Standardizing Randomized Controlled Trials in Celiac Disease: An International Multidisciplinary Appropriateness Study

BACKGROUND & AIMS

There is a need to develop safe and effective pharmacologic options for the treatment of celiac disease (CeD); however, consensus on the appropriate design and configuration of randomized controlled trials (RCTs) in this population is lacking.

METHODS

A 2-round modified Research and Development/University of California Los Angeles Appropriateness Method study was conducted. Eighteen gastroenterologists (adult and pediatric) and gastrointestinal pathologists voted on statements pertaining to the configuration of CeD RCTs, inclusion and exclusion criteria, gluten challenge, and trial outcomes. Two RCT designs were considered, representing the following distinct clinical scenarios for which pharmacotherapy may be used: trials incorporating a gluten challenge to simulate exposure; and trials evaluating reversal of histologic changes, despite attempted adherence to a gluten-free diet. Each statement was rated as appropriate, uncertain, or inappropriate, using a 9-point Likert scale.

RESULTS

For trials evaluating prevention of relapse after gluten challenge, participants adherent to a gluten-free diet for 12 months or more with normal or near-normal-sized villi should be enrolled. Gluten challenge should be FODMAPS (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) free, and efficacy evaluated using histology with a secondary patient-reported outcome measure. For trials evaluating reversal of villus atrophy, the panel voted it appropriate to enroll participants with a baseline villus height to crypt depth ratio ≤2 and measure efficacy using a primary histologic end point. Guidance for measuring histologic, endoscopic, and patient-reported outcomes in adult and pediatric patients with CeD are provided, along with recommendations regarding the merits and limitations of different end points.

CONCLUSIONS

We developed standardized recommendations for clinical trial design, eligibility criteria, outcome measures, gluten challenge, and disease evaluations for RCTs in patients with CeD.

Impact of Gluten-free Diet on Anthropometric Indicators in Individuals With and Without Celiac Disease: A Systematic Review and Meta-analysis

PURPOSE

Previous studies have found that a gluten-free diet (GFD) may have improve obesity-related factors. For this reason, we conducted a systematic review and meta-analysis to investigate the effect of a GFD on anthropometric indicators.

METHODS

We performed a systematic search in databases from inception until July 12, 2022. We included all relevant articles that evaluate efficacy of a GFD on anthropometric indicators in patients with and without celiac disease (CD). Random-effects models were applied to combine the data. The main outcomes were then analyzed using weight mean differences (WMDs) and 95% CIs.

FINDINGS

A total of 27 articles met the eligible criteria and were included. Pooled results from the random-effects model indicated that the GFD has no significant effect on any of the factors of anthropometry, including weight (WMD, 1.20 kg; 95% CI, -1.16 to 3.55 kg; P = 0.319), body mass index (WMD, 0.70 kg/m2; 95% CI, -0.45 to 1.84 kg/m2; P = 0.233), waist circumference (WMD, 0.92 cm; 95% CI, -1.34 to 3.17 cm; P = 0.497), and body fat (WMD, 1.02%; 95% CI, -0.38% to 2.42%; P = 0.153). The subgroup results indicated that after implementation of a GFD significant increased weight and body fat occurred in patients with compared with without CD. In addition, the effect of this diet on the increase of BMI and body fat in the intervention of more than 48 weeks was significantly higher.

IMPLICATIONS

The results of the present study indicate that a GFD can have a significant and beneficial effect on weight and body fat in patients with CD.

Viruses and celiac disease: what do we know ?

The aim of this review is to provide a comprehensive overview about the link between viruses and celiac disease. A systematic search on PubMed, Embase, and Scopus was conducted on March 07, 2023. The reviewers independently selected the articles and chose which articles to include. The review is a textual systemic review, and all relevant articles were included based on title and abstract. If there was a disagreement between the reviewers, they came to a consensus during deliberation sessions. A total of 178 articles were selected for the review and read in full; only part of them was retained. We found studies between celiac disease and 12 different viruses. Some of the studies were done only on small groups. Most studies were on pediatric population. Evidence for an association was found with several viruses (trigger or protective). It seems that only a part of the viruses could induce the disease. Several points are important to keep in mind: firstly, simple mimicry or that the virus induces a high level of TGA is not sufficient to promote the disease. Secondly, inflammatory background is necessary to induce CD with virus. Thirdly, IFN type 1 seems to have an important role. Some of the viruses are potential or known triggers like enteroviruses, rotaviruses, reoviruses, and influenza. Further studies are needed to better understand the role of viruses in celiac disease to better treat and prevent the disease.

Newfound features associated with Hennekam Syndrome (Intestinal Lymphangiectasia-Lymphedema-Intellectual-Disability Syndrome) complicated with comorbid Waldmann's Disease resulting in Celiac Disease

Key Clinical Message

Adequate evaluation of patients with Hennekam Syndrome (HS) is challenging for physicians, because of multi-organ involvement and complex pathophysiology. We report the first case in an African American with lymphedema, who developed protein-losing enteropathy (PLE) and was successfully diagnosed with HS from cause-and-effect complications by Waldmann's Disease (WD) and comorbid Celiac Disease (CD).

Abstract

As far as we know, this is the 51st case of HS worldwide and the first one in an African American. The examined patient met all diagnostic criteria for HS, suggesting a dysfunction in the development of the lymphatic system, with associated comorbidities including developmental delay, gastrointestinal pathologies, facial and hearing abnormalities, and cardiac defects. Primary intestinal lymphangiectasia (WD) is a consequence of HS, which ultimately results in PLE and worsening interstitial lymph buildup. Based on our findings, CD, a complication not yet reported in HS, may arise from WD. Other autoimmune diseases may be seen in HS: a previous report demonstrated positive anti-thyroid stimulating hormone antibodies in HS patients. We propose that in HS, increased interstitial lymph (WD, if intestinal) with protein loss induces TNF-α- and IL-6-mediated immune reactions in the affected visceral organs, causing autoimmune pathologies. The interstitial lymph fluid-induced TNF-α and IL-6-mediated immunopathogenic reactions lead to inflammation and subsequent destruction of the intestinal mucosa. The chronic inflammatory increase in TGF-β causes gastric mucosa hypertrophy, which results in gastric fold thickening. Eventually, wider tight junctions develop, increasing gastric mucosa permeability, and leading to gastropathy. Considering the examined patient's history of gastroenteritis and the literature stating that CD is a non-mucosal cause of gastropathy and PLE, it is suggested that sequelae of GI complications occur in a cause-and-effect chain in HS. HS results in WD, which causes CD, resulting in hypertrophic gastropathy and loss of parietal and chief cells, eventually leading to malabsorption and PLE (Figure 1). HS primarily affects various organs due to inflammatory-mediated damage and accumulation of lymph fluid. Other findings for HS include keratoconjunctivitis sicca (dry eye disease), fibrous lymphedema exhibiting lymphorrhea, chylous ascites, anemia, and parathyroid abnormalities. Immune impairment in HS predisposes patients to autoimmune disorders, therefore autoimmunity (CD) and WD are concomitant comorbidities of HS. HS-associated comorbidities are primarily due to inflammation and damage to immune cell transport or underlying health conditions affecting proper lymphatic function. However, it is suggested that HS mutations may disrupt the development of the lymphatic system leading to further complication. complications can be compound heterozygous, and there is a need for further research to identify nearby genes that can cause concomitant co-morbidity.

Epidemiological, Endoscopic, Clinical, and Pathological Features of Patients with Celiac Diseases in Southern Littoral of Caspian Sea

Background: Celiac disease is an autoimmune disorder resulting from gluten consumption in genetically predisposed individuals. The present study investigated the epidemiological, endoscopic, and clinicopathological features of patients with celiac disease in the southern littoral of the Caspian Sea. Methods: 140 patients with celiac disease were interviewed and examined regarding demographic characteristics, clinical symptoms, and serologic, endoscopic, and pathological findings. Results: 44 (31.4%) of the patients were male and 68.6% were female. The mean age of the patients at diagnosis was 27.13±13.4 years (ranging from 2 to 60 years). The most common gastrointestinal (GI) symptoms were bloating (47.8%), abdominal pain (47.1%) and diarrhea (30.7%), respectively. Also, 17 (12.1%) patients did not complain of any GI symptoms.18 (12.8%) patients had aphthous stomatitis, 10.7% had dermatitis herpetiformis, 3.6% suffered from itching without a rash, two (1.4%) mentioned psoriasis and one (0.7%) had lichen planus. 19 (19.7%) of the female patients complained of menstrual bleeding disorders, 4% mentioned infertility, and 2% experienced primary amenorrhea. The most common comorbid condition was hypothyroidism in 16 (11.4%) patients. The most common endoscopic finding was duodenal scalloping (37.25%). In addition, 7.8% of the patients had a normal endoscopic appearance. 43 (30.7%) patients were classified as Marsh IIIC, 25.7% Marsh IIIB, 17.8% Marsh IIIA, 12.8% Marsh II and 12.8% were classified as Marsh I. Conclusion: Since celiac disease can present with non-GI manifestations and the majority of our patients had Marsh III classification, it seems that celiac disease must be considered as a routine screening test in GI clinics, and also, it should be kept in mind as a differential diagnosis in other specialty fields.

Effect of helicobacter pylori infection eradication on serum level of anti-tissue transglutaminase in children with celiac disease

BACKGROUND

Evidence shows the increase of anti-tissue transglutaminase (tTG) levels in various conditions, including infectious agents, independently of celiac disease (CD). The aim of this study was to investigate the effect of helicobacter pylori (H.pylori) infection eradication on serum level of tTG in children with CD.

METHODS

This study was conducted on children aged 2 to 18 who referred to reference hospitals for diagnosis of CD. After upper endoscopy and biopsy to confirm CD and H.pylori infection, the children were divided into three groups (including group one: 16 CD patients with positive H. pylori; group two: 16 non-CD patients with positive H. pylori; and group three: 56 CD patients with negative H. pylori), respectively. The tTG level in study groups were compared after the eradication of H.pylori.

RESULTS

The mean age of the subjects in the group one, two, and three was 9.7 ± 3.33, 11.8 ± 3.14, and 7.6 ± 3.32 years, respectively. Our results showed that in group one, mean tTG increased after eradication of H.pylori infection, however, these changes were not significant (182.43 vs. 157.18, P = 0.121). In the second group, although unlike the first group, mean tTG decreased after eradication of the infection, but still these changes were not significant (9.56 vs. 22.18, P = 0.449). Furthermore, at the baseline level, the mean tTG in the group three was closer to the mean tTG in the first group.

CONCLUSION

Our findings showed that the eradication of H.pylori infection does not have a significant effect on tTG levels in children with and without CD.

Probiotic with gluten reduction property and its encapsulation in synbiotic aloe vera gel-alginate capsules with banana powder as prebiotic

This study aims to hydrolyze the immunogenic gluten peptides by probiotic bacteria, Lactococcus lactis G01. It was isolated from curd and isolation was done based on ability to hydrolyze gluten. It was also tested for probiotic properties such as survival in gastric juice, bile salts, acid resistance, antibiotic sensitivity, antioxidant potential, sodium chloride tolerance, and antimicrobial activity. Lactococcus lactis G01 exhibited potential probiotic properties also, hence it was selected for microencapsulation. Probiotic was encapsulated in sodium alginate beads using banana powder as prebiotic and aloe vera as the adsorbent. The bead morphology was studied using scanning electron microscopy and transmission electron microscopy. The chemical composition of the bead was confirmed by FTIR. It was observed that 99% of the encapsulated probiotic cells were released into the simulated intestinal fluid in 90 min. Storage study was conducted for encapsulated probiotic and after four weeks of storage, the probiotic count in microcapsules was 7.82 log10 CFU/g. The formulated synbiotic capsules are suggested to incorporate in porridge for celiac patients since the probiotic has gluten reduction property.

Graphical abstract

Increased Fecal Bile Acid Excretion in a Significant Subset of Patients with Other Inflammatory Diarrheal Diseases

BACKGROUND

Increased fecal bile acid excretion (IBAX) occurs in a third of patients with functional diarrhea.

AIMS

To assess the prevalence of IBAX in benign inflammatory intestinal and colonic diseases presenting with chronic diarrhea.

METHODS

All patients with known inflammatory diseases or resections who underwent 48 h fecal fat and BA testing for chronic diarrhea at a single center were included. Quiescent disease was based on clinical evaluation and serum, endoscopic and imaging studies. IBAX was defined by: > 2337 µmol total BA/48 h; or primary fecal BAs > 10%; or > 4% primary BA plus > 1000 µmol total BA /48 h. Demographics, fecal weight, fecal fat, stool frequency and consistency were collected. Nonparametric statistical analyses were used for group comparisons.

RESULTS

Sixty patients had celiac disease (51 quiescent, 9 active), 66 microscopic colitis (MC: 34 collagenous, 32 lymphocytic), 18 ulcerative colitis (UC), and 47 Crohn's disease (CD). Overall, fecal fat, 48 h stool weight, frequency and consistency were not different among subgroups except for inflammatory bowel disease (IBD) based on disease location. Almost 50% patients with celiac disease and MC had IBAX, with a greater proportion with increased primary fecal BA. Among UC patients, rates of IBAX were higher with pancolonic disease. A high proportion of patients with ileal resection or CD affecting ileum or colon had IBAX. IBAX was present even with quiescent inflammation in UC or CD.

CONCLUSIONS

A significant subset of patients with MC, quiescent celiac disease and IBD had increased fecal BA excretion, a potential additional therapeutic target for persistent diarrhea.

Emergence of an adaptive immune paradigm to explain celiac disease: a perspective on new evidence and implications for future interventions and diagnosis

INTRODUCTION

Recent patient studies have shown that gluten-free diet is less effective in treating celiac disease than previously believed, and additionally patients remain vulnerable to gluten-induced acute symptoms and systemic cytokine release. Safe and effective pharmacological adjuncts to gluten-free diet are in preclinical and clinical development. Clear understanding of the pathogenesis of celiac disease is critical for drug target identification, establishing efficacy endpoints and to develop non-invasive biomarkers suitable to monitor and potentially diagnose celiac disease.

AREAS COVERED

The role and clinical effects of CD4+ T cells directed against deamidated gluten in the context of an "adaptive immune paradigm" are reviewed. Alternative hypotheses of gluten toxicity are discussed and contrasted. In the context of recent patient studies, implications of the adaptive immune paradigm for future strategies to prevent, diagnose, and treat celiac disease are outlined.

EXPERT OPINION

Effective therapeutics for celiac disease are likely to be approved and necessitate a variety of new clinical instruments and tests to stratify patient need, monitor remission, and confirm diagnosis in uncertain cases. Sensitive assessments of CD4+ T cells specific for deamidated gluten are likely to play a central role in clinical management, and to facilitate research and pharmaceutical development.

Association of Immune Thrombocytopenia and Celiac Disease in Children: A Retrospective Case Control Study

Objective:

The association between celiac disease (CD) and immune thrombocytopenia (ITP) is still uncertain. The aim of this study was to characterize the coexistence of these two diseases in Italian children.

Materials and Methods:

This is a retrospective multicenter study investigating the occurrence of CD in 28 children with ITP diagnosed from January 1, 2000, to December 31, 2019.

Results:

The first diagnosis was ITP in 57.1% and CD in 32.1% of patients. In 3 patients (10.7%), the two diagnoses were simultaneous. All the potential and silent cases of CD in our cohort were diagnosed in the groups of “ITP first” and “simultaneous diagnosis”. In all children ITP was mild, and in 2 out of 8 not recovered from ITP at the time of CD diagnosis a normalization of platelet counts (>100,000/μL) occurred 3 and 5 months after starting a gluten-free diet, respectively.

Conclusion:

We think that screening for CD should be considered in children with ITP regardless of the presence of gastrointestinal symptoms. Furthermore, some patients may recover from ITP after starting a gluten-free diet.

TagSNP approach for HLA risk allele genotyping of Saudi celiac disease patients: effectiveness and pitfalls

BACKGROUND

Celiac disease (CD) is a genetically complex autoimmune disease which is triggered by dietary gluten. Human leukocyte antigen (HLA) class II genes are known to act as high-risk markers for CD, where >95% of CD patients carry (HLA), DQ2 and/or DQ8 alleles. Therefore, the present study was conducted to investigate the distribution of HLA haplotypes among Saudi CD patients and healthy controls by using the tag single nucleotide polymorphisms (SNP).

METHODS

HLA-tag SNPs showing strong linkage value (r2>0.99) were used to predict the HLA DQ2 and DQ8 genotypes in 101 Saudi CD patients and in 103 healthy controls by using real-time polymerase chain reaction technique. Genotype calls were further validated by Sanger sequencing method.

RESULTS

A total of 63.7% of CD cases and of 60.2% of controls were predicted to carry HLA-DQ2 and DQ8 heterodimers, either in the homozygous or heterozygous states. The prevalence of DQ8 in our CD patients was predicted to be higher than the patients from other ethnic populations (35.6%). More than 32% of the CD patients were found to be non-carriers of HLA risk haplotypes as predicted by the tag SNPs.

CONCLUSION

The present study highlights that the Caucasian specific HLA-tag SNPs would be of limited value to accurately predict CD specific HLA haplotypes in Saudi population, when compared with the Caucasian groups. Prediction of risk haplotypes by tag SNPs in ethnic groups is a good alternate approach as long as the tag SNPs were identified from the local population genetic variant databases.

Use of almond flour and stevia in rice-based gluten-free cookie production

ABSTRACT

The gluten-free cookies were produced by replacing rice flour (RF) and sucrose content with almond flour (AF) and stevia. Supplementation of AF caused to decrease the moisture content of the gluten-free cookies; while ash, total protein, total fat and total dietary fiber content increased. Regarding of total phenolics; extractable, hydrolyzable and bioaccessible fractions of gluten-free cookie samples that were produced with 30% of AF supplementation, were increased by 43.69-73% compared with the control group that was prepared with 100% RF (p ≤ 0.01). Gluten was detected in the cookies with neither RF nor AF. No cross-contamination was detected during the production, too. Quality characteristics of the gluten-free cookies reached the acceptable level while AF and stevia contents were increased. Protein and dietary fiber contents of the cookie with AF and stevia were enriched to 82 and 96%, while the total carbohydrate amount decreased 19% (p ≤ 0.01). The contents of TEAC_ABTS and TEAC_FRAP of gluten-free cookies with AF and stevia were 5.72 ± 0.07 and 26.08 ± 0.49 µmol Trolox/g and higher than the control (100% RF + sucrose). It has found that physicochemical, nutrition and sensorial properties of gluten-free cookies that were produced with AF + stevia supplementation provided to produce more acceptable products.

GRAPHIC ABSTRACT

Why people follow a gluten-free diet? An application of health behaviour models

PURPOSE

To understand factors affecting adherence to GFD by celiac and non-celiac people through the application of behavioural theories, Integrative Model (IM) and Multi Theory Model (MTM).

METHODS

Analyses were conducted for a sample of 308 subjects, majority females, celiac and non-celiac. Adherence to GFD was measured considering two scales, self-declared adherence and scored adherence, in order to discern possible inconsistencies between what subjects believe and what they really do. Subsequently, adherence to GFD was modelled by considering constructs of MTM and IM. Moreover, the constructs were designed based on literature review. Ordered logit (OL) model was used to test the IM and MTM theoretical models.

RESULTS

The findings show that adherence to GFD is affected mainly by attitudes towards GFD, self-efficacy, injunctive norms, knowledge about GFD and health conditions. Between the two models, IM and MTM, results show that all constructs of IM explain the behaviour. Contrary, for MTM, results indicate only some constructs of the MTM explain adherence to GFD.

CONCLUSIONS

Results of this study should be considered for improving the adherence to GFD for celiac people. Furthermore, it is important to consider the non-celiac people's perceptions for GFD and GF products. In other words an accurate information about the diet and products it is relevant for supporting people to make healthier food choices. Finally, as the results show, IM explain adherence to GFD better than MTM.

AGA Clinical Practice Update on the Evaluation and Management of Seronegative Enteropathies: Expert Review

DESCRIPTION

Our aim was to provide a consensus statement for the best approaches for diagnosis and management of patients with suspected enteropathy, but negative results from serologic tests for celiac disease (seronegative enteropathy).

METHODS

We collected findings from published cohort, case-control, and cross-sectional studies of diagnosis and case series and descriptive studies of management of patients believed to have celiac disease or other enteropathies unrelated to gluten, but negative results from serologic tests. BEST PRACTICE ADVICE 1: Review histologic findings with experienced pathologists who specialize in gastroenterology. BEST PRACTICE ADVICE 2: Serologic tests are essential for an accurate diagnosis of celiac disease. For patients with suspected celiac disease but negative results from serologic tests, total IgA level should be measured; patients should also be tested for anti-tissue transglutaminase, IgA against deamidated gliadin peptide, and endomysial antibody (IgA). Patients with total IgA levels below the lower limit of detection and IgG against tissue transglutaminase or deamidated gliadin peptide, or endomysial antibody, should be considered to have celiac disease with selective IgA deficiency rather than seronegative celiac disease. BEST PRACTICE ADVICE 3: Patients' diets should be carefully reviewed and duodenal biopsies should be collected and analyzed at the time of serologic testing to determine exposure to gluten and accuracy of test results. BEST PRACTICE ADVICE 4: Thorough medication histories should be collected from patients, with attention to angiotensin II receptor blockers, such as olmesartan, along with travel histories to identify potential etiologies of villous atrophy. This will guide additional testing. BEST PRACTICE ADVICE 5: Patients should be analyzed for disease-associated variants in human leukocyte antigen genes; results must be carefully interpreted. Negative results can be used to rule out celiac disease in seronegative patients. BEST PRACTICE ADVICE 6: Patients with suspected celiac disease who are seronegative but have villous atrophy and genetic risk factors for celiac disease must undergo endoscopic evaluation after 1-3 years on a gluten-free diet to evaluate improvements in villous atrophy. A diagnosis of seronegative celiac disease can then be confirmed based on clinical and histologic markers of improvement on the gluten-free diet. BEST PRACTICE ADVICE 7: Seronegative patients with an identified cause for enteropathy should be treated accordingly; a follow-up biopsy might or might not be necessary. BEST PRACTICE ADVICE 8: Patients with persistent signs and symptoms who do not respond to a gluten-free diet, and for whom no etiology of enteropathy is ultimately identified, should be treated with budesonide.

CONCLUSIONS

These best practice guidelines will aid in diagnosis and management of patients with suspected celiac disease, but negative results from serologic tests.

The evaluation of part-baked frozen bread produced from wheat flour and guar gum in the diet of celiac patients

The present study evaluated an enzyme strategy for eliminating the gliadin in the flour in order to produce part-baked (PB) frozen bread for celiac patients. At first, tissue transglutaminase with lysine methyl ester transamidated the gliadin and hydrolyses gliadin protein. The deamidated dough was used for producing the PB bread and then stored as the frozen storage at - 18 °C for 15 days, followed by investigating physicochemical, rheological, and sensory properties. The SDS-PAGE result demonstrated that transamidating wheat flour with a tissue transglutaminase and L-lysine methyl ester break down the gliadin protein. The PB frozen bread with the absence of gliadin had lower specific volume, porosity, firmness, and color index (P < 0.05) but adding 0.8% guar gum could improve these factors and recompense the absence of gliadin (P < 0.05). The PB frozen bread with 0.8% guar gum had physicochemical properties such as fresh bread which produced with untreated wheat flour (P < 0.05).

The use of microbial transglutaminase in a bread system: A study of gluten protein structure, deamidation state and protein digestion

Microbial transglutaminase (mTG) catalyses the formation of protein crosslinks, deamidating glutamine in a side-reaction. Gluten deamidation by human tissue transglutaminase is critical to activate celiac disease pathogenesis making the addition of mTG to wheat-based products controversial. The ability of mTG (0-2000 U.kg^-1) to alter gluten's structure, digestibility and the deamidation state of six immunogenic gluten peptides within bread was investigated. Gluten's structure was altered when mTG exceeded 100 U.kg^-1, determined by confocal microscopy, extractability and free sulfhydryl assays. The effect of mTG on six immunogenic peptides was investigated by in vitro digestion (INFOGEST) and mass spectrometry. The addition of mTG to bread (0-2000 U.kg^-1) did not alter the deamidation state or digestibility of the immunogenic peptides investigated. Overall, this investigation indicated that the addition of mTG to bread does not create activated gluten peptides. This analysis provides evidence for risk assessments of mTG as a food processing aid.

Food sources of energy and nutrients among Canadian adults following a gluten-free diet

Background

The gluten-free diet (GFD) involves the elimination of wheat and related grains. Wheat is a key fortification vehicle for nutrients such as iron and B vitamins. While there is growing evidence of low nutrients intake and poor diet quality amongst people following long-term GFD, few studies have used a dietary pattern approach to analyse top food sources of nutrients in today’s complex food environment. Thus, the purpose of this study was to identify food sources of energy and nutrients from previously collected diet records of adults following a GFD.

Methods

Three, 3-day food records were collected from 35 participants in a lifestyle intervention study (n = 240 records). All food items were categorised according to the Bureau of Nutritional Sciences Food Group Codes. Percentages of total dietary intakes from food groups were ranked.

Results

Mean intakes of dietary fibre, calcium and iron (females) were lower than recommended, with half the sample consuming below the recommended proportion of energy as carbohydrate. Meat, poultry and fish were the top source of energy (19.5%) in the diet. Gluten-free (GF) grain products were the top source of carbohydrate, fibre and iron and second greatest source of energy. Amongst grains, breakfast/hot cereals, yeast breads, and mixed grain dishes were the greatest nutrient contributors, despite most commercial cereals and breads (65%) being unenriched. Legumes were not frequently consumed.

Conclusions

GF grains were the top food source of carbohydrate, fibre and iron, despite few brands being enriched or fortified. It is a challenge to assess and monitor nutrient intakes on GFD due to the lack of nutrient composition data for B vitamins and minerals (other than iron). Dietary planning guidance for the appropriate replacement of nutrients provided by wheat is warranted.

Emerging Involvement of long non-coding RNAs in gastrointestinal associated inflammatory disorders

Gastrointestinal (GI) disorders including a wide range of infectious, inflammatory, autoimmune, etc. disorders. Inflammatory bowel and celiac disease are non-fatal but overwhelming GI associated disorders. IBD and celiac's complications, besides the great suffering, disturb the normal life of the patients and make them involved in mental and physical problems. The emerging role of genetic content is deniable for GI inflammatory disorders incidence, and long non-coding RNAs (lncRNAs) function is the recent topic for its association. Analyzing of absolute lncRNAs interference in GI inflammatory appearance remains in infancy, and more studies are requested. Here, we concisely performed a systematic review in the last knowledge up to 2020 to identify all of the significant lncRNAs associated with the initiation and progression of GI inflammatory diseases. Accordingly, this assay attempted to refer to the expression of lncRNAs changing from the normal state, discovery of genetic mechanisms, and main effectors that would trigger associated IBD and celiac expression and immune responses would be effective for therapeutic approaches. It could be useful for prognostic and diagnostic purposes of GI associated inflammatory disorders.

Psychological Needs and Services in a Pediatric Multidisciplinary Celiac Disease Clinic

This study aims to describe the psychological needs in children with celiac disease (CD) and to examine the feasibility of psychological consultation in a multidisciplinary clinic. Participants (N = 69) included children with CD and their parents who completed a pre-clinic mental health survey and a 30-min psychological consultation as part of a multidisciplinary clinic (including gastroenterology, nutrition, education, neurology, and neuropsychology). Quantitative and qualitative analyses examined psychological needs, experiences, and satisfaction. The psychologist identified clinically significant symptoms and provided referrals in 49% of children. There were no significant differences by time since CD diagnosis. During the psychology consultation, families discussed emotional adjustment, impact on life and physical well-being, and management of the gluten-free diet. Parents reported high levels of satisfaction from the clinic visit. We identified frequent psychological needs in pediatric CD. The multidisciplinary approach may be a feasible model for specialized, optimal treatment in this population.

Relationship between motivation, adherence to diet, anxiety symptoms, depression symptoms and quality of life in individuals with celiac disease

OBJECTIVE

Celiac disease is an immuno-mediated pathogenesis disease characterised by a malabsorption of nutrients that causes partial or total atrophy of intestinal villi and the alteration of the absorbing epithelium. Several studies have demonstrated the presence of anxiety and depression symptoms and poor quality of life in people with celiac disease and emphasised the importance of diet in modulating these effects. However, few studies have investigated the role of motivation and the relationship it has with these factors. The purpose of this study was to fill this gap and investigate the relationship between motivation, diet adherence, anxiety symptoms, depression symptoms and physical functioning in people with celiac disease.

METHODS

Questionnaires were administered to 433 people with celiac disease aged between 18 and 79 years (M = 32.73, DS = 11.54) to measure anxiety symptoms (State-Trait Anxiety Inventory-Y2), depression symptoms (Beck Depression Inventory), physical functioning (Scale of Physical Functioning), adherence to diet (Celiac Dietary Adherence Test) and motivation (Treatment Self-Regulation Questionnaire).

RESULTS

We used Structural Equation Modelling to examine the relationships of variables. Results revealed a direct relationship between motivation and diet adherence, anxiety symptoms, depression symptoms and physical functioning. They also illustrated the role played by diet adherence in mediating the relationship between motivation and anxiety symptoms, depression symptoms and physical functioning.

CONCLUSION

The results highlight the vital role played by motivation in people; indeed, analysis showed that motivation correlated to adherence to diet. It is therefore necessary to take this factor into account in the treatment of individuals with celiac disease.

Deamidated gliadin peptide in pediatric patients with moderately increased tissue transglutaminase; does it help?

BACKGROUND

Deamidated gliadin peptide (DGP) is a relatively new serologic assay used in diagnosis and monitoring of celiac disease. DGP IgG is recommended by some in pediatric patients <2 y. Use in other pediatric populations is not well established. The utility of the DGP screen (IgG + IgA) in patients with moderate increase of tissue transglutaminase (TTG) IgA has not been studied.

METHODS

Cases between January 2015 and October 2017 in which a patient had TTG IgA greater >19 and <100, DGP screen, and biopsy were collected. Indication for biopsy and diabetes diagnosis were recorded. Of 495 patients screened, 31 met criteria.

RESULTS

The sensitivity and specificity of DGP screen were calculated, and were 87.4% and 56%, respectively; though lower in patients with diabetes.

CONCLUSIONS

The study suggests in patients with moderately increased TTG-IgA, DGP screen lacks specificity and does not provide additional information about whether or not to biopsy.

Canadian packaged gluten-free foods are less nutritious than their regular gluten-containing counterparts

Background

A strict gluten-free (GF) diet is required for the management of celiac disease (CD). The nutritional adequacy of this diet has been questioned due to the elimination of wheat, an important vehicle for micronutrient fortification and source of fibre. While novel and/or reformulated packaged GF products have rapidly entered the marketplace, providing alternatives to wheat-based staples, it is unknown whether these new products are nutritionally comparable.

Methods

From a database of 3,851 foods collected across 21 grocery stores in Eastern Canada, we compared the nutrient content of 398 unique GF items with 445 gluten-containing (GC) equivalents. Wilcoxon rank tests were conducted on listed nutrient content (g, mg, µg) per 100 g of product and the nutrient contribution of iron, folate and fibre were evaluated using Health Canada's nutrient claim regulations.

Results

GF staples (cereals, breads, flours, pastas) contained 1.3 times more fat and less iron (by 55%), folate (by 44%) and protein (by 36%), than GC counterparts (P < 0.0001). On average, GF pastas had only 37% of the fibre in GC pastas (P < 0.0001). Notably, GF and GC flours were equivalent in nutrient content. Despite GF and GC flours having similar nutritional content, the vast majority of the processed GF foods fell short in key nutrients.

Discussion

Packaged GF foods in Canada are generally less nutritious than their GC counterparts, suggesting that GF diets should not be promoted to those who do not require it. The use of nutrient-dense GF flours in homemade foods may improve nutrient intakes on the GF diet.

Gluten sensitivity and epilepsy: a systematic review

OBJECTIVE

The aim of this systematic review was to establish the prevalence of epilepsy in patients with coeliac disease (CD) or gluten sensitivity (GS) and vice versa and to characterise the phenomenology of the epileptic syndromes that these patients present with.

METHODOLOGY

A systematic computer-based literature search was conducted on the PubMed database. Information regarding prevalence, demographics and epilepsy phenomenology was extracted.

RESULTS

Epilepsy is 1.8 times more prevalent in patients with CD, compared to the general population. CD is over 2 times more prevalent in patients with epilepsy compared to the general population. Further studies are necessary to assess the prevalence of GS in epilepsy. The data indicate that the prevalence of CD or GS is higher amongst particular epileptic presentations including in childhood partial epilepsy with occipital paroxysms, in adult patients with fixation off sensitivity (FOS) and in those with temporal lobe epilepsy (TLE) with hippocampal sclerosis. A particularly interesting presentation of epilepsy in the context of gluten-related disorders is a syndrome of coeliac disease, epilepsy and cerebral calcification (CEC syndrome) which is frequently described in the literature. Gluten-free diet (GFD) is effective in the management of epilepsy in 53% of cases, either reducing seizure frequency, enabling reduced doses of antiepileptic drugs or even stopping antiepileptic drugs.

CONCLUSION

Patients with epilepsy of unknown aetiology should be investigated for serological markers of gluten sensitivity as such patients may benefit from a GFD.

Optimization of gluten-free cake formulation enriched with pomegranate seed powder and transglutaminase enzyme

Celiac disease is an autoimmune disorder caused by a permanent intolerance of genetically susceptible persons to gluten proteins and intake of gluten-free diets throughout their life is the only treatment way. Therefore, studies dealing with the production and improvement of gluten-free food products, especially bakery products are of great importance. The aim of this study was to investigate the effect of adding pomegranate seed powder (0-50%) and transglutaminase enzyme (0-1.2%) on physicochemical, sensory and textural properties of gluten-free cake made from rice flour. The results showed that pomegranate seed powder and transglutaminase had positive effects on fiber and ash contents, and porosity; whilst, the incorporation reduced the weight loss, volume and specific volume. Optimization process was performed and optimum gluten-free formulation contained 25.75% pomegranate seed powder and 0.97% transglutaminase. The optimized gluten-free cake showed higher total antioxidant activity, ash, fiber, protein and moisture contents and lower peroxide value, volume index and porosity compared to the control one. The porosity decrement was confirmed in the optimized cake by scanning electron microscopy images.

Prevalence of Celiac Disease in Patients With Iron Deficiency Anemia-A Systematic Review With Meta-analysis

BACKGROUND & AIMS

Anemia is common in patients with celiac disease (CD) and a frequent mode of presentation. Guidelines recommend screening patients with iron-deficiency anemia (IDA) for CD. However, the reported prevalence of CD in patients with IDA varies. We performed a systematic review to determine the prevalence of biopsy-verified CD in patients with IDA.

METHODS

We performed a systematic review of articles published in PubMed Medline or EMBASE through July 2017 for the term "celiac disease" combined with "anemia" or "iron deficiency." We used fixed-effects inverse variance-weighted models to measure the pooled prevalence of CD. Meta-regression was used to assess subgroup heterogeneity.

RESULTS

We identified 18 studies composed of 2998 patients with IDA for inclusion in our analysis. Studies originated from the United Kingdom, United States, Italy, Turkey, Iran, and Israel. The crude unweighted prevalence of CD was 4.8% (n = 143). Using a weighted pooled analysis, we found a prevalence of biopsy-confirmed CD of 3.2% (95% confidence interval = 2.6-3.9) in patients with IDA. However, heterogeneity was high (I² = 67.7%). The prevalence of CD was not significantly higher in studies with a mean participant age older or younger than 18 years or in studies with a mixed-sex vs female-predominant (≥60%) population. On meta-regression, year of publication, female proportion, age at CD testing, and prevalence in the general population were not associated with the prevalence of CD in patients with IDA. In the 8 studies fulfilling all our quality criteria, the pooled prevalence of CD was 5.5% (95% confidence interval = 4.1-6.9).

CONCLUSIONS

In a systematic review and meta-analysis, we found that approximately 1 in 31 patients with IDA have histologic evidence of CD. This prevalence value justifies the practice of testing patients with IDA for CD.

Nutritional Consideration in Celiac Disease and Nonceliac Gluten Sensitivity

Celiac disease is an autoimmune disorder due to the inflammatory response to gluten in genetically predisposed individuals. It causes an enteropathy associated with several nutritional complications. Strict compliance to a gluten-free diet (GFD) is the current primary therapy. Nonceliac gluten sensitivity (NCGS) is a condition in which gluten ingestion leads to systemic symptoms but is not associated with small bowel atrophy or abnormal celiac serologies. A GFD heals celiac disease enteropathy and improves symptoms in NCGS. However, a long-term GFD can be associated with nutritional deficiencies and requires monitoring and guidance.

Laser Capture Microdissection as a Tool to Study the Mucosal Immune Response in Celiac Disease

Laser capture microdissection (LCM) is a powerful tool for selection and isolation of single cells or compartments from complex primary tissues to perform molecular analyses. Celiac disease is a genetic autoimmune disorder where the ingestion of gluten leads to damage in the small intestine. Increased intraepithelial lymphocytes and the presence of the lamina propria inflammatory infiltrate of the duodenal mucosa is a common part of the disease. These cells promote inflammatory processes through the release of cytokines. Here, we describe the use of LCM and real-time quantitative PCR (RT-qPCR) to analyze cytokine profile information in distinct duodenal mucosa tissue compartments of celiac patients.

Increased risk of herpes zoster in patients with coeliac disease - nationwide cohort study

BACKGROUND AND AIMS

Clinical experience suggests that patients with coeliac disease (CD) are more prone to develop herpes zoster (HZ), but robust studies are lacking.

METHODS

We identified 29,064 patients with CD 1969-2008 using biopsy report data from Sweden's 28 pathology departments. CD was equalled to villous atrophy (Marsh histopathology grade III). Each patient was matched on age, sex, calendar year and county of residence to up to five reference individuals ( n=144,342) from the general population. We then used Cox regression to estimate hazard ratios (HRs) for future HZ (defined as having a hospital-based inpatient or outpatient record of this diagnosis in the Swedish Patient Register).

RESULTS

During follow-up, 154 (0.53%) individuals with CD and 499 (0.35%) reference individuals developed HZ. Among individuals aged ≥60 years, 1.06% of CD individuals and 0.85% of reference individuals had a lifetime record of HZ. Overall, CD was associated with a 1.62-fold increased risk of HZ (95% CI=1.35-1.95), and was seen also when we considered comorbidity with lymphoproliferative disease, systemic lupus erythematosus, type 1 diabetes, thyroid disease, rheumatoid disease and excluded individuals with a record of dermatitis herpetiformis. The increased risk remained significant after more than five years of follow-up (1.46; 1.16-1.84) Conclusions: CD is associated with HZ, the increased relative risk persists over time from celiac diagnosis but the absolute risk is small.

Screening for celiac disease, by endomysial antibodies, in patients with unexplained hypertransaminasaemia

OBJECTIVE

To do a serological screening for celiac disease in patients with unexplained liver cytolysis.

MATERIALS AND METHODS

Fifty-six patients with liver cytolysis without known aetiology were studied. Endomysial antibodies were determined by indirect immunofluorescence on human umbilical cord. Two thousand and five hundred blood donors served as control group. For statistical analysis, we used Chi-square or Fisher's exact test.

RESULTS

The frequency of IgA endomysial antibodies in our patients was significantly higher than in the control group (8.92% vs. 0.28%, p < .001). In female, endomysial antibodies were significantly more frequent in patients than in healthy subjects (12.12% vs. 0.4%; p < .001). In male, endomysial antibodies were significantly more frequent in patients than in healthy subjects (4.34% vs. 0.22%; p = .006). The frequency of positive EMA in female patients was higher than in male, but the difference was not statistically significant (12.12% vs. 4.43%; p = .6). Two patients were non-compliant with the gluten-free diet. One patient was out of touch. For the two other patients, transaminase levels reverted to normal level within six months of strict gluten withdrawal.

CONCLUSIONS

A screening for celiac disease should be included within the diagnosis protocol of liver cytolysis.

Anxiety and depression in caregivers of individuals with celiac disease - A population-based study

BACKGROUND & AIMS

Partner burden is common in celiac disease (CD), but it is unclear if parents of children with CD have increased burden, and if this may translate into depression and anxiety meriting healthcare.

METHODS

Nationwide population-based study of 41,753 parents and spouses ("caregivers") to 29,096 celiac patients and 215,752 caregivers to 144,522 matched controls. Caregivers were identified from the Swedish Total Population Register, and linked to data on psychiatric disease in the National Patient Registry. Hazard ratios (HRs) for depression, anxiety, and (as a reference outcome measure) bipolar disorder were examined in a lifetime fashion but also in temporal relationship to date of CD diagnosis using Cox regression. A priori, we focused on parents of individuals diagnosed ≤19 years of age (children at the age of disease onset) and spouses of individuals diagnosed in adulthood, as such parents and spouses ("high-risk caregivers") were most likely to live together with the patient at time of disease onset.

RESULTS

On Cox analysis, depression was 11% more common in high-risk caregivers (HR=1.11: 95%CI=1.03-1.19) than in control caregivers while anxiety was 7% more common (HR=1.07: 95%CI=0.98-1.16). Combining anxiety and depression into a composite outcome measure, there was an 8% statistically significant risk increase (95%CI=1.02-1.14). The highest excess risks for both depression and anxiety were seen just before and 4-8 years after the CD diagnosis. In contrast, bipolar disorder was not more common in caregivers to CD patients.

CONCLUSION

Caregivers to patients with CD may be at increased risk of severe burden.

Increased rate of abdominal surgery both before and after diagnosis of celiac disease

BACKGROUND

The detection of celiac disease (CD) is suboptimal.

AIMS

We hypothesized that misdiagnosis is leading to diagnostic delays, and examine this assertion by determining if patients have increased risk of abdominal surgery before CD diagnosis.

METHODS

Through biopsy reports from Sweden's 28 pathology departments we identified all individuals with CD (Marsh stage 3; n=29,096). Using hospital-based data on inpatient and outpatient surgery recorded in the Swedish Patient Register, we compared abdominal surgery (appendectomy, laparotomy, biliary tract surgery, and uterine surgery) with that in 144,522 controls matched for age, sex, county and calendar year. Conditional logistic regression estimated odds ratios (ORs).

RESULTS

4064 (14.0%) individuals with CD and 15,760 (10.9%) controls had a record of earlier abdominal surgery (OR=1.36, 95% CI=1.31-1.42). Risk estimates were highest in the first year after surgery (OR=2.00; 95% CI=1.79-2.22). Appendectomy, laparotomy, biliary tract surgery, and uterine surgery were all associated with having a later CD diagnosis. Of note, abdominal surgery was also more common after CD diagnosis (hazard ratio=1.34; 95% CI=1.29-1.39).

CONCLUSIONS

There is an increased risk of abdominal surgery both before and after CD diagnosis. Surgical complications associated with CD may best explain these outcomes. Medical nihilism and lack of CD awareness may be contributing to outcomes.

Celiac disease and Down syndrome mortality: a nationwide cohort study

Background

Individuals with Down syndrome (DS) have increased mortality and are also at increased risk of celiac disease (CD). It is unknown if CD influences mortality in DS. In this study we examined the risk of death in individuals with DS according to celiac status.

Methods

In this nationwide population-based cohort study, we first identified individuals with CD (diagnosed 1969–2008) through small intestinal biopsy report data showing villous atrophy (Marsh stage III) from Sweden’s 28 pathology departments. Celiac individuals were then matched with up to five reference individuals from the general population. In these cohorts we identified individuals with DS using International Classification of Disease codes (ICD) registered in the Swedish Patient Register (includes inpatients and hospital-based outpatients), the Medical Birth Register, and the Register of Congenital Malformations. Of 29,096 individuals with CD, 201 (0.7%) had DS compared to 124 of the 144,522 reference individuals (0.09%). Data on mortality were obtained from the Swedish Cause of Death Registry. Hazard ratios (HRs) for death were calculated using Cox regression.

Results

During follow-up, there were seven deaths among individuals with DS and CD (7/201, 3.5%) as compared with 14 deaths among DS individuals without a record of CD (14/124, 11.3%). Adjusting for potential confounders, CD did not influence the risk of death in DS (HR = 1.36; 95%CI = 0.33–5.59). Cardiovascular death occurred in two individuals with CD and three individuals without CD, while death from malignancy occurred in one individual with CD and two individuals without CD.

Conclusion

While both DS and CD have been linked to increased risk of death, this study found no excess mortality in DS patients with a concurrent diagnosis of CD, however confidence intervals were wide.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0801-4) contains supplementary material, which is available to authorized users.

Economic burden made celiac disease an expensive and challenging condition for Iranian patients

AIM

The aim of this study was to estimate the economic burden of celiac disease (CD) in Iran.

BACKGROUND

The assessment of burden of CD has become an important primary or secondary outcome measure in clinical and epidemiologic studies.

METHODS

Information regarding medical costs and gluten free diet (GFD) costs were gathered using questionnaire and checklists offered to the selected patients with CD. The data included the direct medical cost (including Doctor Visit, hospitalization, clinical test examinations, endoscopies, etc.), GFD cost and loss productivity cost (as the indirect cost) for CD patient were estimated. The factors used for cost estimation included frequency of health resource utilization and gluten free diet basket. Purchasing Power Parity Dollar (PPP$) was used in order to make inter-country comparisons.

RESULTS

Total of 213 celiac patients entered to this study. The mean (standard deviation) of total cost per patient per year was 3377 (1853) PPP$. This total cost including direct medical cost, GFD costs and loss productivity cost per patients per year. Also the mean and standard deviation of medical cost and GFD cost were 195 (128) PPP$ and 932 (734) PPP$ respectively. The total costs of CD were significantly higher for male. Also GFD cost and total cost were higher for unmarried patients.

CONCLUSION

In conclusion, our estimation of CD economic burden is indicating that CD patients face substantial expense that might not be affordable for a good number of these patients. The estimated economic burden may put these patients at high risk for dietary neglect resulting in increasing the risk of long term complications.

Tissue Transglutaminase Levels Are Not Sufficient to Diagnose Celiac Disease in North American Practices Without Intestinal Biopsies

BACKGROUND

Celiac serology is crucial for the diagnosis of celiac disease in children. The American guideline for celiac disease in children suggested that positive serology should be followed by confirmatory intestinal histology. The relationship between high tissue transglutaminase titers and celiac disease in children has not been well investigated in children from North America.

AIMS

In the present study, we investigated whether different tissue transglutaminase titers in symptomatic children could predict celiac disease without the confirmation of intestinal histology.

METHODS

Data from biopsy confirmed celiac children were collected from four different clinics in North America. Clinical, serological, histological, and follow-up data were collected. The accuracy rates of various tissue transglutaminase titers to predict celiac disease in children were calculated.

RESULTS

The data from 240 children were calculated. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy rate of tissue transglutaminase titers at ≥10× upper limit of normal were 75.4, 48.8, 87.7, 29.0, and 70.8 %, respectively. Similar data were noted in the other tissue transglutaminase titers (≥3× upper limit of normal, >100 U/ml, or >100 U/ml and >10× upper limit of normal).

CONCLUSIONS

The positive predictive value of tissue transglutaminase titers at ≥3× upper limit of normal or higher was too low to predict celiac disease in children. Our data suggested that in routine clinical practice, high titers of tissue transglutaminase are not sufficient to diagnose celiac disease in North American children without intestinal biopsies.

The utility of including pathology reports in improving the computational identification of patients

BACKGROUND

Celiac disease (CD) is a common autoimmune disorder. Efficient identification of patients may improve chronic management of the disease. Prior studies have shown searching International Classification of Diseases-9 (ICD-9) codes alone is inaccurate for identifying patients with CD. In this study, we developed automated classification algorithms leveraging pathology reports and other clinical data in Electronic Health Records (EHRs) to refine the subset population preselected using ICD-9 code (579.0).

MATERIALS AND METHODS

EHRs were searched for established ICD-9 code (579.0) suggesting CD, based on which an initial identification of cases was obtained. In addition, laboratory results for tissue transglutaminse were extracted. Using natural language processing we analyzed pathology reports from upper endoscopy. Twelve machine learning classifiers using different combinations of variables related to ICD-9 CD status, laboratory result status, and pathology reports were experimented to find the best possible CD classifier. Ten-fold cross-validation was used to assess the results.

RESULTS

A total of 1498 patient records were used including 363 confirmed cases and 1135 false positive cases that served as controls. Logistic model based on both clinical and pathology report features produced the best results: Kappa of 0.78, F1 of 0.92, and area under the curve (AUC) of 0.94, whereas in contrast using ICD-9 only generated poor results: Kappa of 0.28, F1 of 0.75, and AUC of 0.63.

CONCLUSION

Our automated classification system presented an efficient and reliable way to improve the performance of CD patient identification.

Generating Transgenic Mouse Models for Studying Celiac Disease

This chapter provides a brief overview of current animal models for studying celiac disease, with a focus on generating HLA transgenic mouse models. Human Leukocyte Antigen class II molecules have been a particular target for transgenic mice due to their tight association with celiac disease, and a number of murine models have been developed which had the endogenous MHC class II genes replaced with insertions of disease susceptible HLA class II alleles DQ2 or DQ8. Additionally, transgenic mice that overexpress interleukin-15 (IL-15), a key player in the inflammatory cascade that leads to celiac disease, have also been generated to model a state of chronic inflammation. To explore the contribution of specific bacteria in gluten-sensitive enteropathy, the nude mouse and rat models have been studied in germ-free facilities. These reductionist mouse models allow us to address single factors thought to have crucial roles in celiac disease. No single model has incorporated all of the multiple factors that make up celiac disease. Rather, these mouse models can allow the functional interrogation of specific components of the many stages of, and contributions to, the pathogenic mechanisms that will lead to gluten-dependent enteropathy. Overall, the tools for animal studies in celiac disease are many and varied, and provide ample space for further creativity as well as to characterize the complete and complex pathogenesis of celiac disease.

Cardiovascular disease in patients with coeliac disease: A systematic review and meta-analysis

BACKGROUND

Coeliac disease has been associated with an increased risk of cardiovascular disease in some studies, whereas other studies have shown no association. We performed a systematic review and meta-analysis of cardiovascular disease in celiac disease.

METHODS

Pubmed, Cinahl, EMBASE and Medline via Ovid were searched for relevant articles published until January 5, 2015. English-language articles on studies with more than 20 patients were included, and were quality rated using the GRADE risk of bias tool. We used random-effects models and assessed heterogeneity using the I(2) statistic.

RESULTS

Ten studies were relevant, reporting the risk of myocardial infarction, cardiovascular death and stroke in 33,128/32,903/32,466 coeliac disease patients respectively. Only one study examined celiac disease and a composite measure of cardiovascular disease and this study found a hazard ratio of 1.10 (95%CI 1.03-1.28). In a meta-analysis, we observed an increased risk of stroke (OR 1.11; 95%CI 1.02-1.20). The risks of myocardial infarction (OR 1.12; 95%CI 0.83-1.40) and cardiovascular death (OR 1.12; 95%CI 0.96-1.29) were similar but were estimated with less certainty. Heterogeneity was low for all outcomes except for myocardial infarction where it was moderate.

CONCLUSION

Coeliac disease was associated with a modestly increased risk of cardiovascular disease, but the evidence base is limited.

Digestibility of gluten proteins is reduced by baking and enhanced by starch digestion

Scope

Resistance of proteins to gastrointestinal digestion may play a role in determining immune‐mediated adverse reactions to foods. However, digestion studies have largely been restricted to purified proteins and the impact of food processing and food matrices on protein digestibility is poorly understood.

Methods and results

Digestibility of a total gliadin fraction (TGF), flour (cv Hereward), and bread was assessed using in vitro batch digestion with simulated oral, gastric, and duodenal phases. Protein digestion was monitored by SDS‐PAGE and immunoblotting using monoclonal antibodies specific for celiac‐toxic sequences (QQSF, QPFP) and starch digestion by measuring undigested starch. Whereas the TGF was rapidly digested during the gastric phase the gluten proteins in bread were virtually undigested and digested rapidly during the duodenal phase only if amylase was included. Duodenal starch digestion was also slower in the absence of duodenal proteases.

Conclusion

The baking process reduces the digestibility of wheat gluten proteins, including those containing sequences active in celiac disease. Starch digestion affects the extent of protein digestion, probably because of gluten‐starch complex formation during baking. Digestion studies using purified protein fractions alone are therefore not predictive of digestion in complex food matrices.

Autoimmune Disease in First-Degree Relatives and Spouses of Individuals With Celiac Disease

BACKGROUND & AIMS

First-degree relatives of individuals with celiac disease are at increased risk for this disorder, but little is known about their risk for other autoimmune diseases. We assessed the risk of nonceliac autoimmune disease in first-degree relatives and spouses of people with celiac disease.

METHODS

We identified individuals with celiac disease by searching computerized duodenal and jejunal biopsies, collected from 1969 through 2008, at 28 pathology departments in Sweden. Celiac disease was identified based on biopsy reports of villous atrophy (equal to Marsh grade 3; n = 29,096). Individuals with celiac disease were matched with up to 5 controls (people without celiac disease) for sex, age, county, and calendar year (total, 144,522 controls). Through Swedish health care registries, we identified all first-degree relatives (fathers, mothers, siblings, and offspring) and spouses of individuals with celiac disease (n = 84,648) and controls (n = 430,942). We used Cox regression analysis to calculate hazard ratios (HRs) for nonceliac autoimmune disease (Crohn's disease, type 1 diabetes mellitus, hypothyroidism, hyperthyroidism, psoriasis, rheumatoid arthritis, sarcoidosis, systemic lupus erythematosus, or ulcerative colitis) in these groups.

RESULTS

During the follow-up period (median, 10.8 y), 3333 of the first-degree relatives of patients with celiac disease (3.9%) and 12,860 relatives of controls (3.0%) had an autoimmune disease other than celiac disease. First-degree relatives of people with celiac disease were at increased risk of nonceliac autoimmune disease, compared with controls (HR, 1.28; 95% confidence interval, 1.23-1.33), as were spouses (HR, 1.20; 95% confidence interval, 1.06-1.35). Risk estimates for nonceliac autoimmune disease did not differ between first-degree relatives and spouses of individuals with celiac disease (interaction test: P = .11). HRs for nonceliac autoimmune disease were highest in the first 2 years of follow-up evaluation.

CONCLUSIONS

First-degree relatives and spouses of individuals with celiac disease are at increased risk of nonceliac autoimmune disease. In addition to genetic factors, environmental factors and ascertainment bias might contribute to the increased risk of autoimmunity in first-degree relatives of individuals with celiac disease.

Perinatal risk factors for development of celiac disease in children, based on the prospective Norwegian Mother and Child Cohort Study

BACKGROUND & AIMS

There have been inconsistent reports of prenatal and perinatal factors that affect risk for development of celiac disease. We assessed the association of fetal growth, birth weight, and mode of delivery with development of celiac disease within the Norwegian Mother and Child (MoBa) Cohort Study.

METHODS

The MoBa cohort contains pregnancy information on 95,200 women and data on their 114,500 children, which were collected in Norway from 1999 through 2008; it is linked to the Medical Birth Registry. Women and children with celiac disease were identified from the National Patient Registry and from women's responses to MoBa questionnaires. We calculated odds ratios (ORs) for celiac disease by using a multivariable logistic regression model, adjusting for maternal celiac disease, sex of children, and children's age (model 1); in a second model, we adjusted for age of gluten introduction and duration of breastfeeding (model 2).

RESULTS

We identified 650 children with celiac disease and 107,828 controls in the MoBa database. We found no association between birth weight or height with celiac disease (born small for gestational age was not associated). Celiac disease was not associated with mode of delivery (cesarean section, model 1: OR, 0.84; 95% confidence interval [CI], 0.65-1.09, and model 2: OR, 0.83; 95% CI, 0.63-1.09). Maternal celiac disease, adjusted for age and sex of the children (OR, 12.45; 95% CI, 8.29-18.71) and type 1 diabetes (model 1: OR, 2.58; 95% CI, 1.19-5.53, and model 2: OR, 2.61; 95% CI, 1.14-5.98) were associated with development of celiac disease in children, whereas maternal type 2 diabetes and gestational diabetes were not.

CONCLUSIONS

On the basis of analysis of the Norwegian MoBa cohort, development of celiac disease in children is significantly associated with sex of the child, maternal celiac disease, and type 1 diabetes but not with intrauterine growth.

MICA∗078: A novel allele identified in a Moroccan individual affected by celiac disease

A novel MICA allele, MICA(∗)078, has been identified during HLA/MICA high resolution typing of Moroccan patients with celiac disease. MICA(∗)078 shows an uncommon variation at a highly conserved nucleotide position (nt 493, G → A), resulting in one amino acid change at codon 142 (V → I) of MICA gene (compared to MICA(∗)002:01), located in the α2-domain, in which V142 is the common residue.

Evaluation of hearing loss in pediatric celiac patients

OBJECTIVES

Celiac disease (CD) is a chronic immune-mediated enteropathy caused by the ingestion of gluten in genetically predisposed individuals. In some reports, sensorineural hearing loss (SNHL) has been identified as an extraintestinal symptom of CD. We aimed to further investigate the possible association between CD and SNHL by examining a greater number of pediatric CD patients.

METHODS

The study was carried out from March to September 2014 and included 110 pediatric patients with biopsy-confirmed CD (220 ears) and 41 age- and sex-matched controls (82 ears); participants were evaluated by tympanometry and pure tone audiometry (frequency, 250-8000Hz frequency).

RESULTS

Audiometric bone conduction thresholds were significantly different between the CD patients and the controls (p<0.05), but there were no significant differences in pure tone averages for air conduction (p>0.05). When the results for CD patients were analyzed according to duration of disease (≤36 months and >36 months), a significant difference in bone conduction thresholds (p<0.05) was noted, with significant increments at the later stages of disease. However, this difference was not sufficient to define clinical hearing loss, as the pure tone average thresholds remained below 20dB.

CONCLUSION

These results indicate that subclinical hearing loss may be present in children with CD, which could presage more serious hearing impairments at older ages and later stages of the disease. Hearing screenings should be recommended for children with CD in order to prevent the potentially unfavorable effects of hearing loss on the emotional, behavioral, cognitive, and sensorimotor development of these patients.

Survey on computer aided decision support for diagnosis of celiac disease

Celiac disease (CD) is a complex autoimmune disorder in genetically predisposed individuals of all age groups triggered by the ingestion of food containing gluten. A reliable diagnosis is of high interest in view of embarking on a strict gluten-free diet, which is the CD treatment modality of first choice. The gold standard for diagnosis of CD is currently based on a histological confirmation of serology, using biopsies performed during upper endoscopy. Computer aided decision support is an emerging option in medicine and endoscopy in particular. Such systems could potentially save costs and manpower while simultaneously increasing the safety of the procedure. Research focused on computer-assisted systems in the context of automated diagnosis of CD has started in 2008. Since then, over 40 publications on the topic have appeared. In this context, data from classical flexible endoscopy as well as wireless capsule endoscopy (WCE) and confocal laser endomicrosopy (CLE) has been used. In this survey paper, we try to give a comprehensive overview of the research focused on computer-assisted diagnosis of CD.

•

The state-of-the-art research in automated diagnosis of celiac disease is presented.

•

A systematic review of methods and techniques used in this field is given.

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Specific issues and challenges in the field are identified and discussed.

Frequency and characterization of celiac ganglia diagnosed on fine-needle aspiration

INTRODUCTION

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is frequently used to sample intra-abdominal lesions and lymph nodes. Celiac ganglia normally located near the celiac artery may be sampled during these procedures. The aim of this study was to determine the frequency of detection and cytologic findings of celiac ganglia diagnosed on FNA.

MATERIALS AND METHODS

A 14-year retrospective review of radiologic and endoscopic FNA cases involving the celiac region was performed. Cases in which ganglia were reported were further analyzed and slides reviewed.

RESULTS

A total of 354 patients underwent FNA of a suspected celiac lymph node (334 patients) or celiac mass (20 cases). In 9 of these patients (2.5%), ganglion cells were identified. These were identified in cases only after 2008 via EUS-guided FNA. Aspirates were hypocellular and bloody. Large ganglion cells were either sparsely dispersed or present in clusters. Ganglion cells had a low N: C ratio, granular cytoplasm with neuromelanin, and eccentric small round nucleus with a prominent nucleolus. One specimen had concomitant pancreatic adenocarcinoma. None of these cases had a false positive on-site adequacy assessment or final misdiagnosis.

CONCLUSIONS

These data show that celiac ganglia may be infrequently encountered, especially with intra-abdominal EUS-guided FNA targeting nodes or masses near the celiac region. Therefore, cytologists should be aware of the possibility of finding ganglionic cells in EUS-guided FNA samples.

An unusual cause of constipation in a patient without any underlying disorders

Constipation is the most common digestive complaint in the general population. It is associated with considerable adverse effect on quality of life and substantial economic costs and often has no underlying pathology. Non-Celiac Gluten Sensitivity (NCGS) has been described as a cause of constipation in a few studies. We present a 62-year-old male with long standing constipation without any underlying cause during extensive surveys and not responding to any conservative treatment but significant response with gluten free diet (GFD).

Celiac Disease: Diagnosis

Historically the diagnosis of celiac disease has relied upon clinical, serological, and histological evidence. In recent years the use of sensitive serological methods has meant an increase in the diagnosis of celiac disease. The heterogeneous nature of the disorder presents a challenge in the study and diagnosis of the disease with patients varying from subclinical or latent disease to patients with overt symptoms. Furthermore the related gluten-sensitive disease dermatitis herpetiformis, while distinct in some respects, shares clinical and serological features with celiac disease. Here we summarize current best practice for the diagnosis of celiac disease and briefly discuss newer approaches. The advent of next-generation assays for diagnosis and newer clinical protocols may result in more sensitive screening and ultimately the possible replacement of the intestinal biopsy as the gold standard for celiac disease diagnosis.

Does gluten-free diet protect children with celiac disease from low bone density?

OBJECTIVE

We aimed to assess the effect and duration of gluten-free diet on bone health in children with celiac disease in our study.

METHODS

Sixty three patients with celiac disease (CD) formed the study group. They were divided into two subgroups according to their dietary compliance. Bone mineral density (BMD) values of the patients at two and five years of gluten-free diet (GFD) were determined. Findings : The relationship between BMD and compliance to GFD was found to be statistically significant (P<0.01). BMD z-scores were increased (0.12±0.15 and 0.10±0.14 units respectively) (P<0.01). The patients in group 1 and 2 had mean -1.18±0.83 and -2.06±0.73 z-scores in the first DXA. In the second DXA, these values were -1.10±0.73 and-1.94±0.93 respectively.

CONCLUSION

Dietary compliance is important for bone health, and the time needed to normalize the BMD is not known. Patients with positive anti-endomysium antibody (EMA), poor dietary history and history of bone pain should be evaluated with DXA during follow-up.

Risk of congenital malformations among offspring of mothers and fathers with celiac disease: a nationwide cohort study

BACKGROUND & AIMS

Many patients with celiac disease experience malabsorption, weight loss, and anemia; undiagnosed celiac disease during pregnancy has been linked with adverse outcomes. Studies of celiac disease and congenital malformations in offspring have been underpowered. We investigated the risk of congenital malformations among the offspring of parents with celiac disease.

METHODS

We performed a nationwide cohort study of data from linked health care registers in Sweden from 1973 through 2009. We collected histopathology data from 28 pathology departments in Sweden to identify individuals with celiac disease (based on the presence of villous atrophy). We estimated the risks of malformations in the offspring of mothers and fathers with and without celiac disease. Logistic regression was used to estimate adjusted prevalence odds ratios (aPORs) with 95% confidence intervals (CIs).

RESULTS

Among 11,382 offspring of mothers with celiac disease, there were 672 cases (5.9%) of malformation compared with 2098 cases (5.1%) among 40,922 offspring of mothers without celiac disease. Similarly, 352 (5.9%) of 6002 offspring of fathers with celiac disease and 1009 (5.1%) of 19,600 offspring of fathers without celiac disease had a malformation. In adjusted analyses, the offspring of mothers or fathers with celiac disease had a slightly increased risk of having children with malformations (for those with mothers with celiac disease: aPOR, 1.15; 95% CI, 1.05-1.26; for those with fathers with celiac disease: aPOR, 1.14; 95% CI, 1.00-1.29). However, these excess risks decreased or vanished entirely when we restricted our data to births since 2000 (for those with mothers with celiac disease: aPOR, 1.11; and 95% CI, 0.79-1.56; for those with fathers with celiac disease: aPOR, 1.01; 95% CI, 0.81-1.26).

CONCLUSIONS

In a nationwide study, we found an increased risk for malformation among the offspring of mothers or fathers with celiac disease. However, the excess risk is small; the upper limits of the CIs for malformation indicate a 29% maximum relative increase.