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Shiha MG, Oka P, Nandi N, Ingham K, Raju SA, Penny HA, Elli L, Sanders DS, Sidhu R. Role of capsule endoscopy and double-balloon enteroscopy in the management of adult patients with coeliac disease and persisting symptoms. Dig Liver Dis 2024:S1590-8658(24)00881-8. [PMID: 39095248 DOI: 10.1016/j.dld.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 07/13/2024] [Accepted: 07/16/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Small bowel capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are recommended for the management of patients with nonresponsive or refractory coeliac disease (CD). However, there is a paucity of data regarding the clinical profiles and outcomes of patients undergoing these investigations. METHODS We conducted a retrospective analysis of two databases of adult patients with CD who underwent CE and/or DBE between 2017 and 2022 at the National Centre for Refractory CD in England. Patient demographic, clinical and endoscopic data were collected, and clinically relevant outcomes were reported. RESULTS A total of 132 patients (median age 53 years, 64.4 % female) underwent 146 CEs and 25 DBEs. The most common symptoms were diarrhoea (51.5 %), abdominal pain (37.8 %), bloating (34.8 %), and weight loss (29.5 %). The overall detection rate of CE and DBE was 87.6 % and 92 %, respectively. Following CE and DBE, 14 patients (10.6 %) were diagnosed with CD-related complications such as ulcerative jejunitis, strictures and malignancy. Seven patients (5.3 %) died during follow-up, with five of these deaths directly attributed to CD. Older age, weight loss and anaemia were associated with poor outcomes. CONCLUSIONS The sequential approach of CE and DBE identified CD-related complications in almost 1 in 10 patients with nonresponsive or refractory CD. Older patients with persistent villous atrophy, weight loss and anaemia require close monitoring to help with the early diagnosis and management of complications.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK.
| | - Priya Oka
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Nicoletta Nandi
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy
| | - Katerina Ingham
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Reena Sidhu
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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2
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Tye‐Din JA. Evolution in coeliac disease diagnosis and management. JGH Open 2024; 8:e13107. [PMID: 38957478 PMCID: PMC11217771 DOI: 10.1002/jgh3.13107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/04/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
The traditional gut-centric view of coeliac disease is evolving as immune and genetic insights underscore the central importance of a systemic, T cell immune response to gluten in disease pathogenesis. As the field increasingly recognize the limitations of small intestinal histology as the diagnostic standard, data supporting the accuracy of an immune (serologic) diagnosis of coeliac disease - well demonstrated in children - are growing for adults. Novel biomarkers such as interleukin-2 that identify the gluten-specific T cell demonstrate high sensitivity and specificity for coeliac disease and offer the potential for a diagnostic approach that avoids the need for gluten challenge. Asymptomatic disease and manifestations outside the gut pose considerable challenges for diagnosis using a case-finding strategy and enthusiasm for population screening is growing. The gluten-free diet remains a highly restrictive treatment and there is a paucity of controlled data to inform a safe gluten intake threshold. Ongoing symptoms and enteropathy are common and require systematic evaluation. Slowly-responsive disease is prevalent in the older patient diagnosed with coeliac disease, and super-sensitivity to gluten is an emerging concept that may explain many cases of nonresponsive disease. While there is great interest in developing novel therapies for coeliac disease, no drug has yet been registered. Efficacy studies are generally assessing drugs in patients with treated coeliac disease who undergo gluten challenge or in patients with nonresponsive disease; however, substantial questions remain around specific endpoints relevant for patients, clinicians and regulatory agencies and optimal trial design. Novel immune tools are providing informative readouts for clinical trials and are now shaping their design.
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Affiliation(s)
- Jason A Tye‐Din
- Immunology DivisionWalter and Eliza Hall InstituteParkvilleVictoriaAustralia
- Department of Medical BiologyUniversity of MelbourneParkvilleVictoriaAustralia
- Department of GastroenterologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia
- Centre for Food & Allergy ResearchThe Murdoch Children's Research InstituteParkvilleVictoriaAustralia
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3
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Perez-Junkera G, Ruiz de Azua L, Vázquez-Polo M, Lasa A, Fernandez Gil MP, Txurruka I, Navarro V, Larretxi I. Global Approach to Follow-Up of Celiac Disease. Foods 2024; 13:1449. [PMID: 38790748 PMCID: PMC11119929 DOI: 10.3390/foods13101449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/17/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Celiac disease, an autoimmune disorder induced by the ingestion of gluten, affects approximately 1.4% of the population. Gluten damages the villi of the small intestine, producing symptoms such as abdominal pain, bloating and a subsequent loss of nutrient absorption, causing destabilization of the nutritional status. Moreover, gluten can trigger extra intestinal symptoms, such as asthma or dermatitis, but also mental disorders such as depression or anxiety. Moreover, people suffering from celiac disease sometimes feel misunderstood by society, mainly due to the lack of knowledge about the disease and the gluten-free diet. Thus, the treatment and follow-up of patients with celiac disease should be approached from different perspectives, such as the following: (1) a clinical perspective: symptomatology and dietary adherence monitorization; (2) nutritional assessment: dietary balance achievement; (3) psychological assistance: mental disorders avoidance; and (4) social inclusion: educating society about celiac disease in order to avoid isolation of those with celiac disease. The aim of this narrative review is to gain deep insight into the different strategies that currently exist in order to work on each of these perspectives and to clarify how the complete approach of celiac disease follow-up should be undertaken so that the optimum quality of life of this collective is reached.
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Affiliation(s)
- Gesala Perez-Junkera
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain; (G.P.-J.); (L.R.d.A.); (M.V.-P.); (M.P.F.G.); (I.T.); (V.N.); (I.L.)
- Children’s National Hospital 111 Michigan Avenue NW, Washington, DC 20010, USA
- Bioaraba, Nutrición y Seguridad Alimentaria, 01006 Vitoria-Gasteiz, Spain
| | - Lorea Ruiz de Azua
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain; (G.P.-J.); (L.R.d.A.); (M.V.-P.); (M.P.F.G.); (I.T.); (V.N.); (I.L.)
| | - Maialen Vázquez-Polo
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain; (G.P.-J.); (L.R.d.A.); (M.V.-P.); (M.P.F.G.); (I.T.); (V.N.); (I.L.)
- Bioaraba, Nutrición y Seguridad Alimentaria, 01006 Vitoria-Gasteiz, Spain
| | - Arrate Lasa
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain; (G.P.-J.); (L.R.d.A.); (M.V.-P.); (M.P.F.G.); (I.T.); (V.N.); (I.L.)
- Bioaraba, Nutrición y Seguridad Alimentaria, 01006 Vitoria-Gasteiz, Spain
| | - María Pilar Fernandez Gil
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain; (G.P.-J.); (L.R.d.A.); (M.V.-P.); (M.P.F.G.); (I.T.); (V.N.); (I.L.)
| | - Itziar Txurruka
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain; (G.P.-J.); (L.R.d.A.); (M.V.-P.); (M.P.F.G.); (I.T.); (V.N.); (I.L.)
- Bioaraba, Nutrición y Seguridad Alimentaria, 01006 Vitoria-Gasteiz, Spain
| | - Virginia Navarro
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain; (G.P.-J.); (L.R.d.A.); (M.V.-P.); (M.P.F.G.); (I.T.); (V.N.); (I.L.)
- Bioaraba, Nutrición y Seguridad Alimentaria, 01006 Vitoria-Gasteiz, Spain
| | - Idoia Larretxi
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain; (G.P.-J.); (L.R.d.A.); (M.V.-P.); (M.P.F.G.); (I.T.); (V.N.); (I.L.)
- Bioaraba, Nutrición y Seguridad Alimentaria, 01006 Vitoria-Gasteiz, Spain
- Centro Integral de Atención a Mayores San Prudencio, Ayuntamiento de Vitoria-Gasteiz, 01006 Vitoria-Gasteiz, Spain
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Damasceno RPB, Zandonadi RP, Mendes M, Cunha Junior LC, Raposo A, Teixeira-Lemos E, Chaves C, Farage P. Risk of Gluten Cross-Contamination Due to Food Handling Practices: A Mini-Review. Nutrients 2024; 16:1198. [PMID: 38674888 PMCID: PMC11055037 DOI: 10.3390/nu16081198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Celiac disease (CD) is an autoimmune disease triggered by the ingestion of gluten in genetically predisposed individuals, affecting 1.4% of the world population. CD induces an inflammatory reaction that compromises small intestine villi, leading to nutrient malabsorption, and gastro and extraintestinal manifestations. Although other treatment approaches are being studied, adherence to a gluten-free diet (GFD) is the only effective intervention to date. Despite this, about 50% of patients experience persistent inflammation, often associated with unintentional gluten ingestion through contaminated food. There are regulations for labeling gluten-free foods which specify a limit of 20 mg/kg (20 ppm). The risks of gluten cross-contamination above that level are present throughout the whole food production chain, emphasizing the need for caution. This review explores studies that tested different procedures regarding the shared production of gluten-containing and gluten-free food, including the use of shared equipment and utensils. A literature review covering PubMed, Scielo, Web of Science, VHL and Scopus identified five relevant studies. The results indicate that shared environments and equipment may not significantly increase gluten cross-contamination if appropriate protocols are followed. Simultaneous cooking of gluten-containing and gluten-free pizzas in shared ovens has demonstrated a low risk of contamination. In general, shared kitchen utensils and equipment (spoon, ladle, colander, knife, fryer, toaster) in controlled experiments did not lead to significant contamination of samples. On the other hand, cooking gluten-free and gluten-containing pasta in shared water resulted in gluten levels above the established limit of 20 ppm. However, rinsing the pasta under running water for a few seconds was enough to reduce the gluten content of the samples to less than 20 ppm.
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Affiliation(s)
- Renatta Pereira B. Damasceno
- School of Nutrition, Federal University of Goiás (FANUT/UFG), Goiânia 74690-900, Goiás, Brazil; (R.P.B.D.); (M.M.)
| | - Renata Puppin Zandonadi
- Department of Nutrition, College of Health Sciences, University of Brasília (UNB), Brasília 70910-900, Federal District, Brazil;
| | - Marcela Mendes
- School of Nutrition, Federal University of Goiás (FANUT/UFG), Goiânia 74690-900, Goiás, Brazil; (R.P.B.D.); (M.M.)
| | | | - António Raposo
- CBIOS (Research Center for Biosciences and Health Technologies), Universidade Lusófona de Humanidades e Tecnologias, Campo Grande 376, 1749-024 Lisboa, Portugal
| | - Edite Teixeira-Lemos
- CERNAS Research Centre, Polytechnic University of Viseu, 3504-510 Viseu, Portugal;
| | - Cláudia Chaves
- ESSV, Centre for Studies in Education and Innovation (CI&DEI), Polytechnic University of Viseu, 3504-510 Viseu, Portugal;
| | - Priscila Farage
- School of Nutrition, Federal University of Goiás (FANUT/UFG), Goiânia 74690-900, Goiás, Brazil; (R.P.B.D.); (M.M.)
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Mehtab W, Agarwal A, Chauhan A, Agarwal S, Singh A, Ahmad A, Bhola A, Singh N, Ahuja V, Malhotra A, Makharia G. Barriers at various levels of human ecosystem for maintaining adherence to gluten free diet in adult patients with celiac disease. Eur J Clin Nutr 2024; 78:320-327. [PMID: 38216646 DOI: 10.1038/s41430-024-01399-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 12/06/2023] [Accepted: 01/02/2024] [Indexed: 01/14/2024]
Abstract
INTRODUCTION While lifelong and strict adherence to gluten-free diet (GFD) is essential for the successful treatment of celiac disease (CeD), only 30-50% of patients are able to maintain a good adherence to GFD. We determined factors influencing the adherence to GFD at various ecological levels including intra-personal, inter-personal, organizational, community and system-based levels in adult patients with CeD. METHODS A questionnaire to assess the adherence was developed and it was administered in the CeD clinic to patients with CeD on GFD for >1 year. Adherence to GFD was assessed in a subset of patients (n = 320) using Celiac Disease Adherence Test (CDAT). RESULTS Overall, 978 patients [median age: 29 years; females: 592] with CeD on GFD were recruited. They reported many barriers to adherence to GFD including intra-personal barriers such as lack of knowledge about GFD (19%), inadequate financial resources (27.2%) and lack of self-motivation/confidence (55.3%); inter-personal barriers such as intake of gluten-containing food upon forceful insistence of friends/family (23.4%); organizational barriers such as high cost (70.8%) and non-availability of GF-food products (48.6%); community-based barriers like consumption of gluten-containing food at religious occasions/festivals (11.1%) and social occasions (27.2%); and system-based barriers such as non-referral to dietitian for counseling (21.9%). As per CDAT, 204 (63.7%), 73(22.8%) and 43(13.4%) patients had good, average, and poor adherence to GFD, respectively. On multivariable analysis, occasional consumption of gluten, non-availability of GF-food while dining out and coercing by family and friends for consumption of GC-food were found to have highest odds for poor adherence to GFD. CONCLUSIONS Non-referral to a dietitian for counseling, irregular follow-up visits, unavailability of flour mill, non-supportive family/friends, high cost and limited availability of GF-food are the most common barriers to adherence to GFD. There is a need to create infrastructure and develop strategies to overcome these diverse barriers at various levels of ecosystem and thereby facilitate better adherence to GFD.
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Affiliation(s)
- Wajiha Mehtab
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
- Department of Home Science, University of Delhi, New Delhi, India
| | - Ashish Agarwal
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Ashish Chauhan
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Alka Singh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Anam Ahmad
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Anjali Bhola
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Malhotra
- Department of Home Science, Lakshmibai College, University of Delhi, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.
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6
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Stefanolo JP, Segura V, Grizzuti M, Heredia A, Comino I, Costa AF, Puebla R, Temprano MP, Niveloni SI, de Diego G, Oregui ME, Smecuol EG, de Marzi MC, Verdú EF, Sousa C, Bai JC. Effect of Aspergillus niger prolyl endopeptidase in patients with celiac disease on a long-term gluten-free diet. World J Gastroenterol 2024; 30:1545-1555. [PMID: 38617446 PMCID: PMC11008412 DOI: 10.3748/wjg.v30.i11.1545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 12/31/2023] [Accepted: 02/18/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND The gluten-free diet (GFD) has limitations, and there is intense research in the development of adjuvant therapies. AIM To examine the effects of orally administered Aspergillus niger prolyl endopeptidase protease (AN-PEP) on inadvertent gluten exposure and symptom prevention in adult celiac disease (CeD) patients following their usual GFD. METHODS This was an exploratory, double-blind, randomized, placebo-controlled trial that enrolled CeD patients on a long-term GFD. After a 4-wk run-in period, patients were randomized to 4 wk of two AN-PEP capsules (GliadinX; AVI Research, LLC, United States) at each of three meals per day or placebo. Outcome endpoints were: (1) Average weekly stool gluten immunogenic peptides (GIP) between the run-in and end of treatments and between AN-PEP and placebo; (2) celiac symptom index (CSI); (3) CeD-specific serology; and (4) quality of life. Stool samples were collected for GIP testing by ELISA every Tuesday and Friday during run-ins and treatments. RESULTS Forty patients were randomized for the intention-to-treat analysis, and three were excluded from the per-protocol assessment. Overall, 628/640 (98.1%) stool samples were collected. GIP was undetectable (< 0.08 μg/g) in 65.6% of samples, and no differences between treatment arms were detected. Only 0.5% of samples had GIP concentrations sufficiently high (> 0.32 μg/g) to potentially cause mucosal damage. Median GIP concentration in the AN-PEP arm was 44.7% lower than in the run-in period. One-third of patients exhibiting GIP > 0.08 μg/g during run-in had lower or undetectable GIP after AN-PEP treatment. Compared with the run- in period, the proportion of symptomatic patients (CSI > 38) in the AN-PEP arm was significantly lower (P < 0.03). AN-PEP did not result in changes in specific serologies. CONCLUSION This exploratory study conducted in a real-life setting revealed high adherence to the GFD. The AN-PEP treatment did not significantly reduce the overall GIP stool concentration. However, given the observation of a significantly lower prevalence of patients with severe symptoms in the AN-PEP arm, further clinical research is warranted.
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Affiliation(s)
- Juan Pablo Stefanolo
- Small Bowel Section, Department of Medicine, Gastroenterology Hospital of Buenos Aires “Dr. C. Bonorino Udaondo”, Buenos Aires 1264, Argentina
| | - Verónica Segura
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville 41080, Spain
| | - Martina Grizzuti
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Abel Heredia
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville 41080, Spain
| | - Isabel Comino
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville 41080, Spain
| | - Ana Florencia Costa
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Roberto Puebla
- Small Bowel Section, Department of Medicine, Gastroenterology Hospital of Buenos Aires “Dr. C. Bonorino Udaondo”, Buenos Aires 1264, Argentina
| | - María Paz Temprano
- Small Bowel Section, Department of Medicine, Gastroenterology Hospital of Buenos Aires “Dr. C. Bonorino Udaondo”, Buenos Aires 1264, Argentina
| | - Sonia Isabel Niveloni
- Small Bowel Section, Department of Medicine, Gastroenterology Hospital of Buenos Aires “Dr. C. Bonorino Udaondo”, Buenos Aires 1264, Argentina
| | - Gabriel de Diego
- Basic and Applied Research Group in Immunology and Bioactives (GIBAIB), Institute of Ecology and Sustainable Development (INEDES), National University of Lujan, Luján 6700, Buenos Aires, Argentina
| | - María E Oregui
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Edgardo Gustavo Smecuol
- Small Bowel Section, Department of Medicine, Gastroenterology Hospital of Buenos Aires “Dr. C. Bonorino Udaondo”, Buenos Aires 1264, Argentina
| | - Mauricio C de Marzi
- Basic and Applied Research Group in Immunology and Bioactives (GIBAIB), Institute of Ecology and Sustainable Development (INEDES), National University of Lujan, Luján 6700, Buenos Aires, Argentina
| | - Elena F Verdú
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton L8S 4L8, Ontario, Canada
| | - Carolina Sousa
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville 41080, Spain
| | - Julio César Bai
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
- Facultad de Medicina, Universidad del Salvador, Buenos Aires C1051ABB, Argentina
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7
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Elli L, Leffler D, Cellier C, Lebwohl B, Ciacci C, Schumann M, Lundin KEA, Chetcuti Zammit S, Sidhu R, Roncoroni L, Bai JC, Lee AR, Dennis M, Robert ME, Rostami K, Khater S, Comino I, Cebolla A, Branchi F, Verdu EF, Stefanolo JP, Wolf R, Bergman-Golden S, Trott N, Scudeller L, Zingone F, Scaramella L, Sanders DS. Guidelines for best practices in monitoring established coeliac disease in adult patients. Nat Rev Gastroenterol Hepatol 2024; 21:198-215. [PMID: 38110546 DOI: 10.1038/s41575-023-00872-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/20/2023]
Abstract
Coeliac disease (CeD) is an immunological disease triggered by the consumption of gluten contained in food in individuals with a genetic predisposition. Diagnosis is based on the presence of small bowel mucosal atrophy and circulating autoantibodies (anti-type 2 transglutaminase antibodies). After diagnosis, patients follow a strict, life-long gluten-free diet. Although the criteria for diagnosis of this disease are well defined, the monitoring phase has been studied less and there is a lack of specific guidelines for this phase. To develop a set of clinical guidelines for CeD monitoring, we followed the Grading of Recommendations Assessment, Development and Evaluation methodology. Statements and recommendations with the level of evidence were developed and approved by the working group, which comprised gastroenterologists, pathologists, dieticians and biostatisticians. The proposed guidelines, endorsed by the North American and European coeliac disease scientific societies, make recommendations for best practices in monitoring patients with CeD based on the available evidence. The evidence level is low for many topics, suggesting that further research in specific aspects of CeD would be valuable. In conclusion, the present guidelines support clinicians in improving CeD treatment and follow-up and highlight novel issues that should be considered in future studies.
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Affiliation(s)
- Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease-Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Daniel Leffler
- Celiac Center, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, USA
| | - Christophe Cellier
- Department of Gastroenterology and Endoscopy, CELAC network, AP-HP Centre, Hôpital Européen Georges Pompidou, Université de Paris, Cité and Institut National du Cancer, Paris, France
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Carolina Ciacci
- Center for Celiac Disease, Gastrointestinal Unit, AOU San Giovanni di Dio e Ruggi D'Aragona and Department of Medicine Surgery Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Michael Schumann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Berlin, Germany
| | - Knut E A Lundin
- K.G. Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | | | - Reena Sidhu
- Department of Infection, Immunity and Cardiovascular Diseases, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Leda Roncoroni
- Center for Prevention and Diagnosis of Celiac Disease-Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Julio C Bai
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Anne R Lee
- Celiac Disease Center, Department of Medicine, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Melinda Dennis
- Celiac Center, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, USA
| | - Marie E Robert
- Department of Pathology and Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kamran Rostami
- Department of Gastroenterology, Palmerston North District Health Board (DHB), Palmerston North, New Zealand
| | - Sherine Khater
- Department of Gastroenterology and Endoscopy, CELAC network, AP-HP Centre, Hôpital Européen Georges Pompidou, Université de Paris, Cité and Institut National du Cancer, Paris, France
| | - Isabel Comino
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | | | - Federica Branchi
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Berlin, Germany
| | - Elena F Verdu
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Juan Pablo Stefanolo
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Randi Wolf
- Program in Nutrition, Department of Health Studies & Applied Educational Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Sheba Bergman-Golden
- Program in Nutrition, Department of Health Studies & Applied Educational Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Nick Trott
- Department of Infection, Immunity and Cardiovascular Diseases, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Luigia Scudeller
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - Lucia Scaramella
- Center for Prevention and Diagnosis of Celiac Disease-Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - David S Sanders
- Department of Infection, Immunity and Cardiovascular Diseases, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
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8
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Russell AK, Lucas EC, Henneken LM, Pizzey CJ, Clarke D, Myleus A, Tye-Din JA. Stool Gluten Peptide Detection Is Superior to Urinary Analysis, Coeliac Serology, Dietary Adherence Scores and Symptoms in the Detection of Intermittent Gluten Exposure in Coeliac Disease: A Randomised, Placebo-Controlled, Low-Dose Gluten Challenge Study. Nutrients 2024; 16:279. [PMID: 38257173 PMCID: PMC10818827 DOI: 10.3390/nu16020279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
Monitoring adherence to a gluten-free diet is an important goal of coeliac disease management. Urine and stool gluten immunogenic peptide (GIP) assays provide an objective readout of gluten ingestion, with the former favoured due to its convenience and acceptability. This study assessed stool GIP excretion after low-dose gluten challenge designed to mimic accidental gluten exposure. A total of 52 coeliac participants undertook a randomised, double-blind gluten (50-1000 mg) or placebo challenge. Stool and urinary GIP, serology, dietary adherence and symptoms were assessed. Stool GIP was 100% sensitive for gluten intake ≥250 mg and 71% for 50 mg. Peak GIP detection was 12-36 h after gluten exposure. The mean stool GIP after 1000 mg gluten ingestion remained above the limit of quantification for 5 days. Urine GIP assessment had poor sensitivity for GIP excretion compared to stool. Serology, dietary adherence score and symptoms did not correlate with gluten excretion during lead-in. We conclude that stool GIP detection is highly sensitive, with levels related to gluten dose and time from ingestion. Weekly or bi-weekly testing will detect low-level exposure more effectively than urine GIP assessments or traditional methods. In this seronegative, apparently well-treated cohort, a high frequency of baseline-positive GIP suggests ongoing gluten exposure, but the assessment of patient behaviour and assay specificity is needed.
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Affiliation(s)
- Amy K. Russell
- Immunology Division, The Walter and Eliza Hall Institute, Parkville, VIC 3052, Australia; (A.K.R.)
| | - Erin C. Lucas
- Immunology Division, The Walter and Eliza Hall Institute, Parkville, VIC 3052, Australia; (A.K.R.)
| | - Lee M. Henneken
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC 3052, Australia
| | - Catherine J. Pizzey
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC 3052, Australia
| | - Dean Clarke
- National Measurement Institute, Port Melbourne, VIC 3207, Australia
| | - Anna Myleus
- Department of Public Health and Clinical Medicine, Family Medicine, Umea University, 901 87 Umea, Sweden
| | - Jason A. Tye-Din
- Immunology Division, The Walter and Eliza Hall Institute, Parkville, VIC 3052, Australia; (A.K.R.)
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia
- The Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
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9
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Stefanolo JP, Temprano MDLP, Smecuol E, Puebla R, Portillo JD, Niveloni S, Verdú EF, Bai JC. Comparison of weekly gluten immunogenic peptide measurement and conventional tools to assess adherence to the gluten-free diet in celiac disease: An observational prospective study. Am J Clin Nutr 2023; 118:1106-1112. [PMID: 37806557 DOI: 10.1016/j.ajcnut.2023.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Adherence to the gluten-free diet (GFD) is critical to achieving symptom control and mucosal healing in celiac disease (CeD), but its assessment is difficult. OBJECTIVES We sought to compare stool gluten immunogenic peptides (GIPs) measurements over a 4-wk period with conventional tools commonly used to monitor compliance with a GFD. METHODS Consecutive adult patients with CeD attending the Small Bowel Section of the Buenos Aires Gastroenterology Hospital were invited to this observational study and were instructed to collect stool samples on Fridays for 4 consecutive weeks. Weekly mean stool GIP concentration was measured was estimated. GIP results were compared with a self-assessment scale of adherence, specific CeD serology, the celiac symptom index, and the assessment by an expert dietitian. RESULTS Fifty-three CeD patients were enrolled and those with stool GIP ≥0.65 μg/g/wk (n = 13; 24.5%) had higher serum concentrations of IgA deamidated gliadin peptides (DGPs) antibodies [69 (29-109) compared with 14 (13-29); P = 0.0005] and IgA tissue transglutaminase [42 (14-200) compared with 10 (7-16); P = 0.02], higher proportion of cases with IgA DGP antibodies >20 AU/mL (84.6% compared with 33.3%; P = 0.002), and a higher self-estimated adherence score [5 (4-9) compared with 9 (7-10); P = 0.003]. GIP did not correlate with celiac symptom index scores (55.6% compared with 30.8%; P = 0.9). Expert dietitian assessment identified 69% [odds ratio (OR): 5.25; 95% CI: 1.1-27.2; P = 0.01] of nonadherent cases when high stool GIP. Logistic regression analysis determined that IgA DGP (adjusted OR: 1.1; 95% CI: 1.01-1.11; P = 0.02) and males (adjusted OR: 28.3; 95% CI: 1.1-722.6; P = 0.04) were independently associated with excessive gluten exposure. CONCLUSIONS Weekly stool GIP identifies gluten exposure that is not always detected by commonly used GFD adherence assessment methods. The higher the concentration of stool GIP, the better the predictive value of serology and dietitian interviews. Stool GIP is a useful and practical test for GFD monitoring, particularly for risky gluten exposure in real-life scenarios.
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Affiliation(s)
- Juan P Stefanolo
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | | | - Edgardo Smecuol
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Roberto Puebla
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | | | - Sonia Niveloni
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Elena F Verdú
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Julio C Bai
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina; Research Institutes, Universidad del Salvador, Buenos Aires, Argentina.
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10
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Uscanga LF. Adherence to a gluten-free diet: Can just a little bit be harmful? REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:305-306. [PMID: 37095014 DOI: 10.1016/j.rgmxen.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 04/26/2023]
Affiliation(s)
- L F Uscanga
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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11
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Simón E, Molero-Luis M, Fueyo-Díaz R, Costas-Batlle C, Crespo-Escobar P, Montoro-Huguet MA. The Gluten-Free Diet for Celiac Disease: Critical Insights to Better Understand Clinical Outcomes. Nutrients 2023; 15:4013. [PMID: 37764795 PMCID: PMC10537989 DOI: 10.3390/nu15184013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
The gluten-free diet (GFD) remains a complex paradigm in managing celiac disease (CeD) in children and adults, and there are many reasons why GFD adherence should be strict to improve outcomes. However, this is a challenging task for patients, since they need to have access to quality healthcare resources that facilitate optimal GFD adherence. Understanding the strengths and weaknesses of the GFD, tackling coexisting nutritional deficiencies, and dealing with complex situations, such as seronegative CeD or non-responsive CeD, all require the involvement of a multidisciplinary team. The short- and long-term follow-up of CeD patients should preferably be performed by a combined Gastroenterology and Nutrition service with well-defined quality standards and the multidisciplinary involvement of physicians, nurses, dietitians, and psychologists. Nutritional advice and counseling by an experienced dietitian can reduce the costs associated with long-term follow-up of CeD patients. Likewise, psychological interventions may be essential in specific scenarios where implementing and sustaining a lifelong GFD can cause a significant psychological burden for patients. This manuscript aims to provide guidelines to improve clinical practice in the follow-up and monitoring of CeD patients and provide information on the nutritional risks of an ill-advised GFD. Clinicians, biochemists, food technologists, dietitians, and psychologists with a global view of the disease have been involved in its writing.
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Affiliation(s)
- Edurne Simón
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain
| | - Marta Molero-Luis
- Laboratory of Gastroenterology and Trace Elements, Department of Laboratory Medicine, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Ricardo Fueyo-Díaz
- PROSAM Research Group (S69-23R), Department of Psychology and Sociology, Universidad de Zaragoza, 50009 Zaragoza, Spain;
| | - Cristian Costas-Batlle
- Department of Nutrition and Dietetics, Bradford Teaching Hospitals NHS Foundation Trust, Bradford BD9 6DA, UK;
| | - Paula Crespo-Escobar
- ADViSE Research Group, Department of Health Science, European University Miguel de Cervantes, 47012 Valladolid, Spain;
- Department of Nutrition and Obesity, Hospital Recoletas Campo Grande, 47007 Valladolid, Spain
| | - Miguel A. Montoro-Huguet
- Gastroenterology, Hepatology and Nutrition Unit, University Hospital San Jorge, 22004 Huesca, Spain
- Department of Medicine, Faculty of Health and Sport Sciences, University of Zaragoza, 22002 Huesca, Spain
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain
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12
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Horton M, Olshan KL, Gleeson E, Regis S, Morson T, Hintze ZJ, Leonard MM, Silvester JA. Low Levels of Detectable Urine and Stool GIPs in Children with Celiac Disease on a Gluten-Free Diet. JPGN REPORTS 2023; 4:e323. [PMID: 37600614 PMCID: PMC10435043 DOI: 10.1097/pg9.0000000000000323] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 03/05/2023] [Indexed: 08/22/2023]
Abstract
Objectives This study examines the prevalence of detectable gluten immunogenic peptides (GIPs) as a proxy for gluten exposure in children with celiac disease on a gluten-free diet in the United States, as estimated by gluten breakdown products excreted in urine and stool. Methods Urine and stool samples were collected in 3 settings (home, gastroenterology clinic, and endoscopy) for pediatric participants (ages 6-21 years old) across 2 medical centers. Commercial ELISA assays were used to quantify the GIPs in each sample. Results GIPs were detected in 4 out of 44 (9.1%) of stool samples and 6 out of 125 (4.8%) of urine samples provided by 84 children. These samples were collected across all settings, and most participants (70%) were asymptomatic at the time of sample collection. For the urine samples collected at the time of endoscopy, all subjects found to have persistent enteropathy had no detectable GIPs (0/12). Discussion GIPs provide an additional method for screening for gluten exposures in individuals with celiac disease on a gluten-free diet, and may be used across multiple settings. We found a low detection rate of GIPs in children. Our finding of undetectable GIPs in individuals with persistent enteropathy may be expected of a single determination under close observation or represent a lack of gluten exposure within the detection window. More research is needed to understand the dynamics of gluten absorption and excretion in the US pediatric population.
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Affiliation(s)
- Maxwell Horton
- From the Celiac Research Program, Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine L. Olshan
- From the Celiac Research Program, Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
- Mucosal Immunology and Biology Research Center, MassGeneral Hospital for Children, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Elizabeth Gleeson
- Mucosal Immunology and Biology Research Center, MassGeneral Hospital for Children, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Stephanie Regis
- From the Celiac Research Program, Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Taylor Morson
- Mucosal Immunology and Biology Research Center, MassGeneral Hospital for Children, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Zackary J. Hintze
- From the Celiac Research Program, Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maureen M. Leonard
- From the Celiac Research Program, Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
- Mucosal Immunology and Biology Research Center, MassGeneral Hospital for Children, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Jocelyn A. Silvester
- From the Celiac Research Program, Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
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13
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Monachesi C, Catassi G, Catassi C. The use of urine peptidomics to define dietary gluten peptides from patients with celiac disease and the clinical relevance. Expert Rev Proteomics 2023; 20:281-290. [PMID: 37855116 DOI: 10.1080/14789450.2023.2270775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/05/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Determination of urinary gluten immunogenic peptides (GIP) has emerged as one of the most attractive test to monitor the adherence to the gluten-free diet (GFD) of patients with celiac disease (CD), being a simple, noninvasive and direct method to detect gluten contamination of the GFD. AREAS COVERED We conducted a scoping review in Medline (PubMed) of articles published up to April 2023 that analyzed any aspect of the clinical relevance of the use of urinary GIP measurement in patients with CD. A total of 17 articles reporting the clinical use of urinary peptidomics for the follow-up of CD patients were finally included. EXPERT OPINION Available data suggest that a negative urinary GIP result is a reliable noninvasive predictor of intestinal mucosa healing in CD patients treated with the GFD, especially if testing three urine samples on different days including the weekend. Due to conflicting results about the sensitivity and the specificity of the urinary GIP determination, additional in-depth information is needed, particularly related to (1) the relationship between the amount of ingested gluten and the quantity of urinary GIP excreted in treated CD patients, (2) the GIP kinetics and best timing for sample collection.
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Affiliation(s)
- Chiara Monachesi
- Division of Pediatrics and Center for Celiac Research, DISCO Department, Marche Polytechnic University, Ancona, Italy
| | - Giulia Catassi
- Pediatric Gastroenterology and Liver Unit, Department of Maternal and Child Health, Sapienza-University of Rome, Rome, Italy
| | - Carlo Catassi
- Division of Pediatrics and Center for Celiac Research, DISCO Department, Marche Polytechnic University, Ancona, Italy
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14
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Rej A, Penny HA. Current evidence for dietary therapies in irritable bowel syndrome. Curr Opin Gastroenterol 2023; 39:219-226. [PMID: 36976876 DOI: 10.1097/mog.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
PURPOSE OF REVIEW Diet appears to trigger symptoms in the majority of individuals with irritable bowel syndrome (IBS) and is associated with a reduced quality of life. There has been a recent focus on the role of dietary therapies to manage individuals with IBS. The aim of this review is to discuss the utility of traditional dietary advice (TDA), low-FODMAP diet (LFD) and gluten-free diet (GFD) in IBS. RECENT FINDINGS Several recent randomized controlled trials (RCTs) have been published demonstrating the efficacy of the LFD and GFD in IBS, with the evidence base for TDA being predominantly based on clinical experience, with emerging RCTs evaluating TDA. Only one RCT has been published to date comparing TDA, LFD and GFD head to head, with no difference noted between diets in terms of efficacy. However, TDA has been noted to be more patient-friendly and is commonly implemented as a first-line dietary therapy. SUMMARY Dietary therapies have been demonstrated to improve symptoms in patients with IBS. In view of insufficient evidence to recommend one diet over another currently, specialist dietetic input in conjunction with patient preference is required to determine implementation of dietary therapies. Novel methods of dietetic delivery are required in view of the lack of dietetic provision to deliver these therapies.
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Affiliation(s)
- Anupam Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield
- Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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15
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Rubio-Tapia A, Hill ID, Semrad C, Kelly CP, Greer KB, Limketkai BN, Lebwohl B. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Am J Gastroenterol 2023; 118:59-76. [PMID: 36602836 DOI: 10.14309/ajg.0000000000002075] [Citation(s) in RCA: 81] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/23/2022] [Indexed: 01/06/2023]
Abstract
This guideline presents an update to the 2013 American College of Gastroenterology Guideline on the Diagnosis and Management of Celiac Disease with updated recommendations for the evaluation and management of patients with celiac disease (CD). CD is defined as a permanent immune-mediated response to gluten present in wheat, barley, and rye. CD has a wide spectrum of clinical manifestations that resemble a multisystemic disorder rather than an isolated intestinal disease, and is characterized by small bowel injury and the presence of specific antibodies. Detection of CD-specific antibodies (e.g., tissue transglutaminase) in the serum is very helpful for the initial screening of patients with suspicion of CD. Intestinal biopsy is required in most patients to confirm the diagnosis. A nonbiopsy strategy for the diagnosis of CD in selected children is suggested and discussed in detail. Current treatment for CD requires strict adherence to a gluten-free diet (GFD) and lifelong medical follow-up. Most patients have excellent clinical response to a GFD. Nonresponsive CD is defined by persistent or recurrent symptoms despite being on a GFD. These patients require a systematic workup to rule out specific conditions that may cause persistent or recurrent symptoms, especially unintentional gluten contamination. Refractory CD is a rare cause of nonresponsive CD often associated with poor prognosis.
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Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ivor D Hill
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children Hospital, Columbus, Ohio, USA
| | - Carol Semrad
- Division of Gastroenterology, University of Chicago, Chicago, Illinois, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Katarina B Greer
- Department of Medicine, Section of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Berkeley N Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California, USA
| | - Benjamin Lebwohl
- Division of Gastroenterology and Hepatology, Columbia University, New York, USA
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16
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Penny HA, Rej A, Baggus EMR, Coleman SH, Ward R, Wild G, Bouma G, Trott N, Snowden JA, Wright J, Cross SS, Hadjivassiliou M, Sanders DS. Non-Responsive and Refractory Coeliac Disease: Experience from the NHS England National Centre. Nutrients 2022; 14:nu14132776. [PMID: 35807956 PMCID: PMC9268848 DOI: 10.3390/nu14132776] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023] Open
Abstract
We characterised the aetiology of non-responsive coeliac disease (NRCD) and provided contemporary mortality data in refractory coeliac disease (RCD) from our centre. We also measured urine gluten immunogenic peptides (GIPs) in patients with established RCD1 to evaluate gluten exposure in these individuals. Methods: This was a longitudinal cohort study conducted in Sheffield, UK. Between 1998 and 2019, we evaluated 285 adult (≥16 years) patients with NRCD or RCD. Patients with established RCD1 and persisting mucosal inflammation and/or ongoing symptoms provided three urine samples for GIP analysis. Results: The most common cause of NRCD across the cohort was gluten exposure (72/285; 25.3%). RCD accounted for 65/285 patients (22.8%), 54/65 patients (83.1%) had RCD1 and 11/65 patients (16.9%) had RCD2. The estimated 5-year survival was 90% for RCD1 and 58% for RCD2 (p = 0.016). A total of 36/54 (66.7%) patients with RCD1 underwent urinary GIP testing and 17/36 (47.2%) had at least one positive urinary GIP test. Conclusion: The contemporary mortality data in RCD2 remains poor; patients with suspected RCD2 should be referred to a recognised national centre for consideration of novel therapies. The high frequency of urinary GIP positivity suggests that gluten exposure may be common in RCD1; further studies with matched controls are warranted to assess this further.
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Affiliation(s)
- Hugo A. Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
- Correspondence: (H.A.P.); (D.S.S.); Tel.: +44-0114-271-1900 (H.A.P. & D.S.S.)
| | - Anupam Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Elisabeth M. R. Baggus
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Sarah. H. Coleman
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Rosalie Ward
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Graeme Wild
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Gerd Bouma
- Department of Gastroenterology, Vrije Universiteit Medical Center, 1117 Amsterdam, The Netherlands;
| | - Nick Trott
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - John A. Snowden
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S10 2JF, UK; (J.A.S.); (J.W.)
| | - Josh Wright
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S10 2JF, UK; (J.A.S.); (J.W.)
| | - Simon S. Cross
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Marios Hadjivassiliou
- Department of Neurology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S10 2JF, UK;
| | - David S. Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
- Correspondence: (H.A.P.); (D.S.S.); Tel.: +44-0114-271-1900 (H.A.P. & D.S.S.)
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17
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Fung BM, Markarian E, Serper M, Tabibian JH. Current Applications of Telemedicine in Gastroenterology. Am J Gastroenterol 2022; 117:1072-1079. [PMID: 35385404 DOI: 10.14309/ajg.0000000000001761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/29/2022] [Indexed: 12/11/2022]
Abstract
Telemedicine generally refers to the use of technology to communicate with patients and provide health care from a distance. Advances in technology, specifically computers, cellphones, and other mobile devices, have facilitated healthcare providers' growing ability to virtually monitor and mentor patients. There has been a progressive expansion in the use of telemedicine in the field of gastroenterology (GI), which has been accelerated by the COVID-19 pandemic. In this review, we discuss telemedicine-its history, various forms, and limitations-and its current applications in GI. Specifically, we focus on telemedicine in GI practice in general and specific applications, including the management of inflammatory bowel disease, celiac disease, and colorectal cancer surveillance and its use as an aid in endoscopic procedures.
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Affiliation(s)
- Brian M Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
- Banner-University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Eric Markarian
- Academy of Science and Medicine, Crescenta Valley High School, Los Angeles, California, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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18
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Tye‐Din JA. Review article: Follow-up of coeliac disease. Aliment Pharmacol Ther 2022; 56 Suppl 1:S49-S63. [PMID: 35815829 PMCID: PMC9542881 DOI: 10.1111/apt.16847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/12/2022] [Accepted: 02/13/2022] [Indexed: 12/09/2022]
Abstract
Coeliac disease is a lifelong immune-mediated enteropathy with systemic features associated with increased morbidity and modestly increased mortality. Treatment with a strict gluten-free diet improves symptoms and mucosal damage but is not curative and low-level gluten intake is common despite strict attempts at adherence. Regular follow-up after diagnosis is considered best-practice however this is executed poorly in the community with the problem compounded by the paucity of data informing optimal approaches. The aim of dietary treatment is to resolve symptoms, reduce complication risk and improve quality of life. It follows that the goals of monitoring are to assess dietary adherence, monitor disease activity, assess symptoms and screen for complications. Mucosal disease remission is regarded a key measure of treatment success as healing is associated with positive health outcomes. However, persistent villous atrophy is common, even after many years of a gluten-free diet. As the clinical significance of asymptomatic enteropathy is uncertain the role for routine follow-up biopsies remains contentious. Symptomatic non-responsive coeliac disease is common and with systematic follow-up a cause is usually found. Effective models of care involving the gastroenterologist, dietitian and primary care doctor will improve the consistency of long-term management and likely translate into better patient outcomes. Identifying suitable treatment targets linked to long-term health is an important goal.
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Affiliation(s)
- J. A. Tye‐Din
- Immunology DivisionThe Walter and Eliza Hall InstituteParkvilleVictoriaAustralia,Department of Medical BiologyUniversity of MelbourneParkvilleVictoriaAustralia,Department of GastroenterologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia,Centre for Food & Allergy ResearchMurdoch Children’s Research InstituteParkvilleVictoriaAustralia
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19
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Paolini A, Sarshar M, Felli C, Bruno SP, Rostami-Nejad M, Ferretti F, Masotti A, Baldassarre A. Biomarkers to Monitor Adherence to Gluten-Free Diet by Celiac Disease Patients: Gluten Immunogenic Peptides and Urinary miRNAs. Foods 2022; 11:1380. [PMID: 35626950 PMCID: PMC9140451 DOI: 10.3390/foods11101380] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/02/2022] [Accepted: 05/07/2022] [Indexed: 02/01/2023] Open
Abstract
Celiac disease (CD) is a multifactorial autoimmune enteropathy with a prevalence greater than 1% in the pediatric population. The only therapy for CD patients is a strict gluten-free diet (GFD). Gluten-free food contamination by other cereals during packaging and cooking or accidental ingestion of gluten may cause several intestinal and extraintestinal symptoms in CD patients. Therefore, the monitoring of gluten contamination in food and assessing the level of ingested gluten by analytical biomarkers has been of great interest in recent years. To this aim, small gluten immunogenic peptides (GIPs) obtained by the hydrolysis of gluten and present in urine and feces have been studied as biomarkers of gluten intake and to monitor adherence to GFD by CD patients. More recently, the use of circulating, fecal and urinary miRNAs has emerged as a novel diagnostic tool that can be potentially applied to assess adherence to GFD. Moreover, the presence of GIPs and miRNAs in both feces and urine suggests a similar excretion modality and the possibility of using urinary miRNAs, similarly to GIPs, as potential biomarkers of GFD in CD patients.
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Affiliation(s)
- Alessandro Paolini
- Research Laboratories, Bambino Gesù Children’s Hospital-IRCCS, 00146 Rome, Italy; (A.P.); (M.S.); (C.F.); (S.P.B.); (A.B.)
| | - Meysam Sarshar
- Research Laboratories, Bambino Gesù Children’s Hospital-IRCCS, 00146 Rome, Italy; (A.P.); (M.S.); (C.F.); (S.P.B.); (A.B.)
| | - Cristina Felli
- Research Laboratories, Bambino Gesù Children’s Hospital-IRCCS, 00146 Rome, Italy; (A.P.); (M.S.); (C.F.); (S.P.B.); (A.B.)
| | - Stefania Paola Bruno
- Research Laboratories, Bambino Gesù Children’s Hospital-IRCCS, 00146 Rome, Italy; (A.P.); (M.S.); (C.F.); (S.P.B.); (A.B.)
- Department of Science, University Roma Tre, 00146 Rome, Italy
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran 1985717411, Iran;
| | - Francesca Ferretti
- Hepato-Gastroenterology and Nutrition Department, Bambino Gesù Children’s Hospital-IRCCS, 00165 Rome, Italy;
| | - Andrea Masotti
- Research Laboratories, Bambino Gesù Children’s Hospital-IRCCS, 00146 Rome, Italy; (A.P.); (M.S.); (C.F.); (S.P.B.); (A.B.)
| | - Antonella Baldassarre
- Research Laboratories, Bambino Gesù Children’s Hospital-IRCCS, 00146 Rome, Italy; (A.P.); (M.S.); (C.F.); (S.P.B.); (A.B.)
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20
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The global burden of coeliac disease: opportunities and challenges. Nat Rev Gastroenterol Hepatol 2022; 19:313-327. [PMID: 34980921 DOI: 10.1038/s41575-021-00552-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 02/06/2023]
Abstract
Coeliac disease is a systemic disorder characterized by immune-mediated enteropathy, which is caused by gluten ingestion in genetically susceptible individuals. The clinical presentation of coeliac disease is highly variable and ranges from malabsorption through solely extra-intestinal manifestations to asymptomatic. As a result, the majority of patients with coeliac disease remain undiagnosed, misdiagnosed or experience a substantial delay in diagnosis. Coeliac disease is diagnosed by a combination of serological findings of disease-related antibodies and histological evidence of villous abnormalities in duodenal biopsy samples. However, variability in histological grading and in the diagnostic performance of some commercially available serological tests remains unacceptably high and confirmatory assays are not readily available in many parts of the world. Currently, the only effective treatment for coeliac disease is a lifelong, strict, gluten-free diet. However, many barriers impede patients' adherence to this diet, including lack of widespread availability, high cost, cross-contamination and its overall restrictive nature. Routine follow-up is necessary to ensure adherence to a gluten-free diet but considerable variation is evident in follow-up protocols and the optimal disease management strategy is not clear. However, these challenges in the diagnosis and management of coeliac disease suggest opportunities for future research.
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21
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Meijer CR, Bakker J, Boers A, Jansen S, Mengi Z, Mearin ML. Association in Clinical Practice Between Gluten Intake and Gluten Immunogenic Peptides in Celiac Children. GASTRO HEP ADVANCES 2022; 1:652-658. [PMID: 39132079 PMCID: PMC11307387 DOI: 10.1016/j.gastha.2022.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/22/2022] [Indexed: 08/13/2024]
Abstract
Background and Aims The dietary compliance and its assessment in celiac disease (CD) patients on a strict gluten-free diet (GFD) remain a challenge. Two relatively new, validated methods have been proposed to detect occasional gluten ingestion: standardized dietary questionnaire and determination of urinary gluten immunogenic peptides (GIPs). Our aim was to prospectively assess dietary compliance via these methods and compare their results with those of tissue transglutaminase antibodies (tTGA). Methods This was a prospective single-center study. Consecutive CD patients (aged 1-18 years) on a GFD scheduled for regular consultation between March and August 2019 were invited. In addition to standard care, a completed dietary questionnaire and urine sample for GIP were collected. Pearson's chi-square test, Fisher's exact test, and Mann-Whitney U test were performed. Results Of the 156 eligible children, 110 provided informed consent. Completed dietary questionnaire, GIP, and tTGA results were available from 86 children (median age 12.8 years, median GFD duration 30 months, 65% female). Adherence to the GFD evaluated by GIP, dietary questionnaire, and anti-tTGA was 94.2%, 75.6% and 94.2%, respectively. No association was found between the tTGA results and the detection of GIP, as well as between the tTGA results and the dietary questionnaires scores (P = .5 and .312, respectively). The participants perceived both the questionnaire and the measurement of GIP as reassuring with regard to correct implementation of the GFD. Conclusion All the 3 methods have limitations to monitor dietary compliance. The comparison of their performance shows that the best single method is the use of the validated dietary questionnaire, which should therefore be implemented in the regular care for children with CD. The most effective combination of dietary questionnaire and urinary GIP determination should be used in specific clinical situations.
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Affiliation(s)
- Caroline R. Meijer
- Department of Pediatric Gastroenterology, Leiden University Medical Center, Willem Alexander Children's Hospital, Leiden, The Netherlands
| | - Jaap Bakker
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Anneloes Boers
- Department of Pediatric Gastroenterology, Leiden University Medical Center, Willem Alexander Children's Hospital, Leiden, The Netherlands
| | - Sophie Jansen
- Department of Pediatric Gastroenterology, Leiden University Medical Center, Willem Alexander Children's Hospital, Leiden, The Netherlands
| | - Zeliha Mengi
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Maria Luisa Mearin
- Department of Pediatric Gastroenterology, Leiden University Medical Center, Willem Alexander Children's Hospital, Leiden, The Netherlands
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22
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An efficient urine peptidomics workflow identifies chemically defined dietary gluten peptides from patients with celiac disease. Nat Commun 2022; 13:888. [PMID: 35173144 PMCID: PMC8850430 DOI: 10.1038/s41467-022-28353-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 01/20/2022] [Indexed: 12/11/2022] Open
Abstract
Celiac disease (CeD) is an autoimmune disorder induced by consuming gluten proteins from wheat, barley, and rye. Glutens resist gastrointestinal proteolysis, resulting in peptides that elicit inflammation in patients with CeD. Despite well-established connections between glutens and CeD, chemically defined, bioavailable peptides produced from dietary proteins have never been identified from humans in an unbiased manner. This is largely attributable to technical challenges, impeding our knowledge of potentially diverse peptide species that encounter the immune system. Here, we develop a liquid chromatographic-mass spectrometric workflow for untargeted sequence analysis of the urinary peptidome. We detect over 600 distinct dietary peptides, of which ~35% have a CeD-relevant T cell epitope and ~5% are known to stimulate innate immune responses. Remarkably, gluten peptides from patients with CeD qualitatively and quantitatively differ from controls. Our results provide a new foundation for understanding gluten immunogenicity, improving CeD management, and characterizing the dietary and urinary peptidomes. Gluten peptides from wheat enter the bloodstream and are excreted in urine but are yet to be chemically characterised. Here, the authors show by mass spectrometry that quantitative and qualitative differences in urinary peptides can be detected between healthy people and patients with celiac disease.
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Maintaining, Managing, and Tele-Monitoring a Nutritionally Adequate Mediterranean Gluten-Free Diet and Proper Lifestyle in Adult Patients. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12031578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The gluten-free diet (GFD) is a restrictive diet. In many cases, it must be permanent and strict, and it may be associated with both nutritional deficiencies and excesses, which can be prevented by following a healthy, natural Mediterranean GFD (Med-GFD). In this paper, we describe the importance of the Mediterranean diet, the correct intake of vitamins and minerals, and how they may play an important protective role against chronic or degenerative conditions. Herewith, we analyze different aspects that influence the ability to maintain a correct and balanced Med-GFD, which may contribute to the health status of patients, including a conscious use of gluten-free products to maintain a healthy lifestyle. Monitoring the Med-GFD remains a pivotal issue: to evaluate the presence of gluten peptides in urine, it could be important to introduce point-of-care testing, an efficient method for GFD self-monitoring (immunochromatographic technique), together with online nutritional questionnaires. Indeed, medical care via telemedicine can provide practical indications aimed at supporting patients and doctors. A natural Med-GFD can ensure the correct intake of nutrients and could be important for patients affected by gluten-related disorders, helping them to maintain a correct and healthy lifestyle.
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24
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Detection of gluten immunogenic peptides and the Celiac Disease Adherence Test to monitor gluten-free diet: a pilot study. Eur J Clin Nutr 2022; 76:902-903. [PMID: 35001079 DOI: 10.1038/s41430-021-01054-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 10/29/2021] [Accepted: 11/26/2021] [Indexed: 11/09/2022]
Abstract
Gluten immunogenic peptides (GIP) in feces and/or urine have recently been proposed as a sensitive and specific marker to detect ongoing gluten intake. Here, we compared GIP with the Celiac Disease Adherence Test (CDAT), a simple validated self-administered questionnaire that measures adherence to gluten-free diet (GFD). Of 70 subjects (59 women), six were classified as non-adherent by fecal GIP (mean 0.23 µg/g, standard deviation 0.08, range 0.082-0.319), including five classified as non-adherent by CDAT. GFD adherence was significantly higher by GIP than CDAT (p < 0.001). Fecal GIP may be useful as a biomarker for ongoing gluten intake that is not possible to detect with current clinical methods to assess GFD adherence, and may play a role in the management of persistent gastrointestinal symptoms in celiac disease.
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25
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Coto L, Sousa C, Cebolla A. Individual variability in patterns and dynamics of fecal gluten immunogenic peptides excretion after low gluten intake. Eur J Nutr 2022; 61:2033-2049. [PMID: 34993643 PMCID: PMC8739026 DOI: 10.1007/s00394-021-02765-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/30/2021] [Indexed: 12/20/2022]
Abstract
Purpose Determination of Gluten Immunogenic Peptides (GIP) in feces is a direct tool for gluten exposure detection. The sensitivity of GIP detection methods for cases of unintentional low gluten intakes is unknown. We studied the interindividual variability in the kinetic of excretion under homogeneously controlled dietary conditions, and the sensitivity of fecal GIP tests after low amounts of punctual gluten ingestions. Methods Participants (n = 20) followed the same gluten-free menu for 12 days in which two separated doses of gluten (50 mg and 2 g) were ingested and all the depositions were collected. GIP from stool samples were analyzed by ELISA and lateral flow immunoassay (LFIA) tests. Results Most participants had detectable GIP after 50 mg and 2 g gluten ingestions using ELISA test (72.2% and 95%, respectively), whereas the LFIA test showed less sensitivity (22.2% and 80%, respectively). GIP were detected at higher either frequency or concentration in the range of 12–36 h after 50 mg intake, and 12–84 h after 2 g consumption. Considering this period, diagnostic sensitivity of GIP detection after a single 50 mg ingestion may be significatively increased analyzing three stool samples per individual. High variability among participants was found in the time and amount of GIP excretion; however, some individuals showed common patterns for both gluten intakes. Conclusion Sporadic gluten exposure detection may require several fecal samples to achieve level of sensitivity above 90%. Interindividual variability in the dynamic of GIP excretion may suggest patterns of gluten metabolism.
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Affiliation(s)
- Laura Coto
- Biomedal S.L., Polígono Industrial Parque Plata, Calle Calzada Romana, 40, 41900, Camas, Sevilla, Spain
- Human Nutrition and Food Science Doctoral Program, University of Granada, 18011, Granada, Spain
| | - Carolina Sousa
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, 41012, Seville, Spain
| | - Angel Cebolla
- Biomedal S.L., Polígono Industrial Parque Plata, Calle Calzada Romana, 40, 41900, Camas, Sevilla, Spain.
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26
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Alkalay MJ. Nutrition in Patients with Lactose Malabsorption, Celiac Disease, and Related Disorders. Nutrients 2021; 14:nu14010002. [PMID: 35010876 PMCID: PMC8746545 DOI: 10.3390/nu14010002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/17/2021] [Accepted: 12/19/2021] [Indexed: 02/07/2023] Open
Abstract
Lactose malabsorption (LM), celiac disease (CD), non-celiac gluten sensitivity (NCGS), and irritable bowel syndrome (IBS) are conditions associated with food triggers, improvement after withdrawal, treatment with dietary restriction, and subsequent nutritional detriments. LM occurs when there is incomplete hydrolysis of lactose due to lactase deficiency and frequently produces abdominal symptoms; therefore, it can cause lactose intolerance (LI). A lactose-restricted diet is frequently recommended, although it can potentially lead to nutrient deficiencies. Furthermore, lactose is an essential component of fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) and is subsequently associated with intolerance to these compounds, especially in IBS. LM commonly presents in CD. Nutritional deficits are common in CD and can continue even on a gluten-free diet (GFD). Conditions triggered by gluten are known as gluten-related disorders (GRDs), including CD, wheat allergy, and NCGS. IBS can also be associated with a gluten sensitivity. A GFD is the treatment for CD, GRDs, and gluten sensitive IBS, although compliance with this restricted diet can be difficult. Strict dietary therapies can have a negative effect on quality of life. This review aims to provide an overview of the difficult nutritional elements of these disorders, which are critical for medical providers to recognize when managing these patients.
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Affiliation(s)
- Michele J Alkalay
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, TX 75235, USA
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27
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Ciacci C, Gagliardi M, Siniscalchi M, Ruotolo M, Santonicola A, Hajji N, Zingone F. Gluten Immunogenic Peptides (GIP) Point-of-Care Urine Test in Coeliac Disease Follow-up before and during the COVID-19 Lockdown in Italy. Clin Exp Gastroenterol 2021; 14:451-456. [PMID: 34815686 PMCID: PMC8605791 DOI: 10.2147/ceg.s326137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/03/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction Celiac disease (CeD) diagnosis has worldwide shared protocols. Conversely, follow-up of patients is still an object of study. Gluten immunogenic peptide detection in the urine (GIP) appears to be a new and efficient method for dietary gluten control of patients. The present study aims to assess the clinical usefulness of the GIP point-of-care urine test in the follow-up of symptomatic and asymptomatic patients with CeD before and during the COVID-19 lockdown in Italy. Methods Thirty adult CeD patients on a gluten-free diet (GFD) were enrolled before and during the COVID-19 lockdown through follow-up visits or remote consultation. Patients underwent anthropometrical evaluation, dietetic interview, and State-Trait Anxiety Inventory (STAI). Then, two groups were formed: symptomatic and worried about gluten contamination. Each patient received 5 GIP point-of-care tests to perform a maximum of 5 times in the following 5 weeks in case of symptoms or anxiety state due to hypothesized gluten contamination. Results Sixteen symptomatic patients and 14 patients with concerns related to gluten contamination were included. There were no differences in age, BMI, compliance to GFD and GIP positive tests between the two groups. Worried group showed a borderline higher level of anxiety than symptomatic group (p = 0.06), with a significant minor percentage of patients reporting “no or low anxiety” (14.3% vs 50% p = 0.03). The symptomatic patients showed a higher rate of diarrhea than worried group (25% vs 0%, p = 0.04). Gluten in urine samples was globally found in 8 out of 30 cases (26.6%). Conclusion The GIP test is a tool that can be used as a point of care test to assess adequate compliance with GFD and reassure symptomatic CeD patients from the feeling of anxiety for gluten contamination, especially during the COVID-19 pandemic.
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Affiliation(s)
- Carolina Ciacci
- Celiac Center at Department of Medicine, Surgery, and Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Mario Gagliardi
- Celiac Center at Department of Medicine, Surgery, and Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Monica Siniscalchi
- Celiac Center at Department of Medicine, Surgery, and Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Monica Ruotolo
- Celiac Center at Department of Medicine, Surgery, and Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Antonella Santonicola
- Celiac Center at Department of Medicine, Surgery, and Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Najla Hajji
- Celiac Center at Department of Medicine, Surgery, and Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Fabiana Zingone
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Rej A, Aziz I, Sanders DS. Personalizing Dietary Therapies For Irritable Bowel Syndrome: What Is Gluten's Role? Clin Gastroenterol Hepatol 2021; 19:2270-2273. [PMID: 33069879 DOI: 10.1016/j.cgh.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Anupam Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital, NHS Foundation Trust, Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Imran Aziz
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital, NHS Foundation Trust, Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital, NHS Foundation Trust, Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Coto L, Mendia I, Sousa C, Bai JC, Cebolla A. Determination of gluten immunogenic peptides for the management of the treatment adherence of celiac disease: A systematic review. World J Gastroenterol 2021; 27:6306-6321. [PMID: 34712034 PMCID: PMC8515793 DOI: 10.3748/wjg.v27.i37.6306] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/28/2021] [Accepted: 09/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gluten is a complex mixture of proteins with immunogenic peptide sequences triggering the autoimmune activity in patients with celiac disease (CeD). Gluten immunogenic peptides (GIP) are resistant to gastrointestinal digestion and are then excreted via the stool and urine. Most common detection methods applied in the follow-up visits for CeD patients such as serology tests, dietetic interviews, questionnaires, and duodenal biopsy have been proved to be inefficient, invasive, or inaccurate for evaluating gluten-free diet (GFD) compliance. Determination of excreted GIP in stool and urine has been developed as a non-invasive, direct, and specific test for GFD monitoring.
AIM To summarize published literature about the clinical utility of GIP determination in comparison to the tools employed for GFD monitoring.
METHODS PubMed and Web of Science searches were performed using the keywords “gluten immunogenic peptides” or “gluten immunogenic peptide” and a combination of the previous terms with “feces”, “stools”, “urine”, “celiac disease”, “gluten-free diet”, and “adherence” to identify relevant clinical studies published in English and Spanish between 2012 to January 2021. Reference lists from the articles were reviewed to identify additional pertinent articles. Published articles and abstracts reporting the clinical use of GIP determination in stool and/or urine for the follow-up of patients with CeD in comparison with other tools in use were included. Case reports, commentaries, reviews, conference papers, letters, and publications that did not focus on the aims of this review were excluded.
RESULTS Total of 15 publications were found that involved the use of GIP determination in stool and/or urine to monitor the adherence to the GFD in comparison to other tools. Studies included both children and adults diagnosed with CeD and healthy volunteers. Overall, these preliminary studies indicated that this novel technique was highly sensitive for the detection of GFD transgressions and therefore could facilitate the follow-up of patients with CeD. Tools identified in this work included the CeD-specific serology, dietetic questionnaires, symptomatology, and the duodenal biopsy. Review of the literature revealed that the rates of GFD adherence may vary between 30%-93% using either stool or urine GIP determination, 49%-96% by the serology, 59%-94% using the dietetic questionnaires, 56%-95% by the reported symptoms and 44%-76% with the duodenal biopsy. In addition, the association between the different methods and histological abnormalities (Marsh II-III) was found to be 33%-100% for GIP determination (stool and urine), 25%-39% for CeD-specific serology, 3%-50% for dietetic questionnaires, and 22%-28% for the symptomatology.
CONCLUSION Excreted GIP detection is the precise approach for determining voluntary or involuntary gluten consumption in CeD patients preventing future complications arising from gluten exposure.
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Affiliation(s)
- Laura Coto
- Research and Development, Biomedal, Camas 41900, Seville, Spain
- Human Nutrition and Food Science Doctoral Program, University of Granada, Granada 18011, Spain
| | - Irati Mendia
- Research and Development, Biomedal, Camas 41900, Seville, Spain
- Molecular Biology, Biomedicine and Clinical Research Doctoral Program, University of Seville, Seville 41012, Spain
| | - Carolina Sousa
- Department of Microbiology and Parasitology, University of Seville, Seville 41013, Spain
| | - Julio César Bai
- Department of Gastroenterology, Dr. Carlos Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
- Research Institutes, Universidad del Salvador, Buenos Aires 1050, Argentina
| | - Angel Cebolla
- Research and Development, Biomedal, Camas 41900, Seville, Spain
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Monachesi C, Verma AK, Catassi GN, Franceschini E, Gatti S, Gesuita R, Lionetti E, Catassi C. Determination of Urinary Gluten Immunogenic Peptides to Assess Adherence to the Gluten-Free Diet: A Randomized, Double-Blind, Controlled Study. Clin Transl Gastroenterol 2021; 12:e00411. [PMID: 34613954 PMCID: PMC8500619 DOI: 10.14309/ctg.0000000000000411] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/22/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The adherence to a gluten-free diet (GFD) is a trending topic in the management of celiac disease. The aim of our study was to evaluate the diagnostic performance of urinary gluten immunogenic peptides (GIP) determination to detect gluten contamination of the GFD. METHODS In study A, 25 healthy adults on a standard GFD performed 6 gluten challenges (0, 10, 50, 100, 500, and 1,000 mg) with quantification of urinary GIP before (T0) and during the following 24 hours. In study B, 12 participants on a gluten contamination elimination diet underwent urinary GIP determination at T0 and after challenge with 5 or 10 mg gluten. Urine GIP concentration was determined by an immunochromatographic assay. RESULTS In study A, 51 of 150 baseline urine samples were GIP+ on GFD and 7 of 17 were GIP+ after the zero-gluten challenge, whereas only 55 of 81 were GIP+ after the 10-1,000 mg gluten challenges. There was no significant change in the 24-hour urinary GIP when increasing gluten from 10 to 1,000 mg. In study B, 24 of 24 baseline urine samples were GIP-, whereas 8 of 24 were GIP+ after 5 or 10 mg of gluten. DISCUSSION Traces of gluten in the standard GFD may cause positivity of urinary GIP determination, whereas a false negativity is common after a gluten intake of 10-1,000 mg. Owing to the impossibility of standardizing the test in normal conditions, it seems unlikely that urinary GIP determination may represent a reliable tool to assess the compliance to the GFD of patients with celiac disease or other gluten-related disorders.
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Affiliation(s)
- Chiara Monachesi
- Celiac Disease Research Laboratory, Polytechnic University of Marche, Ancona, Italy
| | - Anil K. Verma
- Celiac Disease Research Laboratory, Polytechnic University of Marche, Ancona, Italy
| | - Giulia N. Catassi
- Division of Pediatrics, DISCO Department, Polytechnic University of Marche, Ancona, Italy
| | - Elisa Franceschini
- Division of Pediatrics, DISCO Department, Polytechnic University of Marche, Ancona, Italy
| | - Simona Gatti
- Division of Pediatrics, DISCO Department, Polytechnic University of Marche, Ancona, Italy
| | - Rosaria Gesuita
- Center of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | - Elena Lionetti
- Division of Pediatrics, DISCO Department, Polytechnic University of Marche, Ancona, Italy
| | - Carlo Catassi
- Division of Pediatrics, DISCO Department, Polytechnic University of Marche, Ancona, Italy
- Mucosal Immunology and Biology Research Center, Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, Boston, USA
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Affiliation(s)
- Tracy R Ediger
- Department of Clinical Pediatrics, The Ohio State College of Medicine, and Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Ivor D Hill
- Department of Clinical Pediatrics, The Ohio State College of Medicine, and Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
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Lerner A, Freire de Carvalho J, Kotrova A, Shoenfeld Y. Gluten-free diet can ameliorate the symptoms of non-celiac autoimmune diseases. Nutr Rev 2021; 80:525-543. [PMID: 34338776 DOI: 10.1093/nutrit/nuab039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/05/2021] [Accepted: 05/12/2021] [Indexed: 11/12/2022] Open
Abstract
CONTEXT A gluten-free diet (GFD) is the recommended treatment for gluten-dependent disease. In addition, gluten withdrawal is popular and occasionally is suggested as a treatment for other autoimmune diseases (ADs). OBJECTIVE The current systematic review summarizes those entities and discusses the logic behind using a GFD in classical non-gluten-dependentADs. DATA SOURCES A search for medical articles in PubMed/MEDLINE, Web of Sciences, LILACS, and Scielo published between 1960 and 2020 was conducted, using the key words for various ADs and GFDs. DATA EXXTRACTION Eight-three articles were included in the systematic review (using PRISMA guidelines). DATA ANALYSIS Reduction in symptoms of ADs after observance of a GFD was observed in 911 out of 1408 patients (64.7%) and in 66 out of the 83 selected studies (79.5%). The age of the patients ranged from 9 months to 69 years. The duration of the GFD varied from 1 month to 9 years. A GFD can suppress several harmful intraluminal intestinal events. Potential mechanisms and pathways for the action of GFD in the gut - remote organs' axis have been suggested. CONCLUSION A GFD might represent a novel nutritional therapeutic strategy for classical non-gluten-dependent autoimmune conditions.
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Affiliation(s)
- Aaron Lerner
- A. Lerner and Y. Shoenfeld are with the The Zabludowicz Research Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel Hashomer, Israel. J. Freire de Carvalho is with the Department of Rheumatology, Institute for Health Sciences of the Federal University of Bahia, Salvador, Bahia, Brazil. A. Kotrova and Y. Shoenfeld are with the Department of Autoimmune research, Saint Petersburg State University, St. Petersburg, Russia. Y. Shoenfeld is with the Department of Administration, Ariel University, Israel. Y. Shoenfeld is with the Department of Autoimmune research, I.M Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Jozélio Freire de Carvalho
- A. Lerner and Y. Shoenfeld are with the The Zabludowicz Research Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel Hashomer, Israel. J. Freire de Carvalho is with the Department of Rheumatology, Institute for Health Sciences of the Federal University of Bahia, Salvador, Bahia, Brazil. A. Kotrova and Y. Shoenfeld are with the Department of Autoimmune research, Saint Petersburg State University, St. Petersburg, Russia. Y. Shoenfeld is with the Department of Administration, Ariel University, Israel. Y. Shoenfeld is with the Department of Autoimmune research, I.M Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Anna Kotrova
- A. Lerner and Y. Shoenfeld are with the The Zabludowicz Research Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel Hashomer, Israel. J. Freire de Carvalho is with the Department of Rheumatology, Institute for Health Sciences of the Federal University of Bahia, Salvador, Bahia, Brazil. A. Kotrova and Y. Shoenfeld are with the Department of Autoimmune research, Saint Petersburg State University, St. Petersburg, Russia. Y. Shoenfeld is with the Department of Administration, Ariel University, Israel. Y. Shoenfeld is with the Department of Autoimmune research, I.M Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Yehuda Shoenfeld
- A. Lerner and Y. Shoenfeld are with the The Zabludowicz Research Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel Hashomer, Israel. J. Freire de Carvalho is with the Department of Rheumatology, Institute for Health Sciences of the Federal University of Bahia, Salvador, Bahia, Brazil. A. Kotrova and Y. Shoenfeld are with the Department of Autoimmune research, Saint Petersburg State University, St. Petersburg, Russia. Y. Shoenfeld is with the Department of Administration, Ariel University, Israel. Y. Shoenfeld is with the Department of Autoimmune research, I.M Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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Coto L, Sousa C, Cebolla A. Dynamics and Considerations in the Determination of the Excretion of Gluten Immunogenic Peptides in Urine: Individual Variability at Low Gluten Intake. Nutrients 2021; 13:2624. [PMID: 34444783 PMCID: PMC8398346 DOI: 10.3390/nu13082624] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/20/2021] [Accepted: 07/26/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND A lifelong strict gluten-free diet is the only available treatment for celiac disease, but total exclusion of gluten is difficult to achieve. The aim of this study was to determine the range of time and the amount of gluten immunogenic peptides (GIP) excreted in urine after specific gluten ingestions. METHODS 20 healthy participants followed the same diet for 12 days in which 50 mg and 2 g of gluten were ingested and all the urinations were collected. GIP were analyzed by lateral flow immunoassay (LFIA) tests and quantified using an LFIA reader. RESULTS GIP were detected in 15% and 95% of participants after 50 mg and 2 g gluten intakes, respectively. The higher frequency and concentration of GIP was found between 6 and 9 h after both gluten ingestions. The ranges of detection were 3-12 h (50 mg) and 0-15 h (2 g). CONCLUSIONS An increase in the frequency of urine tests may be a suitable approach to avoid false negative results. The use of the LFIA test in three urine samples collected at different times may show a sensitivity of 19.6% for a gluten ingestion like 50 mg, increasing to 93% after 2 g consumption.
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Affiliation(s)
- Laura Coto
- Biomedal S.L., 41900 Seville, Spain;
- Human Nutrition and Food Science Doctoral Program, University of Granada, 18011 Granada, Spain
| | - Carolina Sousa
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, 41012 Seville, Spain;
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Pobłocki J, Pańka T, Szczuko M, Telesiński A, Syrenicz A. Whether a Gluten-Free Diet Should Be Recommended in Chronic Autoimmune Thyroiditis or Not?-A 12-Month Follow-Up. J Clin Med 2021; 10:3240. [PMID: 34362024 PMCID: PMC8347530 DOI: 10.3390/jcm10153240] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 01/08/2023] Open
Abstract
Elimination diets have recently become extremely popular among people with autoimmune diseases. A gluten-free diet is indicated in celiac disease (CD), but some studies show its effectiveness in cases of autoimmunity. The aim of this study was to assess whether the use of a gluten-free diet is also effective in patients with chronic autoimmune thyroid disease (cAITD), which is the most common thyroid autoimmune pathology associated with chronic inflammation, over-reactivity of the immune system, auto-destruction of thyrocytes and hypothyroidism. The final analysis of the study included 62 Caucasian women randomized into a control group (CG: n = 31) and an experimental group on a gluten-free diet (GFDG: n = 31), were subject to a 12-month follow-up, during which the concentrations of thyrotropin (TSH), free triiodothyronine (fT3), free thyroxine (fT4), anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-TG) antibodies were assessed at baseline and after 3, 6 and 12 months. During the 12-month follow-up between the CG and the GFDG, no differences were found in anti-TPO and anti-TG antibodies, fT3 or fT4 levels, except a significant reduction in TSH levels in the GFDG. Additionally, performed analysis between individual appointments presented no significant differences in changes in the median concentrations of anti-TPO, anti-TG or fT3, but confirmed a significant decrease in TSH and showed accessory an increase in fT4 after 12 months in GFDG. Statistical analyses performed separately for both groups indicated a constant reduction of anti-TG concentrations in the GFDG. In conclusion, a GFD may be administered in cAITD after ruling out celiac disease, but it is necessary to perform more studies to assess if cAITD patients achieve the benefits of following a GFD. Patients with cAITD should be offered proper nutrition education combined with a healthy lifestyle promotion.
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Affiliation(s)
- Jakub Pobłocki
- Department of Endocrinology, Metabolic Diseases and Internal Diseases, Pomeranian Medical University, 70-252 Szczecin, Poland; (T.P.); (A.S.)
| | - Tamara Pańka
- Department of Endocrinology, Metabolic Diseases and Internal Diseases, Pomeranian Medical University, 70-252 Szczecin, Poland; (T.P.); (A.S.)
| | - Małgorzata Szczuko
- Department of Human Nutrition and Metabolomic, Pomeranian Medical University, 71-460 Szczecin, Poland
| | - Arkadiusz Telesiński
- Department of Bioengineering, Faculty of Environmental Management and Agriculture, West Pomeranian University of Technology, 71-434 Szczecin, Poland;
| | - Anhelli Syrenicz
- Department of Endocrinology, Metabolic Diseases and Internal Diseases, Pomeranian Medical University, 70-252 Szczecin, Poland; (T.P.); (A.S.)
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Wieser H, Ruiz-Carnicer Á, Segura V, Comino I, Sousa C. Challenges of Monitoring the Gluten-Free Diet Adherence in the Management and Follow-Up of Patients with Celiac Disease. Nutrients 2021; 13:2274. [PMID: 34209138 PMCID: PMC8308436 DOI: 10.3390/nu13072274] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/24/2021] [Accepted: 06/26/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Carolina Sousa
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, 41012 Seville, Spain; (Á.R.-C.); (V.S.); (I.C.)
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Segura V, Ruiz-Carnicer Á, Sousa C, Moreno MDL. New Insights into Non-Dietary Treatment in Celiac Disease: Emerging Therapeutic Options. Nutrients 2021; 13:2146. [PMID: 34201435 PMCID: PMC8308370 DOI: 10.3390/nu13072146] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 02/07/2023] Open
Abstract
To date, the only treatment for celiac disease (CD) consists of a strict lifelong gluten-free diet (GFD), which has numerous limitations in patients with CD. For this reason, dietary transgressions are frequent, implying intestinal damage and possible long-term complications. There is an unquestionable need for non-dietary alternatives to avoid damage by involuntary contamination or voluntary dietary transgressions. In recent years, different therapies and treatments for CD have been developed and studied based on the degradation of gluten in the intestinal lumen, regulation of the immune response, modulation of intestinal permeability, and induction of immunological tolerance. In this review, therapeutic lines for CD are evaluated with special emphasis on phase III and II clinical trials, some of which have promising results.
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Affiliation(s)
| | | | | | - María de Lourdes Moreno
- Departamento de Microbiología y Parasitología, Facultad de Farmacia, Universidad de Sevilla, 41012 Sevilla, Spain; (V.S.); (Á.R.-C.); (C.S.)
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Study of adherence to the gluten-free diet in coeliac patients. An Pediatr (Barc) 2021; 94:377-384. [PMID: 34090634 DOI: 10.1016/j.anpede.2020.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/11/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The following of a strict gluten-free diet (GFD) is essential in the control of coeliac disease. The aim of this study was to determine the adherence to a GFD in coeliac patients and to evaluate the factors that could influence this adherence. MATERIAL AND METHODS A descriptive observational study was carried out, in which gluten immunogenic peptides (GIP) were determined in faeces using a semi-quantitative method, and the Coeliac Dietary Adherence Test was completed. Sociodemographic and clinical details were collected, and an ad hoc questionnaire was prepared. RESULTS Of the 80 patients included, 92.5% were adherent according to the GIP and 86.3% according to Coeliac Dietary Adherence Test (acceptable agreement; Kappa: 0.31, P = .004). The large majority (83.3%) of patients with positive GIP gave negative anti-transglutaminase antibodies in the latest determination. Current age and time of onset were significantly associated with adherence. Those with a positive GIP had a mean age of 5 years more (P = .0001) and were 52 months more on a GFD (P = .025). One quarter of those surveyed considered the diet difficult to follow. Just under two-thirds (60%) considered that the variability in the eating site was an important factor in leading to infringements, with children's parties being the main area where they occurred (66.7%). The lack of variety (61.4%) and the increased cost (98.6%) of gluten-free foods is highlighted. CONCLUSIONS The adherence to the GFD is generally good. The analysis of GIP helps to detect non-adherent patients that would pass unnoticed in other circumstances. Measures must be established in order to maintain good long-term adherence, taking into account the risk factors and difficulties detected.
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The utility of faecal and urine biomarkers for small bowel diseases. Curr Opin Gastroenterol 2021; 37:284-294. [PMID: 33769381 DOI: 10.1097/mog.0000000000000730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Small bowel diseases pose a unique diagnostic and management challenge and often requires tertiary specialist referral. The use of biomarkers may provide a cheap, noninvasive tool to assess the small bowel in terms of diagnosis, offering a better way to triage referrals and select patients for early management. This review looks at the most recent evidence behind the use of several faecal and urine biomarkers for small bowel diseases. RECENT FINDINGS Faecal calprotectin shows the most promise, with evidence to support its role in predicting relapse postsurgery and monitoring treatment response in patients with Crohn's disease. A faecal calprotectin less than 50 μg/g may also be used as a cut-off to triage further investigation. Faecal lactoferrin also appears promising as a marker of small bowel inflammation. A positive faecal immunohistochemistry test precapsule may help to prioritize referrals for obscure bleeding. SUMMARY The use of biomarkers in the diagnosis and management of small bowel disease is still controversial and remains unclear. More studies are required to further develop their potential and before societal guidelines can be developed to direct their appropriate use in clinical practice.
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Persistent Villous Atrophy in De Novo Adult Patients With Celiac Disease and Strict Control of Gluten-Free Diet Adherence: A Multicenter Prospective Study (CADER Study). Am J Gastroenterol 2021; 116:1036-1043. [PMID: 33491958 DOI: 10.14309/ajg.0000000000001139] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION A substantial proportion of adult patients with celiac disease on a gluten-free diet exhibit persistent villous atrophy, and inadvertent gluten exposure may be one of the causes. The aim of the present study was to evaluate villous atrophy persistence after 2 years on a gluten-free diet in de novo adult patients with celiac disease with strict control of gluten exposure. METHODS Symptomatic de novo adult patients with celiac disease were prospectively included. Clinical visits and dietary surveillance were scheduled every 6 months during a 2-year follow-up period. At each visit, fecal samples were collected and stored at -20 °C until analysis for gluten immunogenic peptides (f-GIPs). A follow-up duodenal biopsy was performed at 2 years. We evaluated the variables associated with persistent villous atrophy. RESULTS Seventy-six patients completed the study (36.5 ± 1.6 years, 73% women); persistent villous atrophy was observed in 40 (53%), whereas 72.5% were asymptomatic and 75% had negative serology. Detectable f-GIP >0.08 μg/g in at least 1 fecal sample was seen in 69% of patients. There were no significant differences in the median f-GIP at each visit and median area under the curve over the serial measurements between patients with persistent villous atrophy and those who recovered. On multivariate analysis, only older age was associated with persistent villous atrophy (32% for 16-30 years; 67% for >30 years; P = 0.016). DISCUSSION The rate of persistent villous atrophy after 2 years was high in adult patients with celiac disease on an intentionally strict gluten-free diet. Low-level ongoing inadvertent gluten exposure could be a contributing factor to persistent villous atrophy.
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Costantino A, Roncoroni L, Noviello D, Nandi N, Lombardo V, Scricciolo A, Scaramella L, Vecchi M, Elli L. Nutritional and Gastroenterological Monitoring of Patients With Celiac Disease During COVID-19 Pandemic: The Emerging Role of Telemedicine and Point-of-Care Gluten Detection Tests. Front Nutr 2021; 8:622514. [PMID: 33928109 PMCID: PMC8076748 DOI: 10.3389/fnut.2021.622514] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/11/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Aims: Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, telemedicine has been supporting many patients with chronic diseases worldwide. However, data on celiac disease (CeD) nutritional and gastroenterological remote monitoring are scanty. The aims of our study were to verify patients' trust in telemedicine and to evaluate the feasibility of telemedicine in nutritional monitoring. Material and Methods: We used telemedicine in place of the scheduled but not provided follow-up visits during the first lockdown of the COVID-19 pandemic. Patients received a phone call, and televisits were conducted for CeD patients with mild or moderate symptoms and/or with blood alterations. The patient's adherence to the gluten-free diet (GFD) was evaluated according to the Celiac Dietary Adherence Test (CDAT). When gluten contamination was suspected, a point-of-care gluten detection test was prescribed. The patient's trust in telemedicine was assessed, through an adapted version of the Patient Trust Assessment Tool (PATAT) questionnaire, as the percentage of patients giving a score of at least 4 out of 5 on a Likert scale for three selected key statements: "I can trust televisit," "I can trust that possible problems with the telemedicine service will be solved properly," and "I feel at ease when working with this website." Results: One hundred and twelve CeD patients were phone called; among symptomatic patients, 39 out of the 42 scheduled (92.9%) televisits were performed. Among the 39 visits, 34 (87.2%) questionnaires were compiled. The patients included in the study obtained a CDAT score from 7 to 13 (11 ± 2). Gluten detection tests were prescribed to 11 patients, resulting positive in 2. Trust in the telemedicine service was achieved in 94.1, 88.2, and 97.1% for the three selected key statements of the PATAT questionnaire. Conclusion: During the COVID-19 pandemic, telemedicine showed to be feasible and the majority of patients trusted the combined gastroenterological and nutritional televisits. Gluten detection tests demonstrated to be useful tools for the patient and for the caregiver to confirm adherence to the GFD remotely.
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Affiliation(s)
- Andrea Costantino
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Leda Roncoroni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy
| | - Daniele Noviello
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Nicoletta Nandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Vincenza Lombardo
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Scricciolo
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lucia Scaramella
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Luca Elli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Lerner A, Benzvi C. "Let Food Be Thy Medicine": Gluten and Potential Role in Neurodegeneration. Cells 2021; 10:756. [PMID: 33808124 PMCID: PMC8065505 DOI: 10.3390/cells10040756] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 12/12/2022] Open
Abstract
Wheat is a most favored staple food worldwide and its major protein is gluten. It is involved in several gluten dependent diseases and lately was suggested to play a role in non-celiac autoimmune diseases. Its involvement in neurodegenerative conditions was recently suggested but no cause-and-effect relationship were established. The present narrative review expands on various aspects of the gluten-gut-brain axes events, mechanisms and pathways that connect wheat and gluten consumption to neurodegenerative disease. Gluten induced dysbiosis, increased intestinal permeabillity, enteric and systemic side effects, cross-reactive antibodies, and the sequence of homologies between brain antigens and gluten are highlighted. This combination may suggest molecular mimicry, alluding to some autoimmune aspects between gluten and neurodegenerative disease. The proverb of Hippocrates coined in 400 BC, "let food be thy medicine," is critically discussed in the frame of gluten and potential neurodegeneration evolvement.
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Affiliation(s)
- Aaron Lerner
- Chaim Sheba Medical Center, The Zabludowicz Research Center for Autoimmune Diseases, Tel Hashomer 5262000, Israel;
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Stefanolo JP, Tálamo M, Dodds S, de la Paz Temprano M, Costa AF, Moreno ML, Pinto-Sánchez MI, Smecuol E, Vázquez H, Gonzalez A, Niveloni SI, Mauriño E, Verdu EF, Bai JC. Real-World Gluten Exposure in Patients With Celiac Disease on Gluten-Free Diets, Determined From Gliadin Immunogenic Peptides in Urine and Fecal Samples. Clin Gastroenterol Hepatol 2021; 19:484-491.e1. [PMID: 32217152 DOI: 10.1016/j.cgh.2020.03.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear how often patients who are on gluten-free diets (GFDs) for treatment of celiac disease still are exposed to gluten. We studied levels of gluten immunogenic peptides (GIP) in fecal and urine samples, collected over 4 weeks, from patients with celiac disease on a long-term GFD. METHODS We performed a prospective study of 53 adults with celiac disease who had been on a GFD for more than 2 years (median duration, 8 y; interquartile range, 5-12 y) in Argentina. At baseline, symptoms were assessed by the celiac symptom index questionnaire. Patients collected stool each Friday and Saturday and urine samples each Sunday for 4 weeks. We used a commercial enzyme-linked immunosorbent assay to measure GIP in stool and point-of-care tests to measure GIP in urine samples. RESULTS Overall, 159 of 420 stool and urine samples (37.9%) were positive for GIP; 88.7% of patients had at least 1 fecal or urine sample that was positive for GIP (median, 3 excretions). On weekends (urine samples), 69.8% of patients excreted GIP at least once, compared with 62.3% during weekdays (stool). The number of patients with a sample that was positive for GIP increased over the 4-week study period (urine samples in week 1 vs week 4: P < .05). Patients with symptoms had more weeks in which GIP was detected in stool than patients without symptoms (P < .05). The number of samples that were positive for GIP correlated with titers of deamidated gliadin peptide IgA in patients' blood samples, but not with levels of tissue transglutaminase. CONCLUSIONS Patients with celiac disease on a long-term GFD still frequently are exposed to gluten. Assays to detect GIP in stool and urine might be used to assist dietitians in assessment of GFD compliance.
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Affiliation(s)
| | - Martín Tálamo
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Samanta Dodds
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | | | | | - María Laura Moreno
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - María Inés Pinto-Sánchez
- Farncombe Family Digestive Health Research Institute, McMaster University Medical Centre, Health Sciences, Hamilton, Ontario, Canada
| | - Edgardo Smecuol
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Horacio Vázquez
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Andrea Gonzalez
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | | | - Eduardo Mauriño
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Elena F Verdu
- Farncombe Family Digestive Health Research Institute, McMaster University Medical Centre, Health Sciences, Hamilton, Ontario, Canada
| | - Julio César Bai
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina; Research Institutes of Health, Universidad del Salvador, Buenos Aires, Argentina.
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43
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Villavicencio Kim J, Wu GY. Celiac Disease and Elevated Liver Enzymes: A Review. J Clin Transl Hepatol 2021; 9:116-124. [PMID: 33604262 PMCID: PMC7868701 DOI: 10.14218/jcth.2020.00089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/08/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023] Open
Abstract
Aminotransferases are commonly found to be elevated in patients with celiac disease in association with two different types of liver dysfunction: cryptogenic liver disorders and autoimmune disorders. The purpose of this review is to discuss the mechanisms by which aminotransferases become elevated in celiac disease, clinical manifestations, and response to gluten-free diet. Many studies have shown that celiac patients with cryptogenic liver disease have normalization in aminotransferases, intestinal histologic improvement and serologic resolution after 6-12 months of strict gluten-free diet. In patients with an underlying autoimmune liver disease, simultaneous treatment for both conditions resulted in normalized elevated aminotransferases. The literature suggests that intestinal permeability may be at least one of the mechanisms by which liver damage occurs. Patients with celiac disease should have liver enzymes routinely checked and treated with a strict gluten-free diet if found to be abnormal. Lack of improvement in patients who have strictly adhered to gluten-free diet should prompt further workup for other causes of liver disease.
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Affiliation(s)
- Jaimy Villavicencio Kim
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
- Correspondence to: Jaimy Villavicencio Kim, Department of Medicine, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06032, USA. Tel: +1-860-899-8739, E-mail:
| | - George Y. Wu
- Division of GastroenterologyHepatology, University of Connecticut Health Center, Farmington, CT, USA
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Iorfida D, Valitutti F, Vestri A, Di Rocco A, Cucchiara S, Lubrano R, Montuori M. Dietary Compliance and Quality of Life in Celiac Disease: A Long-Term Follow-Up of Primary School Screening-Detected Patients. Front Pediatr 2021; 9:787938. [PMID: 34993165 PMCID: PMC8724911 DOI: 10.3389/fped.2021.787938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Whether the diagnostic approach for celiac disease (CD) can really affect quality of life (QoL) and dietary compliance remains controversial. Aims: This study aimed to evaluate QoL and compliance to gluten-free diet (GFD) in adolescents/young adults diagnosed with CD through a screening strategy during childhood compared to age-matched CD patients diagnosed by case-finding and to assess whether follow-up at a referral center for CD influences compliance and QoL. Materials and Methods: Thirty-seven CD patients who were diagnosed by screening programs (SC-group) and 38 age-matched CD patients diagnosed due to symptoms (CF-group) were enrolled. Patients were asked to answer a questionnaire on QoL, dietary compliance, and follow-up care for CD. Results: Twenty-nine patients of the SC-group (median age 18.0 years, interquartile range [IQR] 16.0-19.0) and 31 patients of the CF-group (median age 17.0 years, IQR 15.5-18.0) completed the questionnaire. No significant difference relating adherence to the GFD and QoL was shown between the two groups. The majority (93.5%) of CF-group regularly had annual follow-up at a referral center compared to 37.9% of the SC-group (p < 0.001). Conclusion: The diagnostic strategy does not seem to impact QoL and dietary compliance. However, implementation of follow-up might still be necessary for patients identified through screening.
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Affiliation(s)
- Donatella Iorfida
- Pediatric Gastroenterology and Liver Unit, Department of Maternal and Child Health, Sapienza-University of Rome, Rome, Italy
| | - Francesco Valitutti
- Pediatric Gastroenterology and Liver Unit, Department of Maternal and Child Health, Sapienza-University of Rome, Rome, Italy.,EBRIS (European Biomedical Research Institute of Salerno), Salerno, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy
| | - Arianna Di Rocco
- Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy
| | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Department of Maternal and Child Health, Sapienza-University of Rome, Rome, Italy
| | - Riccardo Lubrano
- Pediatrics and Neonatology Unit, Department of Maternal and Child Health, Santa Maria Goretti Hospital, Sapienza-University of Rome, Latina, Italy
| | - Monica Montuori
- Pediatric Gastroenterology and Liver Unit, Department of Maternal and Child Health, Sapienza-University of Rome, Rome, Italy
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45
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Ruiz-Carnicer Á, Garzón-Benavides M, Fombuena B, Segura V, García-Fernández F, Sobrino-Rodríguez S, Gómez-Izquierdo L, Montes-Cano MA, Rodríguez-Herrera A, Millán R, Rico MC, González-Naranjo C, Bozada-García JM, Díaz J, Coronel-Rodríguez C, Espín B, Romero-Gómez M, Cebolla Á, Sousa C, Comino I, Argüelles F, Pizarro Á. Negative predictive value of the repeated absence of gluten immunogenic peptides in the urine of treated celiac patients in predicting mucosal healing: new proposals for follow-up in celiac disease. Am J Clin Nutr 2020; 112:1240-1251. [PMID: 32692806 DOI: 10.1093/ajcn/nqaa188] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/15/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The treatment of celiac disease (CD) is a lifelong gluten-free diet (GFD). The current methods for monitoring GFD conformance, such as a dietary questionnaire or serology tests, may be inaccurate in detecting dietary transgressions, and duodenal biopsies are invasive, expensive, and not a routine monitoring technique. OBJECTIVES Our aim was to determine the clinical usefulness of urine gluten immunogenic peptides (GIP) as a biomarker monitoring GFD adherence in celiac patients and to evaluate the concordance of the results with the degree of mucosal damage. METHODS A prospective observational study was conducted involving 22 de novo CD patients, 77 celiac patients consuming a GFD, and 13 nonceliac subjects. On 3 d of the week, urine samples were collected and the GIP concentrations were tested. Simultaneously, anti-tissue transglutaminase antibodies, questionnaire results, clinical manifestations, and histological findings were analyzed. RESULTS Approximately 24% (18 of 76) of the celiac patients consuming a GFD exhibited Marsh II-III mucosal damage. Among this population, 94% (17 of 18) had detectable urine GIP; however, between 60% and 80% were asymptomatic and exhibited negative serology and appropriate GFD adherence based on the questionnaire. In contrast, 97% (31 of 32) of the celiac patients without duodenal damage had no detectable GIP. These results demonstrated the high sensitivity (94%) and negative predictive value (97%) of GIP measurements in relation to duodenal biopsy findings. In the de novo CD-diagnosed cohort, 82% (18 of 22) of patients had measurable amounts of GIP in the urine. CONCLUSIONS Determining GIP concentrations in several urine samples may be an especially convenient approach to assess recent gluten exposure in celiac patients and appears to accurately predict the absence of histological lesions. The introduction of GIP testing as an assessment technique for GFD adherence may help in ascertaining dietary compliance and to target the most suitable intervention during follow-up.
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Affiliation(s)
- Ángela Ruiz-Carnicer
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | - Marta Garzón-Benavides
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - Blanca Fombuena
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - Verónica Segura
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | | | | | | | - Marcos A Montes-Cano
- Institute of Biomedicine of Seville (IBiS), Seville, Spain; Faculty of Medicine, University of Seville, Seville, Spain
| | | | - Raquel Millán
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - María C Rico
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - Carmen González-Naranjo
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - Juan M Bozada-García
- Endoscopy of Digestive Diseases Clinical Unit, Virgen del Rocío Hospital, Seville, Spain
| | - Jacobo Díaz
- Clinical Analysis Service, Hospital Universitario INGESA, Ceuta, Spain
| | | | - Beatriz Espín
- Pediatric, Gastroenterology, Hepatology and Nutrition Section, Virgen del Rocio Children's Hospital, Seville, Spain
| | - Manuel Romero-Gómez
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | | | - Carolina Sousa
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | - Isabel Comino
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | - Federico Argüelles
- Digestive Diseases Clinical Unit, Virgen Macarena Hospital, Seville, Spain
| | - Ángeles Pizarro
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
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Abstract
PURPOSE OF REVIEW The current review is prompted by recent studies indicating that adaptive immunity could be sufficient to explain rapid onset symptoms as well as many chronic effects of gluten in celiac disease. RECENT FINDINGS Gluten re-exposure in treated celiac disease drives a coordinated systemic cytokine release response implicating T-cell activation within 2 h. Instead of direct effects of gluten on innate immunity, long lasting memory CD4+ T cells activated within 2 h of ingesting gluten or injecting purified gluten peptides now appear to be responsible for acute digestive symptoms. In addition, memory B cells and plasma cells specific for gluten and transglutaminase 2, rather than innate immune cells, are the preferred antigen-presenting cells for gluten in the gut. A variety of innate immune stimuli such as transient infections and local intestinal microbiome, not necessarily gluten itself, may contribute to disease initiation and transition to overt intestinal mucosal injury. Gluten-specific adaptive immunity in the gut and blood are now shown to be closely linked, and systemic cytokine release after gluten provides an additional explanation for extraintestinal manifestations of celiac disease. SUMMARY Clinical studies utilizing cytokines as new biomarkers for gluten immunity promise to improve understanding of clinical effects of gluten, accelerate therapeutics development, and augment diagnosis.
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47
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Rej A, Aziz I, Sanders DS. Coeliac disease and noncoeliac wheat or gluten sensitivity. J Intern Med 2020; 288:537-549. [PMID: 32573000 DOI: 10.1111/joim.13120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/15/2020] [Accepted: 04/21/2020] [Indexed: 12/15/2022]
Abstract
Coeliac disease (CD) and noncoeliac wheat or gluten sensitivity (NCWS/NCGS) are common gluten-related disorders. Both conditions can present with gastrointestinal and extraintestinal manifestations, which can be a challenge for physicians to discern between. Whilst coeliac serology and histological assessment are required for the diagnosis of CD, there are no clear biomarkers for the diagnosis of NCGS. The management of both conditions is with a gluten-free diet (GFD), although the duration, as well as strictness of adherence to a GFD in NCGS, is unclear. Adherence to a GFD in CD can also be challenging, with recent developments of noninvasive assessments, although histological assessment via duodenal biopsies remains the gold standard. The management of refractory coeliac disease remains particularly challenging, often requiring specialist input. Whilst wheat is noted to be a trigger for symptom generation in NCGS, it is unclear which components of wheat are responsible for symptom generation in this group, with further research required to elucidate the pathophysiology.
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Affiliation(s)
- A Rej
- From the, Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - I Aziz
- From the, Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, Academic Unit of Gastroenterology, University of Sheffield, Sheffield, UK
| | - D S Sanders
- From the, Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, Academic Unit of Gastroenterology, University of Sheffield, Sheffield, UK
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48
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Roca M, Donat E, Masip E, Crespo-Escobar P, Cañada-Martínez AJ, Polo B, Ribes-Koninckx C. Analysis of gluten immunogenic peptides in feces to assess adherence to the gluten-free diet in pediatric celiac patients. Eur J Nutr 2020; 60:2131-2140. [PMID: 33057793 DOI: 10.1007/s00394-020-02404-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/02/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE In celiac disease (CD) there is a need for precise and non-invasive tools to assess dietary compliance to the gluten-free diet (GFD). Our aim is to evaluate the efficacy of the detection of gluten immunogenic peptides (GIP) in feces, to monitor in real life, the adherence to GFD in pediatric patients with CD. METHODS A cross-sectional, prospective study was conducted. Fecal samples from CD children were analyzed by a rapid immunochromatographic (IC) test and by an ELISA method, both based on the antigliadin 33-mer monoclonal antibody. RESULTS Group 1 comprises 43 children on a GFD. According to the food records (FR), 39/43 patients were compliant with the GFD and gluten consumption was recorded in 4. GIP were detected in 15/43 individuals by the ELISA method and also in 7 by IC strips. Group 2: comprise 18 children at CD diagnosis; GIP levels decreased over time (p < 0.001) in a non-linear way (p = 0.028) after starting a GFD and were below the detection limit on the third day in most individuals. CONCLUSION GIP were detected, both by ELISA and by IC strips, in CD patients on a GFD, in which no consumption of gluten had been registered on the FR, confirming GIP detection to be superior to FR discovering involuntary transgressions. Despite a positive correlation between the amount of gluten intake and the concentration of GIP in feces, the interindividual variations observed suggest gastrointestinal factors influencing GIP recovery need to be further investigated.
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Affiliation(s)
- María Roca
- Celiac Disease and Digestive Immunopathology Unit, Instituto de Investigación Sanitaria La Fe, Avda. Fernando Abril Martorell, 106, P.O. Box 46026, Valencia, Spain.
| | - Ester Donat
- Celiac Disease and Digestive Immunopathology Unit, Instituto de Investigación Sanitaria La Fe, Avda. Fernando Abril Martorell, 106, P.O. Box 46026, Valencia, Spain.,Pediatric Gastrohepatology Unit, Hospital Universitario y Politécnico La Fe, P.O. Box 46026, Valencia, Spain
| | - Etna Masip
- Celiac Disease and Digestive Immunopathology Unit, Instituto de Investigación Sanitaria La Fe, Avda. Fernando Abril Martorell, 106, P.O. Box 46026, Valencia, Spain.,Pediatric Gastrohepatology Unit, Hospital Universitario y Politécnico La Fe, P.O. Box 46026, Valencia, Spain
| | - Paula Crespo-Escobar
- Celiac Disease and Digestive Immunopathology Unit, Instituto de Investigación Sanitaria La Fe, Avda. Fernando Abril Martorell, 106, P.O. Box 46026, Valencia, Spain.,Department of Health Science, Universidad Europea Miguel de Cervantes, P.O. Box 47012, Valladolid, Spain
| | | | - Begoña Polo
- Celiac Disease and Digestive Immunopathology Unit, Instituto de Investigación Sanitaria La Fe, Avda. Fernando Abril Martorell, 106, P.O. Box 46026, Valencia, Spain.,Pediatric Gastrohepatology Unit, Hospital Universitario y Politécnico La Fe, P.O. Box 46026, Valencia, Spain
| | - Carmen Ribes-Koninckx
- Celiac Disease and Digestive Immunopathology Unit, Instituto de Investigación Sanitaria La Fe, Avda. Fernando Abril Martorell, 106, P.O. Box 46026, Valencia, Spain.,Pediatric Gastrohepatology Unit, Hospital Universitario y Politécnico La Fe, P.O. Box 46026, Valencia, Spain
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Smecuol E, Constante M, Temprano MP, Costa AF, Moreno ML, Pinto-Sanchez MI, Vázquez H, Stefanolo JP, Gonzalez AF, D'Adamo CR, Niveloni SI, Mauriño E, Verdu EF, Bai JC. Effect of Bifidobacterium infantis NLS super strain in symptomatic coeliac disease patients on long-term gluten-free diet - an exploratory study. Benef Microbes 2020; 11:527-534. [PMID: 33032471 DOI: 10.3920/bm2020.0016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Bifidobacterium infantis NLS super strain (B. infantis NLS-SS) was previously shown to alleviate gastrointestinal symptoms in newly diagnosed coeliac disease (CD) patients consuming gluten. A high proportion of patients following a gluten-free diet experiences symptoms despite dietary compliance. The role of B. infantis in persistently symptomatic CD patients has not been explored. The aim of the study was to evaluate the effect of B. infantis NLS-SS on persistent gastrointestinal symptoms in patients with CD following a long-term GFD. We conducted a randomised, cross-over, double-blind, placebo-controlled trial in symptomatic adult CD patients on a GFD for at least two years. After one-week run-in, patients were randomised to B. infantis NLS-SS or placebo for 3 weeks with cross-over after a 2-week wash-out period. We estimated changes (Δ) in celiac symptom index (CSI) before and after treatment. Stool samples were collected for faecal microbiota analysis (16S rRNA sequencing). Gluten immunogenic peptide (GIP) excretion in stool and urine samples was measured at each study period. Eighteen patients were enrolled; six patients were excluded due violations in protocol. For patients with the highest clinical burden, CD symptoms were lower in probiotic than in placebo treatment (P=0.046). B. infantis and placebo treated groups had different microbiota profiles as assessed by beta diversity clustering. In probiotic treated groups, we observed an increase in abundance of B. infantis. Treatment with B. infantis was associated with decreased abundance of Ruminococcus sp. and Bifidobacterium adolescentis. GIP excretion in stools and urine was similar at each treatment period. There were no differences in adverse effects between the two groups. B. infantis NLS-SS improves specific CD symptoms in a subset of highly symptomatic treated patients (GFD). This is associated with a shift in stool microbiota profile. Larger studies are needed to confirm these findings. ClinicalTrials.gov: NCT03271138.
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Affiliation(s)
- E Smecuol
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina
| | - M Constante
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - M P Temprano
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina
| | - A F Costa
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina
| | - M L Moreno
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina
| | - M I Pinto-Sanchez
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - H Vázquez
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina
| | - J P Stefanolo
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina
| | - A F Gonzalez
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina
| | - C R D'Adamo
- University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - S I Niveloni
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina
| | - E Mauriño
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina
| | - E F Verdu
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - J C Bai
- Dr. C. Bonorino Udaondo Gastroenterology Hospital, Av. Caseros 2061, 1264 Buenos Aires, Argentina.,Research Institutes, School of Medicine; Universidad del Salvador, Buenos Aires, Argentina
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50
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Abstract
INTRODUCTION The following of a strict gluten-free diet (GFD) is essential in the control of coeliac disease. The aim of this study was to determine the adherence to a GFD in coeliac patients and to evaluate the factors that could influence this adherence. MATERIAL AND METHODS A descriptive observational study was carried out, in which gluten immunogenic peptides (GIP) were determined in faeces using a semi-quantitative method, and the Coeliac Dietary Adherence Test was completed. Sociodemographic and clinical details were collected, and an ad hoc questionnaire was prepared. RESULTS Of the 80 patients included, 92.5% were adherent according to the GIP and 86.3% according to Coeliac Dietary Adherence Test (acceptable agreement; Kappa: 0.31, P=.004). The large majority (83.3%) of patients with positive GIP gave negative anti-transglutaminase antibodies in the latest determination. Current age and time of onset were significantly associated with adherence. Those with a positive GIP had a mean age of 5 years more (P=.0001) and were 52 months more on a GFD (P=.025). One quarter of those surveyed considered the diet difficult to follow. Just under two-thirds (60%) considered that the variability in the eating site was an important factor in leading to infringements, with children's parties being the main area where they occurred (66.7%). The lack of variety (61.4%) and the increased cost (98.6%) of gluten-free foods is highlighted. CONCLUSIONS The adherence to the GFD is generally good. The analysis of GIP helps to detect non-adherent patients that would pass unnoticed in other circumstances. Measures must be established in order to maintain good long-term adherence, taking into account the risk factors and difficulties detected.
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