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Verdelho Machado M. Refractory Celiac Disease: What the Gastroenterologist Should Know. Int J Mol Sci 2024; 25:10383. [PMID: 39408713 PMCID: PMC11477276 DOI: 10.3390/ijms251910383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Revised: 09/20/2024] [Accepted: 09/25/2024] [Indexed: 10/20/2024] Open
Abstract
Fewer than 1% of patients with celiac disease (CD) will develop refractory CD (RCD). As such, most gastroenterologists might never need to manage patients with RCD. However, all gastroenterologists must be familiarized with the basic concepts of RCD and non-responsive CD (NRCD), since it can present as a severe disease with high mortality, not only due to intestinal failure, but also due to progression to enteropathy-associated T cell lymphoma (EATL) and a higher susceptibility to life-threatening infections. The diagnostic workup and differential diagnosis with other causes of gastrointestinal symptoms and villous atrophy, as well as the differentiation between type I and II RCD, are complex, and may require specialized laboratories and reference hospitals. Immunosuppression is efficient in the milder RCDI; however, the treatment of RCDII falls short, with current options probably only providing transient clinical improvement and delaying EATL development. This review summarizes the current diagnostic and therapeutic approach for patients with RCD that all doctors that manage patients with CD should know.
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Affiliation(s)
- Mariana Verdelho Machado
- Gastroenterology Department, Hospital de Vila Franca de Xira, 2600-009 Lisbon, Portugal; ; Tel.: +351-912620306
- Gastroenterology Department, Faculdade de Medicina, Lisbon University, 1649-028 Lisboa, Portugal
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2
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Malamut G, Soderquist CR, Bhagat G, Cerf-Bensussan N. Advances in Nonresponsive and Refractory Celiac Disease. Gastroenterology 2024; 167:132-147. [PMID: 38556189 DOI: 10.1053/j.gastro.2024.02.048] [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: 11/10/2023] [Revised: 02/04/2024] [Accepted: 02/20/2024] [Indexed: 04/02/2024]
Abstract
Nonresponsive celiac disease (CeD) is relatively common. It is generally attributed to persistent gluten exposure and resolves after correction of diet errors. However, other complications of CeD and disorders clinically mimicking CeD need to be excluded. Novel therapies are being evaluated to facilitate mucosal recovery, which might benefit patients with nonresponsive CeD. Refractory CeD (RCeD) is rare and is divided into 2 types. The etiology of type I RCeD is unclear. A switch to gluten-independent autoimmunity is suspected in some patients. In contrast, type II RCeD represents a low-grade intraepithelial lymphoma. Type I RCeD remains a diagnosis of exclusion, requiring ruling out gluten intake and other nonmalignant causes of villous atrophy. Diagnosis of type II RCeD relies on the demonstration of a clonal population of neoplastic intraepithelial lymphocytes with an atypical immunophenotype. Type I RCeD and type II RCeD generally respond to open-capsule budesonide, but the latter has a dismal prognosis due to severe malnutrition and frequent progression to enteropathy-associated T-cell lymphoma; more efficient therapy is needed.
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Affiliation(s)
- Georgia Malamut
- Department of Gastroenterology, Assistance Publique-Hôpitaux de Paris Centre-Université Paris Cité, Hôpital Cochin, Paris, France; Laboratory of Intestinal Immunity, INSERM UMR 1163-Institut Imagine, Université Paris Cité, Paris, France.
| | - Craig R Soderquist
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Govind Bhagat
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Nadine Cerf-Bensussan
- Laboratory of Intestinal Immunity, INSERM UMR 1163-Institut Imagine, Université Paris Cité, Paris, France.
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3
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Packova B, Kohout P, Dastych M, Prokesova J, Grolich T, Kroupa R. Malignant complications of celiac disease: a case series and review of the literature. J Med Case Rep 2022; 16:460. [PMID: 36503568 PMCID: PMC9743581 DOI: 10.1186/s13256-022-03682-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Celiac disease is an immune-mediated enteropathy triggered by gluten in genetically susceptible individuals. Diagnosis is based on evaluating specific autoantibodies and histopathologic findings of duodenal biopsy specimens. The only therapy for celiac disease is a gluten-free diet. Celiac disease can be complicated by malnutrition, other autoimmune diseases, refractoriness to treatment, and gastrointestinal tumors. This article presents seven cases of malignancies in patients with celiac disease. Its objective is to raise awareness of the malignant complications of celiac disease, leading to earlier diagnosis and improved outcomes. CASE PRESENTATION Seven cases of malignant complications of celiac disease occurred among 190 patients followed at the Department of Internal Medicine and Gastroenterology, University Hospital Brno from 2014 to 2021. We describe these cases and the presentation, diagnostic process, course, management, and outcomes for each, along with proposed potential risk factors of malignant complications. There was one Caucasian man who was 70 years old and six Caucasian women who were 36, 46, 48, 55, 73, and 82 years old in our cohort. Of the seven cases of malignancies in our cohort, four patients were diagnosed with small bowel adenocarcinoma, one with diffuse large B-cell lymphoma, one with carcinoma of the tongue, and one with colorectal carcinoma. CONCLUSIONS Malignancies occurred in 3.7% of patients followed up for celiac disease. Awareness of the malignant complications of celiac disease, risk factors, presentation, and disease course could lead to earlier diagnosis and improved outcomes.
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Affiliation(s)
- Barbora Packova
- Department of Internal Medicine and Gastroenterology, University Hospital Brno, Faculty of Medicine, Masaryk University, Jihlavska 20, 62500 Brno, Czech Republic
| | - Pavel Kohout
- grid.4491.80000 0004 1937 116XDepartment of Internal Medicine, Third Faculty of Medicine, Charles University Prague and Teaching Thomayer Hospital, 14059 Prague, Czech Republic
| | - Milan Dastych
- Department of Internal Medicine and Gastroenterology, University Hospital Brno, Faculty of Medicine, Masaryk University, Jihlavska 20, 62500 Brno, Czech Republic
| | - Jitka Prokesova
- Department of Internal Medicine and Gastroenterology, University Hospital Brno, Faculty of Medicine, Masaryk University, Jihlavska 20, 62500 Brno, Czech Republic
| | - Tomas Grolich
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
| | - Radek Kroupa
- Department of Internal Medicine and Gastroenterology, University Hospital Brno, Faculty of Medicine, Masaryk University, Jihlavska 20, 62500 Brno, Czech Republic
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Calado J, Verdelho Machado M. Celiac Disease Revisited. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2022; 29:111-124. [PMID: 35497669 PMCID: PMC8995660 DOI: 10.1159/000514716] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/08/2021] [Indexed: 08/30/2023]
Abstract
Celiac disease (CD) is a systemic disease triggered by gluten ingestion in genetically predisposed individuals. It manifests primarily as an autoimmune enteropathy associated with specific circulating autoantibodies and a human leukocyte antigen haplotype (HLA-DQ2 or HLA-DQ8). It afflicts roughly 1% of the population, though the majority of patients remain undiagnosed. Diarrhea and malabsorption are classic manifestations of CD; however, both children and adults can be paucisymptomatic and present extraintestinal manifestations such as anemia, osteoporosis, and abnormal liver tests. CD screening is not recommended for the general population, and it should be focused on high-risk groups. CD diagnosis is challenging and relies on serological tests, duodenal histology, and genetic testing. Particularly difficult presentations to manage are seronegative patients, seropositive patients without villus atrophy, and patients who have started a gluten-free diet before the diagnostic workup. The only proven treatment is a lifelong gluten-free diet. We present an in-depth review on the physiopathology and management of CD, with a particular emphasis on diagnostic challenges.
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Affiliation(s)
- João Calado
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mariana Verdelho Machado
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal
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5
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Alvarez-Lesmes J, Chapman JR, Poveda JC. Pitfalls in gastrointestinal tract haematopoietic lesions. Pathology 2021; 54:177-183. [PMID: 34801278 DOI: 10.1016/j.pathol.2021.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
Specimens from the gastrointestinal (GI) tract are among the most commonly encountered in routine pathology practice worldwide. It is well known that the luminal GI tract is home to various areas rich in mucosa-associated lymphoid tissue (MALT), whether native or acquired. The latter may be particularly problematic due to its well-known predisposing factors such as Helicobacter pylori infection and autoimmune conditions. Nevertheless, native GI structures are often the subject of query, particularly in conditions that may mimic lymphoproliferative conditions, including infectious and inflammatory diseases. Herein, we describe and share common clinicopathological findings in our daily practice that are challenging to distinguish from subtle low-grade neoplastic lymphoproliferative disorders.
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Affiliation(s)
- Jessica Alvarez-Lesmes
- Department of Pathology, Division of Hematopathology, Division of Gastrointestinal Pathology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital, Miami, FL, USA
| | - Jennifer R Chapman
- Department of Pathology, Division of Hematopathology, Division of Gastrointestinal Pathology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital, Miami, FL, USA
| | - Julio C Poveda
- Department of Pathology, Division of Hematopathology, Division of Gastrointestinal Pathology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital, Miami, FL, USA.
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Wang M, Yu M, Kong WJ, Cui M, Gao F. Association between intestinal neoplasms and celiac disease: A review. World J Gastrointest Oncol 2021; 13:1017-1028. [PMID: 34616509 PMCID: PMC8465454 DOI: 10.4251/wjgo.v13.i9.1017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/02/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
Celiac disease (CD) is a chronic immune-mediated intestinal disease with genetic susceptibility. It is characterized by inflammatory damage to the small intestine after ingestion of cereals and products containing gluten protein. In recent years, the global prevalence rate of CD has been approximately 1%, and is gradually increasing. CD patients adhere to a gluten-free diet (GFD) throughout their entire life. However, it is difficult to adhere strictly to a GFD. Untreated CD may be accompanied by gastrointestinal symptoms, such as diarrhea, abdominal pain, and extraintestinal symptoms caused by secondary malnutrition. Many studies have suggested that CD is associated with intestinal tumors such as enteropathy-associated T-cell lymphoma (EATL), small bowel cancer (SBC), and colorectal cancer. In this study, we reviewed related studies published in the literature to provide a reference for the prevention and treatment of intestinal tumors in patients with CD. Compared with the general population, CD patients had a high total risk of SBC and EATL, but not colorectal cancer. The protective effect of GFD on CD-related malignancies is controversial. Further studies are needed to confirm whether GFD treatment can reduce the risk of intestinal neoplasms in CD.
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Affiliation(s)
- Man Wang
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Ming Yu
- Department of General Practice, Xiangyang Central Hospital, The Affiliated Hospital of Hubei University of Arts and Science, Xiangyang 441021 Hubei Province, China
| | - Wen-Jie Kong
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Mei Cui
- Department of Pathology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Feng Gao
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
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7
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Soldera J, Salgado K, Pêgas KL. Refractory celiac disease type 2: how to diagnose and treat? Rev Assoc Med Bras (1992) 2021; 67:168-172. [PMID: 34406238 DOI: 10.1590/1806-9282.67.02.20200618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/16/2020] [Indexed: 11/22/2022] Open
Abstract
Refractory celiac disease is an uncommon condition which might be associated to poor prognosis. It is often treated with immunosuppressive medications, with poor results. It is divided in type 1 and type 2, the latter carrying a high risk for lymphoma and mortality. A case of a 41 year old female patient with refractory celiac disease type 2 is reported. She was treated with oral budesonide for six months, achieving histological remission.
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Affiliation(s)
| | - Karina Salgado
- Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brazil
| | - Karla Lais Pêgas
- Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brazil.,Irmandade Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brazil
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8
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van Wanrooij RLJ, Bontkes HJ, Neefjes-Borst EA, Mulder CJ, Bouma G. Immune-mediated enteropathies: From bench to bedside. J Autoimmun 2021; 118:102609. [PMID: 33607573 DOI: 10.1016/j.jaut.2021.102609] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 12/13/2022]
Abstract
Immune-mediated enteropathies are caused by excessive reactions of the intestinal immune system towards non-pathogenic molecules. Enteropathy leads to malabsorption-related symptoms and include (severe) chronic diarrhea, weight loss and vitamin deficiencies. Parenteral feeding and immunosuppressive therapy are needed in severe cases. Celiac disease has long been recognized as the most common immune-mediated enteropathy in adults, but the spectrum of immune-mediated enteropathies has been expanding. Histological and clinical features are sometimes shared among these enteropathies, and therefore it may be challenging to differentiate between them. Here, we provide an overview of immune-mediated enteropathies focused on clinical presentation, establishing diagnosis, immunopathogenesis, and treatment options.
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Affiliation(s)
- Roy L J van Wanrooij
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, the Netherlands.
| | - Hetty J Bontkes
- Amsterdam UMC, Laboratory Medical Immunology, Department of Clinical Chemistry, AI & I Institute, AGEM Research Institute, Amsterdam, the Netherlands
| | | | - Chris J Mulder
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, the Netherlands
| | - Gerd Bouma
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, the Netherlands
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9
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Cellular and molecular bases of refractory celiac disease. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 358:207-240. [PMID: 33707055 DOI: 10.1016/bs.ircmb.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Refractory celiac disease (RCD) encompasses biologically heterogeneous disorders that develop in a small proportion (0.3%) of individuals with celiac disease that are associated with high morbidity. Two broad categories are currently recognized, type I (RCD I) and type II (RCD II), based on immunophenotypic and molecular features of the intraepithelial lymphocytes (IELs). RCD I is characterized by a polyclonal expansion of IELs displaying a normal immunophenotype, while RCD II represents a clonal proliferation of immunophenotypically "aberrant" IELs, and is considered a low-grade lymphoproliferative disorder. The pathogenesis of RCD I has not been clarified, but limited studies suggest multifactorial etiology. On the other hand, recent immunologic, molecular and immunophenotypic analyses have proposed lineage-negative innate IELs to be the cell of origin of a proportion of RCD II cases. Furthermore, sequencing studies have identified frequent, recurrent, activating mutations in members of the JAK-STAT pathway in RCD II. This finding, in conjunction with prior in vitro experimental observations, suggests roles of deregulated cytokine signaling in disease pathogenesis. In this review, we describe current understanding of environmental, immune and genetic factors associated with the development of RCD and briefly discuss diagnostic and therapeutic considerations.
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10
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Chibbar R, Nostedt J, Mihalicz D, Deschenes J, McLean R, Dieleman LA. Refractory Celiac Disease Type II: A Case Report and Literature Review. Front Med (Lausanne) 2020; 7:564875. [PMID: 33344468 PMCID: PMC7746862 DOI: 10.3389/fmed.2020.564875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/03/2020] [Indexed: 12/11/2022] Open
Abstract
We present an unusual case of 68-year-old male, who presented with acute abdomen, ulcerative jejunitis with perforation, and 2 months later with perforation of the sigmoid colon. We will also discuss difficulties in the delay in diagnosis of refractory celiac disease (RCD), specifically the atypical presentation, multiple surgeries, the consecutive failure of distinct therapeutic options, and multiple complications that occurred within the 3 months since first presentation.
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Affiliation(s)
- Richa Chibbar
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Division of Gastro, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jordan Nostedt
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Dana Mihalicz
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jean Deschenes
- Department of Laboratory Medicine and Pathology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Ross McLean
- Department of Laboratory Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada
| | - Levinus A Dieleman
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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11
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Chan C, Fagarasanu AD, Reid A, Sadowski DC, Gillson AE. Organizing pneumonia associated with T-cell lymphoma. Respirol Case Rep 2020; 8:e00677. [PMID: 33133608 PMCID: PMC7586110 DOI: 10.1002/rcr2.677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/10/2020] [Accepted: 10/01/2020] [Indexed: 11/07/2022] Open
Abstract
A 61-year-old male with a history of coeliac disease was diagnosed with organizing pneumonia (OP) on transbronchial and transthoracic lung biopsies. He then developed refractory coeliac disease type II and haemophagocytic lymphohistiocytosis. Nine months after his initial diagnosis of OP and after multiple biopsies of the lung, duodenum, and bone marrow, he was diagnosed with enteropathy-associated T-cell lymphoma (EATL). Although OP in patients with lymphoma is most commonly attributed to chemotherapeutic agents or bone marrow transplant, it may be seen in the absence of prior anticancer treatment. The mechanism linking OP and lymphoma is unclear but OP could represent a syndrome of T-cell dysfunction or develop as a direct reaction to malignant infiltration of the lung. In patients with atypical presentations, exclusion of an alternate diagnosis must be pursued using surgical lung biopsy, wherever possible. This is the first reported case of OP associated with EATL.
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Affiliation(s)
- Chrystal Chan
- Department of MedicineUniversity of AlbertaEdmontonABCanada
| | | | - Andre Reid
- Department of Laboratory Medicine & PathologyUniversity of AlbertaEdmontonABCanada
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12
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Abstract
PURPOSE OF REVIEW To review the epidemiology, pathophysiology, diagnosis, management, and prognosis of refractory celiac disease, with a specific emphasis on recent literature. RECENT FINDINGS While the pathophysiology of type I refractory celiac disease remains unclear, there have been advances in the understanding of the pathophysiology of type II refractory celiac disease. This has included recognition of the significant role of interleukin-15 and somatic mutations in JAK1 or STAT3 in the proliferation of aberrant T cells. This in turn has led to potential novel therapies targeting these factors, one of which has reached the clinical trial stage. The morbidity and mortality associated with type II refractory celiac disease remain significant; however, recent advances in the understanding of the pathophysiology of this condition have led to potential therapeutic options that should be investigated.
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13
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Penny HA, Baggus EMR, Rej A, Snowden JA, Sanders DS. Non-Responsive Coeliac Disease: A Comprehensive Review from the NHS England National Centre for Refractory Coeliac Disease. Nutrients 2020; 12:E216. [PMID: 31947666 PMCID: PMC7019917 DOI: 10.3390/nu12010216] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/06/2020] [Accepted: 01/09/2020] [Indexed: 02/06/2023] Open
Abstract
Coeliac disease is a common small intestinal enteropathy which manifests following ingestion of gluten in genetically susceptible individuals. Since gluten was identified as the driving factor in coeliac disease, the gluten-free diet (GFD) has remained the mainstay of treatment. While most individuals will display improvement in symptoms and signs of coeliac disease following institution of the GFD, up to 30% will continue to experience symptoms and/or have persisting intestinal inflammation. These individuals can be classified as having non-responsive coeliac disease (NRCD), which may be associated with dietary indiscretion, slow healing, refractory coeliac disease, and/or an alternative condition. The purpose of this review is to provide an overview of the causes of NRCD in adults, highlight a systematic approach to investigate these patients, and appraise the latest management aspects of this subset of coeliac disease.
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Affiliation(s)
- Hugo A. Penny
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
- Lydia Becker Institute of Inflammation and Immunology, University of Manchester, Manchester M13 9PL, UK
| | - Elisabeth M. R. Baggus
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
| | - Anupam Rej
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK;
| | - David S. Sanders
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
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14
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Cellier C, Bouma G, van Gils T, Khater S, Malamut G, Crespo L, Collin P, Green PHR, Crowe SE, Tsuji W, Butz E, Cerf-Bensussan N, Macintyre E, Parnes JR, Leon F, Hermine O, Mulder CJ. Safety and efficacy of AMG 714 in patients with type 2 refractory coeliac disease: a phase 2a, randomised, double-blind, placebo-controlled, parallel-group study. Lancet Gastroenterol Hepatol 2019; 4:960-970. [PMID: 31494097 DOI: 10.1016/s2468-1253(19)30265-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/24/2019] [Accepted: 07/26/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Refractory coeliac disease type 2 is a rare subtype of coeliac disease with high mortality rates; interleukin 15 (IL-15) is strongly implicated in its pathophysiology. This trial aimed to investigate the effects of AMG 714, an anti-IL-15 monoclonal antibody, on the activity and symptoms of refractory coeliac disease type 2. METHODS This was a randomised, double-blind, placebo-controlled, phase 2a study of adults with a confirmed diagnosis of refractory coeliac disease type 2. Patients were randomly assigned at a 2:1 ratio to receive seven intravenous doses over 10 weeks of AMG 714 (8 mg/kg) or matching placebo. Biopsy samples were obtained at baseline and week 12 for cellular analysis and histology. The change in the proportion of aberrant intraepithelial lymphocytes from baseline to week 12 with respect to all intraepithelial lymphocytes was the primary endpoint and was quantified using flow cytometry. Secondary endpoints were the change in aberrant intraepithelial lymphocytes with respect to intestinal epithelial cells; intestinal histological scores (villous height-to-crypt depth ratio; VHCD); intraepithelial lymphocyte counts; Marsh score; and patient-reported symptom measures, including the Bristol stool form scale (BSFS) and gastrointestinal symptom rating scale (GSRS). Main analyses were done in the per-protocol population of patients who received their assigned treatment, provided evaluable biopsy samples, and did not have major protocol deviations; only patients with non-atypical disease were included in the analyses of aberrant intraepithelial lymphocytes, including the primary analysis. Safety was assessed in all patients who received at least one dose of study drug. This study is registered at ClinicalTrials.gov (NCT02633020) and EudraCT (2015-004063-36). FINDINGS From April 13, 2016, to Jan 19, 2017, 28 patients were enrolled and randomly assigned to AMG 714 (n=19) and placebo (n=9). Six patients were not included in the primary analysis because of protocol deviation (one in the AMG 714 group), insufficient biopsy samples (one in the AMG 714 group), and atypical intraepithelial lymphocytes (three in the AMG 714 group and one in the placebo group). At 12 weeks, the least square mean difference between AMG 714 and placebo in the relative change from baseline in aberrant intraepithelial lymphocyte percentage was -4·85% (90% CI -30·26 to 20·56; p=0·75). The difference between the AMG 714 and placebo groups in aberrant intraepithelial lymphocytes with respect to epithelial cells at 12 weeks was -38·22% (90% CI -95·73 to 19·29; nominal p=0·18); the difference in change in Marsh score from baseline was 0·09% (95% CI -1·60-1·90; nominal p=0·92); the difference in VHCD ratio was 10·67% (95% CI -38·97 to 60·31; nominal p=0·66); and the difference in change in total intraepithelial lymphocyte count was -12·73% (95% CI -77·57-52·12); nominal p=0·69). Regarding symptoms, the proportion of patients with diarrhoea per the BSFS score decreased from ten (53%) of 19 at baseline to seven (37%) of 19 at week 12 in the AMG 714 group and increased from two (22%) of nine at baseline to four (44%) of nine at week 12 in the placebo group (nominal p=0·0008); and the difference between the groups in change in GSRS score was -0·14 (SE 0·19; nominal p=0·48). Eight (89%) patients in the placebo group and 17 (89%) in the AMG 714 group had treatment-emergent adverse events, including one (11%) patient in the placebo group and five (26%) in the AMG 714 group who had serious adverse events. The most common adverse event in the AMG 714 group was nasopharyngitis (eight [42%] patients vs one [11%] in the placebo group). INTERPRETATION In patients with refractory coeliac disease type 2 who were treated with AMG 714 or placebo for 10 weeks, there was no difference between the groups in terms of the primary endpoint of aberrant intraepithelial lymphocyte reduction from baseline. Effects on symptoms and other endpoints suggest that further research of AMG 714 may be warranted in patients with refractory coeliac disease type 2. FUNDING Celimmune and Amgen.
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Affiliation(s)
- Christophe Cellier
- Department of Gastroenterology and Endoscopy, University Hospital Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France.
| | - Gerd Bouma
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Medical Centre, Amsterdam, Netherlands
| | - Tom van Gils
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Medical Centre, Amsterdam, Netherlands
| | - Sherine Khater
- Department of Gastroenterology and Endoscopy, University Hospital Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Georgia Malamut
- Department of Gastroenterology and Endoscopy, University Hospital Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Laura Crespo
- Department of Gastroenterology, University Hospital Ramón y Cajal, Madrid, Spain
| | - Pekka Collin
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Peter H R Green
- Celiac Disease Center, Columbia University Medical Center, New York, NY, USA
| | - Sheila E Crowe
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Wayne Tsuji
- Department of Medicine, University of California San Diego, Celimmune, Bethesda, MD, USA
| | - Eric Butz
- Department of Medicine, University of California San Diego, Celimmune, Bethesda, MD, USA
| | | | - Elizabeth Macintyre
- Haematology, Université Paris Descartes, Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris, France
| | | | - Francisco Leon
- Department of Medicine, University of California San Diego, Celimmune, Bethesda, MD, USA; Provention Bio, Oldwick, NJ, USA
| | - Olivier Hermine
- Haematology, Université Paris Descartes, Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Chris J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Medical Centre, Amsterdam, Netherlands
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15
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Jassim SH, Smith LB. New/Revised Entities in Gastrointestinal Lymphoproliferative Disorders. Surg Pathol Clin 2019; 12:733-743. [PMID: 31352985 DOI: 10.1016/j.path.2019.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The gastrointestinal tract is a common extranodal site of involvement by lymphomas. These may be diagnostically challenging because they can mimic a variety of benign conditions and may be difficult to subclassify when malignant. The classification of gastrointestinal lymphomas is an evolving area with some recent changes. Although some of these entities are rare, they are important to recognize because of the variable clinical presentations, comorbidities, and treatment implications. This article explores new and revised entities in gastrointestinal lymphoproliferative disorders.
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Affiliation(s)
- Sarmad H Jassim
- Pathology Department, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 36, Ann Arbor, MI, USA
| | - Lauren B Smith
- Pathology Department, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 36, Ann Arbor, MI, USA.
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16
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Rodrigo L, Pérez-Martinez I, Lauret-Braña E, Suárez-González A. Descriptive Study of the Different Tools Used to Evaluate the Adherence to a Gluten-Free Diet in Celiac Disease Patients. Nutrients 2018; 10:nu10111777. [PMID: 30453479 PMCID: PMC6267102 DOI: 10.3390/nu10111777] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/07/2018] [Accepted: 11/14/2018] [Indexed: 12/12/2022] Open
Abstract
Celiac disease (CD) is a genetically conditioned autoimmune process that appears in susceptible people. It can affect people of any age, and slightly predominates in females. It has a fairly homogenous global distribution, with an average prevalence of 1⁻2%, the frequency having increased in recent decades. The only effective treatment is a strict and permanent gluten-free diet (GFD), although the level of compliance is poor, at about 50% of cases. To monitor the effectiveness of the GFD, several procedures involving various approaches are employed: (a) Periodic visits by expert Nutritionists; (b) Clinical follow-up; (c) Serological time controls of specific antibodies; (d) Serial endoscopies with collection of duodenal biopsies; (e) Use of structured questionnaires; and (f) Determination of gluten peptides derived from gluten in faeces and/or urine. All of these procedures are useful when applied, alone or in combination, depending on the cases. Some patients will only need to consult to their doctors, while others will require a multidisciplinary approach to assess their compliance with the GFD. In children, normalization of duodenal mucosa was achieved in 95% of cases within two years, while it is more delayed in adults, whose mucosa take longer time (3⁻5 years) to heal completely.
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Affiliation(s)
- Luis Rodrigo
- Gastroenterology Unit, Hospital Universitario Central de Asturias (HUCA), CSIC, Avda. de Roma s/n, 33011 Oviedo, Spain.
| | - Isabel Pérez-Martinez
- Gastroenterology Unit, Hospital Universitario Central de Asturias (HUCA), CSIC, Avda. de Roma s/n, 33011 Oviedo, Spain.
| | - Eugenia Lauret-Braña
- Gastroenterology Unit, Hospital Universitario Central de Asturias (HUCA), CSIC, Avda. de Roma s/n, 33011 Oviedo, Spain.
| | - Adolfo Suárez-González
- Gastroenterology Unit, Hospital Universitario Central de Asturias (HUCA), CSIC, Avda. de Roma s/n, 33011 Oviedo, Spain.
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