened for CD. Anti-endomysial antibodies (EMA) were positive in 13 of 94 DM1 patients (13.8%). CD diagnosis was confirmed by histology and organ culture. The mean age and duration of DM1 of patients also affected by CD were similar to those of only diabetic patients, but the metabolic control and the hemocoagulative parameters were significantly different between the two groups: DM1 patients also affected by CD presented significantly lower concentrations of glycosylated hemoglobin (HbA1c) (P < 0.05), cholesterol (P < 0.001), triglycerides (P < 0.001), factor VII antigen (FVII:ag) (P < 0.005), factor VII coagulant activity (FVII:c) (P < 0.05), and prothrombin degradation fragments (F1+2) (P < 0.001), as well as higher values of activated C protein (APC) (<0.001). No retinal abnormalities and no signs of renal damage were observed in DM1 patients also affected by CD. Our results suggest a potential protective role of CD in the prothrombotic state of DM1.

Expression of PARK7 is increased in celiac disease

Recently, it has been suggested that the gene called Parkinson's disease 7 (PARK7) might be an upstream activator of hypoxia-inducible factor (HIF)-1α, which plays a major role in sustaining intestinal barrier integrity. Furthermore, PARK7 has been proposed to participate in the Toll-like receptor (TLR)-dependent regulation of the innate immune system. Our aim was to investigate the involvement of PARK7 in the pathogenesis of coeliac disease (CD). Duodenal biopsy specimens were collected from 19 children with untreated CD, five children with treated CD (maintained on gluten-free diet), and ten children with histologically normal duodenal biopsies. PARK7 mRNA expression and protein level were determined by real-time polymerase chain reaction (PCR) and Western blot, respectively. Localization of PARK7 was visualized by immunofluorescence staining. Protein level of PARK7 increased in the duodenal mucosa of children with untreated CD compared to children with treated CD or to control biopsies (p <0.03). We detected intensive PARK7 staining in the epithelial cells and lamina propria of the duodenal mucosa of children with untreated CD compared with that in control biopsies. Our finding that mucosal expression of PARK7 is increased suggests that PARK7 is involved in the pathogenesis of gastrointestinal diseases, notably CD. Our results suggest that PARK7 may alter processes mediated by HIF-1α and TLR4, which supports a role for PARK7 in the maintenance of epithelial barrier integrity, immune homeostasis, or apoptosis.

Cost-effectiveness of universal serologic screening to prevent nontraumatic hip and vertebral fractures in patients with celiac disease

BACKGROUND & AIMS

Patients with asymptomatic or poorly managed celiac disease can experience bone loss, placing them at risk for hip and vertebral fractures. We analyzed the cost-effectiveness of universal serologic screening (USS) vs symptomatic at-risk screening (SAS) strategies for celiac disease because of the risk of nontraumatic hip and vertebral fractures if untreated or undiagnosed.

METHODS

We developed a lifetime Markov model of the screening strategies, each with male or female cohorts of 1000 patients who were 12 years old when screening began. We screened serum samples for levels of immunoglobulin A, compared with tissue transglutaminase and total immunoglobulin A, and findings were confirmed by mucosal biopsy. Transition probabilities and quality of life estimates were obtained from the literature. We used generalizable cost estimates and Medicare reimbursement rates and ran deterministic and probabilistic sensitivity analyses.

RESULTS

For men, the average lifetime costs were $8532 and $8472 for USS and SAS strategies, respectively, corresponding to average quality-adjusted life year gains of 25.511 and 25.515. Similarly for women, costs were $11,383 and $11,328 for USS and SAS strategies, respectively, corresponding to quality-adjusted life year gains of 25.74 and 25.75. Compared with the current standard of care (SAS), USS produced higher average lifetime costs and lower quality of life for each sex. Deterministic and probabilistic sensitivity analyses showed that the model was robust to realistic changes in all the variables, making USS cost-ineffective on the basis of these outcomes.

CONCLUSIONS

USS and SAS are similar in lifetime costs and quality of life, although the current SAS strategy was overall more cost-effective in preventing bone loss and fractures among patients with undiagnosed or subclinical disease. On the basis of best available supportive evidence, it is more cost-effective to maintain the standard celiac screening practices, although future robust population-based evidence in other health outcomes could be leveraged to reevaluate current screening guidelines.

Diagnosis of coeliac disease in children younger than 2 years

BACKGROUND AND AIM

To diagnose coeliac disease (CD) in children younger than 2 years, the old ESPGHAN criteria based on 3 small bowel biopsies were recommended until recently. The aim of the present study was to investigate the applicability of only 1 small intestinal biopsy plus positive serology for the diagnosis of CD in children younger than 2 years.

METHODS

A prospective cohort study included 81 patients younger than 2 years with symptoms suggestive of CD, who all completed the diagnostic procedure based on 3 small bowel biopsies. According to the finding of the third biopsy, patients were divided into group A-CD confirmed (N = 44), and group B-CD not confirmed, after the gluten challenge (N = 37).

RESULTS

At the time of the first biopsy, total villous atrophy (Marsh IIIc) was found more often in group A than in group B (77% vs 27%, P < 0.01). Also, all of the studied antibodies were more frequently positive in group A than in group B (P < 0.01 for all of the tested antibodies). Positive anti-endomysial antibodies and Marsh IIIc finding were the best discriminators between the group A and the group B and considerably contributed to the prediction of CD.

CONCLUSIONS

The second and the third biopsies (before and after the gluten challenge) may also be avoided when diagnosing CD in children younger than 2 years provided that the child, at the time of presentation, has positive anti-endomysial antibodies and Marsh IIIc on the small bowel biopsy. A gluten challenge should be still considered in all other children younger than 2 years.

Acculturation and celiac disease risk in second-generation immigrants: a nationwide cohort study in Sweden

OBJECTIVES

The burden of celiac disease (CD) is increasingly recognized as a global problem. However, whether this situation depends on genetics or environmental factors is uncertain. The authors examined these aspects in Sweden, a country in which the risk of CD is generally considered to be high. If environmental factors are relevant, CD risk in second-generation immigrant children should be related to maternal length of stay in Sweden before delivery.

MATERIAL AND METHODS

Linking the Swedish Medical Birth Registry to other national registries, the authors investigated all singleton children (n = 792,401) born in Sweden between 1987 and 1993. They studied the risk of CD in children before age 6 as a function of the mother's geographical region of birth and length of stay in Sweden before delivery using Cox regression models.

RESULTS

In children whose mothers immigrated to Sweden from a country outside of Europe, a maternal length of stay in Sweden of more than 5 years increased the hazard ratio (HR) of CD (1.73, 95% confidence interval (CI) 1.06-2.81). The authors observed a similar result among children born to mothers from a Nordic country outside of Sweden (HR 1.57, 95% CI 0.89-2.75), but a non-conclusive protective effect was observed in second-generation immigrant children from a non-Nordic European country (HR 0.65, 95% CI 0.39-1.09).

CONCLUSIONS

The risk of CD among second-generation immigrants seems to be conditioned by maternal length of stay in Sweden before delivery, suggesting that environmental factors contribute to the variation in CD risk observed across populations.

A novel algorithm for the diagnosis of celiac disease and a comprehensive review of celiac disease diagnostics

There is an urgent clinical need for a better laboratory celiac disease diagnosis with both less false positive results and minimal underdetection. The aim of the present study was to evaluate the performance and diagnostic accuracy of different assays in an outpatient population setting for the diagnosis for celiac disease (CD) in order to design an optimal algorithm. We used 15 different ELISA assays to assess 47 blood samples of newly diagnosed children (positive biopsy results) and 52 samples from age- and sex-matched children with negative biopsy results for CD. Scoring criteria were established for grading the assays performance and characteristics. The combined gliadin and tTG assays exhibited the best sensitivity (100%). The addition of other assays to the CeliCheck neo-epitopes assay improved specificity so that the final algorithm had 100% sensitivity, 96.2% specificity, and 98.1% accuracy. The clinical demand for both maximal sensitivity and maximal specificity cannot be achieved with a single test. Using a combination of a sensitive assay together with specific assays improved celiac disease detection rates, with an acceptable number of false positive results. This model, however, needs to be confirmed prospectively in both children and adults.

Do gastroenterologists adhere to diagnostic and treatment guidelines for celiac disease?

AIM

Our group hypothesized that significant variation exists between suggested clinical guidelines, the clinical practices of practicing gastroenterologists and academic experts in celiac disease (CD).

METHOD

We designed 4 CD vignettes comparing experts and practicing gastroenterologists. Practicing gastroenterologists (n=169) were surveyed during Digestive Disease Week 2009 and experts (n=22) answered e-mail surveys. Ratings for answers in each vignette was done using a 9-point RAND Appropriateness Scale (RAS) with endorsement defined as RAS score of 7 to 9. We also calculated the RAND "Disagreement Index" (DI) was calculated, with DI>1.0 indicated extreme variation.

RESULTS

A total of 169 practicing gastroenterologists and 22 experts were included. Differences in all vignette answers were present. Differences were seen for use of IgA anti-endomysial antibodies (P=0.0241), human leukocyte antigen DQ2/8 testing (P=0.0325), gluten challenge (P<0.0001), and oat consumption (P<0.0001). There were differences in recommendations for biopsy review (P=0.0479) and management of dermatitis herpetiformis (P=0.0025). Experts consistently endorsed CD screening in patients with type 1 diabetes, Down and Turner syndromes, and relatives of CD patients compared with practicing physicians (P=0.0054, 0.0003, <0.0001, 0.0304). Experts endorsed CD screening for atypical presentations (delayed puberty, elevated transaminases, primary biliary cirrhosis, autoimmune hepatitis, and infertility).

CONCLUSION

There is significant disagreement between nonexperts and experts in diagnosis and management of CD. Promotion of existing guidelines and further research is advised.

Celiac disease in pediatric patients with autoimmune hepatitis: etiology, diagnosis, and management

Celiac disease (CD) is defined as a permanent intolerance to ingested wheat gliadins and other cereal prolamins, occurring in genetically susceptible people. Persistent elevation of serum aminotransferase activity is expression of liver damage related to CD, which occurs in two distinctive forms. The most frequent is a mild asymptomatic liver injury, with a moderate increase of serum aminotransferase activities and a mild inflammatory portal and lobular infiltrate on liver biopsy (celiac hepatitis), reversible on a gluten-free diet (GFD). More rarely, severe and progressive inflammatory liver damage, induced by an autoimmune process and identified as autoimmune hepatitis (AIH), can develop and it is generally unaffected by gluten withdrawal. Surveys that included only pediatric patients report a wide range of prevalence of CD in AIH of 11.5-46% (mean 21.5%). CD and AIH share selected combinations of genes coding for class II human leukocyte antigens, which could explain their coexistence. Increased intestinal permeability and circulation of anti-tissue transglutaminase (tTG) have also been considered as further potential causes of liver damage in CD patients. tTG in the liver and in other extraintestinal tissues could modify other external- or self-antigens and generate different neo-antigens, which are responsible for liver injury in patients with CD. Patients with AIH represent a population at high risk for developing CD; screening for CD should be integrated into the diagnostic routine of all patients with AIH, with or without gastrointestinal manifestations, before starting immunosuppressive treatments. The only currently available treatment for CD is the GFD and the supportive nutritional care for iron, calcium, and vitamin deficiencies. Due to the difficulties of a GFD, in the past decade researchers have become increasingly interested in therapeutic alternatives to continuous or intermittent use of a GFD in patients with CD. Interventions addressed to correct the defect in the intestinal barrier are currently at the most advanced stage of clinical trials. The impact of a GFD on the outcome of AIH is not clear but it seems to be ineffective in the treatment of AIH. The early detection and treatment of CD, however, may prevent progression to end-stage liver failure.

Autoimmunity: Celiac disease in T1DM-the need to look long term

Does untreated celiac disease associated with type 1 diabetes mellitus worsen microvascular outcomes? Previous studies have concluded that a gluten-free diet offers no major benefit for glycemic control, whereas Leeds and colleagues provide preliminary data to the contrary. The question awaits a long-term prospective study or a clinical trial.

Celiac disease diagnosis and management: a 46-year-old woman with anemia

Celiac disease is one of the most prevalent autoimmune gastrointestinal disorders, but as the case of Ms J illustrates, diagnosis is often delayed or missed. Based on serologic studies, the prevalence of celiac disease in many populations is estimated to be approximately 1% and has been increasing steadily over the last 50 years. Evaluation for celiac disease is generally straightforward and uses commonly available serologic tests; however, the signs and symptoms of celiac disease are nonspecific and highly heterogeneous, making diagnosis difficult. Although celiac disease is often considered a mild disorder treatable with simple dietary changes, in reality celiac disease imparts considerable risks, including reduced bone mineral density, impaired quality of life, and increased overall mortality. In addition, a gluten-free diet is highly burdensome and can profoundly affect patients and their families. For these reasons, care of individuals with celiac disease requires prompt diagnosis and ongoing multidisciplinary management.

Celiac disease in children with diarrhea in 4 cities in China

OBJECTIVE

The aim of the study was to investigate whether celiac disease (CD) could be the cause of chronic diarrhea in Chinese patients.

PATIENTS AND METHODS

During the period of January 2005 to December 2008, patients with chronic diarrhea in pediatric hospitals from 4 major cities (Shanghai, Wuhan, Jinan, and Chengdu) in China were included in the study. The clinical history, physical findings, and laboratory data were collected and analyzed.

RESULTS

Among 199 patients with chronic diarrhea, 118 were enrolled in the study. Fourteen (11.9%) were diagnosed as being affected by CD.

CONCLUSIONS

The 14 patients are the first reported cases of CD in Chinese patients with chronic diarrhea.