Celiac Disease: Diagnostic Standards and Dilemmas

The prevalence of obesity and underweight in celiac patients at the time of diagnosis: a systematic review and meta-analysis

BACKGROUND

This study aimed to estimate the prevalence of obesity, overweight, and underweight in celiac disease (CD) at diagnosis before starting the Gluten-free diet (GFD).

METHODS

A comprehensive search was conducted in PubMed, Embase, Scopus, and Web of Science until July 2024 to find the cross-sectional and longitudinal studies that measured the body mass index (BMI) in CD patients at diagnosis. The risk of bias assessment was conducted using the Newcastle-Ottawa Quality Assessment scale. Meta-regression analyses were applied to understand whether weight status is associated with CD.

RESULTS

A total of 23 studies involving 15,299 CD patients and 815,167 healthy individuals were included in this study. In newly diagnosed CD patients, pooled estimates of the prevalence of obesity, overweight, and underweight before GFD were 11.78%, 18.42%, and 11.04%, respectively. The prevalence of overweight and obesity in newly diagnosed CD patients increased from 22.15% in 2003-2009 to 32.51% in 2016-2021. Meta-regression analyses indicated that the CD patients with higher BMI had a higher mean age (p = 0.001), and female gender had a marginally significant (p = 0.055) association with higher BMI. Only a few CD patients were underweight at the time of diagnosis, and more patients were overweight/obese.

CONCLUSIONS

our meta-analysis demonstrated that only a few CD patients were underweight at the time of diagnosis, and almost 37% were overweight or obese. Meta-regression showed a significant association between higher BMI and higher mean age and female gender. A delay or failure for diagnosis of CD is more common in overweight/obese patients, resulting in more progression of the disease and counteracting any advantages of diagnosis.

Celiac disease - a pluripathological model in pediatric practice

Being defined as an autoimmune, chronic pathology, frequently encountered in any age group, but especially in pediatrics, celiac disease (also called gluten enteropathy), is gaining more and more ground in terms of diagnosis, but also interest in research. The data from the literature of the last decades attest the chameleonic way of its presentation, there may be both classic onset symptoms and atypical symptoms. Given the impact played by celiac disease, especially in the optimal growth and development of children, the current narrative review aims to highlight the atypical presentation methods, intended to guide the clinician towards the inclusion of the pathology in the differential diagnosis scheme. To these we add the summary presentation of the general data and therapeutic lines regarding the underlying condition and the existing comorbidities. In order to place the related information up to date, we performed a literature review of the recent articles published in international databases. We bring forward the current theories and approaches regarding both classic celiac disease and its atypical manifestations. Among these we note mainly constitutional, skin or mucous, bone, neuro-psychic, renal, reproductive injuries, but also disorders of biological constants and association with multiple autoimmunities. Knowing and correlating them with celiac disease is the key to optimal management of patients, thus reducing the subsequent burden of the disease.

Metabolomics and lipidomics signature in celiac disease: a narrative review

Celiac disease (CD) is a chronic immune-mediated inflammatory disease of the small intestine caused by aberrant immune responses to consumed gluten proteins. CD is diagnosed by a combination of the patients reported symptoms, serologic and endoscopic biopsy evaluation of the small intestine; and adherence to a strict gluten-free diet (GFD) is considered the only available therapeutic approach for this disorder. Novel approaches need to be considered for finding new biomarkers to help this disorder diagnosis and finding a new alternative therapeutic method for this group of patients. Metabolomics and lipidomics are powerful tools to provide highly accurate and sensitive biomarkers. Previous studies indicated a metabolic fingerprint for CD deriving from alterations in gut microflora or intestinal permeability, malabsorption, and energy metabolism. Moreover, since CD is characterized by increased intestinal permeability and due to the importance of membrane lipid components in controlling barrier integrity, conducting lipidomics studies in this disorder is of great importance. In the current study, we tried to provide a critical overview of metabolomic and lipidomic changes in CD.

Feasibility of a "No-Biopsy" Approach for the Diagnosis of Celiac Disease in Symptomatic Adults

Celiac disease (CD) is an immune-mediated enteropathy, caused by hypersensitivity to gluten in genetically predisposed individuals. The worldwide prevalence of CD has been estimated to be approximately 1%. Most guidelines for diagnosis of CD rely on a sequential approach, with serological testing of antibodies against tissue transglutaminase (tTG) as a first-line test, followed by a duodenal biopsy. However, GI biopsy is an invasive procedure with various complications. Hence, this study was planned to ascertain whether it could be possible to have a non-biopsy approach, using only serological markers to establish the diagnosis of CD in adults.

MATERIAL AND METHODS

It was a retrospective analysis of medical records of all biopsy-diagnosed CD patients with available anti-tTGA antibodies reports from 2019 to 2023. The patients were divided into three groups based on Marsh grading and anti-tTGA antibody levels were compared using various statistical tests.

RESULTS

A total of 94 biopsy-diagnosed symptomatic CD patients with anti-tTGA antibody reports available formed the study group. Of these, 54 had biopsy findings consistent with Marsh 3 lesion, three had Marsh 2 lesion, and 37 had Marsh 1 lesion. A significant correlation existed between Marsh grading 3 lesion and anti-tTGA antibody levels above the upper limit of normal (ULN) x 10.

CONCLUSION

Serum levels of anti-tTGA antibodies greater than 10 x ULN can be used to identify symptomatic patients with Marsh grade 3 CD lesions.

Clinical Features of Children With Serology Negative, Biopsy Positive Celiac Disease

The prevalence of pediatric serological negative celiac disease (SNCD) is poorly described, with few recognized clinical predictors beyond immunoglobulin A (IgA) deficiency or reduced gluten intake. The purpose of this retrospective review was to describe the prevalence of SNCD at the Stollery Children's Hospital and identify clinical features to help in recognition of these cases. Patients with a positive biopsy and negative serology (SNCD) were compared to those with positive biopsy and serology. SNCD diagnosis required clinical correlation and either confirmatory genetics or follow up endoscopy on a gluten-free diet. Of the 424 patients who met celiac disease (CD) criteria, 4.7% (n = 20) fulfilled our criteria for SNCD. There was a significant difference in the rates of IgA deficiency between the 2 groups, but no other clinical features were found that allowed for ready identification of SNCD patients.

Celiac disease in paediatric patients in the United Arab Emirates: a single-center descriptive study

Introduction

Celiac disease (CD) is an autoimmune disorder that is provoked by the consumption of gluten in genetically vulnerable individuals. CD affects individuals worldwide with an estimated prevalence of 1% and can manifest at any age. Growth retardation and anemia are common presentations in children with CD. The objective of this study is to estimate the prevalence of CD in multiple "at risk groups" and to characterize children with CD, presented to a tertiary hospital in Dubai, United Arab Emirates (UAE).

Methods

The study reviewed medical charts of all patients <18 years who had received serologic testing for CD. The study was conducted at Al Jalila Children's Specialty Hospital in Dubai, UAE, from January 2018 to July 2021. Extracted information from medical records included sociodemographics, laboratory findings, clinical presentation, and any associated co-morbidities. The European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) criteria were used to identify patients with CD.

Results

During the study period, 851 paediatric patients underwent serological screening for CD, out of which, 23 (2.7%) were confirmed with CD. Of the 23 patients diagnosed with CD, 43.5% had no gastrointestinal symptoms. Diabetes type 1 (30.4%) followed by iron deficiency anaemia (30%) and Hashimoto thyroiditis (9%) were the most commonly associated comorbidities. The prevalence of CD among paediatric patients with autoimmune thyroiditis (12.5%) was 1.92-times higher than that among paediatric patients with diabetes type 1 (6.5%).

Conclusion

The results of this study show that almost three out of every 100 paediatric patients who were screened for CD were confirmed to have the condition. These findings highlight the importance of screening children who are at risk or present symptoms suggestive of CD, to ensure early diagnosis and appropriate management.

Mode of presentation and performance of serology assays for diagnosing celiac disease: A single-center study in the United Arab Emirates

Objective

To characterize patients with celiac disease (CD), examines the clinical spectrum of CD, and evaluate the performance of serologic tests used for CD screening, in the United Arab Emirates (UAE).

Methods

Medical charts of patients received at the Digestive Diseases Institute of Cleveland Clinic Abu Dhabi from January 2015 to December 2020 were reviewed. Patients who were screened for four serologic biomarkers (anti-tissue transglutaminase IgA [Anti-tTG-IgA], anti-tissue transglutaminase IgG [Anti-TtG-IgG], anti-deamidated gliadin peptide IgG [Anti-DGP-IgG], and anti-deamidated gliadin peptide IgA [Anti-DGP-IgA]) were included. Histopathology was performed on patients with the seropositive test. Marsh score &gt; 1 considered to confirm CD. Characteristics of the Anti-tTG-IgA seropositive patients were described and that correlated with histopathologically confirmed CD were explored.

Results

Of the 6,239 patients, 1.4, 2.9, 4.7, and 4.9%, were seropositive to Anti-tTG-IgG, Anti-TtG-IgA, Anti-DGP-IgA, and Anti-DGP-IgG, respectively. Overall, 7.7% were seropositive to either of the four biomarkers. Of the biopsy-screened 300 patients, 38.7% (1.9% of the total serologically screened) were confirmed with CD. The mean age of Anti-TtG-IgA seropositive patients was 32.1 ± 10.3 SD years, 72% of them were females, and 93.4% were Emirati. In those patients, overweight (28.7%) and obesity (24.7%) were common while 5.8% of patients were underweight. Anemia prevalence was 46.7%, 21.3% had Gastroesophageal reflux disease (GERD), 7.7% with autoimmune thyroid disease, 5.5% (type 1), and 3.3% (type 2) were diabetic. Vitamin D deficiency was observed in 47.8% of the Anti-TtG IgA seropositive patients. Twelve (10.3%) histopathologically confirmed CD patients were seronegative to Anti-TtG-IgA but seropositive to anti-DGP-IgA and/or Anti-DGP-IgG. Body mass index, GERD, autoimmune thyroid disease, type 1 diabetes, asthma, hemoglobin, and vitamin D concentration, were all correlated with biopsy-confirmed CD (P &lt; 0.05). Compared to the gold-standard biopsy test, Anti-TtG-IgA had the highest sensitivity (89.7%) and specificity (83.7%).

Conclusion

Three and two of every 100 patients were serologically (anti-tTG-IgA positive) and histopathologically diagnosed with CD, respectively. Although Anti-TtG-IgA is the most sensitive, specific, and commonly used test, one of every ten histopathologically confirmed patients and Anti-tTG-IgA seronegative were seropositive to Anti-DGP. To avoid missing patients with CD, a comprehensive serological investigation covering DGP-IgG/IgA is warranted.

Prevalence of celiac disease in China: Meta-analysis and serological survey in high-risk populations

OBJECTIVE

To summarize data from a serological survey of high-risk populations in Guangdong Province, China, and to perform a meta-analysis to investigate the prevalence and seroprevalence of celiac disease (CD) in the Chinese general and high-risk populations.

METHODS

We collected data from the serological survey of high-risk population of CD in Guangdong Province, China (N = 1390) by testing their serum tissue transglutaminase immunoglobulin A (tTG-IgA), deamidated gliadin peptides immunoglobulin A (DGP-IgA) and deamidated gliadin peptides immunoglobulin G (DGP-IgG). Additionally, a literature search was performed on PubMed, EMBASE, Cochrane Library and three Chinese databases for articles published up to 20 December 2020 to estimate the pooled prevalence and seroprevalence of CD in China.

RESULTS

In the serological survey, 0.94% (13/1390) of individuals were positive for CD antibodies. In a meta-analysis of 18 studies, the seroprevalence of CD in the general Chinese population was 0.27% (95% confidence interval [CI] 0.02%-0.71%). While that in the high-risk population was 8.34% (95% CI 4.90%-12.54%) (odds ratio 7.27, 95% CI 4.06-13.04). The prevalence of biopsy-confirmed CD in high-risk Chinese populations was 4.44% (95% CI 1.53%-8.58%). The seroprevalence of CD varied with patients' geographical origin, being higher in northern China than in southern China.

CONCLUSIONS

Early diagnosis of CD by serological screening in high-risk population and generous serological testing in those with vague symptoms, especially in northern China, are recommended.

Wheat/Gluten-Related Disorders and Gluten-Free Diet Misconceptions: A Review

In the last 10,000 years, wheat has become one of the most important cereals in the human diet and today, it is widely consumed in many processed food products. Mostly considered a source of energy, wheat also contains other essential nutrients, including fiber, proteins, and minor components, such as phytochemicals, vitamins, lipids, and minerals, that together promote a healthy diet. Apart from its nutritional properties, wheat has a set of proteins, the gluten, which confer key technical properties, but also trigger severe immune-mediated diseases, such as celiac disease. We are currently witnessing a rise in the number of people adhering to gluten-free diets unwarranted by any medical need. In this dynamic context, this review aims to critically discuss the nutritional components of wheat, highlighting both the health benefits and wheat/gluten-related disorders, in order to address common misconceptions associated with wheat consumption.

Iron Deficiency and the Small bowel​

PURPOSE OF REVIEW

This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options.

RECENT FINDINGS

Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.

Multidimensional Disadvantages of a Gluten-Free Diet in Celiac Disease: A Narrative Review

A gluten-free diet is the mainstay method of treatment and the prevention of celiac disease complications. However, an inadequately balanced gluten-free diet can increase the risk of obesity, negatively affect glucose and lipid metabolism, and increase the risk of the metabolic syndrome. Therefore, an adequate nutritional counselling is necessary for patients diagnosed with celiac disease in order to prevent and treat the components of the metabolic syndrome.

Best practices of handling, processing, and interpretation of small intestinal biopsies for the diagnosis and management of celiac disease: A joint consensus of Indian association of pathologists and microbiologists and Indian society of gastroenterology

The Indian Association of Pathologists and Microbiologists (IAPM) and Indian Society of Gastroenterology (ISG) decided to make a joint consensus recommendation for handling, processing, and interpretation of SI biopsies for the diagnosis and management of celiac disease (CD) recognizing the inhomogeneous practice of biopsy sampling, orientation, processing, and interpretation. A modified Delphi process was used to develop this consensus document containing a total of 42 statements and recommendations, which were generated by sharing the document draft, incorporating expert's opinion, followed by three cycles of electronic voting as well as a full-day face-to-face virtual ZOOM meeting and review of supporting literature. Of the 42 statements, 7 statements are on small intestinal (SI) biopsy in suspected patients of CD, site and the number of biopsies; 7 on handling, fixative, orientation, processing, and sectioning in pathology laboratories; 2 on histological orientation; 13 statements on histological interpretation and histological grading; 3 on the assessment of follow-up biopsies; 2 statements on gluten-free diet (GFD)-nonresponsive CD; 4 on challenges in the diagnosis of CD; 2 statements each on pathology reporting protocol and training and infrastructure in this area. The goal of this guideline document is to formulate a uniform protocol agreed upon both by the experienced pathologists and gastroenterologists to standardize the practice, improve the yield of small bowel biopsy interpretation, patients' compliance, overall management in CD, and generate unified data for patient care and research in the related field.

The Predictive Value of Serum Cytokines for Distinguishing Celiac Disease from Non-Celiac Gluten Sensitivity and Healthy Subjects

Background

It has been established that the level of some inflammatory cytokines increases in celiac disease (CD) and non-celiac gluten sensitivity (NCGS) in comparison with healthy subjects. Therefore, the primary interest in our research was proposing an accurate tool to diagnose patients with CD and NCGS from healthy individuals in an Iranian population.

Methods

The serum samples were examined in 171 participants, including 110 CD patients, 46 healthy individuals, and 15 NCGS. The commercial ELISA kits were used to detect the level of the following cytokines: IL-1, IL-6, IL-8, IL-15, and IFN-γ. The receiver operating characteristic (ROC) curve analysis was applied to determine the optimal thresholds for high sensitivity, specificity, positive and negative predictive values of cytokines, as the indicators of CD, NCGS, and healthy control groups.

Results

In NCGS group, the values of area under the ROC curve for IL-1, IL-8, and IFN-γ were 71%, 78%, and 70%, respectively. To differentiate the CD and NCGS groups from the control group, IL-15 had the highest sensitivity (82.70%), specificity (56.50%), positive predictive value (81.98%), and negative predictive value (57.78%), followed by IL-8 with the highest sensitivity of 74.50%, specificity of 73.30%, and positive and negative predictive values of 95.35% and 30.21%, respectively.

Conclusion

The obtained results demonstrate that IL-15 and IL-8 could be proposed as potential markers in their optimal cut-off points for distinguishing CD from the NCGS and the healthy control. Based on our findings, the evaluation of cytokine levels can be recommended as a useful tool for the diagnosis of CD and NCGS in a clinical practice.

An updated overview of spectrum of gluten-related disorders: clinical and diagnostic aspects

The incidence of gluten-related disorders (GRDs) continues to increase and its global prevalence is estimated at approximately 5% of the population. Celiac disease (CD), dermatitis herpetiformis (DH), gluten ataxia (GA), wheat allergy (WA), and non-celiac gluten sensitivity (NCGS) are the five major GRDs that present with a wide range of clinical manifestations. The diagnosis of GRDs can be challenging because the typical and atypical clinical manifestations of the GRDs overlap. In this review, the current definitions of gluten-related disorders, focusing on their clinical features, diagnostic and therapeutic approaches are presented. We concluded that GRDs are usually diagnosed using a combination of clinical features, serological tests, and histopathological findings. Treatment usually involves dietary modification.

Diagnostic accuracy of a fully automated multiplex celiac disease antibody panel for serum and plasma

Background

An automated multiplex platform using capillary blood can promote greater throughput and more comprehensive studies in celiac disease (CD). Diagnostic accuracy should be improved using likelihood ratios for the post-test probability of ruling-in disease.

Methods

The Ig_plex™ Celiac Disease Panel on the sqidlite™ automated platform measured IgA and IgG antibodies to tTG and DGP in n = 224 CD serum or plasma samples. Diagnostic accuracy metrics were applied to the combined multiplex test results for several CD populations and compared to conventional single antibody ELISA tests.

Results

With multiple positive antibody results, the post-test probability for ruling-in untreated and treated CD increased to over 90%. The number of samples positive for more than one antibody also increased in untreated CD to ≥90%. Measurement of all four CD antibodies generate cut-off dependent accuracy profiles that can monitor response to treatment with the gluten-free diet (GFD). Higher positive tTG and DGP antibodies are seen more frequently in confirmed CD without (81%–94%) than with GFD treatment (44%–64%). In CD lacking biopsy confirmation, overall agreement of plasma to serum was ≥98% for all antibodies, and 100% for venous to capillary plasma.

Conclusions

The Ig_plex Celiac Disease Panel increases the likelihood of confirming CD based on the post-test probability of disease results for multi-reactive markers. Specific positivity profiles and cut-off intervals can be used to monitor GFD treatment and likely disease progression. Using serum, venous and capillary plasma yield comparable and accurate results.

Serologic Diagnosis of Celiac Disease: New Biomarkers

Most patients affected by celiac disease (CD) are asymptomatic or hyposymptomatic and undiagnosed, and are at risk of preventable complications. Therefore, early diagnosis is highly recommended. Multiple diagnostic antibodies are available; the most frequently used is IgA to tissue transglutaminase (IgA-tTg). It may yield false results and, alone, does not address IgA deficiency. Recently, a new generation of anti-neo-epitope tTg check (IgG + IgA) has become available. It is highly sensitive and specific, covers IgA-deficient patients with CD, reflects intestinal damage, and has predictive potential in the diagnosis of CD.