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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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Falcomer AL, de Lima BR, Farage P, Fabris S, Ritter R, Raposo A, Teixeira-Lemos E, Chaves C, Zandonadi RP. Enhancing life with celiac disease: unveiling effective tools for assessing health-related quality of life. Front Immunol 2024; 15:1396589. [PMID: 38742113 PMCID: PMC11089154 DOI: 10.3389/fimmu.2024.1396589] [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: 03/05/2024] [Accepted: 04/15/2024] [Indexed: 05/16/2024] Open
Abstract
Celiac disease (CD) is an autoimmune chronic enteropathy provoked by gluten ingestion in genetically predisposed individuals. Considering it´s only safe treatment is a lifelong gluten-free diet, the burden of living with the disease becomes evident, as well as the need to assess CD health-related quality of life (HRQOL). This review aims to identify and analyze the instruments used to evaluate the HRQOL of adults with CD. This integrative review using a systematic approach was designed to achieve high scientific standards. Accordingly, the search strategy was developed and executed as recommended by the guideline of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Detailed individual searches were developed to Pubmed, Science Direct, Scopus, Web of Science, and Google Scholar. After careful analysis of the papers, 43 studies were included, in which seven instruments were identified: Celiac Disease Questionnaire (CDQ) (n=21), Celiac Disease Specific Quality of Life Instrument (CD-QOL) (n=17), Celiac Disease Assessment Questionnaire (CDAQ) (n=4), CeliacQ-7 (n=1), CeliacQ-27 (n=1), Black and Orfila´s self-developed instrument (n=1) and the Coeliac Disease Quality of Life Questionnaire (CDQL) (n=1). The CDQ and CD-QOL were the two most applied instruments. Since the first focuses on the physical and mental symptoms related to the disease and the second focuses on the emotional repercussions of adhering to the GFD treatment for life (dysphoria), the CDQ application is an interesting option for countries that struggle with public policies for CD patients and patients with active CD. The CD-QOL could be used for countries with strict regulations for CD and gluten-free products and populations in remission. When comparing results among different populations, it is preferable to utilize culturally validated instruments, which have been applied across multiple countries, providing greater comparability between study findings.
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Affiliation(s)
- Ana Luísa Falcomer
- Department of Nutrition, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
- Department of Nutrition, Centro Universitário IESB, Brasília, Brazil
| | - Bernardo Romão de Lima
- Department of Nutrition, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
- Department of Nutrition, Centro Universitário IESB, Brasília, Brazil
| | - Priscila Farage
- Faculty of Nutrition (FANUT), Federal University of Goiás, Goiânia, Brazil
| | - Samantha Fabris
- Department of Nutrition, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
| | - Ruth Ritter
- Department of Nutrition, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
| | - António Raposo
- CBIOS (Research Center for Biosciences and Health Technologies), Universidade Lusófona de Humanidades e Tecnologias, Lisboa, Portugal
| | | | - Cláudia Chaves
- ESSV, Centre for Studies in Education and Innovation (CI&DEI), Polytechnic University of Viseu, Viseu, Portugal
| | - Renata Puppin Zandonadi
- Department of Nutrition, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
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Imran, Cheema HA, Alvi MA, Rehman MU, Ali M, Sarwar HA. Spectrum of Clinical Presentation of Celiac Disease in Pediatric Population. Cureus 2021; 13:e15582. [PMID: 34279518 PMCID: PMC8270062 DOI: 10.7759/cureus.15582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 12/20/2022] Open
Abstract
Background Classic form of celiac disease (CCD) presents with diarrhea and is traditionally taught as malabsorption syndrome. This form of CD is diagnosed with ease but non-classical form presenting without diarrhea is often missed and heavily underdiagnosed. Objective To determine the clinical spectrum of patients with CD. Methods This study was conducted in the Department of Gastroenterology & Hepatology at the Children’s Hospital, Lahore. Confirmed CD children according to NASPGHAN (North American Society of Pediatric Gastroenterology, Hepatology & Nutrition) criteria were enrolled in this study from June to September, 2020. Initial positivity followed by small bowel biopsy with Modified Marsh 2 and above is considered consistent with the diagnosis of CD. Results A total of 90 patients were selected according to NASPGHAN criteria, 77 (85.6%) patients had CCD whereas 13 (14.4%) patients had non-classical CD (NCCD). The mean ± SD age at diagnosis of CCD was 2.6 ± 2.3 years whereas mean ± SD in NCCD was 9 ± 1.8 years. Females clearly predominate in our cohort in general. Chronic diarrhea followed by failure to thrive (85%) were the most common symptoms in CCD whereas short stature (69%) was the most frequent feature in NCCD. Among CD patients, tissue transglutaminase-immunoglobulin A (TTG-IgA) titre was significantly high (>10 times) in 80% of CD patients and the rest had positivity but not up to 10 times. There was no significant difference in titre of anti-TTG between CCD and NCCD. Conclusion Classical CD is still the most common in developing countries like Pakistan. High index of suspicion of CD should be maintained for patients who present with short stature, recurrent abdominal pain and refractory anemia.
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Affiliation(s)
- Imran
- Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital and The Institute of Child Health, Lahore, PAK
| | - Huma Arshad Cheema
- Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital and The Institute of Child Health, Lahore, PAK
| | - Muhammad Arshad Alvi
- Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital and The Institute of Child Health, Lahore, PAK
| | - Mujeeb Ur Rehman
- Pediatric Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Muhammad Ali
- Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital and The Institute of Child Health, Lahore, PAK
| | - Hussan Ali Sarwar
- Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital and The Institute of Child Health, Lahore, PAK
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Walia R, Singh A, Aggarwal A, Thapa B, Guptasarma ML, Bhansali A, Khandelwal N. Look Beyond Gluten in Short Stature with Celiac Disease - A Prospective, Interventional Study. Indian J Pediatr 2021; 88:550-554. [PMID: 33095395 DOI: 10.1007/s12098-020-03543-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/12/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Short stature (SS) is a common manifestation of celiac disease (CD). After starting gluten free diet (GFD), children usually have catch-up growth (improvement in height SDS of >1 SD). However, few children in remission, even on GFD, lack catch up growth. This study was planned to assess the growth hormone (GH) axis and the prevalence of anti-pituitary antibodies in such patients. METHODS It was a single-centre, prospective study. Patients with CD in remission for the last 1 y, having SS and lacking catch-up growth, were included after excluding other common causes of SS. GH dynamics were studied using stimulation tests: Insulin tolerance test, clonidine stimulation test, and glucagon stimulation test. GH deficiency (GHD) was defined as non-stimulable response to 2 GH stimulation tests. Anti-pituitary antibodies were analysed in these patients using rat pituitary extract as antigen. RESULTS Ten patients (8 girls), with a mean age of 10 ± 2.8 y, in serological remission for CD and lacking catch-up growth, were enrolled. All had a height SDS of < -2. Fifteen age matched children with CD and adequate catch up growth served as controls. GHD was seen in 7 patients (70%), out of whom 2 received GH therapy and had an improvement in the height SDS from -2.7 to -1.4 and from -2.1 to 2.4 (over 1 y), respectively. Anti-pituitary antibodies were seen in significant titres in 55.5% of the cases and 40% of the controls. CONCLUSIONS Children with CD in remission but lacking catch-up growth should be evaluated for GHD.
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Affiliation(s)
- Rama Walia
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India.
| | - Amandeep Singh
- Department of Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Anshita Aggarwal
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Baburam Thapa
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Manni Luthra Guptasarma
- Department of Immunopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Singh AD, Singh P, Farooqui N, Strand T, Ahuja V, Makharia GK. Prevalence of celiac disease in patients with short stature: A systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36:44-54. [PMID: 32621396 DOI: 10.1111/jgh.15167] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/05/2020] [Accepted: 06/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Short stature is a common extraintestinal manifestation of celiac disease (CeD). We conducted a systematic review and meta-analysis to assess the global prevalence of CeD in patients presenting with short stature. METHODS We searched Medline and EMBASE databases for the keywords "celiac disease, coeliac disease, anti-gliadin, tissue transglutaminase antibody, anti-endomysial antibody, short stature and growth retardation." All the studies published from January 1991 to May 2020 were included. Patients without any prior evaluation for short stature were classified as all-cause short stature, while prior evaluated patients, where no cause was found for short stature, were classified as idiopathic short stature. The diagnosis of CeD was based on the European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines. A random-effects model was used to pool the data. RESULTS Seventeen studies screening 3759 patients (1582 with all-cause short stature and 2177 with idiopathic short stature) were included. The pooled seroprevalence of CeD based on positive anti-tissue transglutaminase antibody and anti-endomysial antibody was 11.2% (95% CI 4.0-21.2%; I2 = 86%) and 9.7% (95% CI 2.7-20.2%; I2 = 95%) for all-cause and idiopathic short stature, respectively. Similarly, pooled prevalence of biopsy-confirmed CeD was 7.4% (95% CI 4.7-10.6%; I2 = 76%) and 11.6% (95% CI 4.1-22.2%; I2 = 97%), for all-cause and idiopathic short stature, respectively. There was an overall severe risk of selection bias and significant heterogeneity in the pooled results. CONCLUSIONS Approximately one in 14 patients with all-cause short stature and one in nine patients with idiopathic short stature had biopsy-confirmed CeD. Therefore, evaluation for CeD may be prudent in all patients with short stature.
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Affiliation(s)
- Achintya D Singh
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Prashant Singh
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Naba Farooqui
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, Delhi, New Delhi, India
| | - Tor Strand
- Department of Global public health, Innlandet Hospital Trust, Lillehammer, Norway
| | - Vineet Ahuja
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, Delhi, New Delhi, India
| | - Govind K Makharia
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, Delhi, New Delhi, India
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Wit JM, Kamp GA, Oostdijk W. Towards a Rational and Efficient Diagnostic Approach in Children Referred for Growth Failure to the General Paediatrician. Horm Res Paediatr 2020; 91:223-240. [PMID: 31195397 DOI: 10.1159/000499915] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 03/25/2019] [Indexed: 11/19/2022] Open
Abstract
Based on a recent Dutch national guideline, we propose a structured stepwise diagnostic approach for children with growth failure (short stature and/or growth faltering), aiming at high sensitivity for pathologic causes at acceptable specificity. The first step is a detailed clinical assessment, aiming at obtaining relevant clinical clues from the medical history (including family history), physical examination (emphasising head circumference, body proportions and dysmorphic features) and assessment of the growth curve. The second step consists of screening: a radiograph of the hand and wrist (for bone age and assessment of anatomical abnormalities suggestive for a skeletal dysplasia) and laboratory tests aiming at detecting disorders that can present as isolated short stature (anaemia, growth hormone deficiency, hypothyroidism, coeliac disease, renal failure, metabolic bone diseases, renal tubular acidosis, inflammatory bowel disease, Turner syndrome [TS]). We advise molecular array analysis rather than conventional karyotyping for short girls because this detects not only TS but also copy number variants and uniparental isodisomy, increasing diagnostic yield at a lower cost. Third, in case of diagnostic clues for primary growth disorders, further specific testing for candidate genes or a hypothesis-free approach is indicated; suspicion of a secondary growth disorder warrants adequate further targeted testing.
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Affiliation(s)
- Jan M Wit
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands,
| | - Gerdine A Kamp
- Department of Paediatrics, Tergooi Hospital, Blaricum, The Netherlands
| | - Wilma Oostdijk
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
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The spectrum of clinical and subclinical endocrinopathies in treatment-naïve patients with celiac disease. Indian J Gastroenterol 2019; 38:518-526. [PMID: 31879833 DOI: 10.1007/s12664-019-01006-w] [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: 07/17/2019] [Accepted: 10/23/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Strong association exists between celiac disease and autoimmune endocrinopathies such as type I diabetes and hypothyroidism; there is a lack of data on the involvement of other endocrine organs such as pituitary-gonadal axis. Furthermore, there is lack of data on the spectrum of involvement of endocrine organs varying from organ autoimmunity to subclinical and clinical disease. We evaluated consecutive treatment-naïve patients with celiac disease (CeD) for clinical and subclinical endocrinopathies. METHODS Of 154 screened, 74 treatment-naïve patients with CeD were recruited. They underwent hormonal and/or functional assessment of beta cell of pancreas, thyroid gland, pituitary-gonadal axis, and parathyroid glands. RESULTS Of the 74 patients with CeD, 31 (41.9%) had at least one clinical or subclinical endocrinopathy and 9 (12.2%) had multiple endocrinopathies. Most common of them were clinical or subclinical type I diabetes and autoimmune thyroid disease. Interestingly, 8 (10.8%) patients also were found to have functional hypopituitarism and 7/54 (12.9%) having isolated hypogonadotropic hypogonadism. CONCLUSIONS Patients with CeD have high percentages of not only clinical endocrinopathy including pituitary-gonadal axis dysfunction but also subclinical endocrinopathy. Whether commencement of gluten-free diet will lead to reversal of subclinical endocrinopathies requires further follow up studies.
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Aziz DA, Kahlid M, Memon F, Sadiq K. Spectrum of Celiac disease in Paediatric population: Experience of Tertiary Care Center from Pakistan. Pak J Med Sci 2017; 33:1301-1306. [PMID: 29492048 PMCID: PMC5768814 DOI: 10.12669/pjms.336.13489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: To determine clinical features and relevant laboratory investigations of patient with celiac disease (CD) and comparing classical celiac disease (CCD) with Non-diarrheal celiac disease (NDCD). Methods: This is a five years retrospective study conducted at The Aga Khan University Hospital Karachi, Pakistan from January 2010 to December 2015, enrolling children from one year to 15 years of either gender diagnosed as celiac disease in accordance with revised ESPGHAN criteria. Biopsy samples with grade 2 or more on Modified Marsh Classification were considered as consistent with celiac disease. Celiac patients were categorized into Classical celiac disease (with Chronic Diarrhea) and non-diarrheal celiac disease (Atypical celiac) and their clinical features and relevant laboratory investigations were documented. Results: Total 66 patients were selected with celiac disease according to inclusion criteria, 39 (59.09%) patients were labeled as CCD and 27 (40.91%) patients were labeled as NDCD. Marsh grading 3a and above were more marked in CCD as compared to NDCD. Mean titer for Tissue transglutaminase antibodies (TTG) were higher in CCD group in comparison to NDCD group. In CCD, the most common clinical presentations were abdominal distension whereas in NDCD, the most remarkable features were recurrent abdominal pain (62.9%). Frequency of failure to thrive is significantly high in CCD (82.05%) but patients merely with short stature were more common in NDCD (33.3%). Refractory anemia was present in 66.6% patients in NDCD group and 41.1% patients in CCD group. 74.3% patients in CCD group were vitamin D deficient whereas 85% patient had vitamin D deficiency in NDCD group (p= 0.03). Conclusion: NDCD is not uncommon in our population. Recurrent abdominal pain, failure to thrive or patients only with short stature and refractory anemia are prominent features in NCDC group whereas abdominal distension, failure to thrive and recurrent abdominal pain were noticeable features in CCD. High grade histopathology and raised antibodies titer is hallmark of CCD. Vitamin D deficiency is almost equally present in both groups.
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Affiliation(s)
- Danish Abdul Aziz
- Dr. Danish Abdul Aziz, MBBS, MRCPCH, FCPS. Senior Instructor, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Misha Kahlid
- Misha Khalid, Final Year of MBBS Medical Student, Aga Khan University Hospital, Karachi, Pakistan
| | - Fozia Memon
- Dr. Fozia Memon, MBBS, FCPS, Chief Resident, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Kamran Sadiq
- Dr. Kamran Sadiq, MBBS, FCPS. Assistant Professor and Paediatric Gastroenterologist, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
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Pattern and Frequency of Short Stature in Albanian Children. CURRENT HEALTH SCIENCES JOURNAL 2016; 42:390-395. [PMID: 30581594 PMCID: PMC6269620 DOI: 10.12865/chsj.42.04.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/16/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Short stature is defined as a standing height more than 2 standard deviations (SDs) below the mean for age and sex. While there are many medical causes for being short and having poor growth, including growth hormone deficiency, hypothyroidism, Turner syndrome, inflammatory bowel disease, kidney problems, malnutrition, etc., most children who are short are normal. OBJECTIVES The identification and analysis of causes and factors leading to short stature in Albanian children. PATIENTS & METHODS Subjects enrolled in our study were admission with "Short stature" or "Slow growth velocity" from January 2001 to January 2011 and met the criteria: length < -2 z- score and/or height velocity <-2 z- score for age and sex. They were evaluated by anthropometric measurements; biochemical panel; hormonal balance; radiological studies; and hormonal provocative tests. Statistical processing was done with Epi-Info CDC 2000 and SPSS accordingly. RESULTS The age of the 564 children was from 0.65-18.74 years (11.08 ± 3.28 years). M / F 221/343 (39% /61%) respectively. The frequency of diagnoses resulted as follows: the "constitutional short stature" 211children (37.4%), "GH deficit" 155(27.5%), "genetic syndrome" 67(11.9%), "familiar short stature" 38(6.7%), "others pathology" 38(6.7%), "idiopathic short stature" 31(5.5%), "i-uterine short stature" 16(2.8%). CONCLUSIONS The fact that 46% of the explored children resulted positive in terms of a pathology that had caused primary or secondary growth failure, makes it necessity careful monitoring of growth and reference of the children to a specialist as fast as possible. Evidently great age of exploration indicates a weak surveillance on growth monitoring in Albania. RECOMMENDATIONS Assessment of the child's growth must be a routine procedure. The early identification of stature growth delay will significantly increase the early detection of any pathology.
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Abstract
Coeliac disease is a common disorder that can arise at any age and typically presents with a broad spectrum of symptoms. The disease is thought to be underdiagnosed, in part owing to the fact that coeliac disease is often characterized by associated conditions and extraintestinal manifestations that can misdirect and impede diagnosis. Some of these manifestations are direct consequences of autoimmunity, such as dermatitis herpetiformis or gluten ataxia, whereas others are indirectly related to inflammation and/or malabsorption including anaemia, osteoporosis, short stature and delayed puberty. Any organ from the central nervous system to joints, liver or teeth can be affected. In some cases, extraintestinal symptoms are the only clinical manifestations of coeliac disease or occur in conjunction with diarrhoea and malabsorptive symptoms. An increased awareness among medical practitioners of the variety of extraintestinal manifestations of coeliac disease is essential to improve diagnosis and treatment.
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Affiliation(s)
- Daniel A Leffler
- The Celiac Centre at Beth Israel Deaconess Medical Centre, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Peter H R Green
- Celiac Disease Centre at Columbia University, 180 Fort Washington Avenue, HP 934, New York, NY 10032, USA
| | - Alessio Fasano
- Centre for Celiac Research, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Parra-Medina R, Molano-Gonzalez N, Rojas-Villarraga A, Agmon-Levin N, Arango MT, Shoenfeld Y, Anaya JM. Prevalence of celiac disease in latin america: a systematic review and meta-regression. PLoS One 2015; 10:e0124040. [PMID: 25942408 PMCID: PMC4420463 DOI: 10.1371/journal.pone.0124040] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 03/10/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in susceptible individuals, and its prevalence varies depending on the studied population. Given that information on CD in Latin America is scarce, we aimed to investigate the prevalence of CD in this region of the world through a systematic review and meta-analysis. METHODS AND FINDINGS This was a two-phase study. First, a cross-sectional analysis from 981 individuals of the Colombian population was made. Second, a systematic review and meta-regression analysis were performed following the Preferred Reporting Items for Systematic Meta- Analyses (PRISMA) guidelines. Our results disclosed a lack of celiac autoimmunity in the studied Colombian population (i.e., anti-tissue transglutaminase (tTG) and IgA anti-endomysium (EMA)). In the systematic review, 72 studies were considered. The estimated prevalence of CD in Latin Americans ranged between 0.46% and 0.64%. The prevalence of CD in first-degree relatives of CD probands was 5.5%. The coexistence of CD and type 1 diabetes mellitus varied from 4.6% to 8.7%, depending on the diagnosis methods (i.e., autoantibodies and/or biopsies). CONCLUSIONS Although CD seems to be a rare condition in Colombians; the general prevalence of the disease in Latin Americans seemingly corresponds to a similar scenario observed in Europeans.
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Affiliation(s)
- Rafael Parra-Medina
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 #63-C-69, Bogotá, Colombia
| | - Nicolás Molano-Gonzalez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 #63-C-69, Bogotá, Colombia
| | - Adriana Rojas-Villarraga
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 #63-C-69, Bogotá, Colombia
| | - Nancy Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Maria-Teresa Arango
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 #63-C-69, Bogotá, Colombia
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Doctoral Program in Biomedical Sciences Universidad del Rosario, Bogotá, Colombia
| | - Yehuda Shoenfeld
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Incumbent of the Laura Schwarz-Kip Chair for Research of Autoimmune Diseases, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 #63-C-69, Bogotá, Colombia
- * E-mail:
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Al-Jurayyan NA, Al Nemri AM, Al Jurayyan AN, Assiri AM. Celiac disease in children with short stature: A hospital based study. J Taibah Univ Med Sci 2013. [DOI: 10.1016/j.jtumed.2013.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Alencar ML, Ortiz-Agostinho CL, Nishitokukado L, Damião AOMC, Abrantes-Lemos CP, Leite AZDA, Brito TD, Chamone DDAF, Silva MERD, Giannella-Neto D, Sipahi AM. Prevalence of celiac disease among blood donors in São Paulo: the most populated city in Brazil. Clinics (Sao Paulo) 2012; 67:1013-8. [PMID: 23018296 PMCID: PMC3438239 DOI: 10.6061/clinics/2012(09)05] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 04/25/2012] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Celiac disease is a permanent enteropathy caused by the ingestion of gluten, which leads to an immunemediated inflammation of the small intestine mucosa. The prevalence of celiac disease varies among different nations and ethnic backgrounds, and its diversity is determined by genetic and environmental factors. São Paulo city is one of the largest cities in the world, with a vast population and an important history of internal migratory flow from other Brazilian regions, as well as immigration from other, primarily European, countries, resulting in significant miscegenation. The aim of the present study was to estimate the prevalence of adults with undiagnosed celiac disease among blood donors of São Paulo by collecting information on the ancestry of the population studied. METHODS The prevalence of celiac disease was assessed by screening for positive IgA transglutaminase and IgA endomysium antibodies in 4,000 donors (volunteers) in the Fundação Pró-Sangue Blood Center of São Paulo, São Paulo, Brazil. The antibody-positive subjects were asked to undergo a small bowel biopsy. RESULTS Of the 4,000 subjects, twenty-four had positive tests, although both antibody tests were not always concordant. For example, ten subjects were positive for IgA tissue transglutaminase only. In twenty-one positive patients, duodenal biopsies were performed, and the diagnosis of celiac disease was confirmed in fourteen patients (Marsh criteria modified by Oberhuber). In this group, 67% claimed to have European ancestry, mainly from Italy, Portugal and Spain. CONCLUSION The prevalence of celiac disease is at least 1:286 among supposedly healthy blood bank volunteers in São Paulo, Brazil.
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Affiliation(s)
- Marília Lage Alencar
- Laboratorio de Gastroenterologia Clínica e Experimental - LIM 07, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Ahmad F, Alam S, Shukla I, Sherwani R, Ali SM. IgA anti-tTG antibodies in children with severe short stature without gastrointestinal manifestations. Indian J Gastroenterol 2012; 31:32-3. [PMID: 22307886 DOI: 10.1007/s12664-011-0160-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Accepted: 12/18/2011] [Indexed: 02/04/2023]
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Vieira C, Matos M, Quaresma T, de Oliveira J, Ferreira CD, Silva A, Diniz-Santos D, Silva LR. What do Brazilian pediatricians know about celiac disease? Dig Dis Sci 2011; 56:799-804. [PMID: 20632095 DOI: 10.1007/s10620-010-1339-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 06/29/2010] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Celiac disease (CD) is a common illness, affecting 0.5-1% of the population. Its classic presentation consists of gastrointestinal symptoms, however, many extra-intestinal symptoms and some associated diseases have been studied. Pediatricians should know the typical and atypical presentations of CD and how to diagnosis and treat its complications. The aim of this study was describe what pediatricians in Brazil know about CD. METHODS A descriptive, cross-sectional study with pediatricians who participated in the Nestlé Pediatrics Course, in the city of Natal, Brazil, in 2008. They were asked to complete a self-applicable questionnaire covering aspects concerning the prevalence, diagnosis, and treatment of CD and the conditions associated with this disease. RESULTS A total of 632 pediatricians completed the questionnaire. The majority of respondents (82.9%) were female. All the geographical regions of Brazil were represented. More than 65% of respondents had undergone specialist training in pediatrics, and 40% of respondents had worked as pediatricians for more than 25 years. Only 22% replied that celiac disease may be asymptomatic, 57% stated that antigliadin antibody measurement represents the best screening tool for the disease, and two-thirds replied that bowel biopsy would be the most indicated method. The pathologies and conditions associated with celiac disease were identified by fewer than 50% of respondents. Exclusion of gluten from the patient's diet was mentioned as the treatment for celiac disease by 86.4% of the pediatricians. CONCLUSIONS We conclude that pediatricians have superficial information about CD. The need for relevant information on celiac disease is fundamental and is recognized by the pediatricians themselves.
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Affiliation(s)
- Camilo Vieira
- Department of Pediatric Neurology, School of Medicine, Federal University of Bahia, Salvador, Bahia, Brazil.
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Ahmad F, Alam S, Shukla I, Sherwani R, Ali SM. Screening children with severe short stature for celiac disease using tissue transglutaminase. Indian J Pediatr 2010; 77:387-90. [PMID: 20422329 DOI: 10.1007/s12098-010-0040-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Accepted: 12/02/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This prospective study was planned with the aim to determine the prevalence of anti-tissue transglutaminase in children and adolescents with severe short stature (<-3 SD) attending the Pediatric outpatient, inpatient and/or the Pediatric Gastroenterology clinic. METHODS All children in age group of 1-18 years having height less than -3 SD for their age and sex, were included. For each child age and sex matched healthy control (height more than -2 SD) was taken. The included subjects (study & control group) were subjected to anti tissue transglutaminase (tTG) (IgA) antibody assay estimation. RESULTS Of the 112 cases, 23 were tTG positive, giving a prevalence of 20.5% for seropositivity among cases of short stature while all the controls were seronegative for tTG. All the 23 had tTG values above 40 U/ml and 11 had values above 100 U/ml. On univariate analysis we found that the presence of chronic diarrhea (OR = 2.55, 95%CI - 1.08-5.98), bulky stools (OR = 3.03, 95%CI - 1.52-6.05), hemoglobin < 7 gm/dl (OR = 3.12, 95%CI - 1.55-6.29) and more severe short stature (<-4 SD) (OR = 0.41, 95%CI - 0.17-0.95) had significant association with the tTG positivity. On logistic regression analysis in all cases, hemoglobin < 7gm/dl (OR = 0.090, 95%CI = 0.024-0.342) and bulky stools (OR=0.212, 95%CI = 0.069-0.649) were significantly associated with tTG positivity. CONCLUSION More than one fifth of all severe short stature are seropositive for tTG and the chances of seropositivity increases if severe anemia and bulky stool are also associated.
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Affiliation(s)
- Faraz Ahmad
- Department of Pediatrics, J.N. Medical College, AMU, Aligarh, Uttar Pradesh, India
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Commentary on "anti-pituitary antibodies in children with newly diagnosed celiac disease: a novel finding contributing to linear growth". Am J Gastroenterol 2010; 105:697-8. [PMID: 20203647 DOI: 10.1038/ajg.2009.640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The pathogenesis of celiac disease (CD)-associated short stature is still unclear. The authors showed that newly diagnosed CD patients have a high prevalence of positive antipituitary antibodies that correlates with height impairment. Given the association of CD with other autoimmune disease, these authors' findings show one possible etiology for the poor growth seen in children with CD.
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Gueiros ACLN, Silva GAP. Soropositividade para doença celíaca em crianças e adolescentes com baixa estatura. REVISTA PAULISTA DE PEDIATRIA 2009. [DOI: 10.1590/s0103-05822009000100005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJETIVO: Avaliar a frequência da positividade do marcador sorológico para doença celíaca em crianças e adolescentes com baixa estatura, utilizando-se o anticorpo anti-transglutaminase humana como teste de triagem. MÉTODOS: Estudo descritivo com amostra obtida por conveniência. Foi realizado no período de abril a setembro de 2004 no Ambulatório Geral de Pediatria do Instituto Materno Infantil Professor Fernando Figueira e no Ambulatório de Crescimento e Desenvolvimento do Hospital das Clínicas. Foram considerados casos as crianças e os adolescentes portadores de baixa estatura, definida como aquela abaixo do percentil 3 para idade e sexo, utilizando como referência o gráfico de altura/idade do National Center for Health Statistics, 2000. Foi pesquisado o anticorpo anti-transglutaminase humana (AATGh), considerado positivo se concentração >20U/mL e, nos positivos, o anticorpo antiendomísio (AAE). RESULTADOS: Foram avaliados 78 pacientes, sendo 41 (53%) do sexo feminino. O AATGh foi positivo em 3/78 (3,8%) dos pacientes. O AAE foi positivo em um paciente, naquele com concentração mais elevada do AATGh. Considerando-se a positividade para os dois testes, a soropositividade foi de 1,3%. CONCLUSÕES: A presença de marcador sorológico para doença celíaca em crianças e adolescentes portadoras de baixa-estatura e pertencentes a famílias de baixa-renda aponta para a necessidade de investigação sistemática da doença celíaca nesses pacientes.
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Abstract
Celiac disease (CD) is an autoimmune enteropathy triggered in susceptible individuals by ingestion of gliadin-containing grains. Although the autoimmune process targets mainly the intestinal mucosa, CD can manifest itself with a variety signs and symptoms affecting any organ or tissue. For many years, CD has been underdiagnosed because of poor awareness. However, studies showing a high prevalence of CD in North America, followed by a consensus conference on CD organized by the National Institutes of Health, have fueled a campaign to raise awareness among subspecialists and primary physicians. Nevertheless, guidelines for the diagnosis of CD remain poorly appreciated and many health care professionals remain confused about its proper management. This review is intended to clarify "facts and fantasies" about CD diagnosis.
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Affiliation(s)
- Carlo Catassi
- University of Maryland School of Medicine, Mucosal Biology Research Center and Center for Celiac Research, Health Science Facility II, Baltimore, MD 21201, USA
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Hashemi J, Hajiani E, Shahbazin HBB, Masjedizadeh R, Ghasemi N. Prevalence of celiac disease in Iranian children with idiopathic short stature. World J Gastroenterol 2008; 14:7376-80. [PMID: 19109872 PMCID: PMC2778122 DOI: 10.3748/wjg.14.7376] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the prevalence of celiac disease (CD) in children with idiopathic short stature (ISS) and the diagnostic value of immunoglobulin (Ig) A G antigliadin antibodies (AGA) and transglutaminase (TTG) antibodies for CD.
METHODS: A total of 104 children (49 male, 55 female) with ISS without a specific etiology were studied. Extensive endocrine investigations had shown no abnormalities in any subject. Anthropometric parameters and IgA AGA and IgA TTG antibodies were evaluated in this study group. These antibodies were measured by enzyme-linked immunosorbent assay. All patients were referred for an endoscopic intestinal biopsy. The biopsy samples were classified according to revised Marsh criteria (UEGW 2001).
RESULTS: We detected positive IgA TTG antibodies in 36 and IgA AGA in 35 of these patients. Thirty one IgA TTG antibody positive and 28 IgA AGA positive subjects showed histological abnormalities compatible with celiac disease (33.6%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value for IgA AGA were found to be 80%, 88.4%, 77.8% and 89.7%, respectively. Sensitivity, specificity and PPV for IgA TTG antibodies were 88.6%, 94.2% and 88.6%, respectively.
CONCLUSION: We conclude that the prevalence of celiac disease is high in patients with ISS and it is important to test all children with ISS for celiac disease by measuring serologic markers and performing an intestinal biopsy.
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Bhadada SK, Bhansali A, Kochhar R, Menon AS, Sinha SK, Dutta P, Nain CK. Does every short stature child need screening for celiac disease? J Gastroenterol Hepatol 2008; 23:e353-6. [PMID: 18086116 DOI: 10.1111/j.1440-1746.2007.05261.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
AIM To study the etiological profile of short stature at a tertiary care hospital in north India. METHODS In this prospective study, 176 children with short stature were enrolled from January 2005 to December 2006. Appropriate screening and definitive tests were performed to establish the etiology of short stature. RESULTS Celiac disease (CD) emerged as the single most common (15.3%) cause of short stature, followed by various endocrine disorders. It was interesting to note that none of the CD patients presented with gastrointestinal symptoms. CONCLUSION All short children should be screened for CD irrespective of gastrointestinal symptoms.
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Affiliation(s)
- Sanjay Kumar Bhadada
- Departments of Endocrinology, Postgraduate Institute of Medical Education and Research Chandigarh, India
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Abstract
OBJECTIVE The aim of the present study was to determine the prevalence of celiac disease in children with short stature. METHODS In all children with short stature (height more than 2 SD below the mean for age and sex) and normal physical examination, attending Motahary pediatric clinic in Shiraz, Iran, from 2003 till 2005, work-ups were made to find a cause for their short stature and of course their serum was assayed for IgG anti-tissue transglutaminase (TTG) antibody by ELISA test, as a marker for CD. RESULTS There were 26 girls and 46 boys with mean age of 9.8 years. Routine work-up showed microcytic hypochromic anemia in four children (5.6%) and giardiasis in five (6.9%). GH stimulation test revealed GH deficiency in five children (6.9%). Elevated IgG anti-TTG antibody level was detected in two children (2.8%). Duodenal biopsies of these children were in favor of celiac disease. CONCLUSION Although, the prevalence of CD in this study was not significantly different (P value = 0.14) from the prevalence rate in healthy blood donors in Iran, the findings emphasize the fact that CD must be considered in a child with short stature, especially if the height is more than 3 SD below the mean for sex and age, even in the absence of gastrointestinal symptoms. In conclusion, the measurement of anti-TTG antibody should be included in the diagnostic evaluation of children with short stature.
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Affiliation(s)
- Seyed Mohsen Dehghani
- Department of Pediatrics and Gestroentero-hepatology Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran.
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Gadewar S, Fasano A. Celiac disease: is the atypical really typical? Summary of the recent National Institutes of Health Consensus Conference and latest advances. Curr Gastroenterol Rep 2005; 7:455-61. [PMID: 16313875 DOI: 10.1007/s11894-005-0076-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. Gluten is a protein component in wheat and other cereals, such as rye and barley. At present, the only available treatment is a strict gluten-free diet. Recent advances have increased our understanding of the molecular basis for this disorder. The past decade has seen new scientific developments in this disease and led to the formulation of new concepts of pathophysiology and clinical manifestations. There are several targets for new treatments. This article briefly summarizes the National Institutes of Health Consensus Statement and gives an overview of new findings in recent years and of future therapeutic options for CD.
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Affiliation(s)
- Swati Gadewar
- Department of Pediatrics, Mucosal Biology Research Center, University of Maryland School of Medicine, Health Science Facility II Room 8345, 20 Penn Street, Baltimore, MD 21201, USA
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