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Lungaro L, Costanzini A, Manza F, Caputo F, Remelli F, Volpato S, De Giorgio R, Volta U, Caio G. Celiac Disease: A Forty-Year Analysis in an Italian Referral Center. Nutrients 2024; 16:2292. [PMID: 39064734 PMCID: PMC11279732 DOI: 10.3390/nu16142292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/13/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Celiac disease (CD) is an autoimmune disorder triggered by gluten ingestion. Herein, we assessed clinical, serological and histopathological findings of a single-center, large cohort of CD patients diagnosed and followed-up over forty years. METHODS From January 1980 to December 2020, 1547 CD patients (1170 females; age range: 8-81 years; F:M ratio = 3.1:1) were diagnosed in an Italian tertiary referral center. Comorbidities and complications were recorded at diagnosis and during follow-up. RESULTS CD diagnoses quadrupled after 2000. The most frequent phenotype was the non-classical CD (63.3%), and the most prevalent histotype was Marsh 3C (44.7%). Gastrointestinal manifestations, detectable in 51% of patients, were diarrhea (24.3%), bloating (28%) and aphthous stomatitis (19.7%). The most common CD-associated disorder was osteopenia (59.9%), predominant in females (64.3%); extraintestinal manifestations included anemia (35.8% iron-deficiency; 87% folic acid malabsorption), cryptogenic hypertransaminasemia (27.9%), and recurrent miscarriages (11.5%). Thyroiditis (26.9%), type 1 diabetes mellitus (2.9%), and dermatitis herpetiformis (1.4%) were the most common CD-related autoimmune disorders. Six patients had inflammatory bowel disease. Complications and mortality rate occurred in 1.8% and 1.9%, respectively. CONCLUSIONS This single-center, large cohort analysis confirmed that CD presentation changed over the years, with an increase of non-classical and subclinical clinical phenotypes.
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Affiliation(s)
- Lisa Lungaro
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Anna Costanzini
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Francesca Manza
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Fabio Caputo
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Francesca Remelli
- Department of Medical Science, University of Ferrara, 44124 Ferrara, Italy; (F.R.); (S.V.)
| | - Stefano Volpato
- Department of Medical Science, University of Ferrara, 44124 Ferrara, Italy; (F.R.); (S.V.)
- Geriatrics Unit, Azienda Ospedaliero-Universitaria of Ferrara, 44124 Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Giacomo Caio
- Department of Translational Medicine, St. Anna Hospital, University of Ferrara, 44124 Ferrara, Italy; (L.L.); (A.C.); (F.M.); (F.C.)
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, MA 02114, USA
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Adams DW, Moleski S, Jossen J, Tye-Din JA. Clinical Presentation and Spectrum of Gluten Symptomatology in Celiac Disease. Gastroenterology 2024; 167:51-63. [PMID: 38636679 DOI: 10.1053/j.gastro.2024.01.052] [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: 11/03/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 04/20/2024]
Abstract
Views on the clinical presentation and symptomatology of celiac disease have evolved alongside advances in disease detection and understanding of disease pathogenesis. Although historically regarded as a pediatric illness characterized by malabsorption, it is now better viewed as an immune illness of gluten-specific T cells with systemic manifestations affecting all ages. Its broad presentation, including frequent extraintestinal manifestations and asymptomatic disease, contributes to suboptimal disease detection. Adverse symptoms greatly impact patient quality of life and can result from chronic gluten exposure in untreated disease or those poorly responsive to the gluten-free diet. They can also present as acute symptoms after episodic gluten exposure. Functional gastrointestinal disease is a common comorbidity. Biomarkers like interleukin-2 that are highly sensitive and specific for celiac disease highlight a role for gluten-specific T cells in acute gluten symptomatology. A mechanistic understanding of symptoms will inform approaches to better measure and treat them effectively.
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Affiliation(s)
- Dawn W Adams
- Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephanie Moleski
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jacqueline Jossen
- Departments of Medicine and Pediatrics, The Celiac Disease Center at Columbia University, New York, New York
| | - Jason A Tye-Din
- Immunology Division, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia; Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia; Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
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Belei O, Jugănaru I, Basaca DG, Munteanu AI, Mărginean O. The Role of Intestinal Microbiota in Celiac Disease and Further Therapeutic Perspectives. Life (Basel) 2023; 13:2039. [PMID: 37895421 PMCID: PMC10608277 DOI: 10.3390/life13102039] [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: 08/28/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
Celiac disease (CD) is an immune-mediated enteropathy caused by exposure to gluten and related prolamins in genetically susceptible individuals. It is a complex genetic disorder with multiple contributing genes. Linkage studies have identified several genomic regions that probably contain CD susceptibility genes. The most important genetic factors are HLA-DQ2 and DQ8. Several known environmental triggers promote the onset of CD at any age after gluten introduction in individuals with a genetic background, such as viral infections and intestinal dysbiosis. Recent publications have described the interference of the intestinal microbiome in gluten metabolism, modulation of local immune reactions, and in maintaining normal gut permeability. These results have promoted further lines of research on the benefit of probiotic administration to prevent disease onset or alleviate clinical symptoms along with a gluten-free diet (GFD). The relationship between gut microbiome changes and the onset of CD is incompletely understood, still being the subject of current research. This narrative review analyzes the interplay between environmental factors, intestinal microbiome alterations, and the course of CD. Furthermore, this review sets out to discuss if modulation of intestinal microflora with pre- and probiotics along with a GFD could represent a reliable therapeutic target for celiac patients.
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Affiliation(s)
- Oana Belei
- First Pediatric Clinic, Disturbances of Growth and Development on Children Research Center, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (O.B.); (D.-G.B.); (A.I.M.); (O.M.)
- First Pediatric Clinic, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Iulius Jugănaru
- First Pediatric Clinic, Disturbances of Growth and Development on Children Research Center, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (O.B.); (D.-G.B.); (A.I.M.); (O.M.)
- First Pediatric Clinic, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Diana-Georgiana Basaca
- First Pediatric Clinic, Disturbances of Growth and Development on Children Research Center, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (O.B.); (D.-G.B.); (A.I.M.); (O.M.)
- First Pediatric Clinic, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Andrei Ioan Munteanu
- First Pediatric Clinic, Disturbances of Growth and Development on Children Research Center, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (O.B.); (D.-G.B.); (A.I.M.); (O.M.)
- First Pediatric Clinic, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Otilia Mărginean
- First Pediatric Clinic, Disturbances of Growth and Development on Children Research Center, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (O.B.); (D.-G.B.); (A.I.M.); (O.M.)
- First Pediatric Clinic, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
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Barone M, Iannone A, Cristofori F, Dargenio VN, Indrio F, Verduci E, Di Leo A, Francavilla R. Risk of obesity during a gluten-free diet in pediatric and adult patients with celiac disease: a systematic review with meta-analysis. Nutr Rev 2023; 81:252-266. [PMID: 35947766 PMCID: PMC10857815 DOI: 10.1093/nutrit/nuac052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Obesity is a significant risk factor for many pathological conditions. Whether a gluten-free diet (GFD) is a risk factor for overweight or obesity remains controversial. OBJECTIVE The primary aim of this study was to assess the prevalence of body mass index (BMI) categories at disease presentation and the variation in BMI category from underweight/normal to overweight/obese and vice versa during a GFD. DATA SOURCES PubMed, Scopus, and Web of Science databases were searched through February 2021 for retrospective, cross-sectional, and prospective studies reporting BMI categories at disease diagnosis and during a GFD. DATA EXTRACTION Data were extracted by 2 reviewers independently. Disagreements were resolved by consensus; a third reviewer was consulted, if necessary. Risk of bias was assessed with the Cochrane ROBINS-I tool. DATA ANALYSIS Subgroup analysis based on age (pediatric/adult patients), study design (prospective, cross-sectional, retrospective), and duration of GFD was performed.. Forty-five studies were selected (7959 patients with celiac disease and 20 524 healthy controls). The mean BMI of celiac patients at presentation was significantly lower than that of controls (P < 0.001). During a GFD, the mean BMI increased significantly (mean difference = 1.14 kg/m2 [95%CI, 0.68-1.60 kg/m2]; I2 = 82.8%; P < 0.001), but only 9% of patients (95%CI, 7%-12%; I2 = 80.0%) changed from the underweight/normal BMI category to the overweight/obese category, while 20% (95%CI, 11%-29%; I2 = 85.8%) moved into a lower BMI category. CONCLUSION Most celiac patients had a normal BMI at presentation, although the mean BMI was significantly lower than that of controls. A GFD does not increase the risk of becoming overweight/obese, especially in children. The quality of several studies was suboptimal, with moderate or high overall risk of bias and heterogeneity.
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Affiliation(s)
- Michele Barone
- are with the Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari “Aldo Moro,” Bari, Italy
| | - Andrea Iannone
- are with the Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari “Aldo Moro,” Bari, Italy
| | - Fernanda Cristofori
- are with the Interdisciplinary Department of Medicine, Pediatric Section, University of Bari “Aldo Moro,” Bari, Italy
| | - Vanessa Nadia Dargenio
- are with the Interdisciplinary Department of Medicine, Pediatric Section, University of Bari “Aldo Moro,” Bari, Italy
| | - Flavia Indrio
- is with the Department of Pediatrics, Scientific Institute “Casa Sollievo della Sofferenza,” Foggia, Italy
| | - Elvira Verduci
- is with the Department of Pediatrics, Ospedale dei Bambini “Vittore Buzzi,” Milan, Italy
| | - Alfredo Di Leo
- are with the Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari “Aldo Moro,” Bari, Italy
| | - Ruggiero Francavilla
- are with the Interdisciplinary Department of Medicine, Pediatric Section, University of Bari “Aldo Moro,” Bari, Italy
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Mauro A, Giani T, Di Mari C, Sandini M, Talenti A, Ansuini V, Biondi L, Di Nardo G, Bernardo L. Gastrointestinal Involvement in Children with Systemic Lupus Erythematosus. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020309. [PMID: 36832440 PMCID: PMC9955206 DOI: 10.3390/children10020309] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/05/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder. When it presents before the age of 18 years (childhood-onset systemic lupus erythematosus, cSLE), the disease course tends to be more severe with a higher rate of organ involvement and requires an early diagnosis. Gastrointestinal involvement in cSLE is rare and scarcely reported in the literature. Any organ of the gastrointestinal system may be affected, either as a direct consequence of the disease, as a subsequent complication, or as an adverse drug event. Abdominal pain is the most common GI symptom, it can be diffuse or well localized, and can underline different conditions such as hepatitis, pancreatitis, appendicitis, peritonitis, or enteritis. cSLE may have an alteration of the intestinal barrier with features of protein-losing enteropathy or, in genetically predisposed patients, may develop associated autoimmune disorders such as Coeliac Disease or Autoimmune Hepatitis. The aim of this manuscript is to provide a narrative review of gastrointestinal manifestations in cSLE focused on hepatic, pancreatic, and intestinal involvement. A comprehensive literature search based on the PubMed database was performed.
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Affiliation(s)
- Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Teresa Giani
- Department of Pediatrics, Meyer Children's Hospital, 50139 Firenze, Italy
| | - Clelia Di Mari
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Martina Sandini
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Antonella Talenti
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Valentina Ansuini
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Luigi Biondi
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Giovanni Di Nardo
- Faculty of Medicine and Psycology, Sapienza University of Rome-NESMOS Department, Sant'Andrea University Hospital, Via Grottarossa 1035-1039, 00189 Roma, Italy
| | - Luca Bernardo
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
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Tamai T, Ihara K. Celiac Disease Genetics, Pathogenesis, and Standard Therapy for Japanese Patients. Int J Mol Sci 2023; 24:ijms24032075. [PMID: 36768398 PMCID: PMC9916540 DOI: 10.3390/ijms24032075] [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: 12/20/2022] [Revised: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Celiac disease is an autoimmune disease primarily affecting the small intestine that is caused by the ingestion of gluten in genetically susceptible individuals. The development of celiac disease is based on a complex immune response to gluten proteins. The global average prevalence in the general population is about 1%. In recent years, it has become clear that celiac disease is not less common in Asian countries than in Western countries but often remains undiagnosed. Although the number of patients with celiac disease in Asia is expected to increase with improving disease recognition and advances in diagnostic techniques, there remain few reports of celiac disease in the Far East region of Asia, especially in Japan. In this paper, we outline the epidemiology, diagnosis, and treatment of celiac disease. In addition, we summarize the reported Japanese cases of celiac disease with an overview in Japan.
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Saha BK, Saha S, Bonnier A, Saha BN. Association between idiopathic pulmonary hemosiderosis and celiac disease in pediatric patients: A scoping review of the literature over the past 50 years. Pediatr Pulmonol 2022; 57:1127-1144. [PMID: 35088581 DOI: 10.1002/ppul.25847] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage, the mechanism of which is currently unknown. Nearly one-third of pediatric patients with IPH test positive for Celiac disease (CD) serology. Several hypothetical mechanisms have been proposed to unify the coexistence of these two entities, also referred to as Lane-Hamilton syndrome (LHS). METHOD This manuscript is a scoping review of the medical literature. Medline, Embase, and PubMed Central databases were searched between 1971 and 2021 with appropriate search words to identify all cases of pediatric LHS. RESULTS A total of 20 manuscripts with 23 pediatric patients with LHS were identified. The mean age was 11 years, and 13/23 (56.5%) of the children were boys. Hemoptysis was present in 57% of patients during diagnosis. Bronchoscopy with bronchoalveolar lavage demonstrating hemosiderin laden macrophages was the primary mode of diagnostic confirmation. Only three patients underwent lung biopsy. Any significant GI symptom was reported in a minority of patients (22%). Iron deficiency anemia on presentation was described in 83% of children. The majority of patients were malnourished. Serology for CD was positive in all patients, as was the histopathologic analysis of the small bowel biopsy. No patients had any other autoantibody positivity. The introduction of gluten free diet (GFD) was associated with a positive response in 20/23 patients. CONCLUSION All pediatric patients with IPH should undergo screening for CD. Low serum ferritin in patients with IPH could be suggestive of coexisting CD. Strict GFD should be tried as the initial therapy.
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Affiliation(s)
- Biplab K Saha
- Department of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, Missouri, USA
| | - Santu Saha
- Department of Internal Medicine, Bangladesh Medical College, Dhaka, Bangladesh
| | - Alyssa Bonnier
- Department of Critical Care Nursing, Goldfarb School of Nursing, Barnes Jewish College, St. Louis, Missouri, USA
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Pedretti M, Sbravati F, Allegri D, Labriola F, Lombardo V, Spisni E, Zarbo C, Alvisi P. Is the clinical pattern of pediatric celiac disease changing? A thirty-years real-life experience of an Italian center. Ital J Pediatr 2021; 47:235. [PMID: 34906196 PMCID: PMC8670100 DOI: 10.1186/s13052-021-01183-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 11/10/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Clinical presentation of pediatric celiac disease (CD) is heterogeneous and ever-evolving. Our aim is to highlight its changes throughout the years. METHODS Data about clinical presentation of CD in children diagnosed between 1990 and 2020 at the CD Center of Maggiore Hospital, Bologna, were collected. Patients were stratified into groups based on the date [P1 (1990-2011), P2 (2012-2020)] and age [G1 (< 2 years), G2 (2-5), G3 (6-11), G4 (12-18)] at diagnosis, then investigated by comparing CD clinical presentation in different periods and ages. RESULTS 1081 children were selected. Mean age at diagnosis increases from 5.9 to 6.6 years from P1 to P2. Gastrointestinal Symptoms (GIs) are predominant, with a decline of diarrhea (47%VS30%) and an increase of constipation (4%VS19%) (p < 0.001). Among Extraintestinal symptoms (EIs) a decrease of anemia (76%VS43%, p = 0,001) is observed. Failure to Thrive (FTT) is stable throughout the years (p = 0.03), while screenings show a trend of increment (19%VS23%). GIs' frequency decline from G1 to G4 (p = 0,001), with reduction of diarrhea (p < 0.001), and rise of recurrent abdominal pain (p = 0,02). EIs are more frequent at older ages, FTT in younger patients. CONCLUSIONS Changes in clinical presentation of CD have occurred in the last 30 years. We observe a reduction of severe and classic gastroenterologic symptoms and a rise of atypical ones, together with a growth of serological screenings and higher age at diagnosis. Awareness about CD clinical trends is crucial for a proper approach and early diagnosis.
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Affiliation(s)
- Melissa Pedretti
- Specialty School of Paediatrics - Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Francesca Sbravati
- Pediatric Gastroenterology Unit, Maggiore Hospital, Pediatric Department, Bologna, Italy
| | - Davide Allegri
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Italy
| | - Flavio Labriola
- Pediatric Gastroenterology Unit, Maggiore Hospital, Pediatric Department, Bologna, Italy
| | - Virginia Lombardo
- Specialty School of Paediatrics - Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Enzo Spisni
- Department of Biological, Geological and Environmental Sciences, University of Bologna, Bologna, Italy
| | - Chiara Zarbo
- Pediatric Gastroenterology Unit, Maggiore Hospital, Pediatric Department, Bologna, Italy
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Pediatric Department, Bologna, Italy.
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Di Biase AR, Marasco G, Ravaioli F, Colecchia L, Dajti E, Lecis M, Passini E, Alemanni LV, Festi D, Iughetti L, Colecchia A. Clinical Presentation of Celiac Disease and Diagnosis Accuracy in a Single-Center European Pediatric Cohort over 10 Years. Nutrients 2021; 13:4131. [PMID: 34836386 PMCID: PMC8625284 DOI: 10.3390/nu13114131] [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] [Received: 10/28/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
(1) Background: Changes in the clinical presentation of celiac disease (CD) in children have been reported. The guidelines of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) allow esophagogastroduodenoscopy (EGD) with biopsies to be avoided under specific circumstances. We aimed to assess the clinical picture of pediatric CD patients at diagnosis and to validate ESPGHAN non-biopsy criteria. (2) Methods: Patients with suspected CD or undergoing screening from 2004 to 2014 at the University Hospital in Modena, Italy were enrolled. The accuracy of ESPGHAN non-biopsy criteria and modified versions were assessed. (3) Results: In total, 410 patients were enrolled, of whom 403 were considered for analysis. Of the patients considered, 45 were asymptomatic and diagnosed with CD (11.2%) while 358 patients (88.2%) were symptomatic, of whom 295 were diagnosed with CD. Among symptomatic CD patients, 57 (19.3%) had gastrointestinal symptoms, 98 (33%) had atypical symptoms and 140 (47.4%) had both. No difference was found for the presence of gastrointestinal symptoms at different ages. The non-biopsy ESPGHAN criteria yielded an accuracy of 59.4% with a positive predictive value (PPV) of 100%; 173 out of 308 EGD (56.2%) could have been avoided. The modified 7× and 5× upper limit of normal cut-offs for IgA anti tissue-transglutaminase reached 60.7% and 64.3% of EGD avoided, respectively. (4) Conclusions: Over 10 years, late age at diagnosis and increased rates of atypical CD presentation were found. ESPGHAN non-biopsy criteria are accurate for CD diagnosis and allow half of unneeded EGD to be avoided. Modified versions allowed sparing a greater number of EGD.
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Affiliation(s)
- Anna Rita Di Biase
- Pediatric Unit, Modena University Hospital, 41124 Modena, Italy; (A.R.D.B.); (M.L.); (E.P.); (L.I.)
| | - Giovanni Marasco
- Department of Digestive Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy; (F.R.); (E.D.); (L.V.A.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (L.C.); (D.F.)
| | - Federico Ravaioli
- Department of Digestive Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy; (F.R.); (E.D.); (L.V.A.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (L.C.); (D.F.)
| | - Luigi Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (L.C.); (D.F.)
| | - Elton Dajti
- Department of Digestive Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy; (F.R.); (E.D.); (L.V.A.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (L.C.); (D.F.)
| | - Marco Lecis
- Pediatric Unit, Modena University Hospital, 41124 Modena, Italy; (A.R.D.B.); (M.L.); (E.P.); (L.I.)
| | - Erica Passini
- Pediatric Unit, Modena University Hospital, 41124 Modena, Italy; (A.R.D.B.); (M.L.); (E.P.); (L.I.)
| | - Luigina Vanessa Alemanni
- Department of Digestive Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy; (F.R.); (E.D.); (L.V.A.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (L.C.); (D.F.)
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (L.C.); (D.F.)
| | - Lorenzo Iughetti
- Pediatric Unit, Modena University Hospital, 41124 Modena, Italy; (A.R.D.B.); (M.L.); (E.P.); (L.I.)
| | - Antonio Colecchia
- Gastroenterology Unit, Modena University Hospital, 41124 Modena, Italy;
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Persechino F, Galli G, Persechino S, Valitutti F, Zenzeri L, Mauro A, Corleto VD, Parisi P, Ziparo C, Evangelisti M, Quatrale G, Di Nardo G. Skin Manifestations and Coeliac Disease in Paediatric Population. Nutrients 2021; 13:3611. [PMID: 34684612 PMCID: PMC8537533 DOI: 10.3390/nu13103611] [Citation(s) in RCA: 3] [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: 08/27/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 12/16/2022] Open
Abstract
Celiac disease (CD) is an immune-mediated enteropathy caused by gluten ingestion, affecting approximately 1% of the worldwide population. Extraintestinal symptoms may be present as the first signs of CD, years before the CD diagnosis is made. A great variety of extraintestinal manifestations may be associated with CD. Cutaneous manifestations represent the main extraintestinal manifestations, with dermatitis herpetiformis being the most common in patients with CD. In adults, it has been demonstrated that the role of a gluten-free diet is crucial not only for the recovery of signs and symptoms associated with CD but also for cutaneous manifestations, which often improve after gluten avoidance. In children with CD, the association with skin disorders is well documented regarding dermatitis herpetiformis, but studies considering other dermatological conditions, such as psoriasis and atopic dermatitis, are few. The prevalence and manifestations of dermatological disorders in celiac children are often different from those in adults, explaining the gap between these populations. In addition, the therapeutic role of a gluten-free diet in the improvement in skin alterations is not fully understood in children and in adult population except for dermatitis herpetiformis. Therefore, cutaneous CD symptoms need to be known and recognized by physicians despite their specialties to improve early CD diagnosis, which is critical for a better prognosis. This review describes the current scientific evidence on skin manifestations associated with CD in the pediatric population.
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Affiliation(s)
- Flavia Persechino
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy;
| | - Gloria Galli
- Department of Medical-Surgical and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00185 Rome, Italy; (G.G.); (V.D.C.)
| | - Severino Persechino
- Dermatology Unit, NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00185 Rome, Italy;
| | - Francesco Valitutti
- Pediatric Unit, AOU San Giovanni di Dio e Ruggi D’Aragona, Salerno, Italy and EBRIS (European Biomedical Research Institute of Salerno), 84121 Salerno, Italy;
| | - Letizia Zenzeri
- Pediatric Emergency Unit, Emergency Pediatric Department, AORN Santobono-Pausilipon Children’s Hospital, 80129 Naples, Italy; (L.Z.); (A.M.)
- Pediatric Unit, NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00185 Rome, Italy; (P.P.); (C.Z.); (M.E.); (G.Q.)
| | - Angela Mauro
- Pediatric Emergency Unit, Emergency Pediatric Department, AORN Santobono-Pausilipon Children’s Hospital, 80129 Naples, Italy; (L.Z.); (A.M.)
| | - Vito Domenico Corleto
- Department of Medical-Surgical and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00185 Rome, Italy; (G.G.); (V.D.C.)
| | - Pasquale Parisi
- Pediatric Unit, NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00185 Rome, Italy; (P.P.); (C.Z.); (M.E.); (G.Q.)
| | - Chiara Ziparo
- Pediatric Unit, NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00185 Rome, Italy; (P.P.); (C.Z.); (M.E.); (G.Q.)
| | - Melania Evangelisti
- Pediatric Unit, NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00185 Rome, Italy; (P.P.); (C.Z.); (M.E.); (G.Q.)
| | - Giovanna Quatrale
- Pediatric Unit, NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00185 Rome, Italy; (P.P.); (C.Z.); (M.E.); (G.Q.)
| | - Giovanni Di Nardo
- Pediatric Unit, NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00185 Rome, Italy; (P.P.); (C.Z.); (M.E.); (G.Q.)
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Sahin Y. Celiac disease in children: A review of the literature. World J Clin Pediatr 2021; 10:53-71. [PMID: 34316439 PMCID: PMC8290992 DOI: 10.5409/wjcp.v10.i4.53] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/23/2021] [Accepted: 05/22/2021] [Indexed: 02/06/2023] Open
Abstract
Celiac disease is an immune-mediated systemic disease triggered by intake of gluten in genetically susceptible individuals. The prevalence of celiac disease in the general population is estimated to be 1% in the world. Its prevalence differs depending on geographical and ethnic variations. The prevalence of celiac disease has increased significantly in the last 30 years due to the increased knowledge and awareness of physicians and the widespread use of highly sensitive and specific diagnostic tests for celiac disease. Despite increased awareness and knowledge about celiac disease, up to 95% of celiac patients still remain undiagnosed. The presentations of celiac disease have significantly changed in the last few decades. Classical symptoms of celiac disease occur in a minority of celiac patients, while older children have either minimal or atypical symptoms. Serologic tests for celiac disease should be done in patients with unexplained chronic or intermittent diarrhea, failure to thrive, weight loss, delayed puberty, short stature, amenorrhea, iron deficiency anemia, nausea, vomiting, chronic abdominal pain, abdominal distension, chronic constipation, recurrent aphthous stomatitis, and abnormal liver enzyme elevation, and in children who belong to specific groups at risk. Early diagnosis of celiac disease is very important to prevent long-term complications. Currently, the only effective treatment is a lifelong gluten-free diet. In this review, we will discuss the epidemiology, clinical findings, diagnostic tests, and treatment of celiac disease in the light of the latest literature.
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Affiliation(s)
- Yasin Sahin
- Pediatric Gastroenterology-Hepatology and Nutrition, Medical Park Gaziantep Hospital, Gaziantep 27560, Turkey
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12
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Roberts SE, Morrison-Rees S, Thapar N, Benninga MA, Borrelli O, Broekaert I, Dolinsek J, Martin-de-Carpi J, Mas E, Miele E, Pienar C, Ribes-Koninckx C, Thomassen RA, Thomson M, Tzivinikos C, Thorne K, John A, Williams JG. Systematic review and meta-analysis: the incidence and prevalence of paediatric coeliac disease across Europe. Aliment Pharmacol Ther 2021; 54:109-128. [PMID: 34115894 DOI: 10.1111/apt.16337] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 09/30/2020] [Accepted: 03/04/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coeliac disease is one of the most prevalent immune-mediated gastrointestinal disorders in children. AIM To review the incidence and prevalence of paediatric coeliac disease, and their trends, regionally across Europe, overall and according to age at diagnosis. METHODS Systematic review and meta-analysis from January 1, 1950 to December 31, 2019, based on PubMed, CINAHL and the Cochrane Library, searches of grey literature and websites and hand searching of reference lists. A total of 127 eligible studies were included. RESULTS The prevalence of previously undiagnosed coeliac disease from screening surveys (histology based) ranged from 0.10% to 3.03% (median = 0.70%), with a significantly increasing annual trend (P = 0.029). Prevalence since 2000 was significantly higher in northern Europe (1.60%) than in eastern (0.98%), southern (0.69%) and western (0.60%) Europe. Large increases in the incidence of diagnosed coeliac disease across Europe have reached 50 per 100 000 person-years in Scandinavia, Finland and Spain. The median age at diagnosis increased from 1.9 years before 1990 to 7.6 since 2000. Larger increases in incidence were found in older age groups than in infants and ages <5 years. CONCLUSIONS Paediatric coeliac disease incidence and prevalence have risen across Europe and appear highest in Scandinavia, Finland and Spain. The most recent evidence shows large increases in incidence in most regions, but stabilisation in some (notably Sweden and Finland). Sharp increases in the age at diagnosis may reflect increases in milder and asymptomatic cases diagnosed since reliable serology testing became widely used, through endomysial antibodies after 1990 and tissue transglutaminase antibodies around 2000.
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Wilkes M, Graber E, Rapaport R. Screening for celiac disease in youth with type 1 diabetes: Are current recommendations adequate? J Diabetes 2021; 13:525-526. [PMID: 33710760 DOI: 10.1111/1753-0407.13177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/09/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Meredith Wilkes
- Department of Pediatrics, Division of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Graber
- Department of Pediatrics, Division of Pediatric Endocrinology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Robert Rapaport
- Department of Pediatrics, Division of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Crehuá-Gaudiza E, Barrés Fernández A, Jovaní Casano C, Latorre Tejerina M, Largo Blanco EM, Moreno Ruiz MA, Berghezan Suárez A, García-Peris M, Gil Piquer R, Coret Sinisterra A, Martínez-Barona S, Salido-Capilla C, Requena Fernández MÁ, Arcos-Machancoses JV, Martínez-Costa C. Diagnosis of celiac disease in clinical practice: Present and future. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.anpede.2020.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Meijer CR, Schweizer JJ, Peeters A, Putter H, Mearin ML. Efficient implementation of the 'non-biopsy approach' for the diagnosis of childhood celiac disease in the Netherlands: a national prospective evaluation 2010-2013. Eur J Pediatr 2021; 180:2485-2492. [PMID: 33856540 PMCID: PMC8285331 DOI: 10.1007/s00431-021-04068-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/11/2021] [Accepted: 04/04/2021] [Indexed: 01/11/2023]
Abstract
The aim of this study was (1) to prospectively evaluate the nationwide implementation of the ESPGHAN-guidelines for the diagnosis of celiac disease (CD), (2) to investigate the incidence and clinical presentation of diagnosed childhood CD (0-14 years) in the Netherlands, and (3) to compare the findings with national survey data from 1975 to 1990 and 1993 to 2000 using the same approach. From 2010 to 2013, all practicing paediatricians were invited to report new celiac diagnoses to the Dutch Pediatric Surveillance Unit. Data were collected via questionnaires. A total of 1107 children with newly diagnosed CD were reported (mean age, 5.8 years; range, 10 months-14.9 years; 60.5% female). After the introduction of the non-biopsy approach in 2012, 75% of the diagnoses were made according to the guideline with a significant decrease of 46.3% in biopsies. The use of EMA and HLA-typing significantly increased with 25.8% and 62.1%, respectively. The overall incidence rate of childhood CD was 8.8-fold higher than in 1975-1990 and 2.0-fold higher than in 1993-2000. During the study period, the prevalence of diagnosed CD was 0.14%, far below 0.7% of CD identified via screening in the general Dutch paediatric population. Clinical presentation has shifted towards less severe and extra-intestinal symptoms.Conclusion: ESPGHAN guidelines for CD diagnosis in children were effectively and rapidly implemented in the Netherlands. Incidence of diagnosed CD among children is still significantly rising with a continuous changing clinical presentation. Despite the increasing incidence of diagnoses, significant underdiagnosis still remains. What is Known: • Since 2000 the incidence of diagnosed childhood CD in the Netherlands has shown a steady rise. • The rise in incidence has been accompanied by a changing clinical presentation at diagnosis. What is New: • The ESPGHAN guidelines 2012 for CD diagnosis were effectively and rapidly implemented in the Netherlands. • The incidence of diagnosed childhood CD in the Netherlands has continued to rise significantly during the reported period.
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Affiliation(s)
- Caroline R. Meijer
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Joachim J. Schweizer
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anne Peeters
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - M. Luisa Mearin
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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[Diagnosis of celiac disease in clinical practice: present and future]. An Pediatr (Barc) 2020; 94:223-229. [PMID: 32891578 DOI: 10.1016/j.anpedi.2020.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/21/2020] [Accepted: 07/06/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION European guidelines for the diagnosis of celiac disease (CD) have been updated in 2020. The primary objective was to review the compliance with the diagnostic criteria for CD, according to ESPGHAN 2012. Secondarily, to describe the clinical characteristics of the patients and to assess the changes that would be implied by the application of the new 2020 criteria. PATIENTS AND METHODS Retrospective multicenter study in which 10 centers participated. Patients from 0 to 16 years old with a new diagnosis of CD in 2018-2019 were included. Clinical, serological variables and the performance of intestinal biopsy (IB) were collected. RESULTS 163 patients were included (57% female) with a median age of 7.6 years (SD 4.4). The form of presentation was: 47.8% classical, 30.7% no classical and 21.5% asymptomatic, with differences depending on age. Total IgA and anti-transglutaminase IgA antibodies were performed in all centers as the first diagnostic step. IgA anti-endomysial antibodies (EMA) were performed in 80%, and HLA haplotype in 95%. Of the total, 78 cases (47.9%) met criteria for not performing intestinal biopsy (IB). IB was indicated in the remaining 85 patients, but was not performed in 29 cases (17.8%). The performance of IB was lower in the secondary hospitals than in the tertiary ones (p < 0.05). If we applied the ESPGHAN 2020 criteria, we would disregard the HLA study, and 21 more patients would not have required IB (going from 47.9% to 60.7% of the total). CONCLUSIONS Discrepancies are observed in the application of the ESPGHAN 2012 diagnostic criteria due to the different accessibility to EMA and endoscopic IB in secondary centers. With the ESPGHAN-2020 criteria, around 60% of patients will be able to be diagnosed without IB, provided that the determination of EMA is ensured.
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Adherence to Gluten-free Diet in a Celiac Pediatric Population Referred to the General Pediatrician After Remission. J Pediatr Gastroenterol Nutr 2020; 71:78-82. [PMID: 32097372 DOI: 10.1097/mpg.0000000000002676] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Assessment of adherence to gluten-free diet in celiac disease (CD) is generally recommended. Few data are available about consequences of transition from the referral center to the general pediatrician (GP) once remission is achieved. METHODS Adherence was assessed in patients referred to the GP for an annual basis follow-up, called back for re-evaluation. Immunoglobulin A (IgA) antitissue transglutaminase (anti-tTG) antibodies and the Biagi score (BS) were determined at last follow-up at the referral center (V1), and at re-evaluation (V2). Patients were classified as adherent (BS 3-4, IgA anti-tTG <7 U/mL) and nonadherent (BS 0-2, IgA anti-tTG ≥7). Scores of adherence were correlated with personal and clinical data. RESULTS We evaluated 200 patients. Overall, we found good adherence rates in 94.95% of patients at V1 and 83.5% at V2. IgA anti-tTG were negative in 100% at V1 and 96.97% at V2. BS is 3 to 4 in 94.5% at V1 and 84% at V2. Adherence at V2 was significantly worse than V1 (P < 0.001). No significant associations were found between scores of adherence and sex, symptoms and age at diagnosis, family history of CD, comorbidity, and diagnosis by endoscopy. Age 13 years or older represents a risk factor for lack of compliance at V1 (P = 0.02) and V2 (P = 0.04), and foreign nationality at V2 (P = 0.001). CONCLUSIONS The BS, serology, and a clinical interview, integrated, are reliable tools for assessing pediatric adherence to gluten-free diet. We argue that referring patients to the GP after remission of CD is important, but the process must be improved and recommendations are required.
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Severity of Villous Atrophy at Diagnosis in Childhood Does Not Predict Long-term Outcomes in Celiac Disease. J Pediatr Gastroenterol Nutr 2020; 71:71-77. [PMID: 32097370 DOI: 10.1097/mpg.0000000000002675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Current pediatric guidelines allow noninvasive diagnosis of celiac disease in selected children. We investigated in a large cohort study whether the severity of villous atrophy at diagnosis is associated with clinical characteristics or long-term health outcomes, thus having a prognostic significance. METHODS Comprehensive medical data on 906 children with celiac disease were analyzed. Long-term health outcomes of 503 adult patients diagnosed in childhood were moreover assessed with a specific study questionnaire and validated Gastrointestinal Symptom Rating Scale (GSRS) and Psychological General Well-Being (PGWB) questionnaires. Patients were classified into 3 groups according to the severity of villous atrophy at diagnosis, and all variables were compared. RESULTS Altogether 34% of the patients had partial, 40% subtotal, and 26% total villous atrophy. Children with milder lesions were diagnosed more recently (median year 2007 vs 2006 vs 2001, respectively, P < 0.001), more often by screening (30% vs 25% vs 17%, P < 0.001) and they suffered less often from anemia (16% vs 21% vs 32%, P < 0.001) and growth disturbances (22% vs 36% vs 54%, P < 0.001) and had lower transglutaminase-2 antibody levels (median 64 U/L vs 120 U/L vs 120 U/L, P < 0.001). There was no difference in other disease features.Altogether 212 adults diagnosed in childhood completed the questionnaires. Severity of villous atrophy at childhood diagnosis did not predict presence of complications or comorbidities, persistent symptoms, and self-perceived health, quality of life or adherence to a gluten-free diet in adulthood. CONCLUSION Presence of advanced villous atrophy at diagnosis is associated with more severe clinical characteristics but not with poorer long-term health and treatment outcomes.
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The Gluten Free Diet's Impact on Growth in Children with Celiac Disease in Two Different Countries. Nutrients 2020; 12:nu12061547. [PMID: 32466557 PMCID: PMC7352316 DOI: 10.3390/nu12061547] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 01/12/2023] Open
Abstract
The effects of gluten free diet (GFD) on body mass index (BMI) and growth parameters in pediatric patients with celiac disease (CD) and their dependence on different socio-cultural environments are poorly known. We conducted an international retrospective study on celiac patients diagnosed at the University of Verona, Italy, and at the University of Chicago, Chicago, IL, USA, as underweight. A total of 140 celiac children and 140 controls (mean age 8.4 years) were enrolled in Chicago; 125 celiac children and 125 controls (mean age 7.3 years, NS) in Verona. At time of diagnosis, Italian celiac children had a weight slightly lower (p = 0.060) and a BMI z-score significantly (p < 0.001) lower than their American counterparts. On GFD, Italian celiac children showed an increased prevalence of both underweight (19%) as well as overweight (9%), while American children showed a decrease prevalence of overweight/obese. We concluded that while the GFD had a similar impact on growth of celiac children in both countries, the BMI z-score rose more in American than in Italian celiac children. Additionally, in Italy, there was an alarming increase in the proportion of celiac children becoming underweight. We speculate that lifestyle and cultural differences may explain the observed variations.
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Blais-Carrière J, Tétu A, Moreau B. Knowledge and opinions of asymptomatic adolescents and their caregivers on celiac disease screening. Paediatr Child Health 2020; 26:e145-e151. [PMID: 33936344 DOI: 10.1093/pch/pxaa006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/03/2019] [Indexed: 11/12/2022] Open
Abstract
Objectives Celiac disease (CD) is an immune enteropathy caused by sensitivity to gluten affecting one per cent of the general population. Most people with CD are asymptomatic and some may be affected from childhood. Despite the latest recommendations of paediatric gastroenterology societies, targeted screening is still uncommon in clinical paediatric settings. A poor understanding of the asymptomatic population's opinions creates obstacles for broader implementation of CD screening. This study aims to fill this gap by reporting on the knowledge and opinions of adolescents and caregivers of children on CD screening. Methods Adolescents with absence of classical symptoms of CD and caregivers of presumably asymptomatic children were asked about their knowledge and opinions of CD through a self-administered questionnaire. Results There were 227 respondents including 76 adolescents and 151 caregivers. A minority of respondents (8% of caregivers and 23% of adolescents) were identified as having a CD-associated condition (such as hypothyroidism, type 1 diabetes, Down syndrome, etc.). A majority of caregivers (84%) and half of adolescents (49%) already knew about CD. Half of the respondents (46%) were in favour of screening asymptomatic paediatric populations and this agreement increased to 81.7% when they were confronted with hypothetical risks of 10%. Conclusion This study reveals an increased willingness to screen when participants were faced with increasing hypothetical risks. This suggests that screening recommendations targeting high-risk populations, such as those of paediatric and non-paediatric gastroenterology societies, may be more widely accepted.
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Affiliation(s)
- Jasmine Blais-Carrière
- Department of Pediatrics, Centre Intégré Universitaire de Santé et Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Sherbrooke, Québec
| | - Amélie Tétu
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke (CRCHUS), Sherbrooke, Québec
| | - Brigitte Moreau
- Department of Pediatrics, Centre Intégré Universitaire de Santé et Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Sherbrooke, Québec.,Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec
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Krauthammer A, Guz-Mark A, Zevit N, Marderfeld L, Waisbourd-Zinman O, Silbermintz A, Mozer-Glassberg Y, Nachmias Friedler V, Rozenfeld Bar Lev M, Matar M, Assa A, Shamir R. Two decades of pediatric celiac disease in a tertiary referral center: What has changed? Dig Liver Dis 2020; 52:457-461. [PMID: 32111387 DOI: 10.1016/j.dld.2020.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/27/2020] [Accepted: 02/01/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Celiac disease (CD) is common worldwide with increasing prevalence and changing presentation. AIMS To evaluate changes in the presentation and management of CD over the last two decades. METHODS Retrospective chart review of pediatric patients with CD between 01.1999 to 12.2018 was performed. Comparisons were made between an early (1999 to 2008) and late (2009 to 2018) decade, regarding clinical and laboratory parameters at presentation and follow-up. RESULTS In a cohort of 932 patients (early decade n = 316, late decade n = 616), patients from the late decade presented with lower rates of weight loss and abdominal distention (24.2% vs 34.7% and 6% vs 11%, respectively p < 0.01), and with higher rates of abdominal pain or asymptomatic presentation (41.4% vs 27.4%, p < 0.01, and 18% vs 13%, p < 0.05, respectively). Good adherence to gluten-free diet was reported more often in the late decade (64% vs 50.6%, p < 0.001), and fewer patients were lost to follow-up. During the late decade, significantly higher rates of celiac serology normalization were achieved during the first two years of follow-up. CONCLUSION In recent years, children with CD were diagnosed with milder symptoms, showed better adherence and demonstrated earlier normalization of celiac serology.
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Affiliation(s)
- Alexander Krauthammer
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel.
| | - Anat Guz-Mark
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Luba Marderfeld
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Nutrition and Dietetics Department, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Orith Waisbourd-Zinman
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Ari Silbermintz
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Yael Mozer-Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Vered Nachmias Friedler
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Michal Rozenfeld Bar Lev
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Manar Matar
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
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King JA, Jeong J, Underwood FE, Quan J, Panaccione N, Windsor JW, Coward S, deBruyn J, Ronksley PE, Shaheen AA, Quan H, Godley J, Veldhuyzen van Zanten S, Lebwohl B, Ng SC, Ludvigsson JF, Kaplan GG. Incidence of Celiac Disease Is Increasing Over Time: A Systematic Review and Meta-analysis. Am J Gastroenterol 2020; 115:507-525. [PMID: 32022718 DOI: 10.14309/ajg.0000000000000523] [Citation(s) in RCA: 188] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To conduct a systematic review and meta-analysis that defines the worldwide incidence of celiac disease (CD) and examines temporal trends. METHODS MEDLINE and EMBASE were searched for population-based studies reporting the incidence of CD in the overall population, children, or adults. No limits were placed on year or language of publication. Studies solely examining at-risk populations (e.g., patients with type 1 diabetes) were excluded. Random-effects models were performed to meta-analyze sex- and age-specific incidence in the 21st century. Temporal trend analyses assessed the average annual percent change in CD incidence over time. RESULTS Of 11,189 citations, 86 eligible studies were identified for inclusion, of which 50 were deemed suitable for analyses. In the 21st century, the pooled female incidence of CD was 17.4 (95% confidence interval [CI]: 13.7, 21.1) (I = 99.5%) per 100,000 person-years, compared with 7.8 (95% CI: 6.3, 9.2) (I = 98.6%) in males. Child-specific incidence was 21.3 per 100,000 person-years (95% CI: 15.9, 26.7) (I = 99.7%) compared with 12.9 (95% CI: 7.6, 18.2) (I = 99.9%) in adults. Pooling average annual percent changes showed the incidence of CD to be increasing by 7.5% (95% CI: 5.8, 9.3) (I = 79.6%) per year over the past several decades. DISCUSSION Incidence of CD is highest in females and children. Overall, the incidence has been significantly rising in the latter half of the 20th century and into the 21st century throughout the Western world. Population-based studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of CD.
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Affiliation(s)
- James A King
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jocelyn Jeong
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Fox E Underwood
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joshua Quan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicola Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph W Windsor
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephanie Coward
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer deBruyn
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Abdel-Aziz Shaheen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jenny Godley
- Department of Sociology, University of Calgary, Calgary, Alberta, Canada
| | | | - Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong, China
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Gilaad G Kaplan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Popp A, Mäki M. Changing Pattern of Childhood Celiac Disease Epidemiology: Contributing Factors. Front Pediatr 2019; 7:357. [PMID: 31555624 PMCID: PMC6727179 DOI: 10.3389/fped.2019.00357] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/15/2019] [Indexed: 12/14/2022] Open
Abstract
Up until the 1960s and 1970s, diarrhea, malabsorption syndrome, and failure to thrive were the presenting symptoms and signs of celiac disease (CD) in young infants; however this disease was also at the same time reported to be disappearing. Indeed, clinical childhood CD was seen to transform into a milder form, resulting in an upward shift in age at diagnosis during the 1970s (and years later for many countries). This changing pattern of CD presentation then altered the epidemiology of the disease, with major differences between and within countries observed. An awareness of the changing clinical nature of CD and use of case-finding tools to detect even clinically silent CD became an important factor in this changing epidemiology. Countries report both low and high prevalence but it seems to be on the increase resulting in a population-based level of 1-2%. This paper discusses the potential causes and environmental factors behind these observed clinical changes, identifying new clues from different studies published at the time this transformation took place. For instance, it was found that breastfeeding postponed the diagnosis of the disease but did not altogether prevent it. Moreover, gluten introduction at a young age, specifically at the mean age of 2 months, seemed to also have a clear impact in inducing malabsorption syndrome and failure to thrive in young infants in addition to other factors such as gluten intake volume and type of cereal present in the weaning food. Further, the impact of cow's milk and its high osmolarity might have played an important role; humanized milk formulas were not yet invented. Future epidemiological studies on the contributing environmental factors to the shift in CD presentation are thus recommended for countries in which these changing clinical features are still being observed.
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Affiliation(s)
- Alina Popp
- Faculty of Medicine and Health Technology, Tampere Center of Child Health Research, Tampere University and Tampere University Hospital, Tampere, Finland
- National Institute for Mother and Child Health “Alessandrescu-Rusescu”, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Markku Mäki
- Faculty of Medicine and Health Technology, Tampere Center of Child Health Research, Tampere University and Tampere University Hospital, Tampere, Finland
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Potter K, de Koning L, Butzner JD, Gidrewicz D. Survey of the initial management of celiac disease antibody tests by ordering physicians. BMC Pediatr 2019; 19:243. [PMID: 31324159 PMCID: PMC6639898 DOI: 10.1186/s12887-019-1621-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 07/10/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Appropriate interpretation of a positive celiac antibody test by an ordering physician is important in order to institute proper management. We evaluated why children with an initial positive celiac serology were not referred for diagnostic biopsy or followed with serial testing by the ordering physician. METHODS Consecutive celiac serologies in all patients less than 18 years of age were evaluated over 3.5 years and 775 children with a positive tissue transglutaminase antibody (TTG) were identified. If no management of a positive TTG could be identified, a survey was sent to the ordering physician. Responses were categorized as appropriate or inappropriate management. RESULTS Of the 775 patients with a positive TTG, 193 (24.9%, 95% CI 21.9-28.1%) received no follow-up management. We contacted 173 ordering physicians and 120 (69%) responded. Of the 120 responses, 55 patients (45.8%, 95% CI 36.8-55.1%) were managed appropriately and 46 (38.3%, 95% CI 29.7-47.7%) were considered to be inappropriately managed when no repeat TTG was obtained within 18 months. Reasons for inappropriate management included: screen considered to be false positive (44.7%), patient was not experiencing symptoms of celiac disease (31.6%), symptoms had resolved (15.8%), results were not indicative of celiac disease (26.3%) and patients started a gluten-free diet with no evaluation of response (15.8%). In 19 patients the TTG was not acted upon for technical reasons. CONCLUSIONS Positive TTGs require appropriate interventions. These include: subspecialist referral for further evaluation and/or repeat testing to evaluate: 1) treatment response or 2) patients with minimal or no symptoms.
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Affiliation(s)
- Kathryn Potter
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Lawrence de Koning
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Calgary Laboratory Services Calgary, Calgary, Alberta, Canada
| | - J Decker Butzner
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Dominica Gidrewicz
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Division of Pediatric Gastroenterology, Alberta Children's Hospital, 2888 Shaganappi Trail, Calgary, AB, T3B 6A8, Canada.
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Odeh R, Alassaf A, Gharaibeh L, Ibrahim S, Khdair Ahmad F, Ajlouni K. Prevalence of celiac disease and celiac-related antibody status in pediatric patients with type 1 diabetes in Jordan. Endocr Connect 2019; 8:780-787. [PMID: 31085767 PMCID: PMC6590199 DOI: 10.1530/ec-19-0146] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/14/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Scientific findings regarding the prevalence of celiac disease (CD) in pediatric patients with type 1 diabetes (T1D) in the Arab world are scarce. We aimed to determine the prevalence of biopsy-proven celiac disease (BPCD) among pediatric patients with T1D from Jordan. We also assessed the possible predictors for developing CD in this cohort of patients and we compared T1D patients who developed BPCD with those who had positive CD serology but negative histology and/or fluctuating CD serology. METHODS Celiac serology and duodenal biopsy results from 2012 to 2017 were collected from patients with T1D. The outcome of positive celiac serology and the risk factors for CD in T1D patients were investigated. RESULTS A total of 538 children of which 278 boys (51.7%) were included in the study. The prevalence of positive serology and the diagnosis of BPCD in this cohort of T1D patients were 16.6 and 9.1% respectively. Eighty percent of those with BPCD were asymptomatic and 47% were diagnosed with CD at onset of T1D. Spontaneous normalization of celiac serology occurred in 23.6% of those with positive serology. CONCLUSION CD is prevalent in T1D pediatric patients from Jordan (9.1%). It is often asymptomatic and the majority of cases were diagnosed at onset or within 5 years of T1D diagnosis. Spontaneous normalization of CD serology occurred in some patients with T1D. Hence, a watchful follow-up is recommended in such patients.
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Affiliation(s)
- Rasha Odeh
- Section of Pediatric Endocrinology, Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan
- Correspondence should be addressed to R Odeh:
| | - Abeer Alassaf
- Section of Pediatric Endocrinology, Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan
| | | | - Sarah Ibrahim
- Section of Pediatric Endocrinology, Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan
| | - Fareed Khdair Ahmad
- Section of Pediatric Gastroenterology, Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan
| | - Kamel Ajlouni
- The National Center (Institute) for Diabetes, Endocrinology and Genetics (NCDEG), University of Jordan, Amman, Jordan
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Hujoel IA, Reilly NR, Rubio-Tapia A. Celiac Disease: Clinical Features and Diagnosis. Gastroenterol Clin North Am 2019; 48:19-37. [PMID: 30711209 DOI: 10.1016/j.gtc.2018.09.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The presentation in celiac disease is shifting from the classical malabsorptive presentation to more nonclassical presentations, requiring clinicians to maintain a high level of suspicion for the disease and to be aware of the possible extraintestinal manifestations. The diagnosis of celiac disease is guided by initial screening with serology, followed by confirmation with an upper endoscopy and small intestinal biopsy. In some pediatric cases, biopsy may be avoided.
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Affiliation(s)
- Isabel A Hujoel
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Norelle R Reilly
- Division of Pediatric Gastroenterology, Columbia University Medicine Center, 630 West 168th Street, PH-17, New York, NY 10032, USA
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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Prevalence and Clinical Features of Celiac Disease in Healthy School-Aged Children. Dig Dis Sci 2019; 64:173-181. [PMID: 30311156 DOI: 10.1007/s10620-018-5320-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/03/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND/AIMS The aim of this study was to determine the prevalence of celiac disease (CD) in healthy school-aged children in the northern region of Cyprus and to investigate the existence of potential markers that may accompany CD. This is the first study to measure the prevalence of CD in the northern region of Cyprus. METHODS This study included 3792 school-aged children who were between the ages of 6 and 10 years between January 2015 and October 2016. CD was screened using total serum IgA, IgA anti-tissue transglutaminase (tTG), and IgA antiendomysial (EMA) antibodies. Subjects with selective IgA deficiency were further tested for IgG-tTG. Small intestinal biopsies were performed on all subjects with tTG antibody positivity. Risk factors and symptoms related to CD were evaluated using questionnaires in both the CD and control groups. RESULTS Of the 3792 subjects, 39 were antibody positive (IgA-tTG was positive only in 14 subjects, IgA-tTG plus IgA-EMA in 21 subjects, and IgG-tTG in 4 subjects). IgA deficiency was detected in 11 subjects (0.29%). IgG-tTG was positive in 4 subjects with IgA deficiency (36.3%). Intestinal biopsies were performed on 28 of the 39 seropositive subjects. The biopsy findings of 15 children were consistent with CD (IgA-tTG positive in 3, IgA-tTG and IgA-EMA positive in 10, and IgG-tTG positive in 2). Thus, biopsies confirmed CD in 1:256 children (0.39%). CONCLUSIONS Our study, which is the first study of school-aged children from the northern region of Cyprus, revealed that CD is a prevalent disease in this region.
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Nardecchia S, Auricchio R, Discepolo V, Troncone R. Extra-Intestinal Manifestations of Coeliac Disease in Children: Clinical Features and Mechanisms. Front Pediatr 2019; 7:56. [PMID: 30891436 PMCID: PMC6413622 DOI: 10.3389/fped.2019.00056] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 02/13/2019] [Indexed: 12/11/2022] Open
Abstract
Celiac disease (CD) is a systemic autoimmune disease due to a dysregulated mucosal immune response to gluten and related prolamines in genetically predisposed individuals. It is a common disorder affecting ~1% of the general population, its incidence is steadily increasing. Changes in the clinical presentation have become evident since the 80s with the recognition of extra-intestinal symptoms like short stature, iron deficiency anemia, altered bone metabolism, elevation of liver enzymes, neurological problems. Recent studies have shown that the overall prevalence of extra-intestinal manifestations is similar between pediatric and adult population; however, the prevalence of specific manifestations and rate of improvement differ in the two age groups. For instance, clinical response in children occurs much faster than in adults. Moreover, an early diagnosis is decisive for a better prognosis. The pathogenesis of extra-intestinal manifestations has not been fully elucidated yet. Two main mechanisms have been advanced: the first related to the malabsorption consequent to mucosal damage, the latter associated with a sustained autoimmune response. Importantly, since extra-intestinal manifestations dominate the clinical presentation of over half of patients, a careful case-finding strategy, together with a more liberal use of serological tools, is crucial to improve the detection rate of CD.
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Affiliation(s)
- Silvia Nardecchia
- Department of Medical Translational Sciences and European Laboratory for the Investigation of Food-Induced Diseases, University of Naples Federico II, Naples, Italy
| | - Renata Auricchio
- Department of Medical Translational Sciences and European Laboratory for the Investigation of Food-Induced Diseases, University of Naples Federico II, Naples, Italy
| | | | - Riccardo Troncone
- Department of Medical Translational Sciences and European Laboratory for the Investigation of Food-Induced Diseases, University of Naples Federico II, Naples, Italy
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Laurikka P, Nurminen S, Kivelä L, Kurppa K. Extraintestinal Manifestations of Celiac Disease: Early Detection for Better Long-Term Outcomes. Nutrients 2018; 10:E1015. [PMID: 30081502 PMCID: PMC6115849 DOI: 10.3390/nu10081015] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/25/2018] [Accepted: 07/31/2018] [Indexed: 12/11/2022] Open
Abstract
Population-based screening studies have shown celiac disease to be one of the most common chronic gastrointestinal diseases. Nevertheless, because of the diverse clinical presentation, the great majority of patients remain unrecognized. Particularly difficult to identify are the multifaceted extraintestinal symptoms that may appear at variable ages. Although the pathogenesis and long-term outcome of these manifestations are still poorly established, there is some evidence that unrecognized celiac disease predisposes to severe complications if not diagnosed and prevented with an early-initiated gluten-free diet. Therefore, it is of utmost importance that physicians of different disciplines learn to recognize celiac disease in individuals with non-gastrointestinal symptoms. In the future, more studies are needed to clarify the factors affecting development and prognosis of the extraintestinal manifestations.
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Affiliation(s)
- Pilvi Laurikka
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, 33014 Tampere, Finland.
- Department of Internal Medicine, Hospital District of South Ostrobothnia, 60200 Seinäjoki, Finland.
| | - Samuli Nurminen
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, 33014 Tampere, Finland.
| | - Laura Kivelä
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, 33014 Tampere, Finland.
| | - Kalle Kurppa
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, 33014 Tampere, Finland.
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Abstract
OBJECTIVE The aim of the study was to evaluate the efficacy of the gluten-free diet (GFD) on gastrointestinal (GI) and extra-intestinal (EI) symptom resolution and identify predictors for persistence of symptoms in all celiac patients at the University of Chicago. METHODS We conducted a retrospective chart review from 2002 to 2015. GI symptoms included abdominal pain, bloating, constipation, diarrhea, failure to thrive/weight loss, nausea, reflux, and vomiting. EI symptoms included abnormal liver enzymes, arthralgia/arthritis, dermatitis herpetiformis, alopecia, fatigue, headache, anemia, stomatitis, myalgia, psychiatric disorders, rashes, seizures, neuropathy, short stature, delayed puberty, osteoporosis, and infertility. RESULTS A total of 554 patients (227 children) with celiac disease (CeD) were included. Abdominal pain, diarrhea and failure to thrive were the most common GI symptoms in children whereas diarrhea, bloating, and abdominal pain were most common in adults. Short stature, fatigue, and headache were the most common EI symptoms in children whereas iron deficiency anemia, fatigue, and headache/psychiatric disorders were most common in adults. Children had significantly higher rates of EI and GI symptom resolution as compared to adults, with greater rates of improvements in GI versus EI symptoms at more than 24 months. Long duration of symptoms, female sex, and non-adherence to a GFD were the most important significant predictors of failure to clinically improve. CONCLUSIONS On a strict GFD, children report greater rates of both GI and EI symptom resolution as compared to adults with greater rates of improvement in GI over EI symptoms. Early recognition of CeD and close attention to diet adherence may help in symptom resolution.
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Erwin EA, Rhoda DA, Redmond M, Ly JB, Russo JM, Hill ID, Platts-Mills TA. Using Serum IgE Antibodies to Predict Esophageal Eosinophilia in Children. J Pediatr Gastroenterol Nutr 2017; 65:520-525. [PMID: 28981449 PMCID: PMC5665571 DOI: 10.1097/mpg.0000000000001553] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Symptoms of eosinophilic esophagitis are variable and can be nonspecific. Food-specific serum immunoglobulin E (IgE) antibodies are frequently found in patients with eosinophilic esophagitis and are obtained using a widely available blood test. Our objective was to evaluate the ability of food-specific IgE antibodies to predict the presence of esophageal eosinophilia. METHODS We reviewed 144 medical records for pediatric patients having esophageal biopsy and serum analysis for IgE antibodies to food (exploratory group). We performed logistic regression using sex and number of positive food-specific IgE tests to develop a model that predicts ≥15 eosinophils/high-power field (hpf) in the esophagus. We tested the model using 142 additional patients (validation group). RESULTS The probability of having ≥15 eosinophils/hpf in the esophagus was higher in boys and increased with the number of positive food-specific IgE tests from 12% (95% confidence interval 4.8-26) in girls with 0 foods positive to 86% (95% confidence interval 71-94) for boys with 4 or 5 foods positive. The statistical model using sex and number of positive IgE tests to predict patients having ≥15 eosinophils/hpf showed acceptable discriminative ability (area under the receiver operating characteristic curve 0.80). The performance metrics for the model to predict ≥15 eosinophils/hpf in the validation group were similar (area under the receiver operating characteristic curve 0.75). CONCLUSIONS Requiring only a blood test and a simple algorithm, analysis for IgE antibodies to food may expedite an esophagogastroduodenoscopy and decrease delays in the diagnosis and treatment of patients with nonspecific gastrointestinal symptoms who have increased eosinophils in the esophagus.
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Affiliation(s)
- Elizabeth A. Erwin
- Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, OH
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Margaret Redmond
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jean B. Ly
- Division of Allergy and Immunology, All Children's Hospital, Sarasota, FL
| | - John M. Russo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Ivor D. Hill
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH
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The approach to Celiac Disease in children. Int J Pediatr Adolesc Med 2017; 4:124-127. [PMID: 30805515 PMCID: PMC6372481 DOI: 10.1016/j.ijpam.2017.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023]
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Janas RM, Rybak A, Wierzbicka-Rucińska A, Socha P, Śnitko R, Szaflarska-Popławska A, Stolarczyk A, Oralewska B, Cytra-Jarocka E, Iwańczak B, Grzybowska-Chlebowczyk U, Cichy W, Czaja-Bulsa G, Socha J. Serum Concentrations of Insulin, Ghrelin, Adiponectin, Leptin, Leptin Receptor and Lipocalin-2 in Children with Celiac Disease Who Do and Do Not Adhere to a Gluten-Free Diet. Gut Liver 2017; 10:587-94. [PMID: 27074817 PMCID: PMC4933420 DOI: 10.5009/gnl15404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 09/24/2015] [Accepted: 10/12/2015] [Indexed: 12/18/2022] Open
Abstract
Background/Aims The roles of the many bioactive peptides in the pathogenesis of celiac disease remain unclear. To evaluate the serum concentrations of insulin, ghrelin, adiponectin, leptin, leptin receptor, and lipocalin-2 in children with celiac disease who do and do not adhere to a gluten-free diet (GFD, intermittent adherence). Methods Prepubertal, pubertal, and adolescent celiac children were included in this study (74 girls and 53 boys on a GFD and 80 girls and 40 boys off of a GFD). Results Insulin levels in prepubertal (9.01±4.43 μIU/mL), pubertal (10.3±3.62 μIU/mL), and adolescent (10.8±4.73 μIU/mL) girls were higher than those in boys (5.88±2.02, 8.81±2.88, and 8.81±2.26 μIU/mL, respectively) and were neither age-dependent nor influenced by a GFD. Prepubertal children off of a GFD exhibited higher ghrelin levels than prepubertal children on a GFD. Adiponectin levels were not age-, sex- nor GFD-dependent. Adherence to a GFD had no effect on the expression of leptin, leptin receptor, and lipocalin-2. Conclusions Adherence to a GFD had no influence on the adiponectin, leptin, leptin receptor, and lipocalin-2 concentrations in celiac children, but a GFD decreased highly elevated ghrelin levels in prepubertal children. Further studies are required to determine whether increased insulin concentrations in girls with celiac disease is suggestive of an increased risk for hyperinsulinemia.
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Affiliation(s)
- Roman M Janas
- Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Anna Rybak
- Department of Gastroenterology, Hepatology and Nutrition Disorders, The Children's Memorial Health Institute, Warsaw, Poland
| | - Aldona Wierzbicka-Rucińska
- Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Socha
- Department of Gastroenterology, Hepatology and Nutrition Disorders, The Children's Memorial Health Institute, Warsaw, Poland
| | - Rafał Śnitko
- Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Anna Szaflarska-Popławska
- Department of Paediatric Endoscopy and Gastrointestinal Function Testing, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Anna Stolarczyk
- Department of Gastroenterology, Hepatology and Nutrition Disorders, The Children's Memorial Health Institute, Warsaw, Poland
| | - Beata Oralewska
- Department of Gastroenterology, Hepatology and Nutrition Disorders, The Children's Memorial Health Institute, Warsaw, Poland
| | - Elżbieta Cytra-Jarocka
- Department of Pediatrics, Gastroenterology and Allergology, Medical University of Białystok, Białystok, Poland
| | - Barbara Iwańczak
- Second Department of Pediatrics, Gastroenterology and Nutrition, Medical University of Wrocław, Wrocław, Poland
| | - Urszula Grzybowska-Chlebowczyk
- Department of Pediatrics, Division of Gastroenterology, Silesian Center for Child Health, Independent Public Clinical Hospital No. 6, Medical University of Silesia, Katowice, Poland
| | - Wojciech Cichy
- First Department of Paediatric, Department of Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznań, Poland
| | - Grażyna Czaja-Bulsa
- Department of Pediatrics, Gastroenterology and Rheumatology, Pomeranian Medical University, Szczecin, Poland
| | - Jerzy Socha
- Department of Gastroenterology, Hepatology and Nutrition Disorders, The Children's Memorial Health Institute, Warsaw, Poland
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Kivelä L, Kaukinen K, Huhtala H, Lähdeaho ML, Mäki M, Kurppa K. At-Risk Screened Children with Celiac Disease are Comparable in Disease Severity and Dietary Adherence to Those Found because of Clinical Suspicion: A Large Cohort Study. J Pediatr 2017; 183:115-121.e2. [PMID: 28153477 DOI: 10.1016/j.jpeds.2016.12.077] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 11/17/2016] [Accepted: 12/30/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess whether children at risk for celiac disease should be screened systematically by comparing their baseline and follow-up characteristics to patients detected because of clinical suspicion. STUDY DESIGN Five hundred four children with celiac disease were divided into screen-detected (n = 145) and clinically detected cohorts (n = 359). The groups were compared for clinical, serologic, and histologic characteristics and laboratory values. Follow-up data regarding adherence and response to gluten-free diet were compared. Subgroup analyses were made between asymptomatic and symptomatic screen-detected patients. RESULTS Of screen-detected patients, 51.8% had symptoms at diagnosis, although these were milder than in clinically detected children (P < .001). Anemia (7.1% vs 22.9%, P < .001) and poor growth (15.7% vs 36.9%, P < .001) were more common, and hemoglobin (126 g/l vs 124 g/l, P = .008) and albumin (41.0 g/l vs 38.0 g/l, P = .016) were lower in clinically detected patients. There were no differences in serology or histology between the groups. Screen-detected children had better dietary adherence (91.2% vs 83.2%, P = .047). The groups showed equal clinical response (97.5% vs 96.2%, P = .766) to the gluten-free diet. In subgroup analysis among screen-detected children, asymptomatic patients were older than symptomatic (9.0 vs 5.8 years of age, P = .007), but the groups were comparable in other variables. CONCLUSIONS More than one-half of the screen-detected patients with celiac disease had symptoms unrecognized at diagnosis. The severity of histologic damage, antibody levels, dietary adherence, and response to treatment in screen-detected cases is comparable with those detected on a clinical basis. The results support active screening for celiac disease among at-risk children.
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Affiliation(s)
- Laura Kivelä
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Katri Kaukinen
- School of Medicine, University of Tampere, Tampere, Finland; Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Tampere School of Health Sciences, University of Tampere, Tampere, Finland
| | - Marja-Leena Lähdeaho
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Markku Mäki
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Kalle Kurppa
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
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Abstract
OBJECTIVES Response to a gluten-free diet (GFD) in children with celiac disease is determined by symptom resolution and normalization of serology. We evaluated the rate of normalization of the transglutaminase (TTG) and antiendomysial (EMA) for children on a GFD after diagnosis. METHODS Celiac serologies were obtained over 3.5 years after starting a GFD in 228 newly diagnosed children with biopsy-proven celiac disease. Patients were classified into categories based on serology (group A, TTG ≥10 × upper limit of normal [ULN] and EMA ≥ 1:80; group B, TTG ≥10 × ULN and EMA ≤ 1:40; and group C, TTG <10 × ULN) and by severity of histologic injury at diagnosis. RESULTS In children with the highest serology at diagnosis (group A), 79.7% had an abnormal TTG at 12 months after diagnosis (mean TTG 12 months, 68.8 ± 7.3, normal <20 kU/L). At 2 years, an abnormal TTG persisted in 41.7%. In contrast, only 35% of children with the lowest serology at diagnosis (group C) displayed an abnormal TTG at 12 months (mean TTG 14.3 ± 1.9 kU/L). In those with the most severe mucosal injury, Marsh 3C, 74.2% and 33.2% had an abnormal TTG at 1 and 2 years. CONCLUSIONS Normalization of celiac serology took >1 year in approximately 75% of GFD-compliant children with the highest celiac serology or most severe mucosal injury at diagnosis. Clinicians must consider serology and histology at diagnosis to properly evaluate response to GFD.
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Sahin Y, Adrovic A, Barut K, Kutlu T, Cullu-Cokugras F, Sahin S, Kasapcopur O, Erkan T. The frequency of the celiac disease among children with familial Mediterranean fever. Mod Rheumatol 2017; 27:1036-1039. [PMID: 28151032 DOI: 10.1080/14397595.2016.1270497] [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: 10/20/2022]
Abstract
We aimed to assess the frequency of celiac disease (CD) in patients with Familial Mediterranean Fever (FMF). This prospective study was carried out from October 2015 to March 2016 and included 303 patients with FMF. We used 98 sex- and age-matched healthy subjects as a control group. Levels of total IgA and tissue transglutaminase (tTG) IgA antibody were measured in all groups. Those with increased level of tTG IgA were tested for anti-endomysium IgA antibodies (EMA). Patients with positive EMA underwent gastro-duodenoscopy and intestinal biopsy for a definite diagnosis of CD. Only 9 of 303 patients (2.9%) were positive for tTG IgA. Patients positive for tTG IgA were then tested for EMA and only one of them (0.3%) had a positive result. This patient underwent gastro-duodenoscopy. The pathological report was compatible with Marsh 0 classification score for the diagnosis of CD. Two subjects from the control group were positive for tTG IgA but none of them had positive EMA antibodies. We did not find CD in the large cohort of childhood FMF patients. The prevalence of CD did not show association with presence of childhood FMF in this study and CD would not be a considerable complication of childhood FMF.
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Affiliation(s)
- Yasin Sahin
- a Department of Pediatric Gastroenterology , Cerrahpasa Medical School, Istanbul University , Turkey
| | - Amra Adrovic
- b Pediatric Rheumatology , Cerrahpasa Medical School, Istanbul University , Turkey
| | - Kenan Barut
- b Pediatric Rheumatology , Cerrahpasa Medical School, Istanbul University , Turkey
| | - Tufan Kutlu
- a Department of Pediatric Gastroenterology , Cerrahpasa Medical School, Istanbul University , Turkey
| | - Fugen Cullu-Cokugras
- a Department of Pediatric Gastroenterology , Cerrahpasa Medical School, Istanbul University , Turkey
| | - Sezgin Sahin
- b Pediatric Rheumatology , Cerrahpasa Medical School, Istanbul University , Turkey
| | - Ozgur Kasapcopur
- b Pediatric Rheumatology , Cerrahpasa Medical School, Istanbul University , Turkey
| | - Tulay Erkan
- a Department of Pediatric Gastroenterology , Cerrahpasa Medical School, Istanbul University , Turkey
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Value of IgA tTG in Predicting Mucosal Recovery in Children With Celiac Disease on a Gluten-Free Diet. J Pediatr Gastroenterol Nutr 2017; 64:286-291. [PMID: 28112686 PMCID: PMC5457911 DOI: 10.1097/mpg.0000000000001460] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Our objective was to determine the rate of mucosal recovery in pediatric patients with celiac disease on a gluten-free diet. We also sought to determine whether immunoglobulin A tissue transglutaminase (tTG) correlates with mucosal damage at the time of a repeat endoscopy with duodenal biopsy in these patients. METHODS We performed a retrospective chart review of 103 pediatric patients, younger than 21 years, with a diagnosis of celiac disease defined as Marsh 3 histology, and who underwent a repeat endoscopy with duodenal biopsy at least 12 months after initiating a gluten-free diet. RESULTS We found that 19% of pediatric patients treated with a gluten-free diet had persistent enteropathy. At the time of the repeat biopsy, tTG was elevated in 43% of cases with persistent enteropathy and 32% of cases in which there was mucosal recovery. Overall the positive predictive value of the autoantibody tTG was 25% and the negative predictive value was 83% in patients on a gluten-free diet for a median of 2.4 years. CONCLUSIONS Nearly 1 in 5 children with celiac disease in our population had persistent enteropathy despite maintaining a gluten-free diet and immunoglobulin A tTG was not an accurate marker of mucosal recovery. Neither the presence of symptoms nor positive serology were predictive of a patient's histology at the time of repeat biopsy. These findings suggest a revisitation of monitring and management criteria of celiac disease in childhood.
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Polanco I, Koester Weber T, Martínez-Ojinaga E, Molina M, Sarria J. Efficacy of a point-of-care test based on deamidated gliadin peptides for the detection of celiac disease in pediatric patients. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:743-748. [DOI: 10.17235/reed.2017.5028/2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Since the first description of celiac disease (CeD) by Samuel Gee in 1888 and the later "miraculous discovery" that bread was responsible for this condition following World War II in Europe, there has been an exponential growth of knowledge regarding CeD. Just when we thought that we knew everything there was to know about it, the disease is, however, offering new challenges, with its presentation having significantly morphed over the years from cases of overt gastrointestinal symptoms, malnutrition, and atrophic villi on duodenal biopsies to that of largely extraintestinal, subtle, or mild symptoms. Along with these changes, unexpectedly a new parallel entity appeared a few years ago and is gaining ground: the so-called nonceliac gluten sensitivity, an improper name because it should actually be referred to as wheat intolerance syndrome given that the role of gluten in all such cases is far from demonstrated and the implication of an immune involvement suggested by the term "sensitivity" is still unfounded. Lastly, wheat can be an offender also through an immunoglobulin E-mediated allergy, whose presence must also be evaluated and ruled out in selected cases.The practicing physician is therefore now challenged with the task of discerning which patients need to be assessed for one or the other of these disorders, and how.This review aims at providing an updated, critical reassessment of these 2 entities.
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Ediger TR, Hill ID. Going Beyond Gluten-Free. Pediatrics 2016; 138:peds.2016-1311. [PMID: 27565548 DOI: 10.1542/peds.2016-1311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2016] [Indexed: 11/24/2022] Open
Affiliation(s)
- Tracy R Ediger
- Department of Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio; and The Ohio State University, Columbus, Ohio
| | - Ivor D Hill
- Department of Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio; and The Ohio State University, Columbus, Ohio
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Khatib M, Baker RD, Ly EK, Kozielski R, Baker SS. Presenting Pattern of Pediatric Celiac Disease. J Pediatr Gastroenterol Nutr 2016; 62:60-3. [PMID: 26111294 DOI: 10.1097/mpg.0000000000000887] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Celiac disease (CD) is an autoimmune disease that can be complicated by impaired nutrition and growth. With the development of sensitive serologic tests, safe endoscopy, and efforts to educate primary care physicians, more children are diagnosed as having CD. The aim of this study is to evaluate the pattern of the presentation of pediatric CD in western New York. METHODS Chart review of pediatric patients with CD was undertaken. Patients' demographics, presenting features, disaccharidase assay (DA), celiac serology, and Marsh score were reviewed from patients seen at the Digestive Diseases and Nutrition Center, State University of New York at Buffalo from January 2003 through March 2013. RESULTS A total of 165 patients with CD were evaluated. Mean age was 10.7 ± 4.3 years, 76 male patients. The presenting features were abdominal pain (n = 87, 52.7%), constipation (n = 65, 38.9%), diarrhea (n = 52, 31.1%), family history of first-degree relative (n = 47, 28.1%), diabetes mellitus type 1 (n = 37, 22.2%), failure to thrive (n = 36, 21.8%), reflux (n = 25, 15.1%), vomiting (n = 24, 14.5%), fatigue (n = 15, 9%), short stature (n = 9, 5.4%), thyroid disease (n = 9, 5.4%), Down syndrome (n = 8, 4.8%). We found no correlation between Marsh score and serum tissue transglutaminase (tTG) immunoglobulin (Ig) A level at diagnosis and no correlation between DA and serum tTG IgA level, presenting feature and tTG IgA level, presenting feature and Marsh score, tTG IgA and DA, or between the age and the presenting feature. CONCLUSIONS Children newly diagnosed as having CD in western New York presented most frequently with abdominal pain and constipation and were older at the time of diagnosis than those described in the classical presentation of CD. We speculate that our patients may have a different long-term natural history and risk factors than originally described for patients with CD.
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Affiliation(s)
- Maan Khatib
- *Digestive Diseases and Nutrition Center †Department of Pathology, University at Buffalo, Buffalo, NY
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Tapsas D, Hollén E, Stenhammar L, Fälth-Magnusson K. The clinical presentation of coeliac disease in 1030 Swedish children: Changing features over the past four decades. Dig Liver Dis 2016; 48:16-22. [PMID: 26520057 DOI: 10.1016/j.dld.2015.09.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 08/26/2015] [Accepted: 09/28/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND The features of paediatric coeliac disease have changed in recent decades. We hypothesised that the age at diagnosis might continue to increase, whereas the severity of symptoms should decrease. METHODS In the present study, filed data on 1030 paediatric patients diagnosed with coeliac disease between 1973 and 2013 were analysed. The information available covered 99.8% of small bowel biopsies and included information on sex, age and clinical symptoms. RESULTS The age at diagnosis increased significantly, from a mean of 2.2 years during the first 10 years to 8.2 years in recent years. The proportion of children with severe symptoms declined from 92.8% to 78%, as did the proportion of biopsies characterised by severe pathology. In recent years, the monosymptomatic form of coeliac disease has been more common, and the number of patients detected at screening has increased. The frequency of patients with gastrointestinal symptoms, extra-intestinal symptoms, and failure to thrive and/or short stature at presentation decreased. CONCLUSIONS The mean age of newly diagnosed patients has increased over the last 15 years. Currently, coeliac disease shows a less severe picture in terms of symptoms and intestinal pathology. Younger children suffer primarily from gastrointestinal symptoms and growth failure, and adolescents from extra-intestinal manifestations.
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Affiliation(s)
- Dimitrios Tapsas
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Elisabet Hollén
- Division of Microbiology and Molecular Medicine, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Lars Stenhammar
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Pediatrics, Linköping University, Norrköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden
| | - Karin Fälth-Magnusson
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Pediatrics, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Unusually High Incidence of Paediatric Coeliac Disease in Sweden during the Period 1973 - 2013. PLoS One 2015; 10:e0144346. [PMID: 26658809 PMCID: PMC4676692 DOI: 10.1371/journal.pone.0144346] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/17/2015] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The prevalence of coeliac disease in Sweden during the "epidemic period" (1984-1996) was one of the highest in the world. The aim of this study was to assess the coeliac disease incidence in our region over the 41-year period, and how diagnostic activity and diagnostic accuracy were affected by the introduction of antibody testing. We also looked into how patients with mild enteropathy were evaluated. METHODS In the county of Östergötland in Sweden, 2790 paediatric patients were investigated for suspected coeliac disease between 1973 and 2013. Notes were scrutinised for data on sex, age, histopathological reports and final diagnosis. For comparative purposes this period was divided into three sub-periods (1973-1983, 1984-1996 and 1997-2013) named pre-epidemic, epidemic and post-epidemic. RESULTS Coeliac disease diagnosis was received by 1,030 patients. The peak incidence rate, 301 cases/100,000 in 1994 for the age group 0-1.9 years is the highest figure ever reported. The other age groups, 2-4.9, 5-14.9, and 15-17.9 years, also had high incidence rates. After the 1984-1996 "epidemic period" the incidence decreased for the youngest group but continued to increase for the other groups. The cumulative incidence at 18 years-of-age for children born during the epidemic reached 14 cases/1000 births, the highest figure hitherto reported. Diagnostic activity differed significantly between the three sub-periods (p<0.001) increasing gradually from 1984 and reaching a peak value of 0.87 in 2012. Cases of mild enteropathy were more frequently regarded as non-coeliac disease cases, decreasing significantly in the "post-epidemic" period (p<0.001). CONCLUSIONS The incidence rate and cumulative incidence of coeliac disease were possibly the highest ever reported. Changes in diagnostic activity and accuracy could not be attributed to the introduction of new antibody tests, possibly because of other changes e.g. variations in the symptoms at presentation and improved knowledge of the disease among parents and health professionals.
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Kho A, Whitehead M, Day AS. Coeliac disease in children in Christchurch, New Zealand: Presentation and patterns from 2000-2010. World J Clin Pediatr 2015; 4:148-154. [PMID: 26566488 PMCID: PMC4637806 DOI: 10.5409/wjcp.v4.i4.148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 05/16/2015] [Accepted: 09/16/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the presentation patterns of a cohort of children diagnosed with coeliac disease (CD) at Christchurch Hospital, New Zealand.
METHODS: Children aged 16 years or less diagnosed with CD at Christchurch Hospital, Christchurch, New Zealand, over the 11 year period between 2000 and 2010 were identified retrospectively. Diagnosis of CD was based upon standard histological criteria of endoscopically-obtained duodenal biopsies. Overlapping search methods were used to identify all relevant diagnoses within the time period. Endoscopy reports and histology findings were reviewed to confirm diagnosis. The numbers of diagnoses per year were calculated and changes in annual rates over the study period were delineated. Available records were reviewed to ascertain presenting symptoms, baseline anthropometry and the indication for referral for each child. In addition, the results of relevant investigations prior to diagnosis were accessed and reviewed. These key investigations included the results of coeliac serology testing (including tissue transglutaminase and endomysial antibodies) as well as the results of tests measuring levels of micronutrients, such as iron. In addition, the histological findings of concurrent biopsies in the oesophagus and stomach were reviewed.
RESULTS: Over the 11 year study period, 263 children were diagnosed with CD at this New Zealand paediatric facility. Children were diagnosed from late infancy to 16.9 years: the largest subgroup of children (n = 111) were diagnosed between 5 and 12 years of age. The numbers of children diagnosed each year increased from 13 per year to 31 per year over the 11 years (P = 0.0095). Preschool children (aged less than 5 years) were more likely to have low weight, and to have diarrhoea and abdominal pain prior to diagnosis. Older children (over 5 years of age) most commonly presented with abdominal pain. Fifty-six (21.6%) of the 263 children were diagnosed following screening in high risk groups, with 38 of these children having no symptoms at diagnosis. Mean weight Z scores were lower in children aged less than five years than children aged 5-12 years or older children (-0.4096 ± 1.24, vs 0.1196 ± 0.966 vs 0.0901 ± 1.14 respectively: P = 0.0033).
CONCLUSION: Increasing numbers of children were diagnosed with CD in this New Zealand centre over this time, with varied presentations and symptoms.
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Kivelä L, Kaukinen K, Lähdeaho ML, Huhtala H, Ashorn M, Ruuska T, Hiltunen P, Visakorpi J, Mäki M, Kurppa K. Presentation of Celiac Disease in Finnish Children Is No Longer Changing: A 50-Year Perspective. J Pediatr 2015; 167:1109-15.e1. [PMID: 26316370 DOI: 10.1016/j.jpeds.2015.07.057] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 07/07/2015] [Accepted: 07/29/2015] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To chart trends in the presentation of celiac disease in a large cohort of Finnish children diagnosed over a period of 48 years. STUDY DESIGN Clinical and serologic data, severity of small-bowel mucosal damage, and presence of associated conditions were gathered from 596 children diagnosed with celiac disease in 1966-2013. The children were divided into 4 groups based on the year of diagnosis (before 1980, 1980-1999, 2000-2009, and 2010-2013), and the variables were compared between the periods. The incidence of celiac disease autoimmunity in 2001-2013 was calculated based on the number of new antibody-positive cases in each year. RESULTS Age at diagnosis rose from median 4.3 years before 1980 to between 7.6 and 9.0 years in the later periods. The severity of clinical presentation, in general, became milder and poor growth less common during the entire study period of 50 years. Percentages of children with classical gastrointestinal presentation decreased, and those with atypical or subclinical presentation increased after the 1990s, these changes leveling off in 2000-2013. Similarly, the severity of small-bowel mucosal damage was milder after the 1990s. The incidence of celiac disease autoimmunity increased in the early 2000s but then fluctuated without a clear trend. There were no significant secular changes in sex distribution, presence of anemia, levels of celiac antibodies, or celiac disease-associated conditions. CONCLUSIONS The clinical and histologic presentation of celiac disease in children became milder, especially in the 1980s and 1990s. However, most of these changes have reached a plateau in recent years.
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Affiliation(s)
- Laura Kivelä
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Katri Kaukinen
- Department of Internal Medicine, Tampere University Hospital and School of Medicine, University of Tampere, Tampere, Finland
| | - Marja-Leena Lähdeaho
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Tampere School of Health Sciences, University of Tampere, Tampere, Finland
| | - Merja Ashorn
- Department of Pediatrics, Lappeenranta Central Hospital, Lappeenranta, Finland
| | - Tarja Ruuska
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Pauliina Hiltunen
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Jarmo Visakorpi
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Markku Mäki
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Kalle Kurppa
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
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Onset of Thrombin Generation Occurs More Rapidly in Pediatric Patients With Celiac Disease. J Pediatr Gastroenterol Nutr 2015; 61:230-3. [PMID: 25793906 DOI: 10.1097/mpg.0000000000000786] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Celiac disease (CD) is a risk factor for venous thromboembolism (VTE) and stroke, but the mechanisms are unclear. Continuous measurement of thrombin generation in plasma is a feasible way to detect hypercoagulable changes. The aim of this pilot study was to investigate thrombin generation in pediatric patients with CD compared with pediatric controls. METHODS Plasma samples were collected from 19 pediatric patients with CD and 20 healthy controls. In each patient diagnosed as having CD, thrombin generation was determined twice by means of calibrated automated thrombography. The first measurement was undertaken when CD was diagnosed; the second measurement was undertaken after normalization of their IgA antitissue transglutaminase antibody (tTG-Ab) titers following a gluten-free diet. In the controls, measurement for TTG-Ab and thrombin generation was undertaken once during recruitment. RESULTS Patients with CD at diagnosis showed a significantly shorter lag time compared with controls (P < 0.001) and a shorter time-to-peak compared with controls (P < 0.02). These differences were no longer detectable after normalization of TTG-Ab values. The overall amount of generated thrombin, represented by the endogenous thrombin potential (ETP), showed no significant difference between the study groups. CONCLUSIONS Our results show that alterations in coagulation can be found in untreated CD that may help to explain the described increased risk of stroke or VTE. A shorter lag time in patients with untreated CD indicates a more rapid onset of thrombin generation as a sign of hypercoagulability. ETP, the best predictive parameter for thromboembolic disease, however, was not altered.
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Işıkay S, Kocamaz H, Sezer S, Özkars MY, Işıkay N, Filik B, Şan M, Kanmaz A. The Frequency of Epileptiform Discharges in Celiac Disease. Pediatr Neurol 2015; 53:78-82. [PMID: 26092417 DOI: 10.1016/j.pediatrneurol.2015.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/04/2015] [Accepted: 02/09/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND We studied patients with celiac disease to define the frequency of epileptiform discharges on electroencephalography. METHODS A total of 307 children with a diagnosis of celiac disease (study group) and 197 age- and sex-matched healthy children as controls (control group) were included in this study. The study group was further divided into newly diagnosed celiac disease patients (n = 216) and patients who were on a gluten-free diet (n = 91) for at least 6 months. Medical histories of all children including age, sex, symptoms, weight, height, physical examination findings, and laboratory data were recorded. All patients underwent an electroencephalograph in a pediatric neurology electroencephalograph laboratory with a 32-channel electroencephalograph for 30 minutes. RESULTS Twenty-five patients were defined to have epileptiform discharges (spike/sharp-wave discharges); 24 (7.8%) of those patients were in the celiac disease group and 1 (0.5%) was in the control group (P = 0.001). Among those 24 patients, 21 (9.7%) were in newly diagnosed celiac disease group and 3 (3.3%) were in the gluten-free diet group (P = 0.03). CONCLUSIONS Patients diagnosed with celiac disease are prone to epileptiform activities on electroencephalography and should be evaluated carefully. Moreover, strict adherence to a gluten-free diet early should be advised in those patients with epileptiform activities because it may effectively decrease the occurrence of epileptiform activities.
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Affiliation(s)
- Sedat Işıkay
- Department of Pediatric Neurology, Gaziantep Children's Hospital, Şehitkamil, Gaziantep, Turkey.
| | - Halil Kocamaz
- Department of Pediatric Neurology, Gaziantep Children's Hospital, Şehitkamil, Gaziantep, Turkey
| | - Sadettin Sezer
- Department of Pediatric Neurology, Gaziantep Children's Hospital, Şehitkamil, Gaziantep, Turkey
| | - Mehmet Yaşar Özkars
- Department of Pediatric Neurology, Gaziantep Children's Hospital, Şehitkamil, Gaziantep, Turkey
| | - Nurgül Işıkay
- Department of Pediatric Neurology, Gaziantep Children's Hospital, Şehitkamil, Gaziantep, Turkey
| | - Bülent Filik
- Department of Pediatric Neurology, Gaziantep Children's Hospital, Şehitkamil, Gaziantep, Turkey
| | - Murat Şan
- Department of Pediatric Neurology, Gaziantep Children's Hospital, Şehitkamil, Gaziantep, Turkey
| | - Alper Kanmaz
- Department of Pediatric Neurology, Gaziantep Children's Hospital, Şehitkamil, Gaziantep, Turkey
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Zingone F, West J, Crooks CJ, Fleming KM, Card TR, Ciacci C, Tata LJ. Socioeconomic variation in the incidence of childhood coeliac disease in the UK. Arch Dis Child 2015; 100:466-73. [PMID: 25613988 PMCID: PMC4413865 DOI: 10.1136/archdischild-2014-307105] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 11/21/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Serological studies indicate that evidence of coeliac disease (CD) exists in about 1% of all children, but we lack estimates of current diagnostic patterns among children and how they vary by socioeconomic group. METHODS We identified all children aged 0-18 years between 1993 and 2012 who were registered with general practices across the UK that contribute to a large population-based general practice database. The incidence of CD was evaluated in each quintile of the Townsend index of deprivation and stratified by age, sex, country and calendar year. RESULTS Among 2,063,421 children, we identified 1247 CD diagnoses, corresponding to an overall CD incidence of 11.9 per 100,000 person-years, which was similar across the UK countries and higher in girls than in boys. We found a gradient of CD diagnosis across socioeconomic groups, with the rate of diagnosis being 80% higher in children from the least-deprived areas than in those from the most-deprived areas (incident rate ratio 1.80, 95% CI 1.45 to 2.22). This pattern held for both boys and girls and across all ages. Across all four countries of the UK, we found similar associations between CD and socioeconomic status. While CD incidence up to age 2 remained stable over the study period, diagnoses at older ages have almost tripled over the past 20 years. CONCLUSIONS Children living in less socioeconomically deprived areas in the UK are more likely to be diagnosed with CD. Increased implementation of diagnostic guidelines could result in better case identification in more-deprived areas.
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Affiliation(s)
- Fabiana Zingone
- Division of Epidemiology and Public Health, City Hospital Campus, University of Nottingham, Nottingham, UK,Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Joe West
- Division of Epidemiology and Public Health, City Hospital Campus, University of Nottingham, Nottingham, UK
| | - Colin J Crooks
- Division of Epidemiology and Public Health, City Hospital Campus, University of Nottingham, Nottingham, UK
| | - Kate M Fleming
- Division of Epidemiology and Public Health, City Hospital Campus, University of Nottingham, Nottingham, UK
| | - Timothy R Card
- Division of Epidemiology and Public Health, City Hospital Campus, University of Nottingham, Nottingham, UK
| | - Carolina Ciacci
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Laila J Tata
- Division of Epidemiology and Public Health, City Hospital Campus, University of Nottingham, Nottingham, UK
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Evaluation of the ESPGHAN Celiac Guidelines in a North American Pediatric Population. Am J Gastroenterol 2015; 110:760-7. [PMID: 25823767 DOI: 10.1038/ajg.2015.87] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 02/23/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We retrospectively examined the performance of the tissue transglutaminase (TTG), endomysial antibody (EMA) tests, and the ESPGHAN (European Society of Paediatric Gastroenterology, Hepatology and Nutrition) nonbiopsy criteria in a pediatric population. METHODS Consecutive celiac serologies and corresponding intestinal biopsy results were obtained on children <18 years old over 3.5 years. Patients were classified into three categories: positive TTG, negative TTG, and IgA deficiency. RESULTS Of the 17,505 patients with celiac serology performed, 775 had a positive TTG, 574 with a negative TTG were biopsied, and 25 were IgA deficient. Of the patients with a TTG ≥10 × upper limit of normal (ULN), positive EMA, and symptoms, 98.2% had biopsies consistent with celiac disease (CD). Four human leukocyte antigen (HLA) DQ2/DQ8-positive patients who met the ESPGHAN nonbiopsy criteria did not have CD. In the group with a TTG 3-10 × ULN, 75.7% EMA-positive patients and only 40% EMA-negative patients had CD (P<0.001). Of those with a TTG 1-3 × ULN, 52.2% EMA-positive patients vs. only 13.3% EMA-negative patients had CD (P<0.01). Of the patients with bulbar and duodenal biopsies, 9.8% had CD confined only in the bulb, especially those with a low titer TTG (P<0.01). CD prevalence in our cohort was 34.6%. Sensitivity, specificity, and positive predictive value of the TTG were 98.7%, 86.4%, and 79.4%, respectively. CONCLUSIONS The TTG is a very sensitive screen for CD, but positive predictive value improves with a positive EMA titer. To apply the new ESPGHAN guidelines, clinicians must understand the performance of their celiac serology tests.
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