Clinical guidelines for celiac disease in children: what does it mean to the pediatrician/family practitioner?

Current Evidence in the Diagnosis and Treatment of Children With Celiac Disease

Recent statistics report that 3 million people, or 1% of the population in the United States (U.S.), are affected by celiac disease (CD). In addition, in the U.S., as many as 1 in 80 children is affected with CD. However, CD can be challenging to diagnose and many children are not correctly diagnosed or live without a diagnosis for several years. Symptoms, if present, are often nonspecific and may be common manifestations of many pediatric illnesses. The purpose of this review is to examine the current evidence regarding incidence, pathophysiology, diagnosis, and treatment of a child with CD. Clinical implications for nurses caring for children and families are discussed.

HLA class II high-resolution genotyping in Greek children with celiac disease and impact on disease susceptibility

BACKGROUND

Celiac disease (CD) has been associated with HLA class II heterodimers. This study aimed at determining the HLA genotypic and allelic distribution in Greek children with CD as compared with the general population.

METHODS

A total of 118 children with CD and 120 healthy individuals serving as controls were included in the study.

RESULTS

Higher frequencies for HLA-DQB1*02:01 (40.25 vs. 9.58%, P < 0.001) and DQB1*02:02 (20.34 vs. 5.42%, P < 0.001) were observed in patients with CD, whereas HLA-DQB1*03:01 (16.53 vs. 30.42%, P < 0.001), DQB1*05:01 (0.85 vs. 10%, P < 0.001), and DQB1*05:02 (5.51 vs. 17.92%, P < 0.001) were significantly lower, as compared with the controls. DQA1*02:01 (patients with CD vs. controls: 20.76 vs. 6.67%, P < 0.001) and DQA1*05:01 (40.25 vs. 9.58%, P < 0.001) were significantly more frequent in patients. The frequencies of HLA-DQA1* 01:01, *01:02, *01:04, and *05:05 were significantly lower in patients (P < 0.001). The haplotype mainly associated with CD was DRB1*03-DQB1*02:01-DQA1*05:01; patients with CD vs. controls: 39.83 vs. 9.58%, P < 0.001. In total, 84.75% of patients carried DQ2 (vs. 21.67% in controls, P < 0.001), whereas 11.02% were DQ8 positive/DQ2 negative.

CONCLUSION

This study confirms the existing data and provides additional evidence supporting a strong genetic predisposition for CD associated with the class II alleles DQB1*02 and DQA1*05 encoding the serological specificity DQ2.

Gluten-free diet does not appear to induce endoscopic remission of eosinophilic esophagitis in children with coexistent celiac disease

BACKGROUND

Celiac disease and eosinophilic esophagitis are usually considered to be separate gastrointestinal diseases; however, it appears that they may coexist more often than would be expected. It is unknown whether eosinophilic esophagitis in patients with celiac disease responds to a gluten-free diet.

OBJECTIVES

To examine the clinical, endoscopic and histological features of children with both conditions to evaluate whether eosinophilic esophagitis responds to a gluten-free diet.

METHODS

From January 1, 2009, to June 30, 2011, the medical records of children <18 years of age diagnosed with eosinophilic esophagitis and⁄or celiac disease were reviewed. Patients with clinical, endoscopic and histological diagnoses of both diseases were identified and included. These findings were analyzed, as were laboratory results, treatment and follow-up.

RESULTS

During the study period, there were 206 celiac disease patients, 86 eosinophilic esophagitis patients and nine (4.4% of total celiac) patients with both diagnoses. Gluten-free diet was the primary treatment for both conditions in seven of nine (78%) cases. In six of these seven (86%) patients, no endoscopic or histological improvement of eosinophilic esophagitis was observed, while in one patient, histological remission of esophageal eosinophilia occurred while on a gluten-free diet.

CONCLUSION

The prevalence of eosinophilic esophagitis in patients with celiac disease was 4.4%, confirming a higher than expected prevalence of eosinophilic esophagitis compared with the general population. In patients with celiac disease, a gluten-free diet did not appear to induce remission of coexistent endoscopic and histological features of eosinophilic esophagitis.

Reproducibility of the histological diagnosis of celiac disease

OBJECTIVE

A small intestinal biopsy is considered to be the gold standard for the diagnosis of celiac disease (CD). However, the assessment of small intestinal histology may vary between pathologists. Our aim was, therefore, to determine the interobserver variability in the histological diagnosis of CD.

MATERIAL AND METHODS

Biopsy specimens of 297 pediatric patients suspected of having CD were revised by a single experienced pathologist and compared to the original reports. Mucosal changes were scored using the Marsh classification. In patients with a discrepancy in diagnosis, clinical and serological data were used to determine the most probable diagnosis.

RESULTS

Although the interobserver variability for the Marsh classification was found to be moderate with a Kappa value of 0.486, the Kappa value for the diagnosis reached an almost perfect agreement (0.850). Nevertheless, in 22 patients a different diagnosis was made by the second observer. Interestingly, in this subgroup relatively more biopsies were classified to be of suboptimal quality. Based on clinical presentation, serology and follow-up, 19 of those patients truly had CD. In 14 of them the diagnosis was originally missed by the first observer while five cases were under-diagnosed by the second pathologist.

CONCLUSIONS

CD can be missed histologically due to assessment variation between pathologists. A final diagnosis of CD should be based on histology, serology as well as response to the diet.