Chronic inflammatory bowel disease in patients with coeliac disease

Pediatric Inflammatory Bowel Disease Associated With Celiac Disease: A Retrospective Study in a Tertiary Care Hospital in Saudi Arabia

Background. Inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn’s disease (CD), is a chronic relapsing disease indicated by inflammation of the gastrointestinal tract. Celiac disease (CeD) is a chronic autoimmune disease of the small bowel. The prevalence of CeD in IBD patients is unknown. Some studies have described the coexistence of the 2 diseases in the same patient. This study aimed to investigate the prevalence of CeD in Saudi Arabian children with IBD. Methods. We used a retrospective study design because data can be collected immediately and is easier to analyze afterward. The study was conducted on IBD patients in the Pediatric Gastroenterology Department at National Guard Hospital, Jeddah, Saudi Arabia. We enrolled Saudi patients aged between 1 and 18 years who had been diagnosed with IBD and CeD based on positive biochemical serology and histology from January 2011 to January 2020. We excluded patients with immunodeficiency disorders. Results. Among the 46 enrolled patients with IBD, CeD was identified in 4, and they did not develop any relapses. We discovered that the weight at IBD diagnosis improved significantly compared to current weight (P-value < .0001). We also discovered that the height at diagnosis of IBD improved significantly compared to the current height (P-value < .0001). Additionally, we found no significant associations between UC and CeD (P-value = 1), or CD and CeD (P-value = .625). Conclusion. No significant associations were evident between the prevalence of CeD and IBD. More prospective multicenter studies are needed to clarify the prevalence of CeD in children with IBD.

Prevalance of Celiac Disease in Patients with Inflammatory Bowel Disease in Turkish Population

Background

Celiac disease (CD) and inflammatory bowel disease (IBD) involve inflammation of the gastrointestinal lumen, which environmental, genetic, and immunological factors have a role in their pathogenesis. The prevalence of celiac disease in IBD ranges from 0% to 14%. In this study, our aim was to determine the prevalence of CD in IBD patients followed by us who are attending the hospital or outpatient clinic over a period of time of seven years.

Methods

Seven hundred and fifty nine patients (425 M, 334 F, mean age: 46.75, 396 ulcerative colitis (UC), 363 Crohn's disease (CrD)) diagnosed and followed up for IBD between January 2009 and July 2016 were evaluated retrospectively, and clinical, demographic, laboratory, and endoscopic data were collected.

Results

CD was investigated in 79 (%10.4) inflammatory bowel disease patients according to symptoms, and in 5.06% (n = 4) of them, we diagnosed CD. The most common indication for investigating for CD was iron deficiency anemia unreponsive to iron supplementation.

Conclusions

We did not find an increased prevalance of celiac disease in Turkish IBD patients in this study. In the presence of refractory iron deficiency anemia without any other cause in IBD patients, investigations for celiac disease should be considered.

Link Between Celiac Disease and Inflammatory Bowel Disease

GOAL

The aim of this analysis was to assess in patients with inflammatory bowel disease (IBD) the risk of celiac disease and in celiac disease patients the risk of IBD.

BACKGROUND

Previous studies report a possible association between IBD and celiac disease; however, this link is controversial.

STUDY

Using the search terms "inflammatory bowel disease" and "celiac disease," we identified initially 1525 publications. In total 27 studies met inclusion criteria. Proportions and 95% confidence intervals (CIs) for the prevalence of IBD in celiac disease and vice versa were compared with published prevalence rates for the respective geographic regions.

RESULTS

We included 41,482 adult IBD patients (20,357 with Crohn's disease; 19,791 with ulcerative colitis; and 459 patients with celiac disease). Overall, in IBD patients the prevalence of celiac disease was 1110/100,000 (95% CI, 1010-1210/100,000) as compared with a prevalence of 620/100,000 (95% CI, 610-630/100,000) in the respective populations (odds ratio, 2.23; 95% CI, 1.99-2.50). In contrast, in patients with celiac disease, 2130/100,000 had IBD (95% CI, 1590-2670/100,000) as compared with 260/100,000 (95% CI, 250/100,000-270/100,000) in the respective populations (odds ratio, 11.10; 95% CI, 8.55-14.40). This effect was not different for ulcerative colitis and Crohn's disease. Although there was no evidence for publication bias for celiac disease in IBD, the funnel plot suggested that the association between IBD in celiac disease might be influenced by publication bias.

CONCLUSIONS

The data are consistent with the notion that celiac disease is a risk factor for IBD and to lesser degree patients with IBD have an increased risk of celiac disease.

Celiac disease, collagenous sprue and microscopic colitis in IBD. Observations from a population-based cohort of IBD (ICURE)

OBJECTIVE

Inflammatory bowel disease (IBD), microscopic colitis and celiac disease are all diseases with worldwide distribution and increased incidence has been reported from many areas. There is a shortage of studies investigating the occurrence of these diseases in the same individual and whether those affected demonstrate any particular phenotype. The aim of the study was to describe the concomitant incidence of microscopic colitis and celiac disease in a population-based IBD cohort.

METHODS

All 790 individuals in a prospective population-based cohort included 2005-09 from Uppsala region, Sweden, were reviewed regarding the appearance of microscopic or celiac disease before or after IBD diagnosis.

RESULTS

Fifty percent (396/790) of the patients had been examined for the possibility of celiac disease. Seventeen patients with celiac disease were found, representing 2.2% of the cohort. Patients with celiac disease were younger compared to the non-celiac patients and those with colitis had more often an extensive inflammation of the colon. Seventy-one percent (12/17) were women. The majority of the patients were diagnosed with celiac disease before IBD. Five patients with IBD had an earlier diagnosis of microscopic colitis or developed it after the IBD diagnosis. One teenager developed collagenous sprue, misinterpreted as a severe relapse of ulcerative colitis (UC) resulting in colectomy.

CONCLUSIONS

The risk for celiac disease seems not to be increased in IBD, but those affected by both diseases seem to be predominantly women with extensive UC. There is a potential association between microscopic colitis and IBD.

Inflammatory bowel disease and celiac disease: Overlaps and differences

Recent findings demonstrate the common genetic basis for many immune-mediated diseases, and consequently, the partially shared pathogenesis. We collected these findings and reviewed the extension of these overlaps to other disease characteristics. Two autoimmune diseases were selected that also share the specific target organ, the bowel. The etiology and immunopathogenesis of both conditions characterized by chronic intestinal inflammation, inflammatory bowel disease (IBD) and celiac disease (CeD), are not completely understood. Both are complex diseases with genetics and environment contributing to dysregulation of innate and adaptive immune responses, leading to chronic inflammation and disease. CeD constitutes a particular disease because the main environmental and genetic triggers are largely known. IBD comprises two main clinical forms, Crohn’s disease and ulcerative colitis, which most likely involve a complex interplay between some components of the commensal microbiota and other environmental factors in their origin. These multifactorial diseases encompass a broad spectrum of clinical phenotypes and ages of onset, although the clinical presentation often differs depending on childhood or adult onset, with greater heterogeneity commonly observed in adults.

Impact of coexistent celiac disease on phenotype and natural history of inflammatory bowel diseases

OBJECTIVES

Inflammatory bowel disease (IBD) and celiac disease are the two most common immune-mediated gastrointestinal diseases. There is limited knowledge regarding the course of IBD in those with coexisting celiac disease. We conducted this study to determine whether patients with coexisting celiac disease present a unique phenotype of IBD and to examine the frequency of co-occurrence of celiac disease and IBD in comparison with other autoimmune disorders.

METHODS

This was a case-control study performed at two tertiary referral centers. Cases comprised of patients with known diagnoses of celiac disease and IBD. Two random IBD controls without celiac disease were selected for each case after matching for IBD type. Disease phenotype and natural history for both Crohn's disease (CD) and ulcerative colitis (UC) were noted from medical record review, and were compared between IBD patients with and without celiac disease.

RESULTS

We identified a total of 51 patients with IBD (22 UC, 1 indeterminate colitis, 28 CD) and celiac disease. There was no significant difference in the age, gender, or ethnicity between celiac-IBD and controls. Pancolitis was more common in celiac-UC patients as compared with controls (odds ratio (OR) 3.30, 95% confidence interval (CI) 1.05-21.50). There was also a trend toward increased use of immunomodulators (IMMs) among celiac-UC patients than in non-celiac UC controls (OR 2.83, 95% CI 0.95-8.48). No phenotypic differences were found in celiac-CD patients. There were no significant differences in IBD-related medication usage, hospitalizations, or surgeries.

CONCLUSIONS

Patients with UC and celiac disease were more likely to have pancolitis and had a trend toward greater use of IMMs. Coexisting celiac disease did not influence natural history of CD.

Endoscopy in inflammatory bowel disease when and why

Endoscopy plays an important role in the diagnosis and management of inflammatory bowel disease (IBD). It is useful to exclude other aetiologies, differentiate between ulcerative colitis (UC) and Crohn’s disease (CD), and define the extent and activity of inflammation. Ileocolonoscopy is used for monitoring of the disease, which in turn helps to optimize the management. It plays a key role in the surveillance of UC for dysplasia or neoplasia and assessment of post operative CD. Capsule endoscopy and double balloon enteroscopy are increasingly used in patients with CD. Therapeutic applications relate to stricture dilatation and dysplasia resection. The endoscopist’s role is vital in the overall management of IBD.

Does evidence exist to include dietary therapy in the treatment of Crohn's disease?

Prescription drugs and surgery are two common medical therapies for Crohn's disease (CD), an inflammatory bowel disease that affects the GI tract. Unfortunately, certain drugs can cause serious side effects, and surgeries must often be repeated. No diet has been established to alleviate the pain and suffering of CD patients. This is curious given the fact that a higher prevalence of food sensitivities exist in this population of patients, and enteral nutrition is not only the first-line of therapy in Japan, but a known research method used to place the majority of CD patients into remission. Although not all patients respond equally to diet, many simply remove symptom-provoking foods, such as dairy, wheat, corn and certain fruits and vegetables. We suggest assisting these patients in their self-assessment of irritating and symptom-provoking foods by educating them in the use of a food-symptom diary followed by a customized elimination diet trialed for 2-4 weeks to determine if there is any benefit to the individual patient.

Prevalence of celiac disease in inflammatory bowel diseases: An IG-IBD multicentre study

BACKGROUND

An association has been described in case reports between celiac disease and inflammatory bowel diseases. The aim of the present study is to assess the prevalence of celiac disease in a large series of Italian patients with inflammatory bowel disease.

METHODS

The Italian Group for Inflammatory Bowel Disease conducted a multicentre study between January 2002 and December 2004, in which 22 gastroenterology centres in Italy enrolled 1711 consecutive outpatients with inflammatory bowel disease. 860 (50.2%) had Crohn's disease (415 females, mean age 40, range 18-75), 791 (46.2%) had ulcerative colitis (371 females, mean age 40, range 18-80), and 60 (3.5%) had indeterminate colitis (27 females, mean age 40, range 18-78). All patients underwent serological testing for anti-endomysial antibodies and anti-tissue transglutaminase antibodies; if positive upper GI endoscopy with duodenal biopsy was performed.

RESULTS

Nine of the 1711 patients (0.5%) had serological and histological findings compatible with the diagnosis of celiac disease; six of them had ulcerative colitis and three had Crohn's disease.

CONCLUSIONS

Overall we found a lower risk of celiac disease in our cohort of inflammatory bowel disease patients than in the general population; prevalence of celiac disease was higher in patients with ulcerative colitis than in those with Crohn's disease.

Diagnostic value of esophagogastroduodenoscopy in patients with ileal pouch-anal anastomosis

BACKGROUND

Inflammatory and noninflammatory complications of ileal pouch-anal anastomosis (IPAA) are common after restorative proctocolectomy of ulcerative colitis (UC). Some of the patients can have upper gastrointestinal pathology. The diagnostic role of esophagogastroduodenoscopy (EGD) in these patients has not been evaluated. The aim was to estimate the prevalence of upper gastrointestinal (GI) diseases detected by EGD and to assess factors associated with the abnormal EGD findings.

METHODS

IPAA patients with underlying inflammatory bowel disease undergoing diagnostic EGD were recruited from a subspecialty pouchitis clinic. Diagnostic yield and incidental findings of EGD were evaluated. Twenty-three variables were evaluated including age, gender, UC duration, IPAA duration, the Pouchitis Disease Activity Index scores, pouch type, pre-IPAA diagnosis, and disease category of the pouch. Univariate and multivariate analyses were performed; stepwise selection with 0.35 and 0.10 as entry and exit criteria.

RESULTS

Sixty-six patients undergoing EGD were enrolled in the study, of whom 64 (97%) patients had a concomitant pouch endoscopy. Indications for EGD include anemia, upper abdominal pain, weight loss, nausea and vomiting, and persistent diarrhea refractory to antibiotic therapy. Seventeen patients (25.8%) had a conclusive diagnosis and 14 (21.2%) had incidental findings, on EGD. The most common abnormal findings on EGD were Crohn's disease 12%), peptic ulcer disease (3%), gastritis/duodenitis on histology (11%), Candida esophagitis (3%), and arteriovenous malformations (3%). In multivariate analysis, factors associated with a conclusive EGD diagnosis were a high Pouchitis Disease Activity Index endoscopy score of the afferent limb (odds ratio [OR] = 1.8; 95% confidence interval [CI]: 1.09, 2.9; P = 0.02) and pouch types other than original J pouch (OR = 5.9; 95% CI: 1.08, 32.2; P = 0.041).

CONCLUSIONS

EGD evaluation can yield valuable diagnostic information in selected symptomatic patients with IPAA.

Celiac disease and risk of liver disease: a general population-based study

BACKGROUND & AIMS

Celiac disease (CD) is an important cause of hypertransaminasemia. CD might also be associated with severe forms of liver disease. We investigated the risk of liver disease in 13,818 patients with CD (1964-2003) and 66,584 age- and sex-matched reference individuals from a general population cohort.

METHODS

We used Cox regression to estimate hazard ratios (HRs) for later liver disease and conditional logistic regression to estimate the risk of CD in individuals with liver disease before study entry.

RESULTS

CD was associated with an increased risk of acute hepatitis (HR, 5.21; 95% confidence interval [CI], 1.88-14.40; P = .001), chronic hepatitis (HR, 5.84; 95% CI, 2.89-11.79; P < .001), primary sclerosing cholangitis (HR, 4.46; 95% CI, 2.50-7.98; P < .001), fatty liver (HR, 6.06; 95% CI, 1.35-27.16; P = .018), liver failure (HR, 3.30; 95% CI, 2.22-4.88; P < .001), liver cirrhosis or liver fibrosis (HR, 2.23; 95% CI, 1.34-3.72; P < .001), and primary biliary cirrhosis (HR, 10.16; 95% CI, 2.61-39.49; P < .001). There was no increased risk of liver transplantation (HR, 1.07; 95% CI, 0.12-9.62; P = .954). Adjustment for socioeconomic index or diabetes mellitus had no notable effect on the risk estimates. Prior liver disease was associated with a statistically significant 4-fold to 6-fold increased risk of later CD.

CONCLUSION

This study suggests that individuals with CD are at increased risk of both prior and subsequent liver disease.

Patterns of clinical presentation of adult coeliac disease in a rural setting

BACKGROUND

In recent years there has been increasing recognition that the pattern of presentation of coeliac disease may be changing. The classic sprue syndrome with diarrhoea and weight loss may be less common than the more subtle presentations of coeliac disease such as an isolated iron deficiency anaemia. As a result, the diagnosis of this treatable condition is often delayed or missed. Recent serologic screening tests allow non-invasive screening to identify most patients with the disease and can be applied in patients with even subtle symptoms indicative of coeliac disease. Both benign and malignant complications of coeliac disease can be avoided by early diagnosis and a strict compliance with a gluten free diet.

AIM

The aim of this study is to evaluate the trends in clinical presentation of patients diagnosed with adult coeliac disease. In addition, we studied the biochemical and serological features and the prevalence of associated conditions in patients with adult coeliac disease.

METHODS

This is an observational, retrospective, cross-sectional review of the medical notes of 32 adult patients attending the specialist coeliac clinic in a district general hospital.

RESULTS

Anaemia was the most common mode of presentation accounting for 66% of patients. Less than half of the patients had any of the classical symptoms of coeliac disease and 25% had none of the classical symptoms at presentation. Anti-gliadin antibodies, anti-endomysial antibody and anti-tissue transglutaminase showed 75%, 68% and 90% sensitivity respectively. In combination, serology results were 100% sensitive as screening tests for adult coeliac disease. Fifty nine percent patients had either osteoporosis or osteopenia. There were no malignant complications observed during the follow up of our patients.

CONCLUSION

Most adults with coeliac disease have a sub clinical form of the disease and iron deficiency anaemia may be its sole presenting symptom. Only a minority of adult coeliac disease patients present with classical mal-absorption symptoms of diarrhoea and weight loss. Patients with atypical form of disease often present initially to hospital specialists other than a gastro-enterologist. An awareness of the broad spectrum of presentations of adult coeliac disease, among doctors both in primary care and by the various hospital specialists in secondary care, is necessary to avoid delays in diagnosis. It is important to include serological screening tests for coeliac disease systematically in the evaluation of adult patients with unexplained iron deficiency anaemia or unexplained gastro-intestinal symptoms and in those who are considered to be at increased risk for coeliac disease.

Review article: intestinal failure

Intestinal failure is a specific disease entity resulting from intestinal resection or disease-associated malabsorption and characterized by the inability to maintain protein-energy, fluid, electrolyte or micronutrient balance. We performed a MEDLINE search (1966-2006) to identify relevant articles, using keywords intestinal failure, parenteral or enteral nutrition, intestinal fistula and short bowel syndrome. Causes of intestinal failure are varied, with self-limiting or 'Type 1' intestinal failure occurring relatively commonly following abdominal surgery, necessitating short-term fluid or nutritional support. The rarer, 'Type 2' intestinal failure, is associated with septic, metabolic and complex nutritional complications, usually following surgical resection in patients with Crohn's or mesenteric vascular disease. A multidisciplinary approach to the management of patients with Type 2 intestinal failure is crucial: resolution of sepsis is required before adequate nutritional repletion can be achieved, and it is important to optimize nutritional status, not only through enteral or parenteral supplementation, but also by addressing complications of short bowel syndrome, before considering definitive surgical reconstruction. A structured approach to the management of Type 2 intestinal failure should reduce the likelihood of these complex patients developing 'Type 3' intestinal failure, which is characterized by the need for long-term parenteral nutrition.

Collagenous colitis, ulcerative colitis, coeliac disease and hyperparathyroidism in one patient: implications for the management of collagenous colitis

A case of collagenous colitis, ulcerative colitis and coeliac disease all occurring in one individual is reported. In addition to causing confusion over symptoms, this observation coupled with a review of the literature raises the question of whether patients with collagenous colitis should be routinely screened for coeliac disease. Furthermore, the threshold for re-investigating for the possibility of the development of ulcerative colitis may have to be lowered, particularly if symptoms change.

Association of Crohn's disease and latent celiac disease: a case report and review of the literature

BACKGROUND

Crohn's disease is a chronic inflammatory disease of the intestine potentially affecting all parts of the intestine with predilection sites in the terminal ileum and proximal colon. Its prevalence in Western Europe is 20-40/100,000 with equal affection of both sexes and familiar accumulation. Histopathologically, it is characterized by a discontinuous, segmental manifestation and implication of all intestinal layers. Celiac disease, on the other hand, is defined by histologically proven villous atrophy associated with hyperplasia of crypts, lymphocytic infiltration and clinical improvement after a gluten-free diet.

CASE REPORT

We report the case of a 52-year-old man presenting with long-term diarrhea and loss of weight associated with Crohn's disease. After interventional therapy for an unstable coronary artery syndrome and medical therapy for hyperthyroidism, the diarrhea stopped only after maintaining a gluten-free diet. A latent form of celiac disease (clinical symptoms, improvement after gluten-free diet, detection of anti-gliadin IgA antibodies, negative histology) was diagnosed.

CONCLUSION

To our knowledge, this is the first report on the association of Crohn's disease and the latent form of celiac disease in the same patient. Whereas in most cases, Crohn's disease develops secondary to a pre-existing celiac disease, in our patient, latent celiac disease was diagnosed years after the onset of and therapy for Crohn's disease.

Inflammatory bowel disease in patients with celiac disease

BACKGROUND

Several case reports and series report an association between celiac disease and inflammatory bowel disease (IBD); however, there is no current data assessing this association. We therefore studied the occurrence of these conditions in a cohort of patients with celiac disease seen at a referral center.

METHODS

A database of patients with celiac disease seen between 1981 and 2002 was analyzed. Only biopsy-proven adults were included. Patients who had endoscopic and pathologic evidence of IBD were identified, and their pathology was reviewed. Age- and sex-adjusted prevalence rate ratios were determined by comparing results with population-based prevalence data.

RESULTS

Among 455 patients with celiac disease, IBD was identified in 10 (5 had ulcerative colitis and 5 had Crohn's disease). This represented an age- and sex-adjusted prevalence rate ratio for ulcerative colitis of 3.56 (95% confidence interval, 1.48-8.56) and for Crohn's disease of 8.49 (95% confidence interval, 3.53-20.42).

CONCLUSION

Within our cohort of patients with celiac disease, IBD was significantly more common than in the general population.

Scalloping of duodenal mucosa in Crohn's disease

Scalloping of the duodenal mucosal folds is an endoscopic finding of small bowel mucosal pathology that is generally due to villous atrophy. Though it can be seen in many disease processes, it is most commonly associated with celiac disease. We report three patients with scalloping of duodenal folds and histologic confirmation of villous atrophy due to Crohn's disease. All patients had negative celiac serologies and two had positive markers for Crohn's disease (anti-Saccharomyces cerevisiae antibodies). Patients had either ileitis or ileocolitis in addition to duodenal abnormalities. These cases illustrate that scalloping can occur in the duodenum in Crohn's disease.

Liver abnormalities in celiac disease

Celiac disease is an intolerance of the small bowel to gluten. Although most symptomatic patients have symptoms related to the gastrointestinal tract, many extra-intestinal manifestations have been described. A wide spectrum of hepatobiliary diseases have been described, including asymptomatic elevations of liver enzyme levels, nonspecific hepatitis, nonalcoholic fatty liver disease, and autoimmune and cholestatic liver disease. In addition, celiac disease may be the underlying cause of unexplained elevations of liver enzyme levels. Because most patients do not have overt gastrointestinal symptoms, a high index of suspicion is required. Moreover, in the majority of patients, liver enzyme levels will normalize on a gluten-free diet. We review the literature pertaining to hepatic abnormalities that may be seen in association with celiac disease. We also suggest an approach to the investigation and management of these patients.

IgA and IgG tissue transglutaminase antibody prevalence and clinical significance in connective tissue diseases, inflammatory bowel disease, and primary biliary cirrhosis

An association between celiac disease (CD) and other autoimmune diseases such as connective tissue diseases (CTD), inflammatory bowel diseases (IBD), and primary biliary cirrhosis (PBC) has been reported in several studies. However, a high rate of false positives in autoantibody testing was noted, especially when tissue transglutaminase (tTG) from guinea pig liver was used. Thus, the real prevalence of CD in CTD, IBD, and PBC is unclear. In a case-control study, 400 patients with CTD, 170 with IBD, 48 with PBC, and 120 healthy subjects were investigated for CD by the analysis of IgA and IgG tTG antibodies using the more specific human recombinant tTG immunoenzymatic assay. Patients and controls with positive findings were further tested for antiendomysial antibodies by indirect immunofluorescence and HLA typing, and those found positive by either of these tests underwent duodenal biopsy to confirm a possible diagnosis of CD. Twelve patients were positive for IgA or IgG tTG antibodies, showing an overall prevalence of 1.9%. Only 1 healthy subject (0.8%) had a low level positive reaction for IgA anti-tTG. Among the 12 patients and the healthy subject, only 2 (1 SLE and 1 ulcerative colitis patient) were subsequently confirmed to be affected with CD by positive EMA, HLA, and small bowel biopsy findings. The highest rate of false positives was found in PBC patients (10.4%). For these reasons, serological screening testing for CD is not recommended in CTD patients or in subjects affected with IBD or PBC, unless there is a relevant clinical suspicion of CD.

Recombinant Human Tissue Transglutaminase ELISA for the Diagnosis of Gluten-sensitive Enteropathy

Background: Tissue transglutaminase (TGc) has recently been identified as the major, if not the sole, autoantigen of gluten-sensitive enteropathy (GSE). We developed and validated an ELISA based on the human recombinant antigen and compared it to existing serological tests for GSE [guinea pig TGc ELISA and endomysium antibody (EMA) test].

Methods: Human TGc was expressed in the human embryonic kidney cell line 293-EBNA as a C-terminal fusion protein with the eight-amino acid Strep-tag II allowing one-step purification via streptavidin affinity chromatography. We carried out ELISA assays for IgA antibodies against TGc using calcium-activated human and guinea pig TGc. The sera were also tested on monkey esophagus sections by indirect immunofluorescence for IgA EMA. We examined 71 serum samples from patients with GSE (38 with celiac disease, 33 with dermatitis herpetiformis), including 16 on therapy, and 53 controls.

Results: The human TGc could be expressed and purified as an active enzyme giving a single band on a Coomassie-stained gel. The mean intra- and interassay CVs for the human TGc ELISA were 3.2% and 9.2%, respectively. The area under the ROC curve was 0.999. The specificity and sensitivity were 98.1% (95% confidence interval, 95.7–100%) and 98.2% (95.9–100%), respectively.

Conclusions: The human TGc ELISA was somewhat superior to the guinea pig TGc ELISA, and was as specific and sensitive as the EMA test. The human TGc-based ELISA is the method of choice for easy and noninvasive screening and diagnosis of GSE.

Simultaneous presentation of coeliac disease and ulcerative colitis in a child

Coeliac disease and inflammatory bowel disease (IBD) individually are not uncommon in children, but the occurrence of both conditions together is rare. The combined presentation of coeliac disease and IBD in a girl of 7 years is presented with a review of the related literature. The occurrence of coeliac disease with IBD should be considered at the time of diagnosis and at relapse, or where there is difficulty maintaining remission in established IBD. Screening with serum antibody tests may be helpful.

Antibody (IgG, IgA, and IgM) to baker's yeast (Saccharomyces cerevisiae), yeast mannan, gliadin, ovalbumin and betalactoglobulin in monozygotic twins with inflammatory bowel disease

To assess whether dietary antigens play a role in inflammatory bowel disease, 26 monozygotic twin pairs with inflammatory bowel disease and 52 healthy controls were investigated for serum antibodies (IgA, IgG, IgM) against ovalbumin, betalactoglobulin, gliadin, whole yeast (Saccharomyces cerevisiae) and yeast cell wall mannan. The twins were made up of five pairs concordant and nine pairs discordant for Crohn's disease, and two pairs concordant and 10 pairs discordant for ulcerative colitis. Two patients with Crohn's disease had a slight increase in disease activity, the others were in clinical remission. Two striking observations were made: first, individuals with ulcerative colitis were indistinguishable from healthy twins, and controls except for the response to gliadin. Both healthy and diseased twins had higher IgA levels to gliadin than controls. Second, twins who had developed Crohn's disease displayed higher antibody titres towards yeast cell wall mannan in particular, but also to whole yeast (Saccharomyces cerevisiae) of all antibody types (IgA, IgG, and IgM). In contrast, the response to gliadin, ovalbumin, and betalactoglobulin did not differ from healthy twins and was even lower than in the controls. The results argue against an increased systemic antigen presentation caused by an impaired mucosal barrier in the inflammatory bowel disease. Rather, they suggest that yeast cell wall material--that is, mannan, or some antigen rich in mannose and cross reacting with mannan, may play an aetiological role in Crohn's disease, but not in ulcerative colitis. The increases in IgA and IgM, as well as IgG suggest that local and systemic immune systems are selectively activated by antigen(s) present in the cell wall of baker's yeast.

Hepatic lesions in adult coeliac disease

In the period 1970 to 1987, 171 patients with small-intestinal mucosal atrophy have been hospitalized in our department. Of these, 132 patients fulfilled the diagnostic criteria of coeliac disease on the basis of histologic findings and clinical improvement on a gluten-free diet. Aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT), and alkaline phosphatase (ALP) were chosen as markers of hepatic involvement. Elevation above the normal range in one or more of these tests was seen in 62 patients (47.0%, group I). In 70 patients (53.0%, group II) of similar age the levels of these variables were normal. In group I, 14 (10.6%) patients had an elevation of ALP only, leaving 48 (36.4%) patients with pathologic values for one or both transaminases. In group I, 32 patients had their ASAT, ALAT, and ALP reexamined after at least 6 months of gluten-free diet. Among the patients with increased values of one or both transaminases 18 patients were tested before and at least 6 months after start of gluten-free diet. The variables were significantly reduced in all patients. Liver biopsies were performed in 37 patients, and findings were normal in 5. In 25 patients the changes were classified as non-specific. Chronic active hepatitis was demonstrated in five patients. In one of these patients primary sclerosing cholangitis and ulcerative colitis were also diagnosed. Concomitant malignant disease was found in 22 patients, of whom 16 had malignant lymphoma. Malignant disease was seen more often in group I than group II (p less than 0.01). In conclusion, liver lesions were found in a great proportion of the patients with coeliac disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Selective vitamin B12 malabsorption in adult coeliac disease. Report on three cases with associated autoimmune diseases

Three cases of adult coeliac disease with severe vitamin B12 deficiency not accompanied by folate or iron depletion are presented. Two of the patients had the extremely rare combination of coeliac disease and lack of intrinsic factor and autoimmune thrombocytopenic purpura. A close association between coeliac disease and autoimmunity is indicated by the development of autoimmune thyroiditis in the third patient. Vitamin B12 malabsorption caused by coeliac disease is emphasized as a pathogenetic mechanism of megaloblastic anaemia.

Adult coeliac disease within a defined geographic area in Sweden. A study of prevalence and associated diseases

An epidemiologic study of coeliac disease in a geographically defined area of Sweden showed that the prevalence was 95.5/10(5) inhabitants aged 15 years or more. The highest prevalence, 178/10(5) inhabitants, was found in the age group 65-74 years. The lowest prevalence, 39/10(5) inhabitants, was found in patients aged 15-24 years. Among the associated diseases an especially high incidence of associated thyroid disease was observed: thyrotoxicosis occurred in 5.0% and hypothyroidism in 5.8% of the patients.

Coeliac proctitis

An increased association of ulcerative colitis and coeliac disease has been reported, as have the results of several small-bowel biopsy studies in ulcerative colitis. Forty-two patients from a population of 438 patients with coeliac disease had rectal biopsies. Fourteen of these showed inflammation of various degrees of severity, including three compatible with a diagnosis of ulcerative colitis. The presenting complaint in 34 of these patients was diarrhoea or steatorrhoea. Twenty-seven patients had coeliac disease diagnosed at the same time or after their rectal biopsy. The other 15 were previously diagnosed coeliacs. Twelve of the 14 patients with abnormal rectal biopsy specimens were known to have subtotal/total villous atrophy at the time of rectal biopsy. Proctitis as seen in these coeliac patients had no unique features to differentiate it from proctitis caused by other disorders. The diarrhoea/steatorrhoea stopped in all patients on commencement of a gluten-free diet, except in those with ulcerative colitis. Proctitis is common in patients with coeliac disease presenting with diarrhoea/steatorrhoea. This study supports the finding of an increased association of coeliac disease and ulcerative colitis and is, to our knowledge, the first rectal biopsy study of a coeliac population.

Non-tropical sprue. Malignant diseases and mortality rate

The complications of non-tropical sprue were registered in 100 patients seen during an 18-year period. The patients had a significantly higher mortality than the age- and sex-matched general population. They had an increased incidence of malignancies, predominantly malignant lymphomas and carcinomas of the gastrointestinal tract. The disease must be considered a premalignant condition.