Diagnosing celiac disease: A critical overview

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

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

The protective role of Lactobacillus rhamnosus GG postbiotic on the alteration of autophagy and inflammation pathways induced by gliadin in intestinal models

Celiac disease (CD) is an autoimmune enteropathy caused by an abnormal immune response to gliadin peptides in genetically predisposed individuals. For people with CD, the only available therapy thus far is the lifelong necessity for a gluten-free diet (GFD). Innovative therapies include probiotics and postbiotics as dietary supplements, both of which may benefit the host. Therefore, the present study aimed to investigate the possible beneficial effects of the postbiotic Lactobacillus rhamnosus GG (LGG) in preventing the effects induced by indigested gliadin peptides on the intestinal epithelium. In this study, these effects on the mTOR pathway, autophagic function, and inflammation have been evaluated. Furthermore, in this study, we stimulated the Caco-2 cells with the undigested gliadin peptide (P31-43) and with the crude gliadin peptic-tryptic peptides (PTG) and pretreated the samples with LGG postbiotics (ATCC 53103) (1 × 108). In this study, the effects induced by gliadin before and after pretreatment have also been investigated. The phosphorylation levels of mTOR, p70S6K, and p4EBP-1 were increased after treatment with PTG and P31-43, indicating that the intestinal epithelial cells responded to the gliadin peptides by activating the mTOR pathway. Moreover, in this study, an increase in the phosphorylation of NF-κβ was observed. Pretreatment with LGG postbiotic prevented both the activation of the mTOR pathway and the NF-κβ phosphorylation. In addition, P31-43 reduced LC3II staining, and the postbiotic treatment was able to prevent this reduction. Subsequently, to evaluate the inflammation in a more complex intestinal model, the intestinal organoids derived from celiac disease patient biopsies (GCD-CD) and controls (CTR) were cultured. Stimulation with peptide 31-43 in the CD intestinal organoids induced NF-κβ activation, and pretreatment with LGG postbiotic could prevent it. These data showed that the LGG postbiotic can prevent the P31-43-mediated increase in inflammation in both Caco-2 cells and in intestinal organoids derived from CD patients.

Rectal prolapse as a manifestation of inflammatory bowel disease with celiac disease in a 2-year-old male: a rare case report

The co-occurrence of inflammatory bowel disease (IBD) and celiac disease (CeD) is uncommon. The typical sign of this co-occurrence is malabsorption which leads to anemia, diarrhea, and malnutrition. In rare cases, recurrent rectal prolapse may also occur.

Case presentation

A 2-year-old Syrian male baby presented with failure to thrive and chronic diarrhea for 18 months, along with recurrent rectal prolapse for the last 6 months. Biopsies taken confirmed a diagnosis of stage 3b celiac disease according to the Marsh classification. Furthermore, biopsies taken confirmed a diagnosis of IBD. Then, a high-fiber diet to manage IBD and celiac diet were both needed simultaneously, with signs of rectal prolapse, diarrhea, and bloating, occurring when either or both diets were stopped.

Clinical discussion

The diagnosis was initially explained by the malnutrition and anemia. Even after the gluten-free diet, the patient showed no improvement in diarrhea and developed inferior gastrointestinal bleeding suggested anal fissure, infectious colitis, polyps, IBD, or solitary rectal ulcer syndrome. The relationship between celiac disease and IBD, in children, is still unclear. Current studies suggest that such co-occurrence is associated with higher risks of developing other autoimmune-related disorders, growth and puberty delay, and comorbidities.

Conclusions

In the cases of pediatric co-occurrence of IBD and celiac disease, a conservative therapy consisting of two-fold diets for the two diseases should be tried first. If this step succeeds in controlling the clinical picture, it removes the necessity of introducing immunological pharmacologic treatments that may induce unfavorable side effects in a child.

No-biopsy diagnostic approach to coeliac disease

This brief review outlines contributions that Michael Marsh and others made to understanding the structure and function of the upper small bowel mucosa and the formation of abnormalities that occur in coeliac disease (CD). He introduced his classification of lesions 30 years ago that has been widely adopted. The development and use of serological tests to screen for and diagnose CD in children and adults without the need for a small bowel biopsy in a considerable proportion is also recognised and will gain traction.

Predictors of slow responsiveness and partial mucosal recovery in adult patients with celiac disease

Aim

The present study aims to determine the rate of mucosal recovery and predictors of persistent mucosal damage after gluten free diet (GFD).

Background

Celiac disease (CD) is a complex multi-systemic autoimmune disease triggered by exposure to dietary gluten in genetically predisposed individuals. There is still little evidence on the best method for assessing GFD adherence and mucosal recovery during treatment.

Methods

The retrospective study included only adult patients (age≥18 years old), with biopsy-proven CD evaluated at a tertiary referral centre between 2016 and 2021. We performed a logistic regression analysis to identify factors associated with partial mucosal recovery (MR) after GFD. We included in the multivariate analysis parameters available at the time of CD diagnosis.

Results

A total of 102 patients were enrolled, two thirds were females, median age of 39 years (yrs). The initial biopsy analysis showed different stages of villous atrophy (VA) in 79 (77.4%) cases, while in 23(22.5%) cases showed mild enteropathy (Marsh 1, 2). After at least 12 months of GFD, 26 (25.5%) patients had persistent VA despite good or excellent adherence to GFD. Younger patients (< 35yrs), who showed severe mucosal damage (Marsh 3c lesions) and who had increased anti-gliadin antibody (AGA) levels were at risk for failure to obtain mucosal recovery (MR). Logistic regression analysis demonstrated that complete mucosal atrophy (P=0.007) and high AGA antibody levels (cutoff 129 U/ml, P=0.001) were independent risk factors for lack of mucosal improvement after at least 12 months of GFD. Interestingly, genotype, tTG-IgA antibody levels, or duration of GFD levels did not influence the occurrence of MR.

Conclusion

Although AGA seropositivity has lost much of their diagnostic significance in recent years due to the introduction of the more sensitive and specific antibody tests, our study reported that patients aged < 35 yrs, who showed severe mucosal damage (Marsh 3c lesions) and who had increased AGA antibody levels at diagnosis were at risk for failure to obtain MR. The elevated AGA levels at diagnosis could be used as a prognostic tool for assessing MR.

Does contrast-enhanced computed tomography raise awareness in the diagnosis of the invisible side of celiac disease in adults?

PURPOSE

This study aimed to evaluate the diagnosis and determine major and minor criteria of celiac disease (CD) with the malabsorption patterns (MABP) in the small intestine and colon on computed tomography (CT) and additional CT findings.

METHODS

This retrospective study was conducted with 116 patients diagnosed with CD, 14 CD patients recovering with treatment, and 35 control patients with non-CD. All patients had CT examinations and histopathological diagnoses. The sensitivity, specificity, PPV, NPV, and accuracy values of each CT finding defined in the literature were statistically evaluated. According to the patient and control groups, the numerical values of the findings and the sensitivity and specificity values were measured according to this cut-off value. The distribution of CT findings according to pathological Marsh data was evaluated in CD patients.

RESULTS

Sensitivity and specificity were found to be higher in small bowel MABP findings, mesenteric hypervascularity, and increased SMV/aorta diameter. There was a numerically significant difference in MDCT findings between the control and pathological Marsh groups. In the ROC analysis performed in terms of the total numerical values of each MDCT finding observed between the groups, it was found that there were more than 7 MDCT findings, 100% sensitivity, and 92% specificity. The presence of four major and three minor criteria or three major and four minor criteria were considered significant.

CONCLUSIONS

Being aware of CT findings below the iceberg that may suggest CD in abdominal CT examinations performed in patients with atypical clinical and malabsorption findings or other nonspecific findings may prevent diagnostic delay and unnecessary procedures.

Evaluation of celiac disease with uniphasic and multiphasic dynamic MDCT imaging

PURPOSE

An analysis of dynamic contrast MRI has been shown to provide valuable information about disease activity in Crohn's disease and Celiac disease (CD). However, there are no reports of dynamic multi-detector computer tomography use in patients with CD. The aim of this study is to determine and compare the perfusion dynamics of the patients treated with control subjects and the perfusion dynamics in patients with untreated CD, using dynamic contrast in MDCT and compare studying contrast dynamics in Marsh types as well.

METHODS

In this retrospective study, uniphasic and multiphasic MDCT, untreated, treated, incompatible CD patients and healthy control group duodenum wall thickness and HU values were compared in terms of patient groups and modified Marsh types.

RESULT

In dynamic CT, the highest contrast curve was observed in the untreated group and Marsh type 1. While the contrast curve of the untreated and non-compliant patients increased rapidly and showed wash out, the type 4 contrast curve was observed, whereas the treated and control group slowly increased type 5 contrast curve. In the contrast-enhanced CT in the venous phase, in the ROC analysis between Marsh 1-2 and Marsh 3a-c, the sensitivity was 97% and the specificity was 87% when the cut off was taken as 4.45 mm for wall thickness (p: 0.005).

CONCLUSION

Contrast-enhanced single-phase and dynamic MDCT imaging in CD patients may be useful in evaluating the inflammatory and pathological process in the small intestine.

From celiac disease to coccidia infection and vice-versa: The polyQ peptide CXCR3-interaction axis

Zonulin is a physiological modulator of intercellular tight junctions, which upregulation is involved in several diseases like celiac disease (CeD). The polyQ gliadin fragment binds to the CXCR3 chemokine receptor that activates zonulin upregulation, leading to increased intestinal permeability in humans. Here, we report a general hypothesis based on the structural connection between the polyQ sequence of the immunogenic CeD protein, gliadin, and enteric coccidian parasites proteins. Firstly, a novel interaction pathway between the parasites and the host is described based on the structural similarities between polyQ gliadin fragments and the parasite proteins. Secondly, a potential connection between coccidial infections as a novel environmental trigger of CeD is hypothesized. Therefore, this report represents a promising breakthrough for coccidian research and points out the potential role of coccidian parasites as a novel trigger of CeD that might define a preventive strategy for gluten-related disorders in general. Also see the video abstract here: https://youtu.be/oMaQasStcFI.

Significant improvement in bone mineral density in pediatric celiac disease: even at six months with gluten-free diet

OBJECTIVES

Patients with celiac disease had significantly decreased bone mineral density even in patients with no gastrointestinal symptoms. Only few bone studies are available on pediatric patients with celiac disease.

METHODS

Forty-six patients underwent measurement of areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry (DXA) before the initiation of gluten-free diet. Anthropometric, laboratory and DXA measurements at baseline and at sixth month of the treatment were compared.

RESULTS

The frequency of low aBMD Z-score (≤-1 SDS) in both or any site was found to be 78.2% in this study. Of 16 patients with an aBMD Z-score of <-2 SDS five gained more than 1 SDS, and one gained more than 2 SDS. Nine of 20 patients with an aBMD Z-score of <-1 SDS completely normalized.

CONCLUSIONS

The results of the study showed that low BMD is common in children with celiac disease at the time of diagnosis and could improve in a short period of six months with a strict gluten-free diet and adequate supplementation of calcium and vitamin D.

Brain Opioid Activity and Oxidative Injury: Different Molecular Scenarios Connecting Celiac Disease and Autistic Spectrum Disorder

Celiac Disease (CD) is an immune-mediated disease triggered by the ingestion of wheat gliadin and related prolamins from other cereals, such as barley and rye. Immunity against these cereal-derived proteins is mediated by pro-inflammatory cytokines produced by both innate and adaptive system response in individuals unable to adequately digest them. Peptides generated in this condition are absorbed across the gut barrier, which in these patients is characterized by the deregulation of its permeability. Here, we discuss a possible correlation between CD and Autistic Spectrum Disorder (ASD) pathogenesis. ASD can be induced by an excessive and inappropriate brain opioid activity during the neonatal period. Cereal-derived peptides produced in celiac patients cross the blood–brain barrier and bind to endogenous opioid receptors interfering with neurotransmission and generating deleterious effects on brain maturation, learning and social relations. Moreover, an increase in oxidative stress and a decrease in the antioxidant capacity, as well as an extended mitochondrial impairment in the brain, could represent a possible connection between ASD and CD. Therefore, we critically discuss the proposed relationship between ASD and CD and the possible usefulness of a gluten-free diet in ASD patients.

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

Background

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

Methods

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

Results

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

Conclusions

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

From 2-dimensional to 3-dimensional: Overcoming dilemmas in intestinal mucosal interpretation

The purpose of this review is to provide a definitive account of small intestinal mucosal structure and interpretation. The coeliac lesion has been well known, but not well described to date and this review aims to identify the interpretative difficulties which have arisen over time with the histological assessment of coeliac disease. In early coeliac interpretation, there were significant inaccuracies, particularly surrounding intraepithelial lymphocyte counts and the degree of villous flattening which occurred in the tissue. Many of these interpretive pitfalls are still encountered today, increasing the potential for diagnostic errors. These difficulties are mostly due to the fact that stained 2-dimensional sections can never truly represent the 3-dimensional framework of the intestinal tissue under investigation. Therefore, this review offers a critical account occasioned by these 2-dimensional interpretative errors and which, in our opinion, should in general be jettisoned. As a result, we leave a framework regarding the true 3-dimensional knowledge of mucosal structure accrued over the 70-year period of study, and one which is available for future reference.