Coeliac disease in children: the need to improve awareness in resource-limited settings

Celiac Disease in Uzbek Children: Insights into Disease Prevalence and Clinical Characteristics in Symptomatic Pediatric Patients

BACKGROUND

A few studies on pediatric Celiac Disease (CD) are available from Central Asia. Recent immunogenetic research has highlighted that the HLA-DQ2/8 genetic predisposition to CD as well as the dietary intake of gluten in this geographical area, are comparable to other regions of the world where CD prevalence is known to be 1% or higher.

METHODS

This is a prospective and cross-sectional study investigating the prevalence and clinical characteristics of CD in symptomatic children referred to the pediatric gastroenterology department of a tertiary hospital in Uzbekistan from 1 September 2021, until 31 July 2022. In addition to collecting the relevant information related to clinical manifestations and laboratory analyses from the clinical files, a specific survey was also administered to patients' guardians. Serological, histopathological, and immunogenetic parameters specific to CD, fecal zonulin, and pancreatic elastases were assessed in CD patients.

RESULTS

The study population consisted of 206 children. Overall, almost all of them (n = 192; 93.2%) were referred because of gastrointestinal manifestations, which were associated with extra-gastrointestinal manifestations in most cases (n = 153; 74.3%); a minority (n = 14; 6.8%) was mainly referred due short stature and/or growth failure only. Among all of these study participants, CD was diagnosed in 11 children (5.3%). Notably, although diarrhea was similarly reported in CD and non-CD patients, watery diarrhea (type 7 according to the Bristol stool scale) was much more frequently and significantly observed in the former group. All of these CD patients showed anti-tTG IgA 10 times higher than the upper normal limit, except one child with lower serum levels of total IgA; however, all of them received a diagnostic confirmation by histopathological analysis due to the lack of EMA testing in the country. Notably, most CD children (82%) showed a Marsh III histological grading. Around half patients (54.5%) showed zonulin values above the reference range, whereas none showed insufficient levels of pancreatic elastase. However, no correlation or association between zonulin and clinical, laboratory, histopathological, and immunogenetic parameters was found.

CONCLUSIONS

This study may further suggest a relevant prevalence of CD in Uzbek children, based on this partial picture emerging from symptomatic patients only. Additionally, we highlighted the prevalence of typical CD forms with watery diarrhea, which should strongly support a full diagnostic work-up for CD in the local clinical setting. The high levels of anti-tTG IgA and high Marsh grade might also lead us to speculate a significant diagnostic delay despite the classical clinical expression of CD.

Neurologic complications of coeliac disease: first reported from Sudan 50 years ago and dietary solution highlighted 60 years ago

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Sub-acute combined degeneration of the spinal cord as first presentation of coeliac disease in a Sudanese child

The prevalence of coeliac disease (CD) is rapidly rising in both developed and underdeveloped countries. CD classically presents with gastrointestinal manifestations, but it is now increasingly considered as a multisystem disease mostly affecting the central nervous system. Recently, a non-biopsy approach for the diagnosis of CD has been recommended by the European Society for paediatric gastroentrology, hepatology and nutrition. Here, we are reporting a 12-year-old Sudanese boy who presented with chronic diarrhoea and weight loss and lower limbs weakness. His examinations showed emaciation, pallor and weakness of both lower limbs and mixed upper and lower motor neuron signs and peripheral neuropathy, suggestive of sub-acute combined degeneration of the spinal cord (SACDSC). His initial investigations showed microcytic hypochromic anaemia with hypokalaemia and hypocalcaemia and very high titer of the IgA class of tissue transglutaminase (28× upper limit normal ) with a positive anti-endomeseal IgA antibodies. He was diagnosed with acute coeliac crisis with SACDSC, most likely due to Vitamin B12 deficiency. Although his initial cobalamine level was normal, he later developed macrocytosis and his neurological signs improved rapidly with injectable B12. We reported a rare neurological presentation of CD and we highlighted the non-biopsy approach for the diagnosis of CD in children.

IMPROVED ADHERENCE TO THE ESPGHAN GUIDELINES IS NECESSARY FOR DIAGNOSING CELIAC DISEASE IN CHILDREN: A SINGLE-CENTER EXPERIENCE

BACKGROUND

Celiac disease (CD) is an immune-mediated systemic disorder elicited by the ingestion of gluten. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines published in 2012 suggested a no-biopsy pathway (NBP) for symptomatic children with IgA tissue transglutaminase (TGA-IgA) ≥10x upper limit of normal (ULN). Biopsy confirmation remained mandatory for other cases.

OBJECTIVE

This retrospective case note study was aimed at evaluating the adherence to the ESPGHAN 2012 guidelines for diagnosing CD in our unit.

METHODS

Forty-three cases with positive TGA-IgA were identified by a laboratory database search from January 2013 to December 2019. 6 of 43 patients were not referred for a confirmation of CD diagnosis. Data was collected on the diagnostic pathways followed, and appropriateness of adherence was compared with the existing ESPGHAN guidelines.

RESULTS

A total of 37 cases were included with 35 children diagnosed with CD. 29/35 (83%) were diagnosed via the NBP;15/29 (52%) children did not meet all the criteria required for NBP, but were diagnosed and managed as having CD. 20/35 (57%) children were diagnosed with CD in adherence to the 2012 guidelines.

CONCLUSION

The recommended diagnostic guidelines were frequently not implemented; adherence to the guidelines may improve following regular educational sessions. The revised 2020 ESPGHAN guidelines which exclude HLA-DQ2/DQ8 testing would address the issue of diagnosis for the 10/15 NBP cases (with TGA-IgA >10xULN) in our study who did not have HLA testing and were therefore non-adherent to the 2012 diagnostic guidelines. NBP, with the reduced need for endoscopy may be beneficial in resource limited settings.

Challenges of Monitoring the Gluten-Free Diet Adherence in the Management and Follow-Up of Patients with Celiac Disease

Celiac disease (CD) is a chronic gluten-responsive immune mediated enteropathy and is treated with a gluten-free diet (GFD). However, a strict diet for life is not easy due to the ubiquitous nature of gluten. This review aims at examining available evidence on the degree of adherence to a GFD, the methods to assess it, and the barriers to its implementation. The methods for monitoring the adherence to a GFD are comprised of a dietary questionnaire, celiac serology, or clinical symptoms; however, none of these methods generate either a direct or an accurate measure of dietary adherence. A promising advancement is the development of tests that measure gluten immunogenic peptides in stools and urine. Causes of adherence/non-adherence to a GFD are numerous and multifactorial. Inadvertent dietary non-adherence is more frequent than intentional non-adherence. Cross-contamination of gluten-free products with gluten is a major cause of inadvertent non-adherence, while the limited availability, high costs, and poor quality of certified gluten-free products are responsible for intentionally breaking a GFD. Therefore, several studies in the last decade have indicated that many patients with CD who follow a GFD still have difficulty controlling their diet and, therefore, regularly consume enough gluten to trigger symptoms and damage the small intestine.

Functionalized TiO2 Nanotube Platform for Gliadin Electroanalysis

The present paper presents a gliadin detection method. This method is based on a modified Ti electrode. Modification was performed by a simple and cheap anodization. Then, a layer of graphene oxide was added, and gliadin antibody was fixed on the electrode surface. Using this complex system, electrochemical impedance spectroscopy was used for gliadin detection. Solutions with known gliadin (a fraction from gluten) content were used for analysis. Impedance measured at a certain frequency and coating resistance were analyzed. Better results (good linearity and lower detection limit) were obtained by plotting impedance at a certain frequency versus gliadin concentration. Coating resistance was proved to be in linear dependency with gliadin concentration only at lower concentrations. This system based on titanium nanostructured electrode has the potential to be used for gluten contamination detection from foods.