Diagnostic dilemmas in celiac disease

Women's Experience With Celiac Disease: A Phenomenological Study

The purpose of this qualitative study was to explore the lived experience of women who have been diagnosed with celiac disease. Celiac disease is a multisystem autoimmune disease and affects approximately 1% of the population. In addition, celiac disease is seen 1-2 times more often in women and they tend to have more severe disease and treatment burden. Quantitative research has been completed on celiac disease, but there remains a gap related to the implications of the disease from a qualitative perspective. The research tradition used for this qualitative study was phenomenology. Interviews were audio-recorded using a developed questionnaire. Saturation of the data occurred after 12 participant interviews. Following the analysis, 5 themes resulted: (a) Who am I? (b) medical aspects; (c) challenges; (d) daily living; and (e) facing the challenges. There remains a gap in the education, support, advocacy, and follow-up care of this population.

Clinical, endoscopic, and histological differentiation between celiac disease and tropical sprue: A systematic review

BACKGROUND AND AIM

While the prevalence of celiac disease (CD) is increasing globally, the prevalence of tropical sprue (TS) is declining. Still, there are certain regions in the world where both patients with CD and TS exist and differentiation between them is a challenging task. We conducted a systematic review of the literature to find out differentiating clinical, endoscopic, and histological characteristics between CD and TS.

METHODS

Medline, PubMed, and EMBASE databases were searched for keywords: celiac disease, coeliac, celiac, tropical sprue, sprue, clinical presentation, endoscopy, and histology. Studies published between August 1960 and January 2018 were reviewed. Out of 1063 articles available, 12 articles were included in the final analysis.

RESULTS

Between the patients with CD and TS, there was no difference in the prevalence and duration of chronic diarrhea, abdominal distension, weight loss, extent of abnormal fecal fat content, and density of intestinal inflammation. The following features were more common in CD: short stature, vomiting/dyspepsia, endoscopic scalloping/attenuation of duodenal folds, histological high modified Marsh changes, crescendo type of IELosis, surface epithelial denudation, surface mucosal flattening, thickening of subepithelial basement membrane and celiac seropositivity; while those in TS include anemia, abnormal urinary D-xylose test, endoscopic either normal duodenal folds or mild attenuation, histologically decrescendo type of IELosis, low modified Marsh changes, patchy mucosal changes, and mucosal eosinophilia.

CONCLUSIONS

Both patients with CD and TS have overlapping clinical, endoscopic, and histological characteristics, and there is no single diagnostic feature for differentiating CD from TS except for celiac specific serological tests.

Value of routine duodenal mucosal biopsies in the evaluation of anemia in a large Australian referral centre

Background and Aim

Small bowel mucosal biopsies (SBBx) are routinely performed to investigate unexplained anemia; however, previous studies have demonstrated a low yield in diagnosing celiac disease. Our aim was to determine the yield of routine SBBx in a large cohort of patients who underwent gastroscopy for the investigation of anemia.

Methods

Data from consecutive patients who underwent gastroscopy for the investigation of anemia in a tertiary hospital, from January 2008–December 2011, were prospectively collected. Measured outcomes were the prevalence of celiac disease, the yield of duodenal biopsies, and the correlation between celiac serology and diagnosis.

Results

Over 4 years, 987 patients (385 M:602 F; 48.27 ± 15.89 years) underwent endoscopy for anemia, of which 534 (54.1%) had proven iron deficiency anemia (IDA). Abnormal SBBx consistent with celiac disease were found in 2% (22/987), with a higher prevalence in females (3.2%, n = 19 vs 0.8%, n = 3 in males) and in those with IDA (3.6%, n = 19 vs 0.7%, n = 3 in non‐IDA). Macroscopic endoscopic abnormalities were present in 86% (19/22) of patients with celiac disease. Of the 178 patients who had celiac serology, tissue transglutaminase antibody had the highest sensitivity (80%) and specificity (99%). Combined serology had a sensitivity of 85.7%.

Conclusion

Only 2% of patients with unexplained anemia had abnormal SBBx consistent with celiac disease and even fewer patients in non‐IDA. Given the availability and high sensitivity of celiac serology and macroscopic changes on endoscopy, SBBx should not be routine during endoscopy but should be limited to those with positive celiac serology, abnormal endoscopic appearance, or females with IDA.

Small bowel villous atrophy: celiac disease and beyond

Small bowel villous atrophy can represent a diagnostic challenge for gastroenterologists and pathologists. In Western countries small bowel atrophy and mild non-atrophic alterations are frequently caused by celiac disease. However, other pathology can mimic celiac disease microscopically, widening the differential diagnosis. The several novelties on this topic and the introduction of the device-assisted enteroscopy in the diagnostic flowchart make an update of the literature necessary. Areas covered: In this review, a description of the different clinical scenarios when facing with small bowel mucosal damage, particularly small bowel atrophy, is described. The published literature on this subject has been summarized and reviewed. Expert commentary: When an intestinal mucosal alteration is histologically demonstrated, the pathology report forms part of a more complex workup including serological data, clinical presentation and clinical history. A multidisciplinary team, including pathologists and enteroscopy-devoted endoscopists, is frequently required to manage patients with small bowel alterations, especially in cases of severe malabsorption syndrome.

Parental celiac disease and risk of asthma in offspring: a Danish nationwide cohort study

Objective

The incidences of celiac disease (CD) and asthma are increasing and the two conditions are associated in individuals. Risk of asthma may be passed on to the next generation through shared risk factors. We examined whether parental CD is associated with risk of asthma in offspring.

Methods

We conducted a population-based Danish nationwide cohort study, using medical databases, covering the period 1 January 1979 to 31 December 2009. For each child with a parental history of CD, we randomly sampled 100 children without this history from the children born in the same calendar year. We used Cox proportional-hazards regression to estimate incidence rate ratios for asthma, adjusting for measured covariates.

Results

We identified 1,107 children with a parental history of CD and 110,700 children without this parental history. During up to 32 years of follow-up, 6,125 children received a hospital diagnosis of asthma. The adjusted incidence rate ratio for asthma associated with a parental history of CD was 1.09 (95% confidence interval: 0.86–1.39) and was similar for maternal and paternal CD. Inclusion of asthma-medication in the definition of asthma did not substantially change the results.

Conclusion

There was no convincing evidence of an increased risk of asthma among offspring of parents with CD.

Epitope mapping of the N-terminal portion of tissue transglutaminase protein antigen to identify linear epitopes in celiac disease

Celiac disease (CD) is an autoimmune mediated disease with complex and multifactorial etiology. Gluten intake triggers a composite immune response involving T-cells and B-cells and leading to the secretion of autoantibodies if a genetic predisposition is present. Untreated CD patients show high levels of circulating autoantibodies directed to different auto-antigens present in the intestinal mucosa. The most important auto-antigen is the endomysial enzyme tissue transglutaminase (tTG). Both IgA and IgG antibody isotypes to tTG are known, but only the IgA antibodies demonstrate the highest disease specificity and thus are considered disease biomarkers. Because the pathogenicity and exact tTG binding properties of these autoantibodies are still unclear, the characterization of tTG antigenic domains is a crucial step in understanding CD onset and the autoimmune pathogenesis. Overlapping peptide libraries can be used for epitope mapping of selected protein portions to determine antigenic fragments contributing to the immunological activity and possibly develop innovative peptide-based tools with high specificity and sensitivity for CD. We performed an epitope mapping study to characterize putative linear auto-antigenic epitopes present in the tTG N-terminal portion (1-230). A library of 23 overlapping peptides spanning tTG(1-230) was generated by Fmoc/tBu solid-phase peptide synthesis and screened by immunoenzymatic assays employing patients' sera. The results indicate that four synthetic peptides, that is, Ac-tTG(1-15)-NH2 , Ac-tTG(41-55)-NH2 , Ac-tTG(51-65)-NH2 , and Ac-tTG(151-165)-NH2 , are recognized by IgA autoantibodies circulating in CD patients' sera. These results offer important insight on the nature of the antigen-antibody interaction.