SIGNIFICANCE OF A FLAT SMALL-INTESTINAL MUCOSA

Risk of tuberculosis in a large sample of patients with coeliac disease--a nationwide cohort study

BACKGROUND

Research suggests a positive association between coeliac disease and tuberculosis (TB), but that research has often been limited to in-patients and small sample size. We examined the relationship between TB and coeliac disease.

AIM

To examine the association of TB and coeliac disease.

METHODS

We collected biopsy data from all pathology departments in Sweden (n=28) to identify individuals who were diagnosed with coeliac disease between 1969 and 2007 (Marsh 3: villous atrophy; n=29,026 unique individuals). Population-based sex- and age-matched controls were selected from the Total Population Register. Using Cox regression, we calculated hazard ratios (HRs) for TB from data in the Swedish national health registers.

RESULTS

Individuals with coeliac disease were at increased risk of TB (HR=2.0; 95% CI=1.3-3.0) (during follow-up, 31 individuals with coeliac disease and 74 reference individuals had a diagnosis of TB). The absolute risk of TB in patients with coeliac disease was 10/100,000 person-years with an excess risk of 5/100,000. Risk estimates were the highest in the first year. Restricting our outcome to a diagnosis of TB confirmed by (I) a record of TB medication (HR=2.9; 95% CI=1.0-8.3), (II) data in the National Surveillance System for Infectious Diseases in Sweden (HR=2.6; 95% CI=1.3-5.2) or (III) positive TB cultivation (HR=3.3; 95% CI=1.6-6.8) increased risk estimates. The positive association between coeliac disease and TB was also observed before the coeliac disease diagnosis (odds ratio=1.6; 95% CI=1.2-2.1).

CONCLUSION

We found a moderately increased risk of tuberculosis in patients with coeliac disease.

Coeliac disease and risk of tuberculosis: a population based cohort study

BACKGROUND

Coeliac disease (CD) is an autoimmune disease often characterised by malnutrition and linked to a number of complications such as an increased risk of lymphoma, adverse pregnancy outcome, and other autoimmune diseases. Tuberculosis (TB) affects a large proportion of the world population and is more common in individuals with malnutrition. We investigated the risk of TB in 14 335 individuals with CD and 69 888 matched reference individuals in a general population based cohort study.

METHODS

Cox proportional hazards method was used to calculate the risk of subsequent TB in individuals with CD. In a separate analysis, the risk of CD in individuals with prior TB was calculated using conditional logistic regression.

RESULTS

CD was associated with an increased risk of subsequent TB (hazard ratio (HR) 3.74, 95% CI 2.14 to 6.53; p < 0.001). Similar risk estimates were seen when the population was stratified for sex and age at CD diagnosis. Individuals with CD were also at increased risk of TB diagnosed in departments of pulmonary medicine, infectious diseases, paediatrics, or thoracic medicine (HR 4.76, 95% CI 2.23 to 10.16; p < 0.001). The odds ratio for CD in individuals with prior TB was 2.50 (95% CI 1.75 to 3.55; p < 0.001).

CONCLUSIONS

CD is associated with TB. This may be due to malabsorption and lack of vitamin D in persons with CD. Individuals with TB and gastrointestinal symptoms should be investigated for CD.

Susceptibility to tuberculosis in patients with coeliac disease

An increased prevalence of past tuberculosis is reported in an adult coeliac population. Of 76 adult coeliac disease patients, 6 had had a history of tuberculosis. This compared with the finding of no cases in a population of 81 patients with non-inflammatory bowel diseases, (p = 0.023), which was matched for age, sex, smoking, ethnic origin and social class. The 'expected' number of cases of tuberculosis amongst ACD patients has also been calculated based on local annual notification rates; this was 2.9. Radiological evidence of past tuberculosis was found in 13 (17%) ACD patients, compared with 4 (5%) control patients (p less than 0.05). It is postulated that the increased prevalence of past tuberculosis in ACD patients is the result of depressed cell mediated immunity and/or malnutrition.

Sarcoidosis and coeliac disease: an association?

An association between sarcoidosis and coeliac disease is suggested by the occurrence of both diseases in 5 patients. In 3 cases the gastrointestinal symptoms of coeliac disease preceded those of sarcoidosis and in the other 2 patients symptoms of both diseases appeared at the same time.

Chronic non-specific ulcerative duodenojejunoileitis: report of four cases

Four patients with chronic non-specific ulcerative duodenojejunoileitis (CNSUDJI) are reported. The clinical picture included abdominal pain, fever, and a malabsorption syndrome. Main rediological findings were diffuse narrowing of the jejunal loops with total effacement of the mucosal folds. Multiple peroral biopsies of the small intestine showed various degrees of mucosal abnormalities from total villous atrophy to normal villi, but ulcerations were diagnosed only by operative full thickness biopsies or resection of the small bowel. The ulcerative process was associated with well-documented coeliac disease in two patients: in one of them it occurred as a fatal complication involving also the colon, three years after the start of a gluten free diet, while the disease was in full clinical and histological remission. In the other case, coeliac disease was revealed by obstructive symptoms due to stenosing ulcerations; five months after surgical resection of the stenosis, institution of a gluten free diet induced a dramatic improvement. In the two other patients ulcerations were not associated with coeliac disease: one of them had a patchy villous atrophy and resisted a gluten free diet and total parenteral nutrition; she was improved by and dependent upon steroids but finally died. The last patient had normal villous height; ulcerations were located exclusively along the mesenteric border of the small bowel; he had a low-grade protracted evolution resisting any form of therapy and developed a peripheral neuropathy of unknown aetiology. On the basis of our cases and of a review of the literature the discussion focuses on the difficulty in diagnosing CNSUDJI, its relationship with coeliac disease, and its management and prognosis.

Role of gluten, prednisone, and azathioprine in non-responsive coeliac disease

A case of severe "non-responsive" coeliac disease has been shown to be sensitive to gluten whilst under prednisone therapy, but not without prednisone. This adds an additional dimension to the criteria for diagnosis of coeliac disease. Cases of non-responsive coeliac disease may require both prednisone and gluten exclusion to induce a remission. In this patient, azathioprine induced and sustained a remission when unacceptably high doses of prednisone had failed, and may prove to be a valuable immunosuppressive in non-responsive coeliac disease.

Assessment of small bowel function in the elderly using a modified xylose tolerance test

Using the combined results of oral and intravenous xylose tests, it is demonstrated that 26 percent of a group of geriatric patients absorb from the small bowel less efficiently than younger subjects. The method used excludes poor renal function and incomplete bladder emptying as possible causes for the differences found between the two age groups. Altered gastric emptying is also excluded as a possible factor.

The small intestine in diabetes mellitus. Correlation of clinical phenomena to histomorphometric findings in peroral biopsy material

Biopsy material obtained from the first portion of the jejunum of 56 unselected diabetics and 21 normal controls was examined under the electron microscope (in 8 cases) or with a method of stereologic morphometry. Controls were found to have a villous volume (VVi) of 50.19 +/- 10.1%. All values below 40% were interpreted as an expression of deterioration of the mucous membrane. Altogether 12.5% of the diabetics showed total atrophy, and 20% had significant reduction of VVi. These changes did not correlate with intestinal disorders or other signs of diabetes. In total atrophy histochemical changes could be demonstrated. Microangiopathy was not observed in the intestinal mucosa.

Mucosal ulceration and mesenteric lymphadenopathy in coeliac disease

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Incidence of small-intestinal mucosal abnormalities and of clinical coeliac disease in the relatives of children with coeliac disease

Evidence is presented of a higher than normal incidence both of clinical coeliac disease and of small-intestinal mucosal abnormalities in relatives of children with coeliac disease. In such relatives the incidence of mucosal abnormality may differ from the incidence of clinical coeliac disease. The data show an absence of any simple Mendelian pattern of inheritance: in place of the hypothesis that inheritance is through a dominant gene of reduced penetrance, it is argued that the pathogenesis of coeliac disease is multifactorial, the genetic basis of susceptibility being polygenic and interacting with environmental factors. On this hypothesis the relative contributions of inheritance and environment to liability to the clinical condition are estimated, the genetic component being 45% +/- 9. Environmental factors appear more important in the development of mucosal abnormality.

Immunoglobulin-containing cells in the coeliac syndrome

Immunofluorescent studies were performed upon the small intestinal mucosa obtained by jejunal biopsy of seven patients suffering from the coeliac syndrome and six control subjects. Seven patients had normal villous morphology and six had subtotal villous strophy. In the group whose jejunal biopsies were normal using routine histological examination, the predominant type of immunoglobulin-containing cell was IgA followed by IgM, then IgG, with the approximate ratio of 3:2:1 respectively. The cell densities were found to be much higher than in other published series and the predominance of IgA was not so marked. These findings may be in part due to differences in technique, but probably are also due to differences in the patients studied. In the group with villous atrophy the density of IgA cells was significantly lower than in the group with normal histology and three of the six patients showed a reversal in the normal ratio between IgA-and IgM-containing cells. A positive correlation was observed between serum IgM levels and the density of corresponding immunoglobulin-containing cells.

The enterocyte in coeliac disease

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A case of small-intestinal mucosal atrophy

A patient is described with a severe malabsorption syndrome which failed to respond to a gluten-free diet. Although subtotal villous atrophy was present in the jejunal mucosa, histological features of subepithelial fibrosis and apparently normal enterocytes were not suggestive of coeliac disease. The findings of decreased mucosal thickness, of a normal mitotic rate in the crypt cell population, and of the decreased rate of loss of epithelial cells further suggested that the disease process producing the ;flat' mucosa was not that of coeliac disease. The condition was complicated by ileal ulceration and active tuberculosis.

Small-intestinal mucosal abnormalities in various skin diseases--fact or fancy?

Two-thirds of patients with dermatitis herpetiformis have been found to have a flat or convoluted mucosa but no special association has been found in the other dermatoses studied with structural alterations in the small bowel mucosa. The frequency distribution of the predominant and individual small intestinal mucosal features is the same in the patients in the present series with eczema, psoriasis, and rosacea as in the local control population. A predominantly convoluted mucosa has been found in the upper small intestine in 8% of these patients and in 8% of subjects without a rash. The presence of convolutions in patients with these dermatoses is merely a reflection of the incidence in the normal population of Newcastle upon Tyne. Different findings in the same skin disease in different parts of the country are explicable on the basis of variations in the normal mucosa between one geographical region and another. The increased incidence of a convoluted mucosa in the north east of England requires further study to determine whether it is indicative of an increased incidence of the coeliac syndrome in the region, or whether it results from a minor population difference or a local peculiarity of diet.

Malabsorption and subtotal villous atrophy secondary to pulmonary and intestinal tuberculosis

A case of malabsorption and subtotal villous atrophy secondary to pulmonary and intestinal tuberculosis is reported. The patient was a 21-year-old Chinese girl who had active pulmonary tuberculosis, malabsorption, subtotal villous atrophy, atrophic gastritis with hypochlorhydria, ileal stricture, and a severe non-specific anaemia. There was also evidence to suggest protein-losing enteropathy. The association of subtotal villous atrophy and atrophic gastritis with tuberculosis is discussed. When antituberuclous therapy was instituted, improvement was marked not only clinically but also in the tests for intestinal absorption and in the jejunal mucosa.

Tertiary hyperparathyroidism with fluctuating serum calcium levels

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Staining method for the examination of the small intestinal villous pattern in necropsy material

A new technique for the rapid identification of villous structure in postmortem material is described. It has been used with success for over a year and has proved superior in the authors' hands to previously described methods.

Dermatitis herpetiformis in two patients with idiopathic steatorrhoea (adult coeliac disease)

Two patients who had had idiopathic steatorrhoea for several years developed typical eruptions of dermatitis herpetiformis. In each case the rash responded to treatment with dapsone.It is more usual for the rash to precede the enteropathy when the two occur together, but the association between coeliac disease and dermatitis herpetiformis is not yet clear.

Ascaris lumbricoides infectation associated with jejunal mucosal abnormalities

A patient with ascaris lumbricoides infestation associated with small bowel mucosal abnormalities is reported. The importance of careful radiological examination of the small intestine and examination of the faeces is stressed. Morphological changes and disturbed function of small bowel are discussed in relation to infestation with certain worms.

Post-mortem examination of a small intestine in the coeliac syndrome

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