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Protective effects of Acetobacter ghanensis against gliadin toxicity in intestinal epithelial cells with immunoregulatory and gluten-digestive properties. Eur J Nutr 2023; 62:605-614. [PMID: 36175797 DOI: 10.1007/s00394-022-03015-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 09/22/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE The aim of this study was to establish whether Acetobacter ghanensis, the probiotic characteristics of which were evaluated previously, attenuates gliadin-induced toxicity in intestinal epithelial cells with gluten-digestive and immunoregulatory properties. METHODS A co-culture model of human intestinal epithelial cell (Caco-2) monolayers on top of peripheral blood mononuclear cells (PBMCs) obtained from patients with celiac disease (CD) was established. The gluten-digestive properties of A. ghanensis were determined by checking bacterial growth in a medium containing gluten as the main nitrogen source. The mRNA levels of genes encoding TJ-associated proteins were measured by quantitative real-time PCR (qRT-PCR). The concentrations of IL-6 and TNFα were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS We found that PT-gliadin disrupted intestinal barrier integrity by modulating the expression of TJ-associated genes encoding zonulin (increased by ~ 60%), zonula occludens-1 (ZO-1) (decreased by ~ 22%), and occludin (decreased by ~ 28%) in Caco-2 cells. Furthermore, PT-gliadin treatment in Caco-2 cells was associated with increased concentrations of IL-6 (~ 1.6-fold) and TNFα (~ twofold) from PBMCs. These modulatory effects of PT-gliadin, however, were suppressed when Caco-2 cells were subjected to A. ghanensis in the presence of PT-gliadin. As a factor underlying these protective effects, we showed that A. ghanensis could digest gluten peptides. CONCLUSIONS To our knowledge, the current study is the first to demonstrate that A. ghanensis improves intestinal barrier functions by attenuating the modulatory effects of PT-gliadin with immunoregulatory and gluten-digestive properties.
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Anderson RP. Review article: Diagnosis of coeliac disease: a perspective on current and future approaches. Aliment Pharmacol Ther 2022; 56 Suppl 1:S18-S37. [PMID: 35815826 DOI: 10.1111/apt.16840] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/08/2022] [Accepted: 02/08/2022] [Indexed: 12/09/2022]
Abstract
Diagnostics will play a central role in addressing the ongoing dramatic rise in global prevalence of coeliac disease, and in deploying new non-dietary therapeutics. Clearer understanding of the immunopathogenesis of coeliac disease and the utility of serology has led to partial acceptance of non-biopsy diagnosis in selected cases. Non-biopsy diagnosis may expand further because research methods for measuring gluten-specific CD4+ T cells and the acute recall response to gluten ingestion in patients is now relatively straightforward. This perspective on diagnosis in the context of the immunopathogenesis of coeliac disease sets out to highlight current consensus, limitations of current practices, gluten food challenge for diagnosis and the potential for diagnostics that measure the underlying cause for coeliac disease, gluten-specific immunity.
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Ambusaidi S, Al Busaidi AM, Al Salmani A, Davidson R, Alshekaili J, Kindi MA, Al Kindi R. Prevalence of Coeliac Disease in Omani Adults with Iron Deficiency Anaemia of Unknown Cause: Case-finding study. Sultan Qaboos Univ Med J 2022; 22:262-267. [PMID: 35673297 PMCID: PMC9155029 DOI: 10.18295/squmj.5.2021.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/08/2021] [Accepted: 04/27/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives This study aimed to estimate the serological prevalence of coeliac disease in patients with iron deficiency anaemia (IDA) of unknown cause at a primary healthcare facility in Oman. Methods This prospective case-finding study was conducted at the primary care clinics in Sultan Qaboos University Hospital, Muscat, Oman from September 2018 to June 2020. Patients aged 18 to 55 years, with a haemoglobin (Hb) level <11.5 g/dL for males and <11.0 g/dL for females and a ferritin level <30 ng/mL for males and <13 ng/mL for females, were included in the study. Blood samples were obtained for initial serological screening using serum immunoglobulin (Ig)A level; those samples with normal levels of IgA, IgA anti-tissue transglutaminase antibody (tTG) and IgA anti-deamidated gliadin peptide (DGP) were determined. Positive IgA-tTG test was confirmed using IgA-endomysial antibodies. Patients with low IgA levels were tested using IgG-tTG and IgG-DGP. Results A total of 104 patients participated in this study. Eight patients (7.7%) were found to have a positive serological screening result for coeliac disease; of these patients, three (37.5%) had a positive IgA-tTG result. Two of those three (66.7%) had a positive IgA-endomysial antibody. The IgA-DGP result was positive in seven (6.7%) of the 104 patients. Out of those seven patients, two also had a positive IgA tTG. Conclusion Coeliac disease is not a rare disorder. There is a need to increase awareness among healthcare professionals about coeliac disease and its non-classical manifestations such as IDA.
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Affiliation(s)
| | | | - Asma Al Salmani
- Department of Family Medicine & Public Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Robin Davidson
- Department of Family Medicine & Public Health, University of Bristol, Bristol, United Kingdom
| | - Jalila Alshekaili
- Department of Microbiology & Immunology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Mahmood Al Kindi
- Department of Microbiology & Immunology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Rahma Al Kindi
- Department of Family Medicine & Public Health, Sultan Qaboos University Hospital, Muscat, Oman
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Al-Abachi KT. Screening for Celiac Disease in Patients with Irritable Bowel Syndrome Fulfilling Rome III Criteria. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1055/s-0041-1736645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Background Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder. Celiac disease (CD), a treatable autoimmune enteropathy, with varied presentations, may simulate clinically symptoms of IBS. The aim of the present study is to screen for CD in patients with IBS diagnosed based on the Rome III criteria.
Patients and Methods A cross-sectional study was conducted at a secondary care gastrointestinal unit in Al-Salam General Hospital in Mosul city, Iraq, from November 2015 to October 2016. All patients fulfilling the Rome III criteria for IBS were screened for CD using antitissue transglutaminase IgA antibodies (anti-tTG). Patients who tested positive were subjected to endoscopic duodenal biopsy to confirm the diagnosis of CD.
Results A total of 100 patients were included in the present study (58 female and 42 male), the mean age of the participants was 40.8 years old (standard deviation [SD] ± 11.57). Ten patients (10/100, 10%) tested positive for anti-tTG antibodies. Five of the seropositive patients (5/10, 50%) showed positive biopsy results according to the Marsh classification, 3 of whom having diarrhea, and 2 with constipation.
Conclusion Positive serology and biopsy results suggestive of CD are common among patients with IBS. Screening patients with IBS for CD is justified.
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Elwenspoek MMC, Jackson J, Dawson S, Everitt H, Gillett P, Hay AD, Jones HE, Lane DL, Mallett S, Robins G, Sheppard AL, Stubbs J, Thom H, Watson J, Whiting P. Accuracy of potential diagnostic indicators for coeliac disease: a systematic review protocol. BMJ Open 2020; 10:e038994. [PMID: 33020103 PMCID: PMC7537462 DOI: 10.1136/bmjopen-2020-038994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Coeliac disease (CD) is a systemic immune-mediated disorder triggered by gluten in genetically predisposed individuals. CD is diagnosed using a combination of serology tests and endoscopic biopsy of the small intestine. However, because of non-specific symptoms and heterogeneous clinical presentation, diagnosing CD is challenging. Early detection of CD through improved case-finding strategies can improve the response to a gluten-free diet, patients' quality of life and potentially reduce the risk of complications. However, there is a lack of consensus in which groups may benefit from active case-finding. METHODS AND ANALYSIS We will perform a systematic review to determine the accuracy of diagnostic indicators (such as symptoms and risk factors) for CD in adults and children, and thus can help identify patients who should be offered CD testing. MEDLINE, Embase, Cochrane Library and Web of Science will be searched from 1997 until 2020. Screening will be performed in duplicate. Data extraction will be performed by one and checked by a second reviewer. Disagreements will be resolved through discussion or referral to a third reviewer. We will produce a narrative summary of identified prediction models. Studies, where 2×2 data can be extracted or reconstructed, will be treated as diagnostic accuracy studies, that is, the diagnostic indicators are the index tests and CD serology and/or biopsy is the reference standard. For each diagnostic indicator, we will perform a bivariate random-effects meta-analysis of the sensitivity and specificity. ETHICS AND DISSEMINATION Results will be reported in peer-reviewed journals, academic and public presentations and social media. We will convene an implementation panel to advise on the optimum strategy for enhanced dissemination. We will discuss findings with Coeliac UK to help with dissemination to patients. Ethical approval is not applicable, as this is a systematic review and no research participants will be involved. PROSPERO REGISTRATION NUMBER CRD42020170766.
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Affiliation(s)
- Martha Maria Christine Elwenspoek
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joni Jackson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hazel Everitt
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Susan Mallett
- School of Health and Population Sciences, University of Birmingham, Birmingham, West Midlands, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, North Yorkshire, UK
| | | | - Jo Stubbs
- Patient representative, Patient representative, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jessica Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Abstract
Celiac disease (CD) is an immune-mediated enteropathy triggered by dietary ingestion of gluten in genetically susceptible patients. CD is often diagnosed by a "case-finding" approach of symptomatic patients. In recent times, the diagnostic paradigm has shifted to investigate patients who may be asymptomatic, but are at high risk of developing CD due to shared genetic susceptibilities. These high-risk groups include first-degree relatives of CD patients and patients with Type 1 diabetes mellitus, autoimmune thyroid disease, Down's syndrome, and Turner syndrome. Moreover, CD is often diagnosed as the cause of iron deficiency anemia or unexplained chronic diarrhea. Although screening for CD with serological tests is not recommended for the general population, it should be considered in these special populations. In this review, we explore screening for CD among high-risk groups in light of recent research and development in the CD arena.
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Affiliation(s)
- Dennis Kumral
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia, 1215 Lee Street, PO Box 800708, Charlottesville, VA, 22908, USA.
| | - Sana Syed
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Virginia, MR-4 Bldg, 409 Lane Rd., Charlottesville, VA, 22908, USA
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Peleg R, Ben-Zion ZI, Peleg A, Gheber L, Kotler M, Weizman Z, Shiber A, Fich A, Horowitz Y, Shvartzman P. “Bread madness” revisited: screening for specific celiac antibodies among schizophrenia patients. Eur Psychiatry 2020; 19:311-4. [PMID: 15276666 DOI: 10.1016/j.eurpsy.2004.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2003] [Revised: 04/01/2004] [Accepted: 04/06/2004] [Indexed: 11/28/2022] Open
Abstract
AbstractPurposeA possible association between gluten consumption and schizophrenia has been reported. The objective was to compare patients with chronic schizophrenia and matched controls for sociodemographic variables, prevalence of celiac-specific anti-endomysial antibodies and disease-related variables.Subjects and methodsThe study group was comprised of 50 consecutive patients diagnosed with schizophrenia, 18 years of age and older attending the out-patient clinic of the Mental Health Center in Beer-Sheva, Israel. The control group was comprised of mentally normal volunteers who came to primary care clinics for blood tests unrelated to gastrointestinal tract complaints and who were not diagnosed with celiac disease. Known celiac patients and those who refused to participate, did non-speak Hebrew or were incoherent were excluded from the study. All participants in both groups underwent a blood test for anti-endomysial IgA antibody and completed a questionnaire.ResultsEach group was comprised of 50 participants. There were no significant differences between the groups in gender, BMI or country of birth. The mean age of the study group was significantly higher than the controls. All tests for anti-endomysial antibody in both groups were negative.Discussion and conclusionsIn contrast to previous reports, we found no evidence for celiac disease in patients with chronic schizophrenia as manifested by the presence of serum IgA anti-endomysial antibodies. It is unlikely that there is an association between gluten sensitivity and schizophrenia.
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Affiliation(s)
- Roni Peleg
- Department of Family Medicine, Sial Research Center for Family Medicine and Primary Care, Division of Community Health, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
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Diagnosing Celiac Disease: Towards Wide-Scale Screening and Serology-Based Criteria? Gastroenterol Res Pract 2019; 2019:2916024. [PMID: 31467522 PMCID: PMC6701393 DOI: 10.1155/2019/2916024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 07/16/2019] [Indexed: 12/12/2022] Open
Abstract
Celiac disease is one of the most common food-related chronic disorders in children. Unfortunately, this multifaceted disease is challenging to recognize and remains markedly underdiagnosed. Screening of either known at-risk groups or even the whole population could increase the suboptimal diagnostic yield substantially. Many recent guidelines recommend screening of at least selected risk groups, but more wide-scale screening remains controversial. The increasing prevalence of celiac disease and the development of autoantibody assays have also led to a gradual shift in the diagnostics towards less invasive serology-based criteria in a subgroup of symptomatic children. The main open questions concern whether these criteria are applicable to all countries and clinical settings, as well as to adult patients. On the other hand, widening screening and the mistaken practice of initiating a gluten-free diet before the appropriate exclusion of celiac disease increase the number of borderline seropositive cases, which may also challenge the classical histopathological diagnostics. Sophisticated diagnostic methods and a deeper understanding of the natural history of early developing celiac disease may prove useful in these circumstances.
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El-Salhy M, Gilja OH, Hatlebakk JG. Overlapping of irritable bowel syndrome with erosive esophagitis and the performance of Rome criteria in diagnosing IBS in a clinical setting. Mol Med Rep 2019; 20:787-794. [PMID: 31180516 PMCID: PMC6580027 DOI: 10.3892/mmr.2019.10284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 05/15/2019] [Indexed: 02/06/2023] Open
Abstract
Irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD) overlap. It is not clear whether GERD is caused by non-erosive esophagitis, or erosive esophagitis. The Rome criteria are not widely used for the diagnosis of IBS in the clinic. In total, 1,489 IBS patients without red flags were included in the present retrospective study. They comprised of 1,331 females and 158 males with a mean age of 51 years. The diagnosis of IBS was verified by endoscopic and histopathological examinations. Whereas erosive esophagitis occurred in 97% of patients, only 66% had GERD symptoms. Endoscopy and histopathological examinations revealed that 1.4% of the IBS patients with diarrhea as the predominant symptom had other organic gastrointestinal diseases: 0.3% with celiac disease, 0.2% with Crohn's disease, 0.07% with ulcerative colitis, 0.6% with microscopic colitis, and 0.2% with colon cancer. Applying the Rome III criteria produced a sensitivity of 100% [95% confidence intervals (CI)=99.8–100.0%] a specificity of 98.7% (95% CI=98.0–99.2%), a positive likelihood ratio of 76.9%, and a negative likelihood ratio of 0%. IBS is associated with erosive esophagitis. Applying Rome III criteria without red flags and history, was effective in diagnosing IBS. Celiac disease and microscopic colitis should be considered as alternative diagnoses.
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Affiliation(s)
- Magdy El-Salhy
- Section for Gastroenterology, Department of Medicine, Stord Hospital, 5416 Stord, Norway
| | - Odd Helge Gilja
- Department of Clinical Medicine, University of Bergen, 5007 Bergen, Norway
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Elli L, Norsa L, Zullo A, Carroccio A, Girelli C, Oliva S, Romano C, Leandro G, Bellini M, Marmo R, Soncini M, Monica F, De Francesco V, Paulon E, Cappellini MD, Motta I, Ferretti F, Orlando S, Mansueto P, Buscarini E, Manfredi G, Agostoni C, Tomba C, Cannizzaro R. Diagnosis of chronic anaemia in gastrointestinal disorders: A guideline by the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition (SIGENP). Dig Liver Dis 2019; 51:471-483. [PMID: 30850345 DOI: 10.1016/j.dld.2019.01.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/18/2019] [Accepted: 01/29/2019] [Indexed: 12/11/2022]
Abstract
Anaemia is a common pathologic condition, present in almost 5% of the adult population. Iron deficiency is the most common cause; other mechanisms can be involved, making anaemia a multi-factorial disorder in most cases. Anaemia being a frequent manifestation in the diseases of the gastrointestinal tract, patients are often referred to gastroenterologists. Furthermore, upper and lower endoscopy and enteroscopy are pivotal to the diagnostic roadmap of anaemia. In spite of its relevance in the daily clinical practice, there is a limited number of gastroenterological guidelines dedicated to the diagnosis of anaemia. For this reason, the Italian Association of Hospital Gastroenterologists and Endoscopists and the Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition commissioned a panel of experts to prepare a specific guideline on anaemia and its diagnostic roadmap in the gastroenterological scenario. The panel also discussed about the potential involvement of gastroenterologists and endoscopists in the management of patients with anaemia, with particular attention to the correct use of investigations. The panel paid particular attention to practical issues with the aim to support gastroenterologists in their clinical practice when dealing with patients with anaemia.
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Affiliation(s)
- Luca Elli
- Gastroenterology and Endoscopy Division/Center for Prevention and Diagnosis of Coeliac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano.
| | - Lorenzo Norsa
- Division of Paediatric Gastroenterology, Hepatology and Transplantation, ASST "Pope Giovanni XXIII", Bergamo
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, "Nuovo Regina Margherita" Hospital, Rome
| | - Antonio Carroccio
- Internal Medicine, "Giovanni Paolo II" Hospital, Sciacca; Biomedical Department of Internal and Specialist Medicine - DiBiMIS, University of Palermo, Palermo
| | - Carlo Girelli
- Gastroenterology and Digestive Endoscopy Unit, Hospital of Busto Arsizio, Busto Arsizio
| | - Salvatore Oliva
- Paediatric Gastroenterology and Liver Unit, University "La Sapienza" of Rome, Roma
| | - Claudio Romano
- Paediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina
| | - Gioacchino Leandro
- National Institute of Gastroenterology "S. De Bellis" Research Hospital, Castellana Grotte, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa
| | | | - Marco Soncini
- Internal Medicine, "Alessandro Manzoni" Hospital, ASST-Lecco, Lecco
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy Unit, Cattinara Hospital, Trieste
| | | | - Emma Paulon
- Gastroenterology and Digestive Endoscopy Unit, Cattinara Hospital, Trieste
| | - Maria Domenica Cappellini
- Rare Diseases Center, Department of Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano; Department of Clinical Sciences and Community Health, University of Milan, Milano
| | - Irene Motta
- Rare Diseases Center, Department of Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano; Department of Clinical Sciences and Community Health, University of Milan, Milano
| | - Francesca Ferretti
- Gastroenterology and Endoscopy Division/Center for Prevention and Diagnosis of Coeliac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano
| | - Stefania Orlando
- Gastroenterology and Endoscopy Division/Center for Prevention and Diagnosis of Coeliac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano
| | - Pasquale Mansueto
- Biomedical Department of Internal and Specialist Medicine - DiBiMIS, University of Palermo, Palermo
| | | | - Guido Manfredi
- Gastroenterology Unit, ASST Ospedale Maggiore di Crema, Crema
| | - Carlo Agostoni
- Paediatric Intermediate Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano; Department of Clinical Sciences and Community Health, University of Milan, Milano
| | | | - Renato Cannizzaro
- Oncological Gastroenterology Division, Centro di Riferimento Oncologico (CRO) IRCCS, Aviano
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Coeliac disease detection with an IgA/IgG-deamidated gliadin peptide based point of care test in community pharmacies. Int J Clin Pharm 2019; 41:583-588. [PMID: 30778740 PMCID: PMC6509084 DOI: 10.1007/s11096-019-00793-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/18/2019] [Indexed: 11/27/2022]
Abstract
Background Coeliac disease affects 1% of the population, but 75% remain undiagnosed. Objective To conduct a case finding feasibility and efficacy study for the detection of coeliac disease in community pharmacies. Setting Six community pharmacies across Sheffield, UK. Method A prospective study was performed using a point of care test, Simtomax® (IgA/IgG-deamidated gliadin peptide) (C-test) in pharmacies. Pharmacy customers with symptoms suggestive of or risk factors for coeliac disease were tested with the C-test. Positive individuals were referred for a gastroscopy with duodenal biopsies alongside conventional serology. People with known coeliac disease, those on a gluten free diet or those who were investigated for coeliac disease were excluded. Main outcome measure The case detection rate and the uptake rate of the C-test and gastroscopies. Results Five-hundred participants fulfilled the inclusion criteria and were tested with the C-test (369 females, 73.8%; age range 18–87, median 49). The C-test uptake rate was 63%, and the positive rate was 7.2% (36/500). Twenty-seven positive participants (75%) underwent further investigations, confirming three new cases of coeliac disease (0.6%). Conclusion It was feasible to use the C-test as a case finding tool in pharmacies. There was good uptake for the C-test, although the case detection rate and the test specificity were low. Based on this, the C-test has a limited role in case finding in a community pharmacy setting.
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Fuchs V, Kurppa K, Huhtala H, Laurila K, Mäki M, Collin P, Salmi T, Luostarinen L, Saavalainen P, Kaukinen K. Serology-based criteria for adult coeliac disease have excellent accuracy across the range of pre-test probabilities. Aliment Pharmacol Ther 2019; 49:277-284. [PMID: 30592070 DOI: 10.1111/apt.15109] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 10/25/2018] [Accepted: 12/02/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The revised paediatric criteria for coeliac disease allow omission of duodenal biopsies in symptomatic children who have specific serology and coeliac disease-associated genetics. It remains unclear whether this approach is also applicable for adults with various clinical presentations. AIM To evaluate the accuracy of serology-based criteria in adults with variable pre-test probabilities for coeliac disease. METHODS Three study cohorts comprised adults with high-risk clinical coeliac disease suspicion (n = 421), moderate-risk family members of coeliac disease patients (n = 2357), and low-risk subjects from the general population (n = 2722). Serological and clinical data were collected, and "triple criteria" for coeliac disease comprised transglutaminase 2 antibodies >10× the upper limit of normal, positive endomysium antibodies, and appropriate genetics without requirement of symptoms. The diagnosis was based on intestinal biopsy. RESULTS The diagnosis of coeliac disease was established in 274 subjects. Of these, 59 high-risk subjects, 17 moderate-risk subjects, and 14 low-risk subjects fulfilled the "triple criteria". All had histologically proven coeliac disease, giving the criteria a positive predictive value of 100%. Altogether, 90 (33%) of all 274 newly diagnosed patients could have avoided biopsy, including 37% among high-risk, 20% among moderate-risk, and 48% among low-risk patients. No histological findings other than coeliac disease were found in the biopsies of "triple positive" subjects. CONCLUSIONS Coeliac disease can reliably and safely be diagnosed without biopsy in adults fulfilling the "triple criteria" regardless of the pre-test probability. Revised criteria would enable the number of endoscopies to be reduced by one-third.
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Affiliation(s)
- Valma Fuchs
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Kalle Kurppa
- Tampere Center for Child Health Research, University of Tampere, and Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Tampere Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Kaija Laurila
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Markku Mäki
- Tampere Center for Child Health Research, University of Tampere, and Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Pekka Collin
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Teea Salmi
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Dermatology, Tampere University Hospital, Tampere, Finland
| | - Liisa Luostarinen
- Department of Neurology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Päivi Saavalainen
- Research Programs Unit, Immunobiology, and Haartman Institute, Department of Medical Genetics, University of Helsinki, Helsinki, Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
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Abstract
GOALS To compare the diagnostic yield and cost-consequences of 2 strategies, screening regardless of symptoms versus case finding (CF), using a point-of-care test (POCT), for the detection of celiac disease (CD) in primary care, to bridge the diagnostic gap of CD in adults. MATERIALS AND METHODS All subjects under 75 years of age who consecutively went to their general practitioners' offices were offered POCT for anti-transglutaminase immunoglobulin A antibodies. The POCT was performed on all subjects who agreed, and then a systematic search for symptoms or conditions associated with higher risk for CD was performed, immediately after the test but before knowing the test results. The 2 resulting groups were: (a) POCT positive and (b) symptomatic subject at CF. Subjects were defined as symptomatic at CF in the presence of 1 or more symptoms. All POCT-positive or symptomatic subjects at CF were referred to the CD Centers for confirmation of CD. Data on resource consumption were gathered from patients' charts. Cost of examinations, and diagnostic and laboratory tests were estimated with regional outpatient tariffs (Sicily), and a price of &OV0556;2.5 was used for each POCT. RESULTS Of a total of 2197 subjects who agreed to participate in the study, 36 (1.6%) and 671 (30.5%) were POCT positive and symptomatic at CF, respectively. The yield from the screening and CF was 5 new celiac patients. The total cost and mean cost for each new CD case were &OV0556;7497.35 and &OV0556;1499.47 for the POCT screening strategy, and &OV0556;9855.14 and &OV0556;1971.03 for the CF strategy, respectively. Assuming consecutive use of both strategies, performing POCT only in symptomatic subjects at CF, the calculated yield would be 4 new diagnoses with a total cost of &OV0556;2345.84 and a mean cost of &OV0556;586.46 for each newly diagnosed patient. Only 1 patient was celiac despite a negative POCT. CONCLUSIONS Testing symptomatic subjects at CF only by POCT seems the most cost-effective strategy to bridge the diagnostic gap of adult CD in primary care.
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Jelsness-Jørgensen LP, Bernklev T, Lundin KEA. Fatigue as an Extra-Intestinal Manifestation of Celiac Disease: A Systematic Review. Nutrients 2018; 10:nu10111652. [PMID: 30400298 PMCID: PMC6266448 DOI: 10.3390/nu10111652] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 12/30/2022] Open
Abstract
Celiac disease may present with a range of different symptoms, including abdominal problems in a broader sense, iron deficiency and “constant tiredness”. All of these symptoms should consequently lead the clinicians to consider celiac disease as a potential etiopathogenetic cause. Although the pathophysiology of celiac disease is well documented, the actual mechanisms for disease presentation(s) are less well understood. We here address the topic of fatigue in celiac disease. A systematic literature search identified 298 papers of which five met the criteria for full evaluation. None of the reviewed papers were of high quality and had several methodological weaknesses. We conclude that there is an unmet need to study the contributing factors and management of fatigue in celiac disease.
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Affiliation(s)
- Lars-Petter Jelsness-Jørgensen
- Department of Health Science, Østfold University College, N-1757 Halden, Norway.
- Department of Gastroenterology, Østfold Hospital Trust Kalnes, N-1714 Grålum, Norway.
| | - Tomm Bernklev
- Department of Research and Innovation, Vestfold Hospital Trust, N-3103 Tønsberg, Norway.
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, N-0318 Oslo, Norway.
| | - Knut E A Lundin
- K.G. Jebsen Coeliac Disease Research Centre, University of Oslo, N-0318 Oslo, Norway.
- Department of gastroenterology, Oslo University Hospital Rikshospitalet, N-0372 Oslo, Norway.
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Office-Based Point of Care Testing (IgA/IgG-Deamidated Gliadin Peptide) for Celiac Disease. Am J Gastroenterol 2018; 113:1238-1246. [PMID: 29915400 DOI: 10.1038/s41395-018-0143-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/04/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Celiac disease (CD) is common yet under-detected. A point of care test (POCT) may improve CD detection. We aimed to assess the diagnostic performance of an IgA/IgG-deamidated gliadin peptide (DGP)-based POCT for CD detection, patient acceptability, and inter-observer variability of the POCT results. METHODS From 2013-2017, we prospectively recruited patients referred to secondary care with gastrointestinal symptoms, anemia and/or weight loss (group 1); and patients with self-reported gluten sensitivity with unknown CD status (group 2). All patients had concurrent POCT, IgA-tissue transglutaminase (IgA-TTG), IgA-endomysial antibodies (IgA-EMA), total IgA levels, and duodenal biopsies. Five hundred patients completed acceptability questionnaires, and inter-observer variability of the POCT results was compared among five clinical staff for 400 cases. RESULTS Group 1: 1000 patients, 58.5% female, age 16-91, median age 57. Forty-one patients (4.1%) were diagnosed with CD. The sensitivities of the POCT, IgA-TTG, and IgA-EMA were 82.9, 78.1, and 70.7%; the specificities were 85.4, 96.3, and 99.8%. Group 2: 61 patients, 83% female; age 17-73, median age 35. The POCT had 100% sensitivity and negative predictive value in detecting CD in group 2. Most patients preferred the POCT to venepuncture (90.4% vs. 2.8%). There was good inter-observer agreement on the POCT results with a Fleiss Kappa coefficient of 0.895. CONCLUSIONS The POCT had comparable sensitivities to serology, and correctly identified all CD cases in a gluten sensitive cohort. However, its low specificity may increase unnecessary investigations. Despite its advantage of convenience and rapid results, it may not add significant value to case finding in an office-based setting.
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Jinga M, Popp A, Balaban DV, Dima A, Jurcut C. Physicians' attitude and perception regarding celiac disease: A questionnaire-based study. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2018; 29:419-426. [PMID: 30249556 PMCID: PMC6284647 DOI: 10.5152/tjg.2018.17236] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND/AIMS Despite its high prevalence, affecting about 1% of the general population, celiac disease (CD) remains heavily underdiagnosed. Among the reasons for underdiagnosis, awareness among medical professionals has been little studied. The aim of this survey was to determine physicians' knowledge in regard to CD in adult patients. MATERIALS AND METHODS An 18-items questionnaire pointing out general features, clinical presentation, diagnosis and management of CD patients was addressed to physicians from different medical specialties, in training or board-certified, from one universitary center. RESULTS Altogether 153 physicians were invited to complete the survey (69.3% female, 35.9% gastroenterologists). Overall, 69.9% of the physicians questioned considered CD as a rare disorder. Lymphoma increased risk was highlighted in significant higher proportion by gastroenterologists when compared with physicians of other medical specialty. Chronic diarrhea, weight loss, iron-deficiency anemia, and abdominal pain were the first four conditions recognized as associated with CD, by 94.1%, 76.5%, 61.4%, and 54.2% study participants, respectively. About one-third of respondents (34.5%) affirmed to perform total serum IgA testing in all patients tested for CD. Intestinal biopsy confirmation of a positive celiac serology was reported by 65.4% physicians, with a higher proportion among gastroenterologists: 81.5% versus 56.6%. In regard to CD management, both groups concluded that referral to specialized centers should be recommended. CONCLUSION This study highlights poor awareness among the physicians' in regard to important CD features and diagnostic recommendations in adult patients. More efforts are warranted to improve awareness on CD features among physicians of different medical specialties.
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Affiliation(s)
- Mariana Jinga
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Dr Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - Alina Popp
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Alessandrescu-Rusescu Institute for Mother and Child Health, Bucharest, Romania
| | | | - Alina Dima
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ciprian Jurcut
- Dr Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
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Esteve M, Rosinach M, Llordés M, Calpe J, Montserrat G, Pujals M, Cela A, Carrasco A, Ibarra M, Ruiz-Ramirez P, Tristán E, Arau B, Ferrer C, Mariné M, Ribes J, Fernández-Bañares F. Case-finding in primary care for coeliac disease: Accuracy and cost-effectiveness of a rapid point-of-care test. United European Gastroenterol J 2018; 6:855-865. [PMID: 30023063 PMCID: PMC6047282 DOI: 10.1177/2050640618761700] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 01/31/2018] [Indexed: 01/10/2023] Open
Abstract
Background An on-site, rapid, fingertip, whole-blood point-of-care test (POCT) is attractive for active case-finding of coeliac disease (CD) in primary care because of its simplicity. Aim The aim of this article is to assess the usefulness and cost-effectiveness of adult case-finding using a POCT based on deamidated gliadin peptide antibodies (IgA/IgG-DGP) in primary care for CD diagnosis. Methods A case-finding study for CD was conducted by using an easy-to-use, on-site, whole-blood for IgA/IgG-DGP-based fingertip POCT compared with tTG2 in 350 individuals. Sample size was calculated based on 0.28% prevalence in the reference population. Duodenal biopsies for histology, intraepithelial lymphocytes and in situ deposition of tTG2 were obtained if tTG2 and/or POCT were positive. Accuracy and cost-effectiveness of strategies using serology or POCT were calculated. Results Prevalence of CD was 1.14% (95% CI, 0.3–3.4), almost double what was previously observed. Four patients were diagnosed with CD. tTG2 was positive in three (0.85%) and POCT in 29 (8.2%). Sensitivity of POCT for CD was 100%, specificity 93%, PPV 14%, and NPV 100%. POCT followed by duodenal biopsy was the most cost-effective approach in our setting (standard diagnosis: €13,033/case; POCT + duodenal biopsy: €7360/case). Conclusions A negative POCT allows ruling out CD in primary care, making it suitable for case-finding. POCT strategy was the most cost effective.
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Affiliation(s)
- Maria Esteve
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBEREHD), Madrid, Spain
- Maria Esteve, Department of Gastroenterology, Hospital Universitari Mútua Terrassa, University of Barcelona, Pl. Dr. Robert 5, 08221, Terrassa, Spain.
| | - Mercè Rosinach
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBEREHD), Madrid, Spain
| | - Montserrat Llordés
- Sud, Oest and Rambla Primary Care Centers, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Judit Calpe
- Sud, Oest and Rambla Primary Care Centers, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Glòria Montserrat
- Sud, Oest and Rambla Primary Care Centers, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Mar Pujals
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Abel Cela
- Sud, Oest and Rambla Primary Care Centers, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Anna Carrasco
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBEREHD), Madrid, Spain
| | - Montserrat Ibarra
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Pablo Ruiz-Ramirez
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Eva Tristán
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBEREHD), Madrid, Spain
| | - Beatriz Arau
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Carme Ferrer
- Sud, Oest and Rambla Primary Care Centers, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Meritxell Mariné
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBEREHD), Madrid, Spain
| | - Josepa Ribes
- Cancer Plan of the Catalan Government, L’Hospitalet de Llobregat, Catalonia, Spain; Department of Clinical Sciences, School of Medicine, Universitat de Barcelona; Cancer Epidemiology, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Spain
| | - Fernando Fernández-Bañares
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBEREHD), Madrid, Spain
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Paez MA, Gramelspacher AM, Sinacore J, Winterfield L, Venu M. Delay in Diagnosis of Celiac Disease in Patients Without Gastrointestinal Complaints. Am J Med 2017. [PMID: 28623177 DOI: 10.1016/j.amjmed.2017.05.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE The purpose of our study is to investigate the delay in diagnosis of patients with biopsy-proven celiac disease in those who present with gastrointestinal complaints vs nongastrointestinal complaints at our tertiary care center. Celiac disease is an autoimmune disorder that affects approximately 1% of the population worldwide. Celiac disease can have variable clinical presentations; it can be characterized by predominately gastrointestinal symptoms, or it may present without any gastrointestinal symptoms. METHODS We retrospectively reviewed the charts of 687 adult patients who carried the diagnosis of celiac disease. Patients included had biopsy-proven celiac disease and were categorized based on presence or absence of gastrointestinal symptoms prior to their diagnosis. RESULTS There were 101 patients with biopsy-proven celiac disease that met inclusion criteria. Fifty-two patients presented with gastrointestinal symptoms and 49 had nongastrointestinal complaints. Results from Mann-Whitney statistical analysis showed a median delay in diagnosis of 2.3 months for the gastrointestinal symptoms group and 42 months for the nongastrointestinal group (P <.001); 43.2% of patients with nongastrointestinal symptoms had abnormal thyroid-stimulating hormone, as opposed to 15.5% in the gastrointestinal symptom group (P = .004). Of patients with nongastrointestinal symptoms, 69.4% had anemia, compared with 11.5% of the gastrointestinal symptom group (P <.001). The majority of patients in the nongastrointestinal symptom group, 68%, were noted to have abnormal bone density scans, compared with 41% in the gastrointestinal symptom group. No sex differences were noted on chi-squared analysis between the 2 groups (P = .997). CONCLUSIONS Although there is growing awareness of celiac disease, the delay in diagnosis for patients without gastrointestinal symptoms remains prolonged, with an average delay of 3.5 years.
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Affiliation(s)
- Marco A Paez
- Division of Gastroenterology, Department of Medicine, Howard College of Medicine, Washington, DC
| | | | - James Sinacore
- Department of Public Health Sciences, Loyola University Medical Center, Maywood, Ill
| | - Laura Winterfield
- Department of Dermatology, Medical University of South Carolina, Charleston
| | - Mukund Venu
- Division of Gastroenterology, Department of Medicine, Loyola University Medical Center, Maywood, Ill.
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Ludvigsson JF, Sjölander A, Murray JA, Hjalgrim H, Edgren G. Haemoglobin decline before coeliac disease diagnosis: a nationwide transfusion cohort study of 1.1 million blood donors. Gut 2017; 66:2036-2037. [PMID: 28159837 DOI: 10.1136/gutjnl-2016-313541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/16/2017] [Accepted: 01/17/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building 2, City Hospital, Nottingham, UK.,Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA
| | - Henrik Hjalgrim
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.,Department of Hematology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gustaf Edgren
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
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20
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Lau MSY, Sanders DS. Point of care testing for paediatric coeliac disease in the new ESPGHAN era. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:741-742. [PMID: 29082741 DOI: 10.17235/reed.2017.5337/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
One of the challenges in coeliac disease is the significant under-diagnosis despite the increasing prevalence and international guidelines for serological screening in appropriate patient cohorts. Several point-of-care tests for coeliac disease have been developed over the past decade with the aim of improving case detection using rapid and convenient testing. Most point-of-care tests, such as Biocard, detect anti-tissue transglutaminase (tTG) IgA antibodies, whereas Simtomax uniquely detects anti-deamidated gliadin peptide (DGP) IgA/IgG antibodies. A recent head-to-head trial in adults comparing two tTG-based point-of-care tests (Biocard and Celiac Quick Test) and Simtomax found that Simtomax was superior to Biocard and Celiac Quick Test, with sensitivities of 92.7%, 72.2% and 77.8%, respectively.
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21
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Screening for Celiac Disease in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis. Am J Gastroenterol 2017; 112:65-76. [PMID: 27753436 DOI: 10.1038/ajg.2016.466] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/13/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Celiac disease (CD) and irritable bowel syndrome (IBS) share similar symptoms, leading to confusion between the two and diagnostic delay. International guidelines recommend screening individuals with IBS for CD, via serological testing. However, studies published recently have cast doubt on the utility of this. We updated a previous meta-analysis examining this issue. METHODS MEDLINE, EMBASE, and EMBASE Classic were searched through to May 2016. Eligible studies recruited adults with IBS according to symptom-based criteria, physician's opinion, or questionnaire data. Tests for CD included IgA-class antigliadin antibodies (AGA), endomysial antibodies (EMA), tissue transglutaminase antibodies (tTG), or duodenal biopsies following positive serology. The proportion of individuals meeting criteria for IBS testing positive for CD was combined to give a pooled prevalence for all studies, and compared between cases with IBS and, healthy controls without (where reported), using an odds ratio (OR) with a 95% confidence interval (CI). RESULTS There were 36 eligible studies, recruiting 15,256 individuals, of whom 9,275 (60.8%) met criteria for IBS. Pooled ORs for positive IgA AGAs, EMA and/or tTG, and biopsy-proven CD in IBS subjects vs. controls were 3.21 (95% CI 1.55-6.65), 2.75 (95% CI 1.35-5.61), and 4.48 (95% CI 2.33-8.60), respectively. There was no increase in ORs for any test for CD among cases with IBS in North American studies, and results were inconsistent in population-based studies. The prevalence of biopsy-proven CD was significantly higher across all subtypes of IBS. Limitations included heterogeneity in some analyses, and few North American studies. CONCLUSIONS Overall, prevalence of positive celiac serology and biopsy-proven CD was significantly higher in subjects with symptoms suggestive of IBS vs. healthy controls. However, the utility of screening for CD in individuals with suspected IBS in North America or in the community is less clear.
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22
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Development and optimisation of a generic micro LC-ESI-MS method for the qualitative and quantitative determination of 30-mer toxic gliadin peptides in wheat flour for food analysis. Anal Bioanal Chem 2016; 409:989-997. [DOI: 10.1007/s00216-016-0013-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/01/2016] [Accepted: 10/06/2016] [Indexed: 01/06/2023]
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Snyder J, Butzner JD, DeFelice AR, Fasano A, Guandalini S, Liu E, Newton KP. Evidence-Informed Expert Recommendations for the Management of Celiac Disease in Children. Pediatrics 2016; 138:peds.2015-3147. [PMID: 27565547 DOI: 10.1542/peds.2015-3147] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2016] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- John Snyder
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's National Health Systems, Washington, District of Columbia;
| | - J Decker Butzner
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, University of Calgary, Calgary, Alberta, Canada
| | - Amy R DeFelice
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, New York-Presbyterian Hospital, Columbia University, New York, New York
| | - Alessio Fasano
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Stefano Guandalini
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Chicago Medical Center, Chicago, Illinois
| | - Edwin Liu
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; and
| | - Kimberly P Newton
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Rady Children's Hospital and University of California San Diego School of Medicine, San Diego, California
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Abstract
Dietary exclusion of gluten-containing products has become increasingly popular in the general population, and currently ∼30% of people in the United States are limiting gluten ingestion. Although celiac disease (CD), wheat allergy (WA), and nonceliac gluten sensitivity (NCGS) constitute a spectrum of gluten-related disorders that require exclusion of gluten from the diet, together these account for a relatively small percentage of those following a gluten-free diet, and the vast majority has no medical necessity for doing so. Differentiating between CD, WA, and NCGS has important prognostic and therapeutic implications. Because of the protean manifestations of gluten-related disorders, it is not possible to differentiate between them on clinical grounds alone. This clinical report will compare and contrast the manifestations of gluten-related disorders, emphasize the importance of differentiating between these conditions, discuss initial and subsequent tests needed to confirm the diagnosis, and provide recommendations on treatment and follow-up for each condition.
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25
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The prevalence of celiac disease in patients with irritable bowel syndrome and its subtypes. GASTROENTEROLOGY REVIEW 2016; 11:276-281. [PMID: 28053683 PMCID: PMC5209460 DOI: 10.5114/pg.2016.57941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/22/2015] [Indexed: 12/13/2022]
Abstract
Introduction Irritable bowel syndrome (IBS) and celiac disease (CD) share some gastrointestinal symptoms. Celiac disease should be considered in a differential diagnosis of IBS. Aim To estimate the prevalence of predispositions to CD in patients with IBS and its subtypes. Material and methods The study included 48 patients (40 women, 8 men; average age: 41.1 ±14.6 years) with IBS, and a control group: 20 healthy volunteers. All participants completed a questionnaire on their current gastrointestinal symptoms and had a blood sample taken to determine the HLA-DQ2/DQ8 antigens and serum concentration of anti-tTG IgA and anti-DGP IgA and IgG. Results The presence of HLA-DQ2 or DQ8 was found in 50% of patients (n = 24) with IBS. In the control group the presence of HLA-DQ2 was found in 4 (20%) patients and nobody had HLA-DQ8. Increased levels of anti-tTG IgA were found in 5 (10.42%) patients with IBS, anti-DGP in 4 (8.33%), and anti-DGP IgG in 3 (6.25%). In the control group positive test result for anti-tTG was found in 2 (10%) patients; nobody had elevated anti-DGP IgA or IgG. A concomitant positive result of genetic testing and any elevated serum antibodies specific to CD was found in 12.5% of IBS patients (n = 6) and in none of the control group. Conclusions Patients with IBS, regardless of the subtype, significantly more often than healthy controls have the predisposing genetic factors (HLA-DQ2/DQ8) underlying the development of CD.
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Oz B, Akan O, Kocyigit H, Gürgan HA. Proximal muscle weakness as a result of osteomalacia associated with celiac disease: a case report. Osteoporos Int 2016; 27:837-40. [PMID: 26310636 DOI: 10.1007/s00198-015-3285-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 08/05/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED A 24-year-old woman suffering from back and hip pain with difficulty in walking was reported. She had proximal muscle weakness. Laboratory findings led to the diagnosis of osteomalacia. Positivity of antibodies strengthened suspicion of celiac disease. In patients with proximal muscle weakness, osteomalacia should be considered in differential diagnosis even in a young woman. INTRODUCTION A 24-year-old woman suffering from back pain, bilateral hip pain, and difficulty in walking was reported. Her symptoms had started in the first trimester of pregnancy. METHODS In her physical examination, proximal muscle weakness and waddling gait pattern were determined. Her lumbar spine and hip MRI revealed no obvious pathological findings. Electromyography showed a myophatic pattern. RESULTS Physical examination, normal values of creatine kinase, and muscle biopsy were supplied to exclude the diagnosis of primer muscle diseases. Laboratory findings led to the diagnosis of osteomalacia with normal renal function. Gastrointestinal symptoms and positivity of anti-gliadin and anti-endomysium antibodies strengthened the suspicion of celiac disease as a cause of the osteomalacia. The diagnosis of celiac disease was confirmed with duodenal mucosal biopsy. CONCLUSION In patients with proximal muscle weakness and waddling gait pattern, osteomalacia should be considered in differential diagnosis even in a young woman and underlying disease should be investigated.
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Affiliation(s)
- B Oz
- Physical Therapy and Rehabilitation Clinic, Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey.
| | - O Akan
- Physical Therapy and Rehabilitation Clinic, Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey
| | - H Kocyigit
- Physical Therapy and Rehabilitation Clinic, Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey
| | - H A Gürgan
- Physical Therapy and Rehabilitation Clinic, Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey
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Roy A, Smith C, Daskalakis C, Voorhees K, Moleski S, DiMarino AJ, Kastenberg D. Physicians Caring for Celiac Patients do not Routinely Recommend Screening of First-Degree Family Members. ACTA ACUST UNITED AC 2015; 4:1838-1843. [PMID: 28164022 DOI: 10.17554/j.issn.2224-3992.2015.04.585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM Screening first-degree relatives of celiac disease (CD) patients offers an opportunity to diagnose CD in a high-risk population.This study aims to determine how frequently CD patients receive a physician-issued recommendation for first-degree relative screening. MATERIALS AND METHODS A 12-question survey assessing whether CD patients receive a physician recommendation to screen first-degree relatives for CD, and the impact of such a recommendation, was validated with outpatients in a university gastroenterology practice ("University"). The 12-question survey was then distributed online to members of a celiac organization - the National Foundation for Celiac Awareness ("NFCA"). Results were collected over 3 months. Univariate analysis was used to compare cohort means and assess the association between demographic and diagnostic factors and first-degree relative screening recommendations. RESULTS 87 University patients participated in the validation phase. Test-retest reliability of 4 key survey questions was high (Kappa coefficient > 0.80). The main analyses were based on data from 677 NFCA and 82 University respondents. Respondents were predominantly female, with a mean age of 45 years. Significantly more University patients received a recommendation for screening (78% vs 44%, p < 0.001). Ninety-eight percent receiving a screening recommendation (both groups) discussed this with family members, leading to CD screening (University 71%, NFCA 79%) and, ultimately, a CD diagnosis (University 18%, NFCA 27%). CONCLUSIONS Physicians of CD patients often do not recommend screening first-degree family members. The high clinical impact of this recommendation suggests that greater physician compliance with screening may increase the diagnosis of CD in high risk individuals.
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Affiliation(s)
- Abhik Roy
- Department of Medicine, Thomas Jefferson University; 132 South 10th Street, Suite 480, Philadelphia, PA 19107, the United States
| | - Colin Smith
- Department of Medicine, Thomas Jefferson University; 132 South 10th Street, Suite 480, Philadelphia, PA 19107, the United States
| | - Constantine Daskalakis
- Division of Biostatistics, Thomas Jefferson University; 1015 Chestnut Street, Suite M-100 Mezzanine, Philadelphia, PA 19107, the United States
| | - Kristin Voorhees
- National Foundation for Celiac Awareness;124 South Maple Street Ambler, PA 19002, the United States
| | - Stephanie Moleski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University; 132 South 10th Street, Suite 480, Philadelphia, PA 19107, the United States
| | - Anthony J DiMarino
- Division of Gastroenterology and Hepatology, Thomas Jefferson University; 132 South 10th Street, Suite 480, Philadelphia, PA 19107, the United States
| | - David Kastenberg
- Division of Gastroenterology and Hepatology, Thomas Jefferson University; 132 South 10th Street, Suite 480, Philadelphia, PA 19107, the United States
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Habtamu HB, Sentic M, Silvestrini M, De Leo L, Not T, Arbault S, Manojlovic D, Sojic N, Ugo P. A Sensitive Electrochemiluminescence Immunosensor for Celiac Disease Diagnosis Based on Nanoelectrode Ensembles. Anal Chem 2015; 87:12080-7. [DOI: 10.1021/acs.analchem.5b02801] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Henok B. Habtamu
- Department
of Molecular Sciences and Nanosystems, University Ca’Foscari of Venice, via Torino 155, 30172 Venezia Mestre, Italy
- Institut
des Sciences Moléculaires, CNRS UMR 5255, University of Bordeaux, ENSCBP, 33607 Pessac, France
| | - Milica Sentic
- Institut
des Sciences Moléculaires, CNRS UMR 5255, University of Bordeaux, ENSCBP, 33607 Pessac, France
- Faculty
of Chemistry, University of Belgrade, 11000 Belgrade, Serbia
| | - Morena Silvestrini
- Department
of Molecular Sciences and Nanosystems, University Ca’Foscari of Venice, via Torino 155, 30172 Venezia Mestre, Italy
| | - Luigina De Leo
- Institute for
Maternal and Child Health - IRCCS “Burlo Garofolo”, 34100 Trieste, Italy
| | - Tarcisio Not
- Institute for
Maternal and Child Health - IRCCS “Burlo Garofolo”, 34100 Trieste, Italy
- University of Trieste, 34127 Trieste, Italy
| | - Stephane Arbault
- Institut
des Sciences Moléculaires, CNRS UMR 5255, University of Bordeaux, ENSCBP, 33607 Pessac, France
| | - Dragan Manojlovic
- Faculty
of Chemistry, University of Belgrade, 11000 Belgrade, Serbia
| | - Neso Sojic
- Institut
des Sciences Moléculaires, CNRS UMR 5255, University of Bordeaux, ENSCBP, 33607 Pessac, France
| | - Paolo Ugo
- Department
of Molecular Sciences and Nanosystems, University Ca’Foscari of Venice, via Torino 155, 30172 Venezia Mestre, Italy
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El-Salhy M, Hatlebakk JG, Gilja OH, Hausken T. The relation between celiac disease, nonceliac gluten sensitivity and irritable bowel syndrome. Nutr J 2015; 14:92. [PMID: 26345589 PMCID: PMC4561431 DOI: 10.1186/s12937-015-0080-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 08/28/2015] [Indexed: 12/22/2022] Open
Abstract
Wheat products make a substantial contribution to the dietary intake of many people worldwide. Despite the many beneficial aspects of consuming wheat products, it is also responsible for several diseases such as celiac disease (CD), wheat allergy, and nonceliac gluten sensitivity (NCGS). CD and irritable bowel syndrome (IBS) patients have similar gastrointestinal symptoms, which can result in CD patients being misdiagnosed as having IBS. Therefore, CD should be excluded in IBS patients. A considerable proportion of CD patients suffer from IBS symptoms despite adherence to a gluten-free diet (GFD). The inflammation caused by gluten intake may not completely subside in some CD patients. It is not clear that gluten triggers the symptoms in NCGS, but there is compelling evidence that carbohydrates (fructans and galactans) in wheat does. It is likely that NCGS patients are a group of self-diagnosed IBS patients who self-treat by adhering to a GFD.
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Affiliation(s)
- Magdy El-Salhy
- Section for Gastroenterology, Department of Medicine, Stord Hospital, Stord, Norway.
- Section for Neuroendocrine Gastroenterology, Division of Gastroenterology, Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- National Centre for Functional Gastrointestinal Disorders, Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Jan Gunnar Hatlebakk
- Section for Neuroendocrine Gastroenterology, Division of Gastroenterology, Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- National Centre for Functional Gastrointestinal Disorders, Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Odd Helge Gilja
- Section for Neuroendocrine Gastroenterology, Division of Gastroenterology, Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- National Centre for Functional Gastrointestinal Disorders, Department of Medicine, Haukeland University Hospital, Bergen, Norway.
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Trygve Hausken
- Section for Neuroendocrine Gastroenterology, Division of Gastroenterology, Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- National Centre for Functional Gastrointestinal Disorders, Department of Medicine, Haukeland University Hospital, Bergen, Norway.
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway.
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Lundin KEA, Qiao SW, Snir O, Sollid LM. Coeliac disease - from genetic and immunological studies to clinical applications. Scand J Gastroenterol 2015; 50:708-17. [PMID: 25846940 DOI: 10.3109/00365521.2015.1030766] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Coeliac disease is a common and important gastrointestinal disease. It affects at least 1%, most Western European populations and in Nordic countries it is even more frequent. It is strongly associated with certain Human Leukocyte Antigen-DQ genes and triggered by ingestion of wheat gluten and related cereals from rye and barley. The diagnosis relies on a combination of clinical signs, serology and small intestinal biopsy. Work during the last couple of decades has shown that gluten-specific, Human Leukocyte Antigen-DQ-restricted T-cells in the intestinal mucosa are of paramount importance in the disease process. The gluten peptides are chemically modified by the endogenous enzyme transglutaminase 2, the same enzyme that serves as target in today's sensitive serological tests for coeliac disease. The increasing knowledge on the disease process allows for development of improved diagnosis, patient care and new treatment modalities.
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Affiliation(s)
- Knut E A Lundin
- Department of Gastroenterology, Oslo University Hospital-Rikshospitalet , Oslo , Norway
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31
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Skypala IJ, Venter C, Meyer R, deJong NW, Fox AT, Groetch M, Oude Elberink JN, Sprikkelman A, Diamandi L, Vlieg-Boerstra BJ. The development of a standardised diet history tool to support the diagnosis of food allergy. Clin Transl Allergy 2015; 5:7. [PMID: 25741437 PMCID: PMC4349299 DOI: 10.1186/s13601-015-0050-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/30/2015] [Indexed: 01/26/2023] Open
Abstract
The disparity between reported and diagnosed food allergy makes robust diagnosis imperative. The allergy-focussed history is an important starting point, but published literature on its efficacy is sparse. Using a structured approach to connect symptoms, suspected foods and dietary intake, a multi-disciplinary task force of the European Academy of Allergy and Clinical Immunology developed paediatric and adult diet history tools. Both tools are divided into stages using traffic light labelling (red, amber and green). The red stage requires the practitioner to gather relevant information on symptoms, atopic history, food triggers, foods eaten and nutritional issues. The amber stage facilitates interpretation of the responses to the red-stage questions, thus enabling the practitioner to prepare to move forward. The final green stage provides a summary template and test algorithm to support continuation down the diagnostic pathway. These tools will provide a standardised, practical approach to support food allergy diagnosis, ensuring that all relevant information is captured and interpreted in a robust manner. Future work is required to validate their use in diverse age groups, disease entities and in different countries, in order to account for differences in health care systems, food availability and dietary norms.
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Affiliation(s)
| | - Carina Venter
- The David Hide 6. Asthma and Allergy Research Centre, Isle of Wight, UK
| | - Rosan Meyer
- Great Ormond Street NHS Foundation Trust, London, UK
| | | | - Adam T Fox
- Guy's and St Thomas' Hospitals NHS Foundation Trust and Kings College, London, UK
| | - Marion Groetch
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - J N Oude Elberink
- Department of Allergology, University Medical Centre of Groningen, University of Groningen, Groningen, NL Netherlands
| | - Aline Sprikkelman
- Emma Children's Hospital Academic Medical Centre, Amsterdam, NL Netherlands
| | | | - Berber J Vlieg-Boerstra
- Emma Children's Hospital, Paediatric Respiratory Medicine and Allergy, Academic Medical Centre, University of Amsterdam, Amsterdam, NL Netherlands
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Abstract
Among the adverse reactions caused by wheat, celiac disease (CD) is the longest studied and best-known pathology. The more recently defined non-celiac gluten sensitivity (NCGS) presents with symptoms which are often indistinguishable from CD. Diagnosis of CD is based on serologic, molecular, and bioptic testing. The IgA anti-transglutaminase (tTG) test is considered highly important, as it shows high sensitivity and specificity and its levels correlate to the degree of intestinal damage. Small bowel biopsy can be avoided in symptomatic patients with IgA anti-tTG levels above 10× the manufacturer's cut-off. Recently, tests of anti-deamidated peptides of gliadin (DGP) have replaced classic anti-native gliadin (AGA) tests. DGP assays have a considerably higher diagnostic accuracy than AGA assays, especially in the IgG class, and can replace anti-tTG tests in patients with selective IgA deficiency. The combination of IgG anti-DGP plus IgA anti-tTG assays show greater sensitivity than a single test, with very high specificity. EMA tests have great diagnostic accuracy but are not recommended by all the latest guidelines because they are observer dependent. Biopsy must still be considered the gold standard for CD diagnosis. HLA-DQ genotyping can be used to screen asymptomatic children and in cases of histology/serology disagreement. About half of NCGS patients are DQ2 positive and have IgG AGA. To diagnose NCGS, first CD and wheat allergy must be excluded; then the wheat dependence of symptoms must be verified by a gluten-free diet and subsequent gluten challenge.
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Mooney PD, Hadjivassiliou M, Sanders DS. Emerging drugs for coeliac disease. Expert Opin Emerg Drugs 2014; 19:533-44. [DOI: 10.1517/14728214.2014.959490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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34
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Mooney PD, Kurien M, Evans KE, Chalkiadakis I, Hale MF, Kannan MZ, Courtice V, Johnston AJ, Irvine AJ, Hadjivassiliou M, Sanders DS. Point-of-care testing for celiac disease has a low sensitivity in endoscopy. Gastrointest Endosc 2014; 80:456-62. [PMID: 24685008 DOI: 10.1016/j.gie.2014.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 02/06/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Celiac disease (CD) is a common but underdiagnosed condition. A rapid point-of-care test (POCT) could reduce lead times and missed diagnoses. OBJECTIVE To assess the utility of an immunoglobulin (Ig) A tissue transglutaminase (TTG) antibody POCT in an endoscopic setting. DESIGN Prospective observational study. SETTING A single UK university hospital. PATIENTS Patients presenting with suspected CD, known CD, and routine endoscopy for upper GI symptoms. INTERVENTIONS All patients were tested with POCT, serum TTG, endomysial antibody (EMA), and upper GI endoscopy with duodenal biopsies at the same visit. MAIN OUTCOME MEASUREMENTS Comparison was made with histology in all cases, with villous atrophy regarded as diagnostic of CD. RESULTS A total of 576 patients (63.5% female, mean [± standard deviation] age 49.7 years [± 17.6 years]) were recruited. A total of 523 patients had no prior diagnosis of CD, and 53 patients had known CD coming for reassessment. A total of 117 patients were newly diagnosed with CD, and 82 were positively identified by the POCT. Sensitivity, specificity, positive predictive value, and negative predictive value were 70.1%, 96.6%, 85.4%, and 91.8%, respectively. In comparison, TTG and EMA both performed significantly better than the POCT. Sensitivity and specificity of TTG were 91.0% and 83.5%, respectively, and EMA were 83.8% and 97.5%, respectively. Of patients with known CD coming for reassessment, 26 had villous atrophy, and POCT results were positive in 16 (61.5%). There was poor agreement between POCT and standard serology. LIMITATIONS High pre-test probability of CD. CONCLUSION The performance of this POCT was disappointing compared with standard serology and cannot at present be recommended within the context of an endoscopy unit.
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Affiliation(s)
- Peter D Mooney
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Matthew Kurien
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Kate E Evans
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Ioannis Chalkiadakis
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Melissa F Hale
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Mohamad Z Kannan
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Victoria Courtice
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Alexander J Johnston
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Andrew J Irvine
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | | | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
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35
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EL-SALHY MAGDY, GILJA ODDHELGE, GUNDERSEN DORIS, HATLEBAKK JANG, HAUSKEN TRYGVE. Interaction between ingested nutrients and gut endocrine cells in patients with irritable bowel syndrome (review). Int J Mol Med 2014; 34:363-71. [PMID: 24939595 PMCID: PMC4094590 DOI: 10.3892/ijmm.2014.1811] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 02/10/2014] [Indexed: 12/15/2022] Open
Abstract
Several endocrine cell abnormalities have been reported in different segments of the gastrointestinal tract of patients with irritable bowel syndrome (IBS). These cells have specialized microvilli that project into the lumen; they function as sensors for the gut contents and respond to luminal stimuli (mostly ingested nutrients) by releasing hormones into the lamina propria, where they exert their effects via a paracrine/endocrine mode of action. Certain food items trigger the symptoms experienced by IBS patients, including those rich in fermentable oligo-, di- and monosaccharides, and polyols (FODMAPs). In this review, we present the argument that the effects of both FODMAPs and the proportional intake of proteins, fats and carbohydrates on IBS symptoms may be caused by an interaction with the gut endocrine cells. Since the gut hormones control and regulate gastrointestinal motility and sensation, this interaction may be responsible for abnormal gastrointestinal motility and the visceral hypersensitivity observed in these patients. There is no consistent evidence that IBS patients suffer from food allergy. The role of gluten intolerance in the development of IBS symptoms in these patients remains a matter of controversy. Individual guidance on food management, which includes restrictions in the intake of FODMAP-rich foods and testing diets with different proportions of proteins, fats and carbohydrates has been found to reduce the symptoms, improve the quality of life, and make the habitual diet of IBS patients more healthy.
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Affiliation(s)
- MAGDY EL-SALHY
- Section of Gastroenterology, Department of Medicine, Stord Helse-Fonna Hospital, University of Bergen, Bergen, Norway
- Section of Gastroenterology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - ODD HELGE GILJA
- Section of Gastroenterology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - JAN G. HATLEBAKK
- Section of Gastroenterology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - TRYGVE HAUSKEN
- Section of Gastroenterology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Ludvigsson JF, Bai JC, Biagi F, Card TR, Ciacci C, Ciclitira PJ, Green PHR, Hadjivassiliou M, Holdoway A, van Heel DA, Kaukinen K, Leffler DA, Leonard JN, Lundin KEA, McGough N, Davidson M, Murray JA, Swift GL, Walker MM, Zingone F, Sanders DS. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut 2014; 63:1210-28. [PMID: 24917550 PMCID: PMC4112432 DOI: 10.1136/gutjnl-2013-306578] [Citation(s) in RCA: 719] [Impact Index Per Article: 71.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A multidisciplinary panel of 18 physicians and 3 non-physicians from eight countries (Sweden, UK, Argentina, Australia, Italy, Finland, Norway and the USA) reviewed the literature on diagnosis and management of adult coeliac disease (CD). This paper presents the recommendations of the British Society of Gastroenterology. Areas of controversies were explored through phone meetings and web surveys. Nine working groups examined the following areas of CD diagnosis and management: classification of CD; genetics and immunology; diagnostics; serology and endoscopy; follow-up; gluten-free diet; refractory CD and malignancies; quality of life; novel treatments; patient support; and screening for CD.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
| | - Julio C Bai
- Department of Medicine, Dr C. Bonorino Udaondo Gastroenterology Hospital, Del Salvador University, Buenos Aires, Argentina
| | - Federico Biagi
- Coeliac Centre/1st Department of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Timothy R Card
- University of Nottingham, Department of Epidemiology and Public Health, Nottingham City Hospital, Nottingham, UK
| | - Carolina Ciacci
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Paul J Ciclitira
- Gastroenterology, Division of Nutritional Sciences, King's College London, The Rayne Institute, St Thomas Hospital, London, UK
| | - Peter H R Green
- Coeliac Disease Center at Columbia University, New York, New York, USA
| | | | - Anne Holdoway
- Registered dietitian and representative of the British Dietetic Association, Bath, Somerset, UK
| | - David A van Heel
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Katri Kaukinen
- School of Medicine, University of Tampere, Tampere, Finland Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland Department of Medicine, Seinäjoki Central Hospital, Finland
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan N Leonard
- Department of Dermatology, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Knut E A Lundin
- Department of Gastroenterology, Centre for Immune Regulation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | | - Mike Davidson
- Patient Representative & Regional Chairman for Coeliac UK, Sheffield, UK
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Immunology Mayo Clinic, Rochester, Minnesota, USA
| | - Gillian L Swift
- Department of Gastroenterology, University Hospital Llandough, Wales, UK
| | - Marjorie M Walker
- Anatomical Pathology, University of Newcastle, Faculty of Health and Medicine, School of Medicine & Public Health, Callaghan, Australia
| | - Fabiana Zingone
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - David S Sanders
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital & University of Sheffield, Sheffield, UK
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Duodenal chromogranin a cell density as a biomarker for the diagnosis of irritable bowel syndrome. Gastroenterol Res Pract 2014; 2014:462856. [PMID: 25028588 PMCID: PMC4083604 DOI: 10.1155/2014/462856] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 05/03/2014] [Indexed: 12/20/2022] Open
Abstract
Background and Aim. Chromogranin A (CgA) is a common marker for endocrine cells. The density of duodenal CgA cells is reduced in patients with irritable bowel syndrome (IBS). Methods. The present study was undertaken to evaluate the density of duodenal CgA as a biomarker for the diagnosis of IBS. Two hundred and three patients with IBS were recruited (180 females and 23 males; mean age, 36 years; range, 18-66 years). The control group comprised 86 healthy subjects without gastrointestinal complaints (77 females and 9 males; mean age, 38 years; range, 18-67 years). Biopsy samples were taken from the duodenum during gastroscopy. Sections from these biopsy samples were immunostained for CgA using the avidin-biotin complex (ABC) method. CgA cell density was quantified by computerized image analysis. Results. The CgA cell density was lower in IBS-total and in all of the IBS subgroups than in the controls. The sensitivity and specificity for a cutoff of <200 cells/mm(2) were 86% and 95%, respectively. Conclusion. The duodenal CgA cell density seems to be a good biomarker for the diagnosis of IBS. It is an inexpensive, simple, and easy-to-use method that does not require sophisticated equipment or considerable experience.
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38
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Abraham G, Tye-Din JA, Bhalala OG, Kowalczyk A, Zobel J, Inouye M. Accurate and robust genomic prediction of celiac disease using statistical learning. PLoS Genet 2014; 10:e1004137. [PMID: 24550740 PMCID: PMC3923679 DOI: 10.1371/journal.pgen.1004137] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 12/08/2013] [Indexed: 12/25/2022] Open
Abstract
Practical application of genomic-based risk stratification to clinical diagnosis is appealing yet performance varies widely depending on the disease and genomic risk score (GRS) method. Celiac disease (CD), a common immune-mediated illness, is strongly genetically determined and requires specific HLA haplotypes. HLA testing can exclude diagnosis but has low specificity, providing little information suitable for clinical risk stratification. Using six European cohorts, we provide a proof-of-concept that statistical learning approaches which simultaneously model all SNPs can generate robust and highly accurate predictive models of CD based on genome-wide SNP profiles. The high predictive capacity replicated both in cross-validation within each cohort (AUC of 0.87–0.89) and in independent replication across cohorts (AUC of 0.86–0.9), despite differences in ethnicity. The models explained 30–35% of disease variance and up to ∼43% of heritability. The GRS's utility was assessed in different clinically relevant settings. Comparable to HLA typing, the GRS can be used to identify individuals without CD with ≥99.6% negative predictive value however, unlike HLA typing, fine-scale stratification of individuals into categories of higher-risk for CD can identify those that would benefit from more invasive and costly definitive testing. The GRS is flexible and its performance can be adapted to the clinical situation by adjusting the threshold cut-off. Despite explaining a minority of disease heritability, our findings indicate a genomic risk score provides clinically relevant information to improve upon current diagnostic pathways for CD and support further studies evaluating the clinical utility of this approach in CD and other complex diseases. Celiac disease (CD) is a common immune-mediated illness, affecting approximately 1% of the population in Western countries but the diagnostic process remains sub-optimal. The development of CD is strongly dependent on specific human leukocyte antigen (HLA) genes, and HLA testing to identify CD susceptibility is now commonly undertaken in clinical practice. The clinical utility of HLA typing is to exclude CD when the CD susceptibility HLA types are absent, but notably, most people who possess HLA types imparting susceptibility for CD never develop CD. Therefore, while genetic testing in CD can overcome several limitations of the current diagnostic tools, the utility of HLA typing to identify those individuals at increased-risk of CD is limited. Using large datasets assaying single nucleotide polymorphisms (SNPs), we have developed genomic risk scores (GRS) based on multiple SNPs that can more accurately predict CD risk across several populations in “real world” clinical settings. The GRS can generate predictions that optimize CD risk stratification and diagnosis, potentially reducing the number of unnecessary follow-up investigations. The medical and economic impact of improving CD diagnosis is likely to be significant, and our findings support further studies into the role of personalized GRS's for other strongly heritable human diseases.
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Affiliation(s)
- Gad Abraham
- Medical Systems Biology, Department of Pathology and Department of Microbiology & Immunology, The University of Melbourne, Parkville, Victoria, Australia
- NICTA Victoria Research Lab, Department of Computing and Information Systems, The University of Melbourne, Parkville, Victoria, Australia
| | - Jason A. Tye-Din
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Oneil G. Bhalala
- Medical Systems Biology, Department of Pathology and Department of Microbiology & Immunology, The University of Melbourne, Parkville, Victoria, Australia
| | - Adam Kowalczyk
- NICTA Victoria Research Lab, Department of Computing and Information Systems, The University of Melbourne, Parkville, Victoria, Australia
| | - Justin Zobel
- NICTA Victoria Research Lab, Department of Computing and Information Systems, The University of Melbourne, Parkville, Victoria, Australia
| | - Michael Inouye
- Medical Systems Biology, Department of Pathology and Department of Microbiology & Immunology, The University of Melbourne, Parkville, Victoria, Australia
- * E-mail:
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Mooney PD, Leeds JS, Libzo N, Sidhu R, Evans KE, Hall EJ, Jandu VS, Hopper AD, Basumani P, Dear KL, McAlindon ME, Sanders DS. Case-finding for coeliac disease in secondary care: a prospective multicentre UK study. Dig Liver Dis 2014; 46:32-5. [PMID: 24035218 DOI: 10.1016/j.dld.2013.08.127] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 07/08/2013] [Accepted: 08/06/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Coeliac disease affects 1% of the population. Despite this high prevalence, the majority of individuals are undetected. Many patients present with subtle symptoms which may also contribute to under diagnosis. Our aim was to determine the relative importance of different presenting characteristics. METHODS Unselected gastroenterology patients referred to 4 hospitals in South Yorkshire were investigated for coeliac disease. Diagnosis was based on positive serology and the presence of villous atrophy. Odds ratios were calculated for presenting characteristics and multivariate analysis performed to identify independent risk factors. RESULTS 4089 patients were assessed (41.5% male, mean age 55.8 ± 18.2 years); 129 had coeliac disease (3.2%, 95% CI 2.6-3.7%). Multivariate analysis of patients referred to secondary care showed family history of coeliac disease (OR 1.26, p < 0.0001), anaemia (OR 1.03, p < 0.0001) and osteoporosis (OR 1.1, p = 0.006) were independent risk factors for diagnosis of coeliac disease. When compared to population controls, diarrhoea (OR 4.1, p < 0.0001), weight loss (OR 2.7, p = 0.02), irritable bowel syndrome symptoms (OR 3.2, p = 0.005) thyroid disease (OR 4.4, p = 0.01) and diabetes (OR 3.0, p = 0.05) were also associated with increased coeliac disease risk. CONCLUSIONS Coeliac disease accounts for 1 in 31 referrals in secondary care to unselected gastroenterology clinics. A low threshold for coeliac disease testing should be adopted.
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Affiliation(s)
- Peter D Mooney
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield, S10 2JF, UK.
| | - John S Leeds
- Department of Gastroenterology, Aberdeen Royal Infirmary, Forester Hill Road, Aberdeen, AB25 2ZN, UK
| | - Nafan Libzo
- Department of Gastroenterology, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
| | - Reina Sidhu
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield, S10 2JF, UK
| | - Kate E Evans
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield, S10 2JF, UK
| | - Emma J Hall
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield, S10 2JF, UK
| | - Veerinder S Jandu
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield, S10 2JF, UK
| | - Andrew D Hopper
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield, S10 2JF, UK
| | - Pandurangan Basumani
- Department of Gastroenterology, Department of Gastroenterology, Rotherham District General Hospital, Moorgate Road, Rotherham, S60 2UD, UK
| | - Keith L Dear
- Department of Gastroenterology, Chesterfield Royal Hospital, Calow, Chesterfield, S44 5BL, UK
| | - Mark E McAlindon
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield, S10 2JF, UK
| | - David S Sanders
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield, S10 2JF, UK
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Mearin F, Rey E, Balboa A. Trastornos funcionales y motores digestivos. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36 Suppl 2:3-14. [DOI: 10.1016/s0210-5705(13)70048-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Mearin F, Montoro M. [Irritable bowel syndrome, celiac disease and gluten]. Med Clin (Barc) 2013; 143:124-9. [PMID: 24029448 DOI: 10.1016/j.medcli.2013.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 06/03/2013] [Accepted: 06/06/2013] [Indexed: 02/08/2023]
Abstract
For many years irritable bowel syndrome (IBS) and celiac disease (CD) have been considered 2 completely separate entities, with CD being clearly related to a permanent gluten intolerance and IBS having no relation with gluten ingestion. However IBS and CD symptoms may be indistinguishable, especially when diarrhea, bloating or abdominal pain predominate. In the last decade several studies have shown that the separation between CD and IBS is not so clear. Thus, some patients who have been diagnosed of IBS suffer in fact from CD. In addition, it seems that there is a group of patients who, without having CD, suffer gluten intolerance that cause them digestive symptoms similar to those of IBS. Gluten sensitivity is defined as the spectrum of morphological, immunological and functional abnormalities that respond to a gluten-free diet. This concept includes histological, immunological and clinical manifestations in the absence of evident morphological abnormalities. Therefore, it is mandatory to establish in a scientific way in which patients a gluten-free diet will be beneficial as well as when this is not justified.
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Affiliation(s)
- Fermín Mearin
- Instituto de Trastornos Funcionales y Motores Digestivos, Centro Médico Teknon, Barcelona, España.
| | - Miguel Montoro
- Unidad de Gastroenterología y Hepatología, Hospital San Jorge, Huesca, España
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Horvath AR. From evidence to best practice in laboratory medicine. Clin Biochem Rev 2013; 34:47-60. [PMID: 24151341 PMCID: PMC3799219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Laboratory tests offer value if they provide benefit to patients at acceptable costs. Laboratory testing is one of the most widely used diagnostic interventions supporting medical decisions, yet evidence demonstrating its value and impact on health outcomes is limited. This contributes to wide variations in test utilisation including underdiagnosis, overdiagnosis and misdiagnosis, which may impact the quality and the clinical- and cost-effectiveness of care and patient safety. Therefore implementing evidence into the care of patients is a moral and social imperative to laboratory professionals and all health care staff. This review investigates the reasons research does not get into practice, or only does with a very long delay. Apart from reviewing the common barriers to implementation, it also discusses the drivers of inappropriate test utilisation. By reviewing the theoretical and practical aspects of implementation science, recommendations are made for approaches that are thought to be most effective and that can be adopted to close the gap between evidence and practice, and to facilitate evidence-based laboratory medicine. Passive dissemination of the evidence and educational interventions are insufficient and do not offer sustainable solutions. A multifaceted and individualised implementation strategy, including individually tailored academic detailing, reminder systems, clinical decision support systems, feedback on performance, and participation of doctors and laboratory professionals in quality improvement activities addressing test selection and interpretation and in clinical audits, has greater potential for success. Examples of these initiatives at the laboratory and clinical interface are provided with links to valuable resources.
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Affiliation(s)
- A Rita Horvath
- SEALS Department of Clinical Chemistry, Prince of Wales Hospital; Screening and Test Evaluation Program, School of Public Health, University of Sydney, and School of Medical Sciences, University of New South Wales, Sydney, NSW 2031, Australia
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Castro F, Shiroky J, Raju R, Lurix E, Erim T, Johnston Y, Ukleja A. Routine Duodenal Biopsies in the Absence of Endoscopic Markers of Celiac Disease Are Not Useful: An Observational Study. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/623936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background. European studies have shown the utility of limiting endoscopic biopsies to diagnose celiac disease (CD) to patients that have high-risk symptoms or present with positive serology. However, many centers in the U.S. have open access endoscopy. Patients are referred without prior serologic testing, and endoscopists often decide whether or not to biopsy at the time of procedure. Aims. Evaluate the yield of duodenal biopsies for the diagnosis of CD in patients undergoing upper endoscopy without prior serologic testing. Methods. This retrospective study evaluated the frequency of CD diagnosis based duodenal biopsies. Researchers were interested in the yield of endoscopic stigmata findings in patients with high-risk symptoms versus low risk. Results. Eight hundred and ten patients met entry criteria at the Cleveland Clinic Florida between 2004 and 2008; 320 presented with high-risk symptoms; and 490 low risk. Sixty-one (7.5%) displayed endoscopic stigmata, and 10/61 (16.3%) were diagnosed with CD. Only patients who exhibited endoscopic stigmata were later diagnosed based on histologic findings. The presence of endoscopic stigmata greatly increased the probability of diagnosing CD, with a positive likelihood ratio of 15.6. Conclusions. When performing upper endoscopy without known serological markers for CD, clinicians should limit duodenal biopsies to patients with high-risk symptoms or endoscopic stigmata.
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Affiliation(s)
- Fernando Castro
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, FL 33331, USA
| | - Jennifer Shiroky
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, FL 33331, USA
| | - Ramu Raju
- Gastroenterology of the Rockies, Boulder, CO 80303, USA
| | - Einar Lurix
- Gastroenterology Consultants, IMA Greenville Hospital System, Greenville, SC 29607, USA
| | - Tolga Erim
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, FL 33331, USA
| | - Yasmin Johnston
- Department of Pathology, Cleveland Clinic Florida, Weston, FL 33331, USA
| | - Andrew Ukleja
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, FL 33331, USA
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Fingertip rapid point-of-care test in adult case-finding in coeliac disease. BMC Gastroenterol 2013; 13:115. [PMID: 23849178 PMCID: PMC3717015 DOI: 10.1186/1471-230x-13-115] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 07/09/2013] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Coeliac disease (CD), due to its protean clinical manifestation, is still very under diagnosed in adults and delays in diagnosis may take years and even decades. Simple tools to find cases in primary care may help to identify patients for further diagnostic tests. We have evaluated the usefulness of an on site rapid fingertip whole blood point-of-care test (POCT) for such a purpose. METHODS As CD is known to run within families, we tested 148 healthy relatives of 70 Romanian index cases with biopsy-proven CD (87% of all first-degree family members, median age 36 years) for the presence of circulating autoantibodies. In addition to performing the POCT (which measures blood erythrocyte self-TG2-autoantibody complexes) on site, blood was drawn for later evaluations of serum IgA-class endomysial antibodies (EMA). EMA-positive sera were further tested for transglutaminase 2 antibodies (TG2-IgA). All serological parameters were analyzed blindly in a centralized laboratory that had no knowledge of the on site POCT result. Endoscopic small intestinal biopsies was recommended for all POCT- or EMA-test positive subjects. RESULTS In on site testing the POCT was positive in 12/148 first-degree relatives (8%) and all these subjects were also serum EMA-positive. A positive EMA test was found only in one other subject. All remaining 135 healthy first-degree relatives were negative for both POCT and EMA. Four subjects positive for both POCT and EMA were negative for TG2-IgA. Ten out of thirteen of the antibody-positive subjects agreed to undergo endoscopy. The POCT was found to be positive in 8/9 first-degree relatives having coeliac-type mucosal lesions of grade Marsh 2 (n = 3) or Marsh 3 (n = 6). The three POCT-positive subjects not agreeing to undergo endoscopy were also both EMA- and TG2-IgA-positive. CONCLUSION The fingertip whole blood rapid POCT might fulfill the unmet need for a simple and cheap case-finding biomarker for early detection and presumptive diagnosis of CD. Confirmatory studies are warranted in adult case-finding in specialized outpatient clinics and in primary care.
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Al Saidi SS, Al Harthi SO, Mula-Abed WAS. Diagnostic utility of coeliac disease: a descriptive study in a tertiary care hospital, oman. Oman Med J 2013; 28:232-6. [PMID: 23904914 PMCID: PMC3725254 DOI: 10.5001/omj.2013.68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 05/27/2013] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVES The prevalence of coeliac disease in Oman is unknown. We aim to estimate the prevalence of coeliac disease in at-risk subjects, describe the clinical characteristics and laboratory findings associated with coeliac disease and the validity of serological testing for coeliac disease at the Royal Hospital, Oman over a period of three years. METHODS This is a retrospective case finding study. The medical and laboratory records were reviewed for patients for whom serum antiendomysium IgA antibodies were requested at the Royal Hospital during a 3-year period (1(st) Jan 2006-31(st) Dec 2008). The data were extracted in order to assess the following: a) Prevalence rate of coeliac disease among at-risk subjects; b) Clinical characteristics in patients with coeliac disease and clinical manifestations for which the requesting clinicians considered coeliac disease as a possible diagnosis, including their specialties; c) Laboratory tests results in patients with coeliac disease; and d) Validity of antiendomysium antibodies testing in comparison with histopathology of jejunal biopsies for diagnosing coeliac disease. RESULTS The study included 431 patients (250 females, 181 males) who were suspected of having (or screened for) coeliac disease. The median of age was 15 years (range: 9 months-74 years) with mean ± SD 18.95 ± 14.1 years. Of these, 15 (3.5%) patients (10 females, 5 males) with a median age of 19 years and mean 21.4 ± 13.0 years (range: 2.5-38 years), had positive antiendomysium antibodies results with median (range) of 160 (40-320) IU/L and mean± SD 204.5 ± 160 IU/L. Of these 15 patients, 13 had positive jejunal histopathological changes indicative of coeliac disease; the remaining 2 patients had no biopsy examination. Of the 44 patients with negative antiendomysium antibodies <10 IU/L who had jejunal biopsy, 41 were negative and 3 had histopathological changes suggestive of mild coeliac disease. All the 3 patients had serum total IgA levels within the reference range. The calculated validity indicators for antiendomysium antibodies were: sensitivity 81.3%, specificity 100%, positive predictive value 100%, negative predictive value 93.2% and efficiency 94.7%. The most common mode of presentation in patients with coeliac disease was gastrointestinal features, type 1 diabetes mellitus, anemia, short stature and hypothyroidism. The seropositivity in tye 1 diabetics was 4.9%. Investigations for coeliac disease were most frequently made by endocrinologists (pediatric and adult) who accounted for 53.8% followed by gastroenterologists (pediatric and adult) with 40.6% with less consideration by the other clinicians (5.6%). CONCLUSION The availability of highly specific and sensitive serological test and increased awareness for coeliac disease among some medical specialties has increased the number of diagnosed cases of coeliac disease. The requesting for serological test is being made mainly by endocrinologists and gastroenterologists.
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Affiliation(s)
- Safana Salim Al Saidi
- OMSB Resident (R6) Clinical Biochemistry Program; Department of Clinical Biochemistry, Sultan Qaboos University Hospital, PO Box 38, Al Khodh 123, Muscat, Sultanate of Oman
| | - Salim Omar Al Harthi
- Department of Gastroenterology, Royal Hospital, PO Box 1331, Seeb 111, Muscat, Sultanate of Oman
| | - Waad-Allah Sharef Mula-Abed
- Sr. Consultant and Head, Department of Chemical Pathology, Royal Hospital, PO Box 1331, Seeb 111, Muscat, Sultanate of Oman
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Oral administration of Bifidobacterium longum CECT 7347 ameliorates gliadin-induced alterations in liver iron mobilisation. Br J Nutr 2013; 110:1828-36. [PMID: 23657133 DOI: 10.1017/s0007114513001098] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Coeliac disease is an autoimmune disorder triggered by gluten intake, causing intestinal inflammation and mucosal damage commonly associated with the malabsorption of nutrients and ferropenic anaemia. The present study evaluates the effects of the oral administration of Bifidobacterium longum CECT 7347 on gliadin-mediated alterations in hepatic Fe deposition and Hb concentration, liver transferrin receptor (TfR)-2, IL-6, TNF-α and hepcidin (Hamp) expression (mRNA), and active hepcidin peptide production by liquid chromatography–MS/MS. Weanling rats, sensitised or not with interferon (IFN)-γ, were fed with gliadins and/or the bifidobacterial strain. Gliadin feeding increased hepatic Fe deposition; however, only gliadin-fed sensitised animals showed lower Hb concentrations than the controls. TfR2 expression decreased after gliadins were fed to both sensitised and non-sensitised animals,and restored by the administration of B. longum. These observations were accompanied by increases in IL-6 expression levels in all the treatment groups; however, TNF-α expression only increased significantly in animals fed gliadins alone or together with B. longum if they had previously been sensitised with IFN-γ. Liver expression levels of Hamp diminished in all cases to the lowest values in animals sensitised with IFN-γ after being fed with gliadins and/or bifidobacteria. In these animals, plasma Hamp active peptide concentrations significantly increased when compared with the controls. Significant correlations were calculated between Hamp expression and liver Fe contents (liver Fe = 1/0·0032 + 0·032 x Hamp(exp)), and Hb concentrations (Hb = 11·49 + 10·13 x (Hamp(exp))1/2). These data indicate that oral administration of B. longum ameliorates gliadin-mediated perturbations in liver Fe deposition and mobilisation.
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Wakim-Fleming J, Pagadala MR, Lemyre MS, Lopez R, Kumaravel A, Carey WD, Zein NN. Diagnosis of celiac disease in adults based on serology test results, without small-bowel biopsy. Clin Gastroenterol Hepatol 2013; 11:511-6. [PMID: 23305824 DOI: 10.1016/j.cgh.2012.12.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 12/04/2012] [Accepted: 12/07/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Celiac disease is underdiagnosed, with nonspecific symptoms and high morbidity. New diagnostic factors are needed. We aimed to estimate the frequency at which adult patients with positive results from serology tests are referred for small-bowel biopsies and to identify factors that improve the diagnosis of celiac disease. METHODS We performed a retrospective analysis of data from 2477 subjects who received serology tests for celiac disease between 2005 and 2007. We analyzed results for total levels of IgA, IgA against human tissue transglutaminase (hTTG), IgA and IgG against gliadin, as well as dilution titers of IgA against endomysial antibodies (EMA). Biopsy samples were analyzed by pathologists experienced in detecting mucosal changes associated with celiac disease and graded according to the Marsh system. RESULTS Of the 2477 patients, 610 (25%) had abnormal results from serology tests, and 39% of these patients (240 of 610) underwent small-bowel biopsy analyses. Of these patients, 50 (21%) had biopsy findings consistent with celiac disease (Marsh 3 lesions) and were placed on gluten-free diets. Titers of IgA hTTG greater than 118 U identified patients with celiac disease with a 2% false-positive rate. Titers of 21 to 118 U, in combination with an EMA dilution titer of 1:160 or greater, had a positive predictive value of 83% for celiac disease. IgA hTTG levels less than 20 U, in combination with an EMA dilution titer less than 1:10, had a negative predictive value of 92% for celiac disease. CONCLUSIONS Serum levels of IgA hTTG greater than 118 U, or 21 to 118 U in combination with an EMA dilution titer of 1:160 or greater, can be used to identify adult symptomatic patients with celiac disease, in the absence of a small-bowel biopsy.
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Affiliation(s)
- Jamile' Wakim-Fleming
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Hall NJ, Rubin GP, Charnock A. Intentional and inadvertent non-adherence in adult coeliac disease. A cross-sectional survey. Appetite 2013; 68:56-62. [PMID: 23623778 DOI: 10.1016/j.appet.2013.04.016] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 03/04/2013] [Accepted: 04/15/2013] [Indexed: 12/20/2022]
Abstract
Adherence to a gluten-free diet is the mainstay of treatment for coeliac disease. Non-adherence is common as the diet is restrictive and can be difficult to follow. This study aimed to determine the rates of intentional and inadvertent non-adherence in adult coeliac disease and to examine the factors associated with both. A self-completion questionnaire was mailed to adult coeliac patients identified from the computer records of 31 family practices within the North East of England. We received 287 responses after one reminder. Intentional gluten consumption was reported by 115 (40%) of respondents. 155 (54%) had made at least one known mistaken lapse over the same period and 82 (29%) reported neither intentional nor mistaken gluten consumption. Using logistic regression analysis, low self-efficacy, perceptions of tolerance to gluten and intention were found to be independently predictive of intentional gluten consumption. A statistical model predicted 71.8% of cases reporting intentional lapses. Intentional non-adherence to the GFD was found to be common but not as frequent as inadvertent lapses. Distinguishing the factors influencing both intentional and inadvertent non-adherence is useful in understanding dietary self-management in coeliac disease.
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Affiliation(s)
- Nicola J Hall
- Wolfson Research Institute for Health and Wellbeing, Durham University, School of Medicine, Pharmacy and Health, Queen's Campus, Stockton on Tees TS17 6BH, UK.
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Ludvigsson JF, Leffler DA, Bai J, Biagi F, Fasano A, Green PHR, Hadjivassiliou M, Kaukinen K, Kelly C, Leonard JN, Lundin KE, Murray JA, Sanders DS, Walker MM, Zingone F, Ciacci C. The Oslo definitions for coeliac disease and related terms. Gut 2013; 62:43-52. [PMID: 22345659 PMCID: PMC3440559 DOI: 10.1136/gutjnl-2011-301346] [Citation(s) in RCA: 1049] [Impact Index Per Article: 95.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The literature suggests a lack of consensus on the use of terms related to coeliac disease (CD) and gluten. DESIGN A multidisciplinary task force of 16 physicians from seven countries used the electronic database PubMed to review the literature for CD-related terms up to January 2011. Teams of physicians then suggested a definition for each term, followed by feedback of these definitions through a web survey on definitions, discussions during a meeting in Oslo and phone conferences. In addition to 'CD', the following descriptors of CD were evaluated (in alphabetical order): asymptomatic, atypical, classical, latent, non-classical, overt, paediatric classical, potential, refractory, silent, subclinical, symptomatic, typical, CD serology, CD autoimmunity, genetically at risk of CD, dermatitis herpetiformis, gluten, gluten ataxia, gluten intolerance, gluten sensitivity and gliadin-specific antibodies. RESULTS CD was defined as 'a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals'. Classical CD was defined as 'CD presenting with signs and symptoms of malabsorption. Diarrhoea, steatorrhoea, weight loss or growth failure is required.' 'Gluten-related disorders' is the suggested umbrella term for all diseases triggered by gluten and the term gluten intolerance should not to be used. Other definitions are presented in the paper. CONCLUSION This paper presents the Oslo definitions for CD-related terms.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Paediatrics, Örebro University Hospital, 701 85 Örebro, Sweden and Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Daniel A Leffler
- Correspondence and reprint requests: Daniel A Leffler, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA,
| | - Julio Bai
- Department of Medicine, Dr C. Bonorino Udaondo Gastroenterology Hospital. Del Salvador University, Buenos Aires, (1264) Argentina
| | - Federico Biagi
- Coeliac Centre/1st Dept. of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, P.le Golgi, 19, Pavia, 27100 Italy
| | - Alessio Fasano
- Center for Coeliac Research University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Peter HR Green
- MD Coeliac Disease center at Columbia University, New York, NY, 10032, USA
| | | | - Katri Kaukinen
- School of Medicine, FIN-33014 University of Tampere, Finland
| | - Ciaran Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Jonathan N Leonard
- Department of Dermatology, Imperial College NHS Healthcare Trust, St Mary’s Hospital, London W2 1NY, UK
| | - Knut E Lundin
- Dept of Gastroenterology and Centre for Immune Regulation, Oslo University Hospital, 0027 Oslo, Norway
| | | | - David S Sanders
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital & University of Sheffield, Sheffield, 2JF UK
| | - Marjorie M Walker
- Centre for Pathology, Faculty of Medicine, Imperial College, St Mary’s Hospital, London W2 1NY, UK
| | - Fabiana Zingone
- Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, 80131, Italy
| | - Carolina Ciacci
- Chair of Gastroenterology, University of Salerno, Salerno, 84084 Italy
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Abstract
Historically, it has been reported that patients with undetected celiac disease (CD) may present with irritable bowel syndrome (IBS) type symptoms. This has led to the recommendation by the American College of Gastroenterology Task force that patients presenting with diarrhea predominant IBS type symptoms should be serologically tested for CD. Concurrently speculative media data suggest that the US general public have increased their uptake of a gluten-free diet (GFD) far in excess of the known prevalence of CD. This may suggest that individuals with gastrointestinal symptoms are deriving benefit from a GFD even if they do not have CD. This has led to the scientific community considering the evidence for an emerging concept of non-celiac wheat sensitivity. There is a significant disparity in our views about what this phenomenon may be. There is also confusion about the nomenclature for this entity and indeed whether patients are suffering due to symptoms related to gluten or perhaps other components of wheat, for example fructans. In this month's edition of the American Journal of Gastroenterology, we see evidence to support the clinical concept of wheat sensitivity or intolerance. Irrespective of the nomenclature Carroccio provides a clinically applicable approach that may be adopted internationally by clinicians. This offers a new option in our armamentarium when seeing patients with IBS type symptoms.
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