The teenage coeliac: follow up study of 102 patients

Extra-intestinal manifestations of Celiac disease in children: their prevalence and association with human leukocyte antigens and pathological and laboratory evaluations

BACKGROUND

Celiac disease (CD) is an autoimmune disease caused by gluten intake. Traditionally CD was believed to be a disease of the gut, although a wide range of extra-intestinal manifestations (EIM) was recognized. The exact prevalence of EIM and the associated risk factors have not been well studied.

AIM

We aimed to assess the prevalence of EIM in children with CD and their association with human leukocyte antigen (HLA) typing, and pathological and laboratory indices.

METHOD

We conducted a cross-sectional study on children and adolescents with a definite diagnosis of CD. They were followed in the main Celiac Clinic of Southern Iran.

RESULTS

We included 204 children who were visited between 2012 and 2017. Nearly 85% of them were positive for HLA-DQ2 and 40.6% for HLA-DQ8. The most prevalent intestinal complaints reported were abdominal pain (42.6%) and chronic constipation (19.1%). Failure-to-thrive (32.7%), iron deficiency anemia (25%), short stature (20.5%), and eczema (18.6%) were the most common EIMs. However, failure-to-thrive and short stature were presented at significantly younger ages, whereas those patients with concomitant type 1 diabetes mellitus (DM) were significantly older. We also found significant relationships between autoimmune thyroid disease and HLA-DQ5, and the presence of headaches with HLA-DQ7. The prevalence of HLA types of DQ2, DQ8, DQ6, and DQ7 significantly varied among different Marsh groups. Patients who were positive for HLA-DQ8, were significantly older, taller, and weightier. No significant association was found between HLA types and any of the gastrointestinal symptoms, anti-tTG and compliance to gluten free diet. Moreover, there were no statistically significant differences detected between the presence of each individual EIM, the level of IgA anti-tTG, sex, and Marsh typing.

CONCLUSION

This study highlights the presence of EIM in CD and their associated factors. We show the potential role of HLA typing in some EIMs, which may shed light for future studies.

The Relationship between Body Composition and a Gluten Free Diet in Children with Celiac Disease

The primary and proven therapy, in cases of celiac disease (CD), is a rigorous gluten-free diet (GFD). However, there are reports of its negative effects in the form of nutritional deficiencies, obesity, and adverse changes in body composition. The study aimed to assess the impact of a GFD on the body composition of children with CD. In a case-controlled study (n = 41; mean age 10.81 y; SD = 3.96) children with CD, in various stages of treatment, underwent medical assessment. The control group consisted of healthy children and adolescents, strictly matched for gender and age in a 1:1 case-control manner. More than half of the examined children (n = 26) followed a GFD. CD children had significantly higher mean values of the fat free mass (FFM% = 80.68 vs. 76.66, p = 0.015), and total body water (TBW% = 65.22 vs. 60.47, p = 0.012), and lower mean values of the fat mass (FM% = 19.32 vs. 23.34, p = 0.015). Children who were on a GFD presented slightly higher, but not statistically significant, mean values of FM and FFM, than children who did not follow dietary recommendations (FM [kg] = 7.48 vs. 5.24, p = 0.064; FM% = 20.81 vs. 16.73, p = 0.087; FFM [kg] = 28.19 vs. 22.62, p = 0.110). After minimum one year of a GFD, CD children showed significantly higher values of FFM [kg] (p = 0.001), muscle mass (MM) [kg] (p < 0.001), TBW [L] (p < 0.001) and body cell mass (BCM) [kg] (p < 0.001). Furthermore, CD children who were on a GFD presented a significantly higher increase in weight (p = 0.034) and body mass index (BMI) (p = 0.021). The children adhering to a GFD demonstrate a tendency towards higher indices of selected body composition components.

Younger age at diagnosis predisposes to mucosal recovery in celiac disease on a gluten-free diet: A meta-analysis

Background and aims

Persistent intestinal damage is associated with higher complication rates in celiac disease. We aimed to assess the potential modifiers of mucosal recovery.

Materials and methods

We screened databases (PubMed, Embase, Cochrane Trials, and Web of Science) for papers on celiac disease. Papers discussing (1) celiac patients (2) follow-up biopsy and (3) mucosal recovery after commencement of a gluten-free diet were included. The primary outcome was to produce a comprehensive analysis of complete mucosal recovery (i.e., Marsh 0 on follow-up). We compared children’s recovery ratios to those of adults. Patients following a strict gluten-free dietary regimen were included in a subgroup. Summary point estimates, 95% confidence intervals (CIs), and 95% predictive intervals (PIs) were calculated. Heterogeneity was tested with I²-statistic. The PROSPERO registration number is CRD42016053482.

Results

The overall complete mucosal recovery ratio, calculated from 37 observational studies, was 0.36 (CI: 0.28–0.44, PI: -0.12–0.84; I²: 98.4%, p<0.01). Children showed higher complete mucosal recovery ratio than adults (p<0.01): 0.65 (CI: 0.44–0.85, PI: -0.10–1.39; I²: 96.5%, p<0.01) as opposed to 0.24 (CI: 0.15–0.33, PI: -0.19–1.08; I²: 96.3%, p<0.01). In the strict dietary adherence subgroup, complete mucosal recovery ratio was 0.47 (CI: 0.24–0.70, PI: -0.47–1.41; I²: 98.8%, p<0.001). On meta-regression, diagnostic villous atrophy (Marsh 3) ratio (-8.97, p<0.01) and male ratio (+6.04, p<0.01) proved to be a significant determinant of complete mucosal recovery, unlike duration of gluten-free diet (+0.01, p = 0.62). The correlation between complete mucosal recovery ratio and age on diagnosis is of borderline significance (-0.03, p = 0.05).

Conclusions

There is considerable heterogeneity across studies concerning complete mucosal recovery ratios achieved by a gluten-free diet in celiac disease. Several celiac patients fail to achieve complete mucosal recovery even if a strict dietary regimen is followed. Younger age on diagnosis, less severe initial histologic damage and male gender predispose for achieving mucosal recovery.

Managing the pediatric patient with celiac disease: a multidisciplinary approach

Celiac disease (CD) is an autoimmune reaction to gluten, leading to intestinal inflammation, villous atrophy, and malabsorption. It is the most common autoimmune gastrointestinal disorder, with an increasing prevalence. A life-long gluten-free diet (GFD) is an effective treatment to alleviate symptoms, normalize autoantibodies, and heal the intestinal mucosa in patients with CD. Poorly controlled CD poses a significant concern for ongoing malabsorption, growth restriction, and the long-term concern of intestinal lymphoma. Achieving GFD compliance and long-term disease control poses a challenge, with adolescents at particular risk for high rates of noncompliance. Attention has turned toward innovative management strategies to improve adherence and achieve better disease control. One such strategy is the development of multidisciplinary clinic approach, and CD is a complex life-long disease state that would benefit from a multifaceted team approach as recognized by multiple national and international bodies, including the National Institutes of Health. Utilizing the combined efforts of the pediatric gastroenterologist, registered dietitian, registered nurse, and primary care provider (general practitioner or general pediatrician) in a CD multidisciplinary clinic model will be of benefit for patients and families in optimizing diagnosis, provision of GFD teaching, and long-term adherence to a GFD. This paper discusses the benefits and proposed structure for multidisciplinary care in improving management of CD.

Transition from childhood to adulthood in coeliac disease: the Prague consensus report

The process of transition from childhood to adulthood is characterised by physical, mental and psychosocial development. Data on the transition and transfer of care in adolescents/young adults with coeliac disease (CD) are scarce. In this paper, 17 physicians from 10 countries (Sweden, Italy, the USA, Germany, Norway, the Netherlands, Australia, Britain, Israel and Denmark) and two representatives from patient organisations (Association of European Coeliac Societies and the US Celiac Disease Foundation) examined the literature on transition from childhood to adulthood in CD. Medline (Ovid) and EMBASE were searched between 1900 and September 2015. Evidence in retrieved reports was evaluated using the Grading of Recommendation Assessment, Development and Evaluation method. The current consensus report aims to help healthcare personnel manage CD in the adolescent and young adult and provide optimal care and transition into adult healthcare for patients with this disease. In adolescence, patients with CD should gradually assume exclusive responsibility for their care, although parental support is still important. Dietary adherence and consequences of non-adherence should be discussed during transition. In most adolescents and young adults, routine small intestinal biopsy is not needed to reconfirm a childhood diagnosis of CD based on European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) or North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) criteria, but a biopsy may be considered where paediatric diagnostic criteria have not been fulfilled, such as, in a patient without biopsy at diagnosis, additional serology (endomysium antibody) has not been performed to confirm 10-fold positivity of tissue transglutaminase antibodies or when a no biopsy strategy has been adopted in an asymptomatic child.

Coeliac disease and the gluten-free diet: a review of the burdens; factors associated with adherence and impact on health-related quality of life, with specific focus on adolescence

Adherence and non-adherence to a gluten-free diet (GFD) may impact negatively on health-related quality of life (HRQoL). Understanding the factors that influence compliance could help inform management and also guide support. With a particular focus on adolescence, this narrative review critiques current literature on the burdens associated with following a GFD and the factors associated with adherence. Studies highlight a variety of burdens faced by individuals with coeliac disease, including the cost, access and availability of gluten-free (GF) foods, as well as the dilemmas experienced when eating out, travelling and socialising with friends. A number of studies report that adolescents face stigmatisation and feel isolated in social situations and at school. Additional burdens that are highlighted are a lack of knowledge regarding CD and GFD difficulties in interpreting food labels, as well as dissatisfaction with the organoleptic properties of GF foods. Factors associated with poor adherence in adolescence include older age, an absence of immediate symptoms, difficulties eating out and poor palatability of GF foods. Conversely, better emotional support and stronger organisation skills have been associated with superior adherence. Significant associations have been reported between HRQoL measures and adherence, although the findings are inconsistent. Limitations in research methodologies exist and data are restricted to just a few countries. Further research specific to adolescence is required to identify independent predictors of adherence.

Avaliação nutricional e consumo alimentar de pacientes com doença celíaca com e sem transgressão alimentar

OBJETIVO: Avaliar o estado nutricional e a ingestão de energia e de macronutrientes de pacientes com diagnóstico de doença celíaca que transgrediam ou não a dieta isenta de glúten. MÉTODOS: Foram estudados 63 pacientes com doença celíaca: 34 crianças e 29 adolescentes. Transgressão à dieta isenta de glúten foi caracterizada por meio da dosagem sérica do anticorpo antitransglutaminase tissular recombiante humana. O estado nutricional foi avaliado com base nos escores-Z de peso/idade, estatura/idade e no índice de massa corporal. A ingestão alimentar foi avaliada por meio do inquérito alimentar de 24 horas. RESULTADOS: A transgressão à dieta sem glúten foi constatada em 41,2% das crianças e em 34,5% dos adolescentes. Nas crianças com transgressão alimentar, a média do escore-Z de estatura/idade foi inferior à das crianças do grupo que não transgredia (p=0,024). Todavia, o grupo com transgressão apresentou maior escore-Z do índice de massa corporal em relação aos que não transgrediam (p=0,021). Os adolescentes que não transgrediam apresentaram maior índice de massa corporal quando comparados aos que transgrediam a dieta (p=0,037). Em relação à ingestão alimentar, não se observou diferença estatística entre os grupos. Todavia, cerca de 70,0% das crianças e adolescentes apresentaram consumo de energia acima de 120,0% da recomendação. CONCLUSÃO: As crianças que transgrediam a dieta apresentaram menor escore-Z de estatura/idade e maior escore-Z para índice de massa corporal do que crianças que seguem sem transgressões alimentares. Os adolescentes que não transgrediam a dieta apresentaram maior média de índice de massa corporal quando comparados aos que transgrediam a dieta. Consumo energético elevado foi observado tanto nas crianças quanto nos adolescentes.

Celiac disease presentation in a tertiary referral centre in India: current scenario

BACKGROUND

Nondiarrheal celiac disease (NDCD) is being increasingly reported but data from India is limited.

AIM

We undertook this study to compare the clinical spectrum of NDCD with that of diarrheal/classical celiac disease (CCD).

METHOD

This facility-based retrospective observational study included consecutive patients diagnosed with celiac disease (CD) (as per modified ESPGHAN criteria) from October 2009 to August 2011.

RESULTS

A total of 381 patients were diagnosed with CD during the study period. NDCD was present in 192 (51.8 %). NDCD had higher mean age at presentation (5.8 ± 2.8 vs. 6.9 ± 2.9 years respectively; p = 0.003) and longer duration of symptoms prior to diagnosis (2.9 ± 1.7 years vs. 3.6 ± 2.2 years; p = 0.02) as compared to CCD. In the NDCD group, the most frequent gastrointestinal (GI) symptoms were recurrent abdominal pain [122 (63.5 %)] and abdominal distension [102 (53.1 %)] followed by constipation [48 (25 %)], vomiting [76 (39.6 %)] and recurrent oral ulcers [89 (46.4 %)]. Vomiting and constipation were more frequently seen in NDCD as compared to CCD (p < 0.001 in both). Commonly enumerated extraintestinal manifestations in NDCD included failure to thrive [109 (56.8 %)], isolated short stature [36 (18.8 %)], persistent anemia [83 (43.2 %)] and hepatomegaly/splenomegaly or both [56 (29.2 %)]. Associated comorbidities included autoimmune thyroiditis [11 (5.7 %)], type 1 diabetes mellitus [8 (4.2 %)], bronchial asthma [23 (11.9 %)], idiopathic pulmonary hemosiderosis [4 (2.1 %)], Down's syndrome [3 (1.6 %)], alopecia areata [6 (3.1 %)], polyarthritis [2 (1.0 %)], dermatitis herpetiformis [6 (3.1 %)] and chronic liver disease [6 (3.1 %)]. The number of patients with a Marsh score IIIb and above of duodenal biopsy was significantly more in the CCD group (p < 0.001).

CONCLUSIONS

NDCD is not uncommon in India. Long-term follow up is needed to evaluate the impact of the disease and of treatment in these children.

Recent advances in the development of new treatments for celiac disease

INTRODUCTION

Celiac disease is a common autoimmune condition induced by dietary gluten in genetically susceptible individuals. So far, the only available treatment for the disorder is a lifelong strict gluten-free diet, because of which small intestinal histological changes recover and symptoms disappear. However, gluten-free dieting is restrictive, and nutritionally less than optimal, and gluten is difficult to avoid.

AREAS COVERED

With improving insight into the pathogenesis of celiac disease, several possible drug targets have been suggested. The new strategies include degradation of gluten intraluminally, reduction of mucosal permeability, inhibition of the transglutaminase 2 enzyme, blocking antigen presentation by HLA-DQ2 or HLA-DQ8, modulation of the immune responses of many cytokines, and vaccination.

EXPERT OPINION

Non-dietary treatment options are warranted either as adjunctive therapy together with dieting or to replace the gluten-free diet. The key question is whether the envisaged novel drug is able to prevent gluten-induced small intestinal mucosal injury as efficiently as a strict gluten-free diet, alleviating symptoms and signs of the disease. Furthermore, the gluten dose that can be detoxified, if at all, must be established. The new drug should also be as safe as dietary treatment. Several novel treatment options are under development.

Small- bowel mucosal changes and antibody responses after low- and moderate-dose gluten challenge in celiac disease

BACKGROUND

Due to the restrictive nature of a gluten-free diet, celiac patients are looking for alternative therapies. While drug-development programs include gluten challenges, knowledge regarding the duration of gluten challenge and gluten dosage is insufficient.We challenged adult celiac patients with gluten with a view to assessing the amount needed to cause some small-bowel mucosal deterioration.

METHODS

Twenty-five celiac disease adults were challenged with low (1-3 g) or moderate (3-5g) doses of gluten daily for 12 weeks. Symptoms, small-bowel morphology, densities of CD3+ intraepithelial lymphocytes (IELs) and celiac serology were determined.

RESULTS

Both moderate and low amounts of gluten induced small-bowel morphological damage in 67% of celiac patients. Moderate gluten doses also triggered mucosal inflammation and more gastrointestinal symptoms leading to premature withdrawals in seven cases. In 22% of those who developed significant small- intestinal damage, symptoms remained absent. Celiac antibodies seroconverted in 43% of the patients.

CONCLUSIONS

Low amounts of gluten can also cause significant mucosal deterioration in the majority of the patients. As there are always some celiac disease patients who will not respond within these conditions, sample sizes must be sufficiently large to attain to statistical power in analysis.

[Gluten-free diet for children]

Children with celiac disease do not share the same risks as adults, and should have an adapted diet and a prolonged follow-up until adulthood. The following indications seem reasonable: in symptomatic children and adults, gluten free diet during several years in children and for the entire life in adults; in children becoming "silent", without any clinical or biological signs of malnutrition, discussion of coming back to normal diet, under the condition a strict follow-up and restarting gluten free diet at age of 25 and/or in case of pregnancy, to prevent the complications of celiac disease in adulthood; prolonged follow-up for adolescents and young adults returned to a "latent" disease.

New and developing therapies for celiac disease

The treatment for celiac disease, a removal of gluten in the diet, is safe and effective for the vast majority of patients. There is a large body of evidence that the diagnosis and treatment of those with celiac disease ensures considerable health benefits. Although a gluten-free diet is the principal treatment for celiac disease, it is relatively expensive, inconvenient and difficult to adhere to. For these reasons, there is interest in developing alternative therapies. Emerging research for the treatment of celiac disease has focused on three areas: to decrease gluten exposure, to modify intestinal permeability and to modulate immune activation. Therapies developed thus far consist of enzymes designed to digest gluten and the use of inhibitors of paracellular permeability to decrease the migration of gluten peptides into the lamina propria. Other potential therapeutic maneuvers include the binding of gluten by polymers, the use of tissue transglutaminase (TTG) inhibitors and DQ2 or DQ8 blockers, or modulation of cytokine production. While all represent new and exciting therapies, an ideal therapy should have virtually no side effects similar to a gluten-free diet. A pharmaceutical agent may be used on an intermittent basis, such as following occasional gluten exposure or on a chronic basis to mitigate the effects of potential inadvertent ingestion of gluten.

Celiac disease in children and adolescents at a singe center in Saudi Arabia

BACKGROUND AND OBJECTIVES

Celiac disease (CD) is an immune-mediated enteropathy, induced by gluten in genetically susceptible individuals. The objective of this study was to describe the clinical pattern of CD in children from the western region of Saudi Arabia.

DESIGN AND SETTING

Retrospective, hospital-based.

PATIENTS AND METHODS

This study included children with a biopsy-proven diagnosis of CD made between September 2002 and July 2007. Children were admitted to the endoscopy unit for a small-bowel biopsy if they had gastrointestinal symptoms suggestive of CD or if they were positive for a CD-antibody screen performed for the high-risk groups.

RESULTS

Eighty children were identified with a diagnosis of CD. Their mean (SD) age was 9.6 (4.9) years (range, 0.5-18 years). There were 44 (55%) female patients. Forty-one (51%) patients were detected during screening of high-risk groups, while 39 (49%) patients had classical symptoms of malabsorption. The screening also detected asymptomatic patients. Of 65 patients tested, 11 (17%) had elevated liver function tests, which reverted to normal after introduction of a gluten-free diet (GFD) except in one case. Seventy-three (91%) patients were positive for anti-tissue transglutaminase antibodies, 18 (23%), for IgG anti-gliadin antibodies; and 46 (58%), for IgA anti-gliadin antibodies. Forty-one (56%) patients showed good adherence to GFD as assessed by dietary history and the decline in anti-tTG level.

CONCLUSION

CD may present with classical symptoms or be identified through screening programs. Growth and laboratory abnormalities usually improve after introduction of a GFD. Adherence to a GFD remains a problem; therefore, thorough assessment and counseling at the time of diagnosis and ongoing care are crucial.

Five year time course of celiac disease serology during gluten free diet: results of a community based "CD-Watch" program

BACKGROUND

Little information is available on the effect of a follow-up strategy in celiac disease patients during gluten-free diet.

AIMS

To assess 5 year time course of t-transglutaminase antibodies (t-TG) in celiac disease patients enrolled in a community based follow-up program.

METHODS

Annual t-TG testing and periodical clinic visit in 2245 patients.

RESULTS

Proportion of patients with negative t-TG progressively increased from 83% to 93% during the 5-year follow-up: poor adherence to gluten-free diet (HR 4.764), long duration of gluten-free diet (HR 0.929) and female gender (HR 1.472) were independently associated with serological outcome. In individual patients, 69% tested t-TG "persistently negative", 1% "persistently positive" and 30% "intermittently negative or positive". By applying mathematical modelling to t-TG conversion rates observed in this latter group at beginning and end of the follow-up program, the predicted proportion of t-TG negative population increased from 90% to 95% over 5 years.

CONCLUSIONS

Time-course of t-TG serology in the community fluctuates in 1/3 of celiac disease patients suggesting inconstant adherence to gluten-free diet and need of follow-up strategy. Periodical serological and clinical follow-up is a viable and efficacious strategy to promote adherence to gluten-free diet as inferred from time-course of t-TG serology.

Celiac disease: predictors of compliance with a gluten-free diet in adolescents and young adults

AIMS

To identify risk as well as protective factors related to compliance with the gluten-free diet in a cohort of teenagers with celiac disease (CD).

PATIENTS AND METHODS

Two hundred four patients with CD (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition criteria) older than or equal to 13 years and residents of Campania (southern Italy) were enrolled in the study. Patients underwent clinical examination and blood sampling, and were interviewed about school performance, social relationships, family integration, smoking habit, and compliance with a gluten-free diet. Anti-tissue transglutaminase antibodies were assayed with an enzyme-linked immunosorbent assay.

RESULTS

One hundred fifty of 204 (73.5%) reported no dietary transgressions, and 54 of 204 (26.5%) reported occasional or frequent transgressions. During the previous month 29 of 54 (53.7%) poor compliers ate from 0.001 to 1 g of gluten per day, 14 (25.9%) from 1 to 5 g, and 11 (20.4%) more than 5 g. The daily intake of gluten was significantly related to anti-tissue transglutaminase antibodies (chi2 = 38.872, P = 0.000). Height was below the third percentile in 19 of 204 (9.3%), and weight was above the 97th percentile in 20 of 204 (9.8%). Diet compliance did not seem to influence the weight and height. One hundred eleven of 150 good compliers (74%) and 31 of 54 (57.4%) poor compliers were asymptomatic. Most patients reported good family relationships (88.7%), social relationships (91.2%), and school integration (88.2%). Alternatively, 54% of patients reported some limitation in their social life. Compliance was good in patients who reported excellent school integration (83%) and social relationships (81%).

CONCLUSION

Optimal school integration significantly contributes to the likelihood of good compliance. A better understanding within the school environment about CD-related issues could improve motivation to adhere to a gluten-free diet.

The changing face of childhood celiac disease in north america: impact of serological testing

OBJECTIVE

The goal was to evaluate the impact of immunoglobulin A endomysial antibody testing on the incidence and clinical presentation of childhood celiac disease.

METHODS

The incidence and clinical presentation of celiac disease in patients <18 years of age in 1990-1996 (pretesting group) versus 2000-2006 (testing group) were compared.

RESULTS

The median age at diagnosis was 2 years (95% confidence interval: 2-4 years) in the pretesting group (N = 36), compared with 9 years (95% confidence interval: 8-10 years) in the testing group (N = 199; P < .001); the female/male ratios (1.6:1) were similar (P = .982). The incidence of celiac disease increased from 2.0 cases per 100000 children (pretesting group) to 7.3 cases per 100000 children (testing group; P = .0256). The frequency of classic celiac disease presentations decreased from 67% (pretesting group) to 19% (testing group; P < .001), but the incidence of classic celiac disease did not differ (0.8 vs 1.6 cases per 100000; P = .154). In the testing group, 13 previously unrecognized clinical presentations were observed in 98 children, including 35 with family history, 18 with abdominal pain, and 14 with type 1 diabetes mellitus. The frequency of Marsh IIIc lesions decreased from 64% (pretesting group) to 44% (testing group; P = .0403). In the testing group, classic celiac disease remained predominant (67%) in young children (<3 years), whereas atypical gastrointestinal and silent presentations predominated in older children.

CONCLUSIONS

Antibody testing for celiac disease tripled the incidence of celiac disease and quadrupled the median age at diagnosis.

Coeliac disease

Coeliac disease is a chronic inflammatory disorder of the small bowel induced in genetically susceptible people by the irritant gluten and possibly other environmental cofactors. The disorder is characterised by a diverse clinical heterogeneity that ranges from asymptomatic to severely symptomatic, and it manifests with frank malabsorption, an increased morbidity attributable to the frequent association with autoimmune disorders and increased mortality resulting from the emergence of T-cell clonal proliferations that predispose the patient to enteropathy-type T-cell lymphoma. Our understanding of the molecular basis for this disorder has improved and enabled the identification of targets for new therapies, although a strict gluten-free diet remains the mainstay of safe and effective treatment. In this Seminar we critically reassess the clinical and diagnostic aspects of this disease and new perspectives in its pathogenesis and treatment.

Psychological correlates of gluten-free diet adherence in adults with celiac disease

GOALS

To determine whether personality traits and psychological characteristics are related to gluten-free diet (GFD) adherence in an adult population diagnosed with celiac disease (CD).

BACKGROUND

Little research has examined psychological correlates of adherence to the GFD.

STUDY

One hundred fifty-seven adults with biopsy-confirmed CD on the GFD for >3 months completed measures of personality and self-reported GFD adherence, provided a blood sample, and participated in an evaluation of GFD adherence conducted by an expert dietician at a clinical care center in a major teaching hospital in Boston, MA.

RESULTS

An expert evaluation of GFD adherence remained the "gold standard" for measuring GFD adherence when compared with self-report and serology. Logistic regression results indicated that the following were independently associated with GFD adherence: conscientiousness (B=-0.04, SE=0.01, P<0.00), values (B=-0.10, SE=0.05, P<0.05), other food intolerances [odds ratio=0.28, 95% confidence interval=0.10-0.78], and CD symptoms (B=0.05, SE=0.02, P<0.03). A model accounting for these associations effectively predicted whether a participant was adherent or nonadherent on the basis of psychological and demographic/disease-specific factors. Successful prediction rates of GFD adherence for the final model were 75.8% for those rated to be adherent with the GFD and 54.5% for those rated to be nonadherent with the GFD.

CONCLUSIONS

The model of psychological and demographic/disease-specific characteristics developed can be used to identify patients who may be at risk for poor dietary adherence to provide additional support, education, and encouragement to individuals with CD.

Treatment regimen adherence in pediatric gastroenterology

OBJECTIVE

To review and critically evaluate the extant research pertaining to adherence in pediatric gastroenterological diseases, particularly inflammatory bowel disease and celiac disease, and to provide recommendations for future research development.

MATERIALS AND METHODS

A literature search with no date restriction was conducted using PubMed and PsychInfo electronic databases and bibliographies of relevant articles.

RESULTS

Adherence rates in inflammatory bowel disease and celiac disease range considerably from 16% to 62% and 5% to 70%, respectively, across treatments and assessment method; nonadherence frequency was generally not reported. Measures used to assess adherence included self-report, interview, diet record, and bioassay methods, and each measure demonstrated strengths and limitations. Limited evidence suggests that adherence in both disease populations is related to patient and family behavioral factors and that nonadherence is related to poor disease outcome. Treatment outcome research for nonadherence is scant in the current literature.

CONCLUSIONS

Future research should focus on refining assessment method, examining adherence and concomitant behavioral factors longitudinally, testing theoretical models of adherence, and developing efficacious treatments for nonadherence.

Compliance with gluten-free diet in children with coeliac disease

OBJECTIVES

Coeliac disease (CD) is a lifelong disorder with gluten-induced manifestations in different organs. Gluten-free diet (GFD) is required to achieve remission and prevent complications; however, study reports on GFD growth effect are not consistent.

METHODS

Compliance with GFD was estimated according to current body mass and height; presence of anaemia and other signs and symptoms; and attitude toward GFD.

RESULTS

Seventy-one patients with CD (mean age = 12 years; mean age after CD diagnosis = 9 years) were examined and their blood sampled for determination of endomysial antibodies (EMA), haemoglobin, and red blood cell count. Questionnaire analysis revealed 42 (59.1%; 4 EMA positive) patients to be on strict GFD, 19 (26.8%; 5 EMA positive) were taking small amounts of gluten, and 10 (14.1%; all EMA positive) were not on a diet at all. The patients on strict GFD had greatest body height, yet the difference was not significant. These patients also had a higher mean body mass (P = 0.05) and significantly higher mean haemoglobin and mean cell haemoglobin levels (P = 0.05 and P < 0.05, respectively). Apart from chronic fatigue in patients on partial diet (P = 0.05), patient groups did not differ significantly in the frequency of symptoms. Anaemia and delayed puberty were recorded only in noncompliers (P < 0.01 and P < 0.05, respectively). Noncompliers often found the specific diet to pose a major life burden (P < 0.01) and did not visit a gastroenterologist on a regular basis (P < 0.01).

CONCLUSIONS

Almost half of the coeliac patients were likely to abandon GFD without experiencing major symptoms, thus increasing the risk for developing complications later in life. An active attitude is required in the follow-up of patients with CD.

Is adult height of patients with celiac disease influenced by delayed diagnosis?

OBJECTIVES

Short stature is one of the presenting symptoms of celiac disease (CD), and growth acceleration can be achieved with gluten-free diet (GFD). However, the data regarding final adult height of CD patients are scarce and inconclusive. Our aim was to evaluate the adult height of CD patients in relation to the age at diagnosis: < or =18 yr or >18 yr.

METHODS

Questionnaires were sent to CD patients > or =18 yr of age, who were either members of the Israeli Celiac Association or patients followed by the pediatric gastroenterology unit, including questions about height, weight, gender, age at diagnosis, and GFD adherence. The height Z scores were calculated for each patient.

RESULTS

In total, 290 patients (M/F = 83/207), age 38.9 +/- 15.5 yr (range 18-76), were included: 113 were diagnosed before and 177 after 18 yr of age (groups 1 and 2, respectively). The mean adult height was: 178.4 +/- 6.6 cm and 176.2 +/- 8.6 cm for men (P= 0.22), and 163.0 +/- 6.6 cm and 162.6 +/- 6.5 cm for women (P= 0.68) in groups 1 and 2, respectively. The height Z scores were 0.230 +/- 0.931 and -0.07 +/- 1.19 for men (P= 0.22), and -0.05 +/- 1.02 and -0.101 +/- 0.990 for women (P= 0.68) in groups 1 and 2, respectively. The final height inversely correlated with age at diagnosis in men (R =-0.275, P= 0.012) but not in women (R =-1.0, P= not significant [NS]).

CONCLUSIONS

The final height of patients with CD is similar to the general population. The adult height of male patients with CD is inversely related to the age at diagnosis. Delayed diagnosis of CD may lead to a shorter adult height in men but not in women.

Factors that influence adherence to a gluten-free diet in adults with celiac disease

OBJECTIVE

The only treatment for celiac disease is lifelong adherence to a gluten-free diet, yet adherence is limited and factors influencing adherence are poorly understood. The purpose of this study was to determine factors influencing gluten-free diet adherence in adults with celiac disease.

METHODS

A questionnaire was developed and administered to 154 adults with celiac disease who then underwent a standardized gluten-free diet evaluation by an experienced nutritionist. Multivariate analysis was conducted to determine factors associated with adherence level.

RESULTS

Thirteen factors hypothesized to contribute to gluten-free diet adherence were found to be significantly associated with improved adherence including: understanding of the gluten-free diet, membership of a celiac disease advocacy group, and perceived ability to maintain adherence despite travel or changes in mood or stress (P < 0.001).

CONCLUSIONS

This study identified specific factors correlated with gluten-free diet adherence. These results provide a foundation for the design of educational interventions to improve adherence.

Economic burden of a gluten-free diet

BACKGROUND

Coeliac disease is a common, autoimmune disorder, for which the only treatment is lifelong adherence to a gluten-free diet. This study evaluates the economic burden of adhering to a gluten-free diet.

METHODS

A market basket of products identified by name brand, weight or package size for both regular wheat-based products and gluten-free counterparts was developed. The differences in price between purchase venues, both type of store (general grocery store, an upscale grocery store and a health food store and four internet-based grocery sites) and region was also analysed.

RESULTS

Availability of gluten-free products varied between the different venues, regular grocery stores carried 36%, while upscale markets carried 41%, and health food stores 94%, compared with 100% availability on the internet. Overall, every gluten-free product was more expensive than their wheat-based counterpart (P <or= 0.05). Bread and pasta was twice as expensive as their wheat-based counterparts. Cost was affected more by shopping venue than geographic location.

CONCLUSIONS

This study demonstrated that gluten-free foods have poor availability and are more expensive than their gluten-containing counterparts. The impact of these findings on dietary compliance and the quality of life needs to be addressed.

Long-term follow-up of 61 coeliac patients diagnosed in childhood: evolution toward latency is possible on a normal diet

BACKGROUND/AIMS

Whether a life-long gluten-free diet (GFD) is necessary in all children with diagnosed coeliac disease (CD) remains debated. To address this question, a retrospective analysis of the clinical and biological status of adult coeliac patients diagnosed in childhood, who remained on a normal diet after gluten challenge and were clinically silent, was carried out.

METHODS

Patients aged 18-65 years with CD diagnosed in childhood were included. Clinical status, gluten intake, biological parameters of malabsorption, bone mineral density, human leucocyte antigen (HLA) genotype, serological markers of CD, and histological and immunohistochemical parameters in duodenal biopsies were recorded.

RESULTS

Sixty-one patients had resumed a normal diet and were asymptomatic. Forty-eight showed different degrees of villous atrophy (silent CD), while 13 had no detectable atrophy (latent CD) on duodenal biopsies. Latent CD patients had significantly less osteopenia/osteoporosis (1/9 (11%) vs 23/33 (70%), p<0.001)), and lower T cell receptor (TCR) alphabeta+ intraepithelial T cell counts (38+/-20 vs 55+/-15, p<0.01) than silent CD patients. The mean age at diagnosis and first GFD was lower in latent than in silent patients (14.4+/-5 vs 40.1+/-47 months, p<0.05). Latent patients did not differ significantly from the seven control patients on a long-term GFD, except for a higher frequency of CD-specific serum antibodies. However, two latent patients relapsed clinically and histologically during subsequent follow-up.

CONCLUSIONS

Long-term latency developed in about 20% of CD patients who remained symptom free after gluten reintroduction. This latency can be transient and thus a regular follow-up is mandatory. In silent patients, the increased risk of osteoporosis substantiates the need for a GFD.

Intestinal malabsorption in the elderly

BACKGROUND

Intestinal malabsorption in the elderly is infrequent, and clinical features are muted so that the diagnosis is often missed. Physiologic changes with aging are restricted to altered absorption of calcium and perhaps zinc and magnesium; however, achlorhydria can lead to impaired absorption of vitamin B(12), folic acid, and calcium.

METHODS AND RESULTS

Small bowel bacterial overgrowth occurs more commonly in elderly than in younger patients, accompanying gastric hypochlorhydria, altered intestinal motor activity, or diseases such as Parkinson's disease. Changes in pancreatic anatomy and secretion occur but are insufficient to produce macronutrient malabsorption. In addition to pancreatic cancer and pancreatic stones, older patients may present with severe pancreatic insufficiency of unknown etiology. Celiac disease is recognized as very common at all ages and may not become evident until late in life. Manifestations of celiac disease in the elderly are occult and the diagnosis often is not considered until serologic tests are performed and confirmed by upper small intestinal biopsy. Associated intestinal lymphoma, esophageal carcinoma, intestinal pseudo-obstruction, and splenic atrophy may be more common in the elderly. Treatment of older patients with celiac disease with a gluten-free diet may be difficult, and intensive vitamin and micronutrient replacement is mandatory. A pragmatic approach to the evaluation of malabsorption in elderly patients is discussed.

Growth hormone impaired secretion and antipituitary antibodies in patients with coeliac disease and poor catch-up growth after a long gluten-free diet period: a causal association?

INTRODUCTION

Coeliac disease (CD) is usually associated with impaired growth in children. A gluten-free diet (GFD) induces a catch-up growth with the recovery of height in about 2 years. AIM AND DISCUSSION: The lack of the height improvement has been related to growth hormone (GH) secretion impairment. CD is an autoimmune disease often associated with other endocrine and non-endocrine autoimmune disease. The aim of this study was to evaluate antipituitary autoantibodies (APA) and antihypothalamus autoantibodies in CD children with poor clinical response to a GFD and growth hormone deficiency (GHD). We diagnosed CD on the basis of specific antibodies and endoscopic biopsies in 130 patients aged 1-15 years. Seven CD children, without catch-up growth after at least 12-months GFD, were tested for GH secretion and, in five out of seven patients, the diagnosis of GHD was made in the absence of metabolic and systemic diseases.

RESULTS

APA and antihypothalamus antibodies were detected by the indirect immunofluorescence method in the seven CD children without catch-up growth factor and in 25 CD children without growth impairment matched for sex and age, and in 58 healthy children as control groups. APA resulted positive at high titres in four out of five CD-GHD patients and were also positive at low titres (<1:8) in three of only CD children and in two out of 58 controls. Hypothalamic-pituitary magnetic resonance imaging (MRI) was normal in all patients except in one with cystic pineal. APA have been previously detected not only in adults with GHD, but also in idiopathic GHD children, suggesting the occurrence of an autoimmune hypophysitis in these patients.

CONCLUSION

In our study, the presence of APA in CD children without catch-up growth after GFD seems to be able to identify an autoimmune form of hypophysitis involving the somatotrophs cells.

Change in lipid profile in celiac disease: beneficial effect of gluten-free diet

PURPOSE

Celiac disease is associated with hypocholesterolemia, which is thought to contribute to a favorable cardiovascular risk profile. This led to suggestions that the diagnosis of celiac disease and its treatment with a gluten-free diet may result in elevation of the serum cholesterol level and worsen this risk profile. However, no study proves this in adults. We therefore examined the effect of a gluten-free diet on the lipid profile in patients with celiac disease.

SUBJECTS AND METHODS

We identified 132 patients with celiac disease who adhered to a gluten-free diet and had lipid profiles performed before and after a median of 20.5 months on the diet. The patients lacked diseases that may affect serum lipids.

RESULTS

There were significant increases in total cholesterol and high-density lipoprotein (HDL) cholesterol (P < .0001) but not low-density lipoprotein (LDL) cholesterol (P=.06). The LDL/HDL ratio decreased by 0.36+/-0.7 (P < .0001). Both men and women had a significant increase in total cholesterol and HDL and a significant decrease in the LDL/HDL ratio. Only men had increases in LDL (P=.02). The greatest increase in lipid values was seen in those with the lowest initial values. The largest increase in HDL was seen in subjects with more severe disease as indicated by low albumin level and presence of total villous atrophy.

CONCLUSIONS

Diagnosis of celiac disease and its treatment with a gluten-free diet resulted in improvement in the lipoprotein profile, which included an increase in HDL and a decrease in the LDL/HDL ratio.

Nutritional management of the gluten-free diet in young people with celiac disease in The Netherlands

BACKGROUND

For young people with celiac disease, adherence to the gluten-free diet may be difficult to achieve and gluten restriction may lead to insufficient nutrient intake and unbalanced food intake resulting in overweight. In The Netherlands, no nutritional information is available. Therefore, we evaluated the nutritional management and nutritional state in young celiac patients.

METHODS

The Dutch Celiac Society invited all its members aged 12 to 25 years to complete a food record and a questionnaire. Nutrient intakes were compared with the recommendations and the intake in the general population. Total immunoglobin A, endomysial antibody, tissue transglutaminase and IgA gliadin were determined, and height and weight were assessed.

RESULTS

Strict dietary compliance was reported by 75%. The fiber and iron intakes were significantly lower, and the saturated fat intake significantly higher than recommended but comparable with the general population. Most of the patients (61%) found the diet easy to follow. Regular medical controls were reported by 86% but regular dietary controls by only 7% of the patients. Mean and SD scores for height and body mass index were -0.3 +/- 1.1 and -0.3 +/- 0.8, respectively.

CONCLUSIONS

The dietary compliance in this group is high, the nutritional state is adequate, but the nutrient intake is not. Better medical and dietary support is necessary to prevent long-term complications and to achieve an ongoing satisfying management in this group of young patients with a chronic disorder.

Celiac disease in African-Americans

Celiac disease is generally under diagnosed in the United States and it is unclear whether the disease is encountered in ethnic minorities. Our purpose is to describe a case series of African-American patients with celiac disease. Nine (1.3%) African-American patients with celiac disease were identified from a prospectively generated database of 700 patients with biopsy proven celiac disease and seen between 1981 and 2004. Females predominated, with seven, compared to two males. Diarrhea was the presentation in only two patients, while three presented with iron deficiency anemia. One third had at least one autoimmune disease. Compliance with a gluten-free diet, the only medical therapy of this disease, was poor. Only four patients adhered strictly to the diet. Celiac disease occurs in African-Americans and may well be underdiagnosed. Special attention needs to be given to methods that encourage adherence to the diet in minority groups.

Outcome of infants with celiac disease

AIMS

Determine the proportion of infants whose celiac disease (CD) was confirmed in childhood and evaluate their prognosis in adulthood.

PATIENTS AND METHODS

The diagnosis of CD was established between 1971 and 1982 in 84 infants based on intestinal biopsy data; a gluten-free diet was prescribed and the cohort followed prospectively.

RESULTS

Thirty-six infants were followed less than 5 years. A second biopsy was performed in 25. Mucosa had healed in 13 and remained atrophic in 12. Three children developed partial villous atrophy between 6 and 12 years of age in spite of the gluten-free diet. Forty-five patients underwent a gluten challenge between 5 and 10 years of age: in 41 histological lesions relapsed, in two mucosa remained normal and clinical and immunological relapse developed in two. Among those 45 patients, 18 were examined after 18 years follow-up: the exclusion diet was resumed in four, overt clinical relapse developed in four and four experienced intermittent gastrointestinal disorders. All biopsies performed during a period of normal diet showed villous atrophy (except in one patient) without correlation with clinical symptoms.

CONCLUSION

The diagnosis of celiac disease in infants was confirmed in nearly all cases in childhood. When they reached adulthood, these patients had few symptoms but their histological lesions persisted. These data are in favor of a lifelong exclusion diet.

Review article: safe amounts of gluten for patients with wheat allergy or coeliac disease

For both wheat allergy and coeliac disease the dietary avoidance of wheat and other gluten-containing cereals is the only effective treatment. Estimation of the maximum tolerated amount of gluten for susceptible individuals would support effective management of their disease. Literature was reviewed to evaluate whether an upper limit for gluten content in food, which would be safe for sufferers from both diseases, could be identified. When setting gluten limits for coeliac disease sufferers, the overall potential daily intake should be considered, while for wheat allergy limits should be based on single servings. For coeliac disease sufferers this limit should lie between 10 and 100 mg daily intake. For wheat allergy, lowest eliciting doses for children lie in the lower milligram range, while for adults they are most significantly higher. Gliadins (part of the gluten proteins) not only trigger coeliac disease, but are also major allergens in wheat allergy. Therefore, measurement of gliadins with validated enzyme-linked immunosorbent assay methods provides an appropriate marker for assessing gluten and/or wheat protein contents in food. Available data suggest that a maximum gluten content for 'gluten-free' foods could be set, which protects both wheat allergy sufferers and coeliac patients.

Celiac disease: evaluation of the diagnosis and dietary compliance in Canadian children

OBJECTIVES

We sought to characterize the clinical features at presentation as well as the associated disorders, family history, and evaluation of compliance with a gluten-free diet in children with celiac disease from across Canada.

STUDY DESIGN

All members (n = 5240) of the Canadian Celiac Association were surveyed with a questionnaire. Of the 2849 respondents with biopsy-confirmed celiac disease, 168 who were < 16 years old provided the data reported here.

RESULTS

The mean age when surveyed was 9.1 +/- 4.1 years, and 58% were female. Median age at diagnosis was 3.0 years with a range of 1 to 15 years. Presenting symptoms included abdominal pain (90%), weight loss (71%), diarrhea (65%), weakness (64%), nausea/vomiting (53%), anemia (40%), mood swings (37%), and constipation (30%). Almost one third of families consulted > or = 2 pediatricians before confirmation of the diagnosis. Before the recognition of celiac disease, other diagnoses received by these children included anemia (15%), irritable bowel syndrome (11%), gastroesophageal reflux (8%), stress (8%), and peptic ulcer disease (4%). A serological test was performed to screen for celiac disease in 70% of those in this population. Eight percent had either type 1 diabetes mellitus or a first-degree relative with celiac disease. Almost all respondents (95%) reported strict adherence to a gluten-free diet, and 89% noted improved health. Reactions after accidental gluten ingestion developed in 54% of the children between 0.5 and 60 hours after ingestion with a median of 2.0 hours. Reactions included abdominal discomfort (87%), diarrhea (64%), bloating (57%), fatigue (37%), headache (24%), and constipation (8%), and most displayed > 1 symptom. Although most adjusted well to their disease and diet, 10% to 20% reported major disruptions in lifestyle. Twenty-three percent felt angry all or most of the time about following a gluten-free diet. Only 15% avoided traveling all or most of the time, and during travel, 83% brought gluten-free food with them all of the time. More than half of the families avoided restaurants all or most of the time. Twenty-eight percent of the respondents found it extremely difficult to locate stores with gluten-free foods, and 27% reported extreme difficulty in finding gluten-free foods or determining if foods were free of gluten. Sixty-three percent of the respondents felt that the information supplied by the Canadian Celiac Association was excellent. Gastroenterologists provided excellent information to 44%, dietitians to 36%, and the family physician to 11.5%. When asked to select 2 items that would improve their quality of life, better labeling of gluten-containing ingredients was selected by 63%, more gluten-free foods in the supermarket by 49%, gluten-free choices on restaurant menus by 49%, earlier diagnosis of celiac disease by 34%, and better dietary counseling by 7%.

CONCLUSIONS

In Canada, children with celiac disease present at all ages with a variety of symptoms and associated conditions. Delays in diagnosis are common. Most children are compliant with a gluten-free diet. A minority of these children experience difficulties in modifying their lifestyles, and gluten-free foods remain difficult to obtain.

Follow-up of patients with celiac disease: achieving compliance with treatment

Celiac disease is the only autoimmune condition for which we know the environmental trigger: gluten. Complete removal of gluten from the diet in a patient with celiac disease should result in symptomatic, serologic, and histologic remission. However, compliance with the gluten-free diet, especially in the United States, is extremely challenging. Compliance can be measured both noninvasively, by dietary history and measurement of serum antibodies, and invasively, by using endoscopic and histologic criteria. The advantages and disadvantages of these various modalities are discussed. The highest rates of compliance are reported in patients who are diagnosed as young children, whereas adolescents and those diagnosed via mass serologic screening have the most transgressions. Barriers to compliance include the poor palatability of gluten-free foods, confusing food-labeling practices, and common comorbid psychologic burdens such as anxiety and depression. Because celiac disease is a multisystemic disorder, physicians need to be aware of the potential autoimmune, nutritional, and malignant complications. An algorithm for the follow-up and management of the newly diagnosed celiac disease patient is presented, which includes regular follow-up; measurement of serum antibodies; eliciting a detailed dietary history; and examination for signs and symptoms of nutritional deficiencies, malignancy, and other autoimmune diseases. Ideally, a team approach to the follow-up of the newly diagnosed patient should include regular supervision by an interested physician, medical nutritional counseling by a registered dietician, and access to local and national support groups knowledgeable about this condition.

Should adults be screened for celiac disease? What are the benefits and harms of screening?

The symptoms of celiac disease are diverse, and the disease is often asymptomatic. Without active serologic screening, most cases probably remain undiagnosed. Recent serologic screening assays allow mass screening for the disease. However, there is no evidence as yet to suggest that symptom-free celiac disease patients run an increased risk of small intestinal lymphoma or other complications. The prevention of osteoporosis seems to be the strongest indicator for widespread screening today. Screening asymptomatic individuals for celiac disease may be even harmful. A lifelong gluten-free diet is not easy to maintain, and the subject's quality of life may deteriorate. It is also debatable whether patients found by active screening adhere to a gluten-free diet similarly to symptomatic ones. The cost-effectiveness of population screening is dubious. Serologic screening should be applied in individuals with even subtle symptoms indicative of celiac disease, such as subclinical-isolated iron deficiency. In various autoimmune conditions, the risk of celiac disease is approximately 5% and, in individuals with affected first-degree relatives, 15%. Infertility, neurologic symptoms such as polyneuropathy, ataxia, epilepsy with posterior cerebral calcification, and osteoporosis are conditions in which celiac disease should be kept in mind. Elevated aminotransferases and liver failure can lead to a diagnosis of celiac disease. Evidence today does not support mass screening of celiac disease. Instead, increased alertness should be observed in patients at risk of the condition.

Practical considerations for the identification and follow-up of children with celiac disease

Celiac disease is an immune-mediated enteropathy affecting 0.5% to 1% of children and is induced by dietary gluten in susceptible individuals carrying the human leukocyte antigen DQ2 or DQ8 heterodimer. If serological screening is positive or if a patient displays suggestive symptoms, an endoscopic biopsy of the distal duodenum is required to confirm the diagnosis. Symptoms of celiac disease are often mild or absent. Overt malabsorption occurs in only 2% to 10% of children. Individuals with a higher risk of developing celiac disease, including first-degree relatives of affected patients and children with type I diabetes, Turner syndrome, Williams syndrome or Down syndrome, should be offered screening for celiac disease along with a discussion of the implications. If serological testing is negative, a high index of suspicion should remain if malabsorption, iron deficiency or osteopenia is present. Also, immunoglobulin A deficiency should be excluded. At-risk individuals should undergo serial serological screening. Lifelong adherence to a gluten-free diet is the only treatment. If left untreated, symptomatic children with celiac disease carry an increased risk of developing osteoporosis and have a greater lifetime risk of cancer. The long-term outcome of undiagnosed or untreated asymptomatic individuals is less clear.

Effect of gluten-free diet and adherence on growth and diabetic control in diabetics with coeliac disease

AIMS

To study the effect of gluten-free diet on growth and diabetic control of children with type 1 diabetes mellitus and coeliac disease.

METHODS

Twenty one children (mean age 7.5 years, range 1.6-12.9) with type 1 diabetes, primarily initially identified on the basis of symptoms and consecutively diagnosed with coeliac disease by biopsy over a 10 year period, were matched by sex, age at onset, and duration of diabetes with two diabetic controls without coeliac disease. Weight, height, haemoglobin A1c, and insulin requirements were measured before and for 12 months after the diagnosis and treatment of coeliac disease. Dietary awareness and adherence were assessed by structured questionnaire.

RESULTS

A gluten-free diet resulted in a significant increase in weight-for-age z scores at 12 months after diagnosis (mean increase in z score 0.33) and in BMI (mean increase in z score 0.32). Increases in height did not achieve statistical significance. Controls showed no significant changes in weight, height, or BMI over the same period. Insulin dosage at diagnosis was less in coeliacs than in controls (mean difference 0.16 units/kg/day), but was similar to controls once a gluten-free diet had been established. Questionnaires were obtained in 20 patients. There appeared to be a relation between dietary awareness/adherence and growth parameters, but the small number of patients with "poor/fair" dietary adherence prevented meaningful analysis of this group.

CONCLUSION

Identification and dietary treatment of coeliac disease in children with diabetes improved growth and influenced diabetic control. Evaluation of the outcome of treatment of coeliac disease in diabetics should include assessments of gluten intake.

Oats can diversify a gluten-free diet in celiac disease and dermatitis herpetiformis

Finnish celiac disease and dermatitis herpetiformis patients have used oat-containing gluten-free diets since 1997. The aim of this study was to evaluate how the use of oats has been adopted. The use of oats and the effect of oats on symptoms and quality of life were investigated in 1,000 randomly selected members of the Celiac Society. Altogether, 710 patients responded: 423 (73%) with celiac disease and 70 (55%) with dermatitis herpetiformis were currently consuming oats. Patients appreciated the taste, the ease of use, and the low costs; 94% believed that oats diversified the gluten-free diet; 15% of celiac disease and 28% of dermatitis herpetiformis patients had stopped eating oats. The most common reasons for avoiding oats were fear of adverse effects or contamination. There is a market demand for oats, and celiac societies and dietitians should make efforts to promote the development of products free of wheat contamination.

Oats to children with newly diagnosed coeliac disease: a randomised double blind study

BACKGROUND

Treatment of coeliac disease (CD) requires lifelong adherence to a strict gluten free diet (GFD) which hitherto has consisted of a diet free of wheat, rye, barley, and oats. Recent studies, mainly in adults, have shown that oats are non-toxic to CD patients. In children, only open studies comprising a small number of patients have been performed.

AIM

To determine if children with CD tolerate oats in their GFD.

PATIENTS AND METHODS

In this double blind multicentre study involving eight paediatric clinics, 116 children with newly diagnosed CD were randomised to one of two groups: one group was given a standard GFD (GFD-std) and one group was given a GFD with additional wheat free oat products (GFD-oats). The study period was one year. Small bowel biopsy was performed at the beginning and end of the study. Serum IgA antigliadin, antiendomysium, and antitissue transglutaminase antibodies were monitored at 0, 3, 6, and 12 months.

RESULTS

Ninety three patients completed the study. Median (range) daily oat intake in the GFD-oats group (n = 42) was 15 (5-40) g at the six month control and 15 (0-43) g at the end of the study. All patients were in clinical remission after the study period. The GFD-oats and GFD-std groups did not differ significantly at the end of the study regarding coeliac serology markers or small bowel mucosal architecture, including numbers of intraepithelial lymphocytes. Significantly more children in the youngest age group withdrew.

CONCLUSIONS

This is the first randomised double blind study showing that the addition of moderate amounts of oats to a GFD does not prevent clinical or small bowel mucosal healing, or humoral immunological downregulation in coeliac children. This is in accordance with the findings of studies in adult coeliacs and indicates that oats, added to the otherwise GFD, can be accepted and tolerated by the majority of children with CD.

Small bowel neoplasia in coeliac disease

There is an increased risk of small bowel adenocarcinoma in patients with coeliac disease compared with the normal population. It has been suggested that adenocarcinoma of the small intestine in coeliac disease arises through an adenoma-carcinoma sequence but there has been only one reported case of a small bowel adenoma in a patient with coeliac disease. We report three additional cases of a small bowel adenoma in the setting of coeliac disease. In addition, four cases of small bowel adenocarcinoma are also reported, one of which was found adjacent to a jejunal villous adenoma. These cases emphasise the risk of the development of small bowel neoplasia for patients with coeliac disease and support the concept that small bowel adenocarcinoma in coeliac disease arises from adenomas.

Endocrine aspects of coeliac disease

Coeliac disease (CD) is a permanent intolerance to gluten that results in damage of the small intestinal mucosa, and it is one of the common causes of chronic malabsorption in children. It is well known that patients with CD are at great risk of malignant complications, but in patients with CD many other disorders have been recognized. Autoimmunity diseases, such as type 1 diabetes mellitus, thyroid diseases, and autoimmune polyglandular syndromes are known to be associated with CD, and they seem to be related to gluten exposure. Growth, bone metabolism, and fertility can be affected in patients with CD, especially if they are not on a gluten-free diet. We review the literature on endocrine aspects of CD, because patients with CD are at great risk of developing endocrine disorders.

Beneficial effects of oats in the gluten-free diet of adults with special reference to nutrient status, symptoms and subjective experiences

In several studies oats have been reported to be tolerated by coeliac patients. The aim of the present study was to investigate the nutritional and symptomatic effects of including oats in the gluten-free diet, as well as the patients' subjective experiences. Twenty adult coeliac patients included large amounts of oats in their diet. Food intake, gastrointestinal symptoms, blood samples and body weight were examined and compared with examination at baseline. Diet compliance was checked monthly. The results are based on fifteen patients eating oats for 2 years plus three with only 6-months consumption. The median daily intake of oats was 93 (range 27-137) g/d, and the compliance was good. The mean intakes of Fe and dietary fibre increased (P<0.001) with the oat diet, as well as the intakes of thiamin and Zn (P<0.02). The bioavailability of Fe tended to decrease; this seems not to have influenced the Fe status. Temporary increased flatulence was experienced the first few weeks, as well as improved bowel function with oats in the diet. All patients who carried out the whole study period wanted to continue eating oats after the study, as they found that addition of oats in the gluten-free diet gave more variation, better taste and satiety. Oats improved the nutritional value of the gluten-free diet, had no negative effects on nutritional status and were appreciated by the subjects. Including oats can help coeliac patients following a strict gluten-free diet.

Reliability of antitransglutaminase antibodies as predictors of gluten-free diet compliance in adult celiac disease

OBJECTIVE

Strict lifelong compliance to a gluten-free diet (GFD) minimizes the long-term risk of mortality, especially from lymphoma, in adult celiac disease (CD). Although serum IgA antitransglutaminase (IgA-tTG-ab), like antiendomysium (IgA-EMA) antibodies, are sensitive and specific screening tests for untreated CD, their reliability as predictors of strict compliance to and dietary transgressions from a GFD is not precisely known. We aimed to address this question in consecutively treated adult celiacs.

METHODS

In a cross-sectional study, 95 non-IgA deficient adult (median age: 41 yr) celiacs on a GFD for at least 1 yr (median: 6 yr) were subjected to 1) a dietician-administered inquiry to pinpoint and quantify the number and levels of transgressions (classified as moderate or large, using as a cutoff value the median gluten amount ingested in the overall noncompliant patients of the series) over the previous 2 months, 2) a search for IgA-tTG-ab and -EMA, and 3) perendoscopic duodenal biopsies. The ability of both antibodies to discriminate celiacs with and without detected transgressions was described using receiver operating characteristic curves and quantified as to sensitivity and specificity, according to the level of transgressions.

RESULTS

Forty (42%) patients strictly adhered to a GFD, 55 (58%) had committed transgressions, classified as moderate (< or = 18 g of gluten/2 months; median number 6) in 27 and large (>18 g; median number 69) in 28. IgA-tTG-ab and -EMA specificity (proportion of correct recognition of strictly compliant celiacs) was 0.97 and 0.98, respectively, and sensitivity (proportion of correct recognition of overall, moderate, and large levels of transgressions) was 0.52, 0.31, and 0.77, and 0.62, 0.37, and 0.86, respectively. IgA-tTG-ab and -EMA titers were correlated (p < 0.001) to transgression levels (r = 0.560 and R = 0.631, respectively) and one to another (p < 0.001) in the whole patient population (r = 0.834, N = 84) as in the noncompliant (r = 0.915, N = 48) group. Specificity and sensitivity of IgA-tTG-ab and IgA-EMA for recognition of total villous atrophy in patients under a GFD were 0.90 and 0.91, and 0.60 and 0.73, respectively.

CONCLUSIONS

In adult CD patients on a GFD, IgA-tTG-ab are poor predictors of dietary transgressions. Their negativity is a falsely secure marker of strict diet compliance.

Duodenal histology in patients with celiac disease after treatment with a gluten-free diet

BACKGROUND

The diagnosis of celiac disease requires characteristic histopathologic changes in an intestinal biopsy with clinical improvement in response to a gluten-free diet. Endoscopy with procurement of biopsy specimens is often performed to document response to the diet, but there are little data on the appearance of treated celiac disease. This study examined the endoscopic and histopathologic appearance of the duodenum of patients with celiac disease whose diet was gluten-free.

METHODS

A cohort of 39 adult patients (mean age 52 years, range 20-74 years) with biopsy-proven celiac disease was retrospectively reviewed. All had responded clinically to a gluten-free diet that they had maintained for a mean of 8.5 years (range 1-45 years). The endoscopic and histopathologic appearances of the duodenal mucosa were reviewed. Blinded review of the diagnostic (initial) and post-treatment biopsy specimens was also performed to assess response of individual patients to the diet.

RESULTS

The endoscopic appearance was normal in 23%, reduced duodenal folds were present in 46%, scalloping of folds in 33%, mucosal fissures in 44%, and nodularity in 33%. There was more than 1 abnormality present in 46%. Histology was normal in only 21%. The remainder had villous atrophy (69% partial, 10% total). Paired (diagnostic and follow-up) biopsy specimens were reviewed blindly for 12 patients. The mean (SD) intraepithelial lymphocyte count fell from 61 (22) to 38 (17) (normal <30 per 100 epithelial cells) and the crypt-to-villous ratio improved although it did not normalize.

CONCLUSIONS

Despite a good clinical response, abnormal endoscopic and histopathologic appearances persist in the majority of patients with celiac disease treated with a gluten-free diet.