Coeliac proctitis

Association Between Inflammatory Bowel Diseases and Celiac Disease: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

There is controversy over the association between celiac disease (CeD) and inflammatory bowel diseases (IBD). We performed a systematic review and meta-analysis to assess evidence for an association between CeD and IBD.

METHODS

We searched databases including MEDLINE, EMBASE, CENTRAL, Web of Science, CINAHL, DARE, and SIGLE through June 25, 2019 for studies assessing the risk of CeD in patients with IBD, and IBD in patients with CeD, compared with controls of any type. We used the Newcastle-Ottawa Scale to evaluate the risk of bias and GRADE to assess the certainty of the evidence.

RESULTS

We identified 9791 studies and included 65 studies in our analysis. Moderate certainty evidence found an increased risk of CeD in patients with IBD vs controls (risk ratio [RR] 3.96; 95% confidence interval [CI] 2.23-7.02) and increased risk of IBD in patients with CeD vs controls (RR 9.88; 95% CI 4.03-24.21). There was low-certainty evidence for the risk of anti-Saccharomyces antibodies, a serologic marker of IBD, in patients with CeD vs controls (RR 6.22; 95% CI 2.44-15.84). There was low-certainty evidence for no difference in risk of HLA-DQ2 or DQ8 in patients with IBD vs controls (RR 1.04; 95% CI 0.42-2.56), and very low-certainty evidence for an increased risk of anti-tissue transglutaminase in patients with IBD vs controls (RR 1.52; 95% CI 0.52-4.40). Patients with IBD had a slight decrease in risk of anti-endomysial antibodies vs controls (RR 0.70; 95% CI 0.18-2.74), but these results are uncertain.

CONCLUSIONS

In a systematic review and meta-analysis, we found an increased risk of IBD in patients with CeD and increased risk of CeD in patients with IBD, compared with other patient populations. High-quality prospective cohort studies are needed to assess the risk of CeD-specific and IBD-specific biomarkers in patients with IBD and CeD.

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.

Diagnosis and Management of Microscopic Colitis

Microscopic colitis (MC) is a relatively common cause of chronic watery diarrhea, especially in older persons. Associated symptoms, including abdominal pain and arthralgias, are common. The diagnosis is based upon characteristic histological findings in the presence of diarrhea. The two types of MC, collagenous and lymphocytic colitis, share similar clinical features, with the main difference being the presence or absence of a thickened subepithelial collagen band. There are several treatment options for patients with MC, although only budesonide has been well studied in multiple controlled clinical trials. This review will describe the clinical features, epidemiology, pathophysiology, diagnostic criteria, and treatment of patients with MC.

The Watery Diarrhea-Colitis Syndrome

Collagenous and lymphocytic/microscopic colitis represent a distinct histopathologic spectrum of findings, with occasional transition, observed in patients with normal or near-normal colonoscopic findings and chronic watery diarrhea (watery diarrhea- colitis syndrome). Biopsies are characterized by surface epithelial damage, an increased number of chronic inflamatory cells in the lamina propria, intraepithelial lymphocyto sis, intact crypt architecture, and in the cases of collagenous colitis, a thickened subepi thelial collagen layer (SCL). While their precise interrelationship is unclear, as their clinicopathologic similarities far outweigh their differences, it appears reasonable for pathologists and clinicians to consider them conceptually together as part of a syn drome of chronic watery diarrhea and colitis distinct from other forms of chronic inflammatory bowel disease. The etiology and pathogenesis of this syndrome are un clear. Colorectal surface epithelial damage appears to be for the most part responsible for the secretory diarrhea, while the thickened SCL appears to be a variable response to the surface epithelial damage. Why the thickened SCL occurs only in some cases, why it does not occur in other forms of colitis, and whether it functions as a diffusion barrier are unknown. The propensity of the watery diarrhea-colitis syndrome to pref erentially affect middle-aged and elderly women, an association with autoimmune disorders, and clinicopathologic similarities to celiac disease suggest that host immune factors are important. Other dietary factors, medications, or other agents may also play a role, and this is currently under investigation. Small bowel villous atrophy appears to account for the presence of steatorrhea noted in some reports. Definitive diagnosis is facilitated by the procurement of multiple, well-oriented biopsies, prefera bly extending at least into the proximal left colon. A thickened SCL occasionally can only be demonstrated in biopsies from the right colon. An appreciation of the normal variation found in colorectal biopsies and recognition of artifactual thickening of the subepithelial basement membrane in maloriented sections and in relation to bowel preparation will eliminate overdiagnosis of normal biopsies, while the absence of fea tures typical for other forms of inflammatory bowel disease facilitates differential diag nosis. Patients may respond dramatically to therapeutic intervention with drugs often used for ulcerative colitis and Crohn's disease, however, spontaneous remissions are well documented. A colitis-dysplasia-carcinoma sequence has not as yet been docu mented to occur in this patient population. In just over one decade the morphologic features of the watery diarrhea-colitis syndrome have come to be recognized. Hope fully, the next decade of observation and investigation will help to clarify the precise relationship between cases with and without a thickened SCL, as well as the etiology and pathogenesis of the secretory diarrhea. Int J Surg Pathol 1 (1): 65-82, 1993

Review article: Microscopic colitis--lymphocytic, collagenous and 'mast cell' colitis

BACKGROUND

Microscopic colitis is a relatively common cause of chronic diarrhoea in predominantly older adults, traditionally termed lymphocytic colitis and collagenous colitis. Increased mast cells found in the colonic biopsies of some patients with chronic diarrhoea may represent a distinct type of microscopic colitis.

AIM

To provide an updated review of the epidemiology, diagnosis and treatment of microscopic colitis, and to discuss the role of mast cells in the gastrointestinal tract and their potential role in cases of functional diarrhoea.

METHOD

A MEDLINE literature search was performed to identify pertinent articles. Relevant clinical abstracts were also reviewed.

RESULTS

Incidence rates of microscopic colitis (lymphocytic and collagenous colitis) have increased over time, to levels comparable with other forms of inflammatory bowel disease. The possibility of drug-induced microscopic colitis and concomitant coeliac sprue are important considerations when evaluating these patients. There are few controlled treatment trials in microscopic colitis, with much of the data on treatment coming from retrospective studies. Mast cells have been implicated in functional bowel disorders, with increased mast cells possibly contributing to cases of otherwise unexplained chronic diarrhoea, although this concept requires further investigation.

CONCLUSIONS

In patients with microscopic colitis, a systematic approach to therapy often leads to satisfactory control of symptoms. The role of mast cells in chronic diarrhoea represents an evolving field, with the potential to offer alternative treatment pathways in patients with otherwise unexplained functional diarrhoea.

Microscopic colitis

Microscopic colitis is a common cause of chronic watery diarrhea, especially among older persons. Diagnosis requires histologic analysis of colon biopsy samples in the appropriate clinical setting. Recent studies have shown an increase in the incidence of microscopic colitis, and several have addressed potential mechanisms. We review recent findings about the clinical features, diagnosis, epidemiology, pathophysiology, and treatment of microscopic colitis.

Fecal calprotectin concentration in celiac disease

GOALS

We aimed to determine fecal calprotectin (FC) concentration and its relation with histopathologic findings of children with celiac disease (CD) and to observe the probable alterations under gluten-free diet (GFD).

BACKGROUND

As FC is regarded as a marker of inflammation in the gastrointestinal tract, we hypothesized that it might be increased in untreated CD.

STUDY

The study included 29 newly diagnosed patients with CD (mean age: 6.6+/-0.6 y) and sex and age-matched 10 healthy children. All of the children with CD admitted to the hospital were classical form who has chronic diarrhea and failure to thrive. The degree of mucosal damage was graded according to the modified Marsh criteria. FC concentration was determined by enzyme-linked immunosorbent assay method on admission and after 1 year of GFD.

RESULTS

Mean FC concentration of children with CD on admission and of healthy children were 13.40+/-8.5 and 4.3+/-3.3 mg/L, respectively (P=0.004). FC concentration under GFD was 4.6+/-2.7 mg/L and there was a significant statistical difference between untreated patients and those under GFD for 1 year (P=0.001). There was no statistical difference between FC concentration of those under GFD and healthy children (P=0.8). Mean FC concentrations of children with total-villous atrophy and partial-villous atrophy were significantly different (13.8+/-9.3 mg/L vs. 3.7+/-1.8 mg/L, P=0.005).

CONCLUSIONS

It was found that FC concentration is increased in childhood CD, related to the severity of histopathologic findings and responsive to GFD. The pathogenetic mechanism by which FC is increased in CD should be investigated in further studies.

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.

Microscopic colitis: an update

Microscopic colitis is an increasingly common cause of chronic diarrhea, and often causes abdominal pain and weight loss. The colonic mucosa appears normal or nearly normal endoscopically, and the diagnosis is made in the appropriate clinical setting when there is intraepithelial lymphocytosis and a mixed lamina propria inflammatory infiltrate. The 2 subtypes, collagenous and lymphocytic colitis, are similar clinically and histologically, and are distinguished by the presence or absence of a thickened subepithelial collagen band. Many potential pathophysiologic mechanisms have been proposed, but no convincing unifying mechanism has been identified. There are many anecdotal reports on treatment, but few controlled trials have been performed in these patients, although a systematic approach to therapy often leads to the satisfactory control of symptoms.

Microscopic colitis: a review

Microscopic colitis is a relatively common cause of chronic watery diarrhea, often accompanied by abdominal pain and weight loss. The colonic mucosa appears normal grossly, and the diagnosis is made when there is an intraepithelial lymphocytosis and a mixed inflammatory infiltrate in the lamina propria. The two main subtypes, collagenous and lymphocytic colitis, are similar clinically and histologically, distinguished by the presence or absence of a thickened subepithelial collagen band. Many potential pathophysiological mechanisms have been described, although none have been conclusively proved. There is a paucity of randomized treatment trials in these patients, although a rational approach to therapy often leads to satisfactory control of symptoms.

The histologic spectrum and clinical outcome of refractory and unclassified sprue

The vast majority of patients with celiac disease respond to a gluten-free diet; yet, a small number of refractory patients do not respond and have persistent malabsorption and residual mucosal abnormalities of the small intestine. The histologic features of refractory/unclassified sprue have been published as case reports, often without long-term follow up, and no clear histologic picture has emerged. We present the results of a long-term study of the clinical and histologic features of 10 patients with refractory/unclassified sprue. The histologic features of small bowel biopsies in this group of patients were compared with those of 10 patients with responsive celiac disease and with 10 patients without malabsorption who had normal duodenal biopsies. Five of the 10 refractory patients ultimately developed collagenous sprue as a distinct histologic marker of refractory disease. Additional distinctive findings found in small bowel biopsies in the refractory group were subcryptal chronic inflammation (10 of 10) and marked mucosal thinning in three patients. Other nonspecific findings included acute inflammation and gastric metaplasia. One patient with collagenous sprue developed a B-cell lymphoma of the ileum, and in general collagenous sprue was associated with a poor prognosis. Two of five patients died whereas two others require total parenteral nutrition for survival. Pathologists evaluating small bowel biopsies in the setting of malabsorption should be aware of the subtle histologic changes described here that may portend a refractory course.

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.

Colonic histopathology in untreated celiac sprue or refractory sprue: is it lymphocytic colitis or colonic lymphocytosis?

Colonic histopathology in some patients with untreated celiac sprue and refractory sprue has been said to be indistinguishable from lymphocytic colitis, but there have been no objective comparisons on which this is based. The purpose of this study was to determine the prevalence and to characterize the nature of colonic histopathology at the time of diagnosis in patients with celiac or refractory sprue. Colonoscopic biopsy specimens obtained at the time of diagnosis from 16 patients with celiac sprue, six patients with refractory sprue, nine patients with lymphocytic colitis, and five normal controls were analyzed blindly by histological and morphometric methods, quantitating the number and specific subtypes of inflammatory cells within the lamina propria and epithelium. Immunoperoxidase staining of intraepithelial lymphocytes with a monoclonal antibody to CD8 also was performed. Three of 16 patients with untreated celiac sprue (19%) were thought to have colonic histological abnormalities, which by morphometry consisted of slightly increased numbers of lymphocytes in the surface epithelium and lamina propria, many of which were CD8-positive. These abnormalities were distinguishable from lymphocytic colitis by the lack of increased overall lamina propria cellularity and surface epithelial abnormalities, and by fewer intraepithelial lymphocytes. In refractory sprue, colonic histological abnormalities were more frequent than in celiac sprue, occurring in four of six patients (67%), more pronounced, and identical to those in the lymphocytic colitis syndrome. However, colonic intraepithelial lymphocytes in lymphocytic colitis were mostly CD8-positive, whereas those in the colitis of refractory sprue rarely were. Mild colonic lymphocytosis in patients with untreated celiac sprue should be distinguished from lymphocytic colitis by the lack of surface epithelial abnormalities, the lack of increased cellularity of the lamina propria, and the lack of ongoing watery diarrhea after treatment with a gluten-free diet. In contrast, colonic histopathology in refractory sprue is indistinguishable from lymphocytic colitis, although immunohistochemical differences do exist.

T-cell responses and cellular immunity in coeliac disease

Increasing evidence points to a direct role for T cells in the mediation of the coeliac intestinal lesion. There is good evidence for increased local T-cell reactivity, manifest as increased in T-cell activation in the lamina propria and T-cell proliferation in the epithelial compartment. A likely scenario is that gluten elicits antigen-specific responses by lamina propria T helper cells, probably of the Th1 (inflammatory-mediator) subtype, leading to secretion of pro-inflammatory cytokines. Such cytokines may have direct effects on intestinal enterocytes, as well as mediating indirect effects by upregulation of MHC antigens and by enhancing the activity of cytolytic T cells. Although gluten-specific IEL responses have not been demonstrated by intraepithelial T lymphocytes (IELs), increasing evidence suggests that IELs can act as cytolytic effector cells and hence are likely to exert enteropathic effects under the influence of pro-inflammatory cytokines.

Morphometric analysis of intestinal mucosa. V. Quantitative histological and immunocytochemical studies of rectal mucosae in gluten sensitivity

To study changes in rectal mucosa that might be attributable to the effects of gluten, rectal biopsy specimens from untreated and treated gluten sensitised subjects were analysed morphometrically and by immunohistochemical techniques and were compared with a series of disease control mucosae. Although morphometry showed increased populations of plasma cells, lymphocytes, and mast cells in the mucosae of untreated patients, which were reduced (except for mast cells) by dietary gluten restriction, immunohistochemical techniques were far more sensitive in defining these changes. There were highly significant increases in CD3+ and gamma delta+ lymphocytes within both the lamina propria and the epithelium while neutrophils (CD15+ cells) were not at all prominent. Activated (CD25+) lymphocytes expressing interleukin (IL)-2 receptors were increased in lamina propria, usually subjacent to basal lamina, although a few IL-2R+ intraepithelial lymphocytes were found: other IL-2R+ cells were deemed to be macrophages (CD68+). These results clearly indicate that in untreated, gluten sensitised subjects the rectal mucosa shows a lymphoplasmacytoid reaction that is responsive to gluten restriction. The absence of neutrophilia suggests that this lesion is not a conventional inflammatory type proctitis, but rather one presumed to be induced by gluten antigen(s) present in the faecal stream--that is, a cell mediated form of response.

Collagenous colitis: jejunal and colorectal pathology

AIMS

To determine: (1) whether there is an association between collagenous colitis and coeliac disease or lymphocytic colitis; (2) the distribution of lymphocyte subsets and macrophages in the lamina propria and surface epithelial layer in collagenous colitis; and (3) the colorectal distribution of the disease and whether a mucosal biopsy specimen, using a flexible sigmoidoscope, is sufficient to diagnose it.

METHODS

The clinical data and colorectal biopsy specimens from 38 patients with collagenous colitis were studied. In 10, small bowel biopsy specimens were also available for review. Immunostaining of the mucosal lymphoid infiltrate with a panel of relevant antibodies was carried out on formalin fixed tissue in seven cases; in three the phenotyping was performed on fresh biopsy specimens separately frozen or fixed in B5 solution.

RESULTS

Coeliac disease was found in four out of the 10 patients with collagenous colitis who had had a small bowel biopsy, in contrast to the prevalence of the disease in Australia of 1 in 3000. Collagenous colitis did not respond to gluten withdrawal. Five of 29 (17%) of the patients had a mixed pattern of lymphocytic and collagenous colitis. Immunostaining of the lymphoid infiltrate showed that the striking increase in intraepithelial lymphocytes in collagenous colitis was due to an influx of CD8 positive cells. The occurrence and severity of collagenous colitis along the large bowel were independent of the anatomical site, and in more than 90% of cases biopsy specimens from the sigmoid colon or rectum were diagnostic.

CONCLUSIONS

There is a very high incidence of coeliac disease among patients with collagenous colitis so that jejunal biopsy should be an essential part of their investigations, especially if symptoms persist. However, only a minority showed a mixed pattern of lymphocytic and collagenous colitis. The intraepithelial lymphocytes in collagenous colitis are CD8 positive cells. Collagenous colitis can be diagnosed from rectal or sigmoid colon biopsy specimens in more than 90% of cases.

Colonic lymphocytosis in patients with celiac sprue

We examined colonic biopsies from 39 patients with clinical and small bowel biopsy changes of celiac sprue. In 12 of 39 patients (31%), striking lymphocytic infiltration of the superficial colonic epithelium and chronic inflammation of the lamina propria were identified. These 12 cases had a mean of 30.4 lymphocytes per 100 superficial colonic epithelial cells, compared with means of 8.4 in sprue cases without colonic epithelial lymphocytosis, 4.8 in normal controls, and 32.4 in nine cases of lymphocytic colitis without concurrent celiac sprue. No case showed subepithelial collagen layer thickening. Four patients with celiac sprue and colonic lymphocytosis also had gastric biopsies; two showed gastric lymphocytosis. Intraepithelial lymphocytes at all sites were positive for the T-cell marker MT-1. These findings indicate that sprue-associated colonic lymphocytosis and lymphocytic colitis are histologically, quantitatively, and immunohistochemically indistinguishable, that the epithelial T-cell infiltration of celiac sprue occurs in glandular mucosa at all levels of the gastrointestinal tract, and that colonic subepithelial collagen deposition in patients with celiac sprue is an infrequent occurrence. These findings also suggest that gastrointestinal epithelial T-cell infiltration may be an immunologic response that is common in individuals sensitized to absorbed lumenal antigens, and that colonic lymphocytosis may occur as a response to a number of antigens, including gluten.